Correlation Between Accompanying Symptoms of Facial Nerve Palsy, Clinical Assessment Scales and Surface Electromyography

Article information

J Acupunct Res. 2022;39(4):297-303

doi : https://doi.org/10.13045/jar.2022.00220

Gyu Hui Kim¹, Jung Hyeon Park¹, Tae Kyung Kim¹, Eun Ju Lee¹, Su Eun Jung², Jong Cheol Seo¹, Cheol Hong Kim¹, Yoo Min Choi³, Hyun Min Yoon^1,

¹Department of Acupuncture and Moxibustion, Dong-eui University College of Korean Medicine, Busan, Korea

²Department of Korean Medicine Rehabilitation, Dong-eui University College of Korean Medicine, Busan, Korea

³Department of Acupuncture and Moxibustion Medicine, Korean Medicine Hospital of Woosuk University, Jeonju, Korea

^*Corresponding author: Hyun Min Yoon, Department of Acupuncture and Moxibustion, Dong-eui University College of Korean Medicine, 62, Yanjeong-ro, Busanjin-gu, Busan 47227 Korea, E-mail: yhmin@deu.ac.kr

Received 2022 September 14; Revised 2022 October 11; Accepted 2022 October 17.

Abstract

Introduction

Facial nerve palsy is the most common cranial nerve disorder and has a sudden onset. Paralysis of unilateral facial muscles occurs and the eyes and mouth deviate to one side, and this is accompanied by other symptoms. It is also called “Guanwasa” in Korea [1,2]. The following are the two types of facial nerve palsy: central and the peripheral. Central facial nerve palsy can be caused by a cerebrovascular condition/disease or brain tumor, and peripheral facial nerve palsy can be idiopathic, or due to the herpes zoster virus, or trauma.

Bell’s palsy accounts for approximately 70% of peripheral facial nerve palsy cases and has a prevalence of 20 per 100,000 individuals worldwide. There is no difference in the incidence of Bell’s palsy according to sex or race [3], no clear causes have been reported, it has a sudden onset, and approximately 7% of patients experience recurrence during a 10-year interval [4]. Symptoms of Bell’s palsy generally peak on the 7^th day of onset and are gradually relieved within 3 weeks to 3 months [5]. Approximately 70% of patients with Bell’s palsy recover spontaneously within 6 months without treatment [5].

Ramsay-Hunt syndrome is the 2^nd most common type of peripheral facial paralysis and is caused by the herpes zoster virus. Fifty-four percent of these patients show unsatisfactory recovery, and the overall prognosis is believed to be worse than Bell’s palsy [6].

Korean medicine uses various treatments for facial palsy, including acupuncture, pharmacopuncture, herbal medicine, physical therapy, Chuna therapy [7], electroacupuncture [8], and embedding therapy [9]. Along with the main symptom of facial nerve palsy there are several other symptoms including ear pain, taste disorder, hyperacusis, tinnitus, and lacrimation. These symptoms may appear 3–7 days before or after the facial palsy and are one of the main reasons why patients experience discomfort.

Measurement of facial palsy symptoms is performed using clinical assessment scales and surface electromyography (SEMG), however, there is a lack of research on the relationship between these tests and the accompanying symptoms. Therefore, we retrospectively analyzed data from patients with facial palsy to determine whether there was an association between these tests and the accompanying symptoms.

Materials and Methods

Methods

In this study, patients judged to be suitable were evaluated three times at about two-week intervals (Visit 1 to Visit 3). Using the clinical assessment scales [House-Brackmann grading system (HBGS) and Yanagihara’s unweighted grading system(Y-score)] and SEMG, the degree of facial nerve palsy was measured, and accompanying symptoms were investigated on Visit 1 (which was within 7 days from onset), and Visit 2 and 3, which were 2 and 4 weeks after Visit 1, respectively. All patients were evaluated in the same manner.

Accompanying symptoms of facial nerve palsy

The accompanying symptoms were divided into six groups: (1) the cephalic and facial regions; (2) eyes; (3) ears, mouths; (4) the cervical region; and (5) the whole body. The sum of the number of accompanying symptoms was obtained by asking the patient (Table 1).

Table 1

Accompanying Symptoms of Facial Palsy.

Results

General characteristics of the study patients

This study included 30, 22, and 10 cases on Visit 1, 2, and 3, respectively. On Visit 1, of the 30 patients, 10 (33%) were male and 20 (67%) were female patients, with a total mean age of 59.87 ± 10.04 years. Palsy was noted on the right side in 14 (47%) cases and on the left side in 16 (53%) cases. Additionally, Bell’s palsy was noted in 29 (97%) cases and Ramsay-Hunt was noted in 1 (3%) case. On Visit 2, of the 22 patients, 8 (36%) were male and 14 (64%) were female patients, with a total mean age of 60.41 ± 10.39 years. Palsy was noted on the right side in 12 (55%) cases and on the left side in 10 (45%) cases. Furthermore, Bell’s palsy was noted in 21 (95%) cases and Ramsay-Hunt was noted in 1 (5%) case. On Visit 3, of the 10 patients, 4 (40%) were male and 6 (60%) were female patients, with a total mean age of 55.50 ± 11.70 years. Palsy was noted on the right side in 3 (30%) cases and on the left side in 7 (70%) cases. Moreover, Bell’s palsy was noted in 10 (100%) cases (Table 2).

