The importance of posterior auricular pain in Bell’s palsy diagnosis and treatment

Acupuncture for Bell’s Palsy

Chinese Medicine in general and acupuncture in particular, are known for their ability to assist with the recovery from the facial nerve paralysis known as Bell’s palsy, and with good success rates at that.

According to the relevant literature from China or in western countries on the use of acupuncture for this palsy, the emphasizes is on the use of local acupuncture points on the face. In the acupuncture departments of hospitals in China, those suffering from this disorder are given a treatment which is mostly localized in the face region, in combination with some general distal points that are suitable for the condition.

Dr. Wang presents a unique approach, combining his understanding of channel theory with western medicine anatomy and knowledge. This approach significantly improves the success rate of the treatment as well as the speed of recovery.

Background

Facial paralysis or what’s known as Bell’s Palsy is the most common cause of unilateral peripheral facial paralysis. Both sides of the face and both Genders are equally affected and the paralysis may happen at any age but the median age is 40 years old. The incidence varies between 11.5–53.3 cases per 100,000 person years. The facial nerve is a predominant motor nerve which controls the facial muscles and consider as a mononeuropathy of the VII cranial nerve.

Causes

There are three main etiologies:

  • Paralysis following CVA, internal damage due to lack of blood supply to the brain tissues. As a result of this stroke the facial nerve is injured. These patients will initially go to the hospital and will arrive to Chinese Medicine in the chronic stage of the disease. This delay in receiving Chinese medicine treatment lowers the chance for recovery, extends the recovery time (which will differ from patient to patient) and decreases the recovery percentage. Despite this, it is still possible to help some of the patients even in the chronic stage.
  • Peripheral nerve inflammation due to an external cause – this disorder is called Bell’s palsy. The external cause is most often viral, and according to recent understanding, the most common one is the herpes simplex virus type 1.
  • Nerve damage due to external causes – trauma, accident, surgery or any other cause, which could damage the nerve. This cause is the least common of the three.

Prognosis

70% of those suffering from peripheral type of palsy recover spontaneously within a short period however, inadequate recovery can occur in 20-30% of patients and as consequence, physical and social impairments are exist in these patients. The complication usually include the following:

Hemifacial spasm, disfiguring facial weakness and voluntary or involuntary contraction of facial muscles.

Treatment

pharmacotherapy treatment:

The main objective is to remove the cause which stimulates an immune system response creating inflammation in the body. If the cause is identified, as in the case of a virus, then anti-viral medicine will be prescribed. Should the cause be unidentified, steroids are given to decrease the immune response. Inflammation in the area of the nerve may give rise to edema, which in turn may aggravate the compression of the surrounding tissues, which may cause irreversible damage. The effectiveness of medicinal treatment is recognized mainly for the first stages of the disease. The further the treatment time is from the time of injury, the less the reaction to the medicines. Therefore, it is extremely important to go for a medical check-up the moment the first signs appear. (Sings are discussed later in this article)

Chinese Medicine Perspective

The movement of Qi in the channels associated to the face is injured, resulting in a deficiency of Qi and Blood supply to the area of the face.

There are three main causes:   

  1. Weakness and/or tiredness, combined with exposure to wind-cold – very common.
  2. Exposure to wind-cold.
  3. Exposure to wind-heat.

Signs and Symptoms

An important preliminary sign for this condition is the appearance of pain in the mastoid process area (posterior auricular pain). This sign is of great importance during the treatment. Most patients suffering from Bell’s Palsy will complain of pain in this area even after the appearance of the paralysis symptoms. In this area the 7th cranial nerve ‘sprouts’, exiting from the brain directly to the face. When this area is injured by an external pathogen such as wind, wind-cold or wind-heat, the Qi movement in the area is obstructed (in western medical terms this would be an inflammation caused by an immune response of the immune system to the virus).

This obstruction is the cause of insufficient blood supply to the nerve, which causes the nerve to atrophy. Due to damage to the nerve’s functionality, the facial muscles are injured, resulting in an aesthetic as well as a functional disorder, at times an extremely severe one at that. In the severe stages of the disease, the patient can not move the facial muscles on one side of the face, can not smile, can not raise an eyebrow, and at times has difficulty speaking.. In addition, as the nerve is also connected to the eye and to the salivary gland in the tongue, he patient can not close the eye and the sense of taste is damaged.

