By Cara O. Frank, L.OM.

The following is an excerpt from my book TCM Case Studies: Eye, Ear, Nose, and Throat Disorders. The full chapter with comparison cases and more discussion will be in the book.

Bells Palsy is a form of facial paralysis that results from inflammation of the 7th cranial (or facial) nerve. Named after Charles Bell, a Scottish anatomist who first described the syndrome in 1812, it is the most common form of acute facial paralysis. The Palsy is usually one-sided and causes an inability to control the muscles on the affected side. Only 1% of cases occur bilaterally.

The paralysis occurs when the facial nerve, which travels through a narrow bony canal called the fallopian canal[i], becomes compressed, swollen, or inflamed. The nerve controls a wide range of functions, including blinking and closing the eyes, raising the eyebrows, smiling, and frowning. Further, the facial nerve carries nerve impulses to the lacrimal glands, the saliva glands, and the stapes in the ear. The facial nerve also transmits taste sensations from the tongue.

The disease usually has an acute onset, reaching its peak within 48 hours. It may be caused by exposure to a virus, such as herpes simplex, viral meningitis, or Epstein-Barr virus, or caused by bacteria such as Lyme disease. The infection can be acute or can be caused by dormant