Table 2

General Characteristics of the Patients.

Average measurements

The mean number of accompanying symptoms were 6.53 ± 2.81, 4.86 ± 3.63, and 4.50 ± 3.66 on Visit 1, 2, and 3, respectively. The mean values of the HBGS were 3.60 ± 0.56, 2.91 ± 0.81, and 2.60 ± 0.84 on Visit 1, 2, and 3, respectively. The mean values of the Y-score were 15.47 ± 6.00, 25.05 ± 10.04, and 28.00 ± 10.51 on Visit 1, 2, and 3, respectively. The mean values of the SEMG assessment ratio of the frontalis muscle were 22.19 ± 18.52, 38.96 ± 27.48, and 48.70 ± 24.17 on Visit 1, 2, and 3, respectively. The mean values of the SEMG assessment ratio of the zygomaticus muscle were 41.42 ± 24.71, 64.56 ± 41.39, and 65.36 ± 29.66 on Visit 1, 2, and 3, respectively. The mean values of the SEMG assessment ratio of the orbicularis oris muscle were 44.13 ± 21.69, 56.00 ± 30.83, and 58.51 ± 28.98 on Visit 1, 2, and 3, respectively. The mean values of the average of three parts of SEMG were 35.71 ± 13.32, 54.88 ± 27.21, and 57.50 ± 23.16 on Visit 1, 2, and 3, respectively (Table 3).

Table 3

Average of Measurements.

Correlations between number of accompanying symptoms, clinical assessment scales and SEMG from the onset to 1 week

From the onset of symptoms to 1 week later, at Visit 1, the number of accompanying symptoms had no significant correlation with other measures. The HBGS had a significant negative correlation with the Y-score. SEMG-F had significant positive correlations with SEMG-O and SEMG-T. Significant positive correlations between SEMG-Z and SEMG-T, and between SEMG-O and SEMG-T were noted. Among them, the positive correlation between SEMG-O and SEMG-T was the most significant (Table 4).

Table 4

Correlations between Accompanying Symptoms, Clinical Assessment Scales and SEMG from Onset to 1 week.

Correlations between accompanying symptoms, clinical assessment scales and SEMG approximately 2–3 weeks after onset

Approximately 2–3 weeks after onset of symptoms, at Visit 2, the number of accompanying symptoms had a significant positive correlation with the HBGS, and significant negative correlations with the Y-score, SEMG-F, SEMG-Z, SEMG-O and SEMG-T. The HBGS had significant negative correlations with the Y-score, SEMG-F, SEMG-Z, SEMG-O, and SEMG-T. The Y-score had significant positive correlations with SEMG-F, SEMG-Z, SEMG-O, and SEMG-T. SEMG-F had significant positive correlations with SEMG-Z, SEMG-O, and SEMG-T. Significant positive correlations between SEMG-Z and SEMG-T, and between SEMG-O and SEMG-T were noted. Among them, the positive correlation between the Y-score and SEMG-T was the most significant (Table 5).

Table 5

Correlations Between the Accompanying Symptoms, Clinical Assessment Scales and SEMG Approximately 2–3 Weeks After Onset.

Correlations between accompanying symptoms, clinical assessment scales and SEMG approximately 4–5 weeks after onset

Approximately 4–5 weeks after onset of symptoms, at Visit 3, the number of accompanying symptoms had a significant positive correlation with the HBGS and a significant negative correlation with the Y-score. The HBGS had significant negative correlations with the Y-score, SEMG-F, SEMG-O, and SEMG-T. The Y-score had significant positive correlations with SEMG-F, SEMG-O, and SEMG-T. SEMG-F had significant positive correlations with SEMG-O and SEMG-T. Significant positive correlations between SEMG-Z and SEMG-T, and between SEMG-O and SEMG-T were noted. Among them, the negative correlation between the HBGS and Y-score was the most significant (Table 6).

Table 6

Correlations Between the Accompanying Symptoms, Clinical Assessment Scales and SEMG Approximately 4–5 Weeks after Onset.

Discussion

Facial nerve palsy is a condition/disease where there is central and peripheral nerve paralysis in which temporary weakness or a lack of movement affects one side of the face and the eyes and mouth deviate. Peripheral facial nerve palsy is a disorder involving a facial nerve, specifically, the seventh cranial nerve. It is a disorder in which paralysis and dysfunction appear in the damaged area of the facial nerve. Patients may show multiple accompanying symptoms including facial discomfort, paresthesia, pain, hypoacusis or hyperacusis, tinnitus, ageusia, xerophthalmia, hypoptyalism, and dizziness [15]. Peripheral facial palsy is associated with ipsilateral pain around the mastoid or migraine following 2–3 days of facial muscle paralysis. In total paralysis, the patients cannot close their eyes, they may drool, and have dysarthria. If the lesion is above the cuneiform ganglion, the amount of tears decreases, and if the stapedial nerve is paralyzed, hyperacusis occurs. When the chorda tympani is paralyzed, the frontal two-thirds of the tongue loses the sense of taste, and the amount of saliva decreases [16].