From a Chinese perspective there is an obstruction of Qi in the channel that is involved in the disease. The root of the problem is in the mastoid process region, where the movement of Qi was disturbed. Therefore we should concentrate on this area. Ignoring this sign will impede both the speed and the process of recovery, which for some patients can be a very long period (sometimes years), despite the condition being treated with acupuncture. Thus, at this first stage, Dr. Wang would check if there is any pain in the mastoid process area, by questioning the patient as well as palpating the area itself. (If the patient comes in a relatively early stage (just a few weeks), it is very likely that he/she will experience pain in this area. Yet, if the patient arrives at a later stage, the chances of pain appearing in this area decrease. It depends on the time and stage of arriving to the treatment.) Dr. Wang would diagnose the channel involved by additional symptoms and palpating the channels, and then administer treatment to relieve the pain in the area.

Differential Diagnosis

  • Wind-cold – This syndrome mainly involves the Tai Yang channel. The channel regulates the climatic factor of cold, and is the first layer of the body which meets the exterior, thus being in charge of preventing the entrance of pathogens from outside into the body. If an external pathogen invades the body, this is the layer which expels it outward. The forcefulness of the Qi dynamic in the Tai Yang differs from person to person, this being the reason why some people get affected by an external factor and some don’t. (This channel is directly associated with the body’s immune system.) The Qi dynamic in this channel is important and affects the next channel in line. If the Tai Yang channel does not function properly, the movement of Qi in the channel is injured and becomes obstructed. This syndrome will very often also involve the Shao Yang channel. The obstruction will affect the ability of the Shao Yang channel to be a pivot (axis) between the external and the internal. At this stage the Shao Yang becomes involved in the disorder, and its Qi transformation is injured.
  • Wind-heat – Invasion of wind heat (mostly due to the involvement of a viral factor) which affects the Yang Ming channel. We can say that it is due to heat trapped in this channel or from wind-heat and toxicity invading the body. In addition, the area of injury is the face, which is very much associated with the Yang Ming channel. Therefore is it important to consider this channel as well.

Diagnosis of the Painful Area

Palpation of the region where the nerve exits, the area of the mastoid process, will result in finding that the area feels hardened, and the patient will complain of pain. We should find the most sensitive area, mainly : GB12, GB20, or even Bl10, SJ18. Very often there could be sensitivity in the area of Bl9, GB19, or even involvement of the Du Mai channel at the area of GV16. We should also pay attention to additional signs and symptoms associated with each channel, and of course palpate the channels and diagnose according to channel findings.

Treatment Strategy 

Move the Qi in the injured channel and regulate the Qi dynamic in the channel.

In the early stage, when the pain is in the mastoid process area, we should needle distal points.

Only after the pain in this area is relieved local needling is possible.

Acupuncture Points   

While there is pain the mastoid process area     

Tai Yang – Bl10, distal points on Hand Tai Yang

Shao Yang – GB4, SJ17, distal points on Hand Shao Yang

Yang Ming – LI11, distal points on Hand Yang Ming, in the event of signs of wind-heat and toxicity LI1 can be bled and the addition of St8 with superficial acupuncture.

After the mastoid process pain is relieved

According to the channel involved in the pathology, it is possible to needle local points on the face in order to activate Qi movement to this area, as well as appropriate distal points.

Summary

This case emphasizes the importance of the channel theory. The acupuncture points are the last detail in treating the disorder. The main and most important thing is to comprehend the Qi dynamic in the channels. Such in-depth knowledge will assist in understanding which is the affected channel. Only later, in the final stage, will the points most suitable for the condition at hand be chosen.

Dr. Wang used the method of channel palpation as his main diagnostic tool, after, of course, crosschecking the information with the questionnaire, as well pulse and tongue diagnosis. There are many cases such as this one, where Dr. Wang would head straight for channel palpation, disregarding other diagnostic methods. His vast experience would afford him the ability to choose the ideal diagnostic tool. In this case it was important to diagnose which channel is most affected by the pathology. In palpation there is a possibility to discover this in an objective manner.

Dr. Wang emphasized many a time the importance of the manifestation of pain the area of the mastoid process. According to his clinical experience, as long as there was pain in this area, the localized treatment would be inefficient, and even more so, would even hurt not only the chances for recovery but also affect the recovery speed. Only after the local pain disappeared would it be possible to administer localized treatment.