There are clinical assessment scales and electrophysiological tests to evaluate facial nerve palsy. The clinical evaluation methods include the HBGS, Y-score, and Sunnybrook Facial Grading System. The electrophysiological tests include the nerve conduction study, electromyography (EMG), and the nerve excitability test [17].

The HBGS was first introduced by House in 1983, and was used internationally as a method to evaluate facial nerve palsy; it was modified and published by House and Brackman in 1985 [10]. It has the advantage of simplicity during examinations and ease of understanding the patient’s condition by using a grade. However, it lacks objectivity owing to its subjective evaluation method, and it is difficult to quantify the various degrees of paralysis because of its simplicity. Therefore, it cannot reflect minute changes in the facial function [10,18].

The Y-score, which was introduced by Yanagihara in 1976, is a method used to evaluate facial nerve palsy and is widely used in Japan [11]. It classifies facial function into 10 domains, evaluates them separately, and makes it possible to evaluate various states of paralysis. However, it does not consider secondary deficits, it is highly subdivided, and this makes evaluations inconvenient and calculations complicated [11,18].

In the clinical assessment scales, a highly significant correlation between the HBGS and Y-score was reported by Kim and Xu et al [19] who determined that the Y-score reflected paralysis more precisely in incomplete recovery and in the after-effect stages.

SEMG is a noninvasive method whereby the motor function of the muscle group of that site can be evaluated by attaching electrodes to the surface of the skin to measure electrical activity of the muscle. Currently, along with the nerve conduction study, and EMG (intramuscular motor function detection), which are widely used in facial palsy, SEMG has been studied for its objectivity as a measured value and is use in examinations of individuals with facial nerve palsy [20,21]. However, there are insufficient studies on the correlation between the number of accompanying symptoms related facial nerve palsy and the HBGS, Y-score, and SEMG. Therefore, we retrospectively analyzed and reported the observed correlations

The accompanying symptoms did not have a significant correlation with other measures on Visit 1; however, on Visit 2, they had a significant positive correlation with the HBGS, and significant negative correlations with the Y-score and all SEMG measurements. On Visit 3, they also had a significant positive correlation with the HBGS, and a significant negative correlation with the Y-score.

The HBGS on Visit 1 had a significant negative correlation with the Y-score. On Visit 2, HBGS had significant negative correlations with the Y-score and all SEMG measurements. On Visit 3, HBGS had significant negative correlations except for the accompanying symptoms and SEMG-Z.

The Y-score on Visit 2 had significant positive correlations with all SEMG measurements. On Visit 3, it had significant positive correlations with all SEMG measurements except for SEMG-Z.

On Visit 1, except for a few significant correlations between SEMG measurements, most showed no significant correlations. Furthermore, SMEG measurements in the zygomaticus muscle area showed negative and positive errors in relation to other measures on Visit 1. They had no significant correlations with SEMG-O on Visit 2 and other values except SEMG-T on Visit 3.

However, significant correlations were observed in most of the results between the clinical assessment scales and SEMG measurements on Visit 2 and 3, although, not on Visit 1. This finding was consistent with the results report by Kim et al who determined that SEMG can be used as an objective evaluation tool for facial nerve palsy and as a prognostic factor for facial palsy similar with other electrophysiological tests [20].

Therefore, because the accompanying symptoms showed significant correlations with the HBGS, Y-score, and all SEMG measurements on Visit 2 and the HBGS and Y-score on Visit 3, when diagnosing peripheral facial nerve palsy, the accompanying symptoms, including both clinical assessment scales and SEMG measurements, should be considered at 2–5 weeks after onset that the accompanying symptoms have a significant positive correlation with the HBGS, and nagative correlations with the Y-score and all SMEG measurements.

There are three possible reasons that SEMG measurements had errors in relation to other measures. The first is believed to be due to the very early measurement date of Visit 1, which was from onset to 1 week. The nerve conduction velocity tracks and observes the changes in nerve conduction that resulted from denatured nerves and abnormal response of its dominant muscles. It is typically tested more than 7 days after the onset of facial paralysis [22]. To identify nerve damage sites, the appropriate test time for fine needle EMG is usually 14 days after the onset [23]. Seong et al [24] reported that electroneurography measured on 6–8 days after onset showed a more significant correlation than that measured 3–5 days after onset using EMG measured 14 days after onset of symptoms. In the studies by Kim [20] and Ryu et al [21], SEMG was measured between 1 and 2 weeks from onset. The second possible reason is that in the zygomaticus region, there are several muscles, such as the zygomaticus major and minor muscles, and during the examination it is difficult to accurately attach the surface electrode to the relevant muscle due to the facial curve. Moreover, the movement performed by the patient is a complex movement of several muscles. Therefore, it is presumed that the test accuracy decreased due to several factors that may affect the results. A third reason is believed to be attributable to the relatively small number of patients studied. Therefore, in the future larger sample sizes are needed to power the study.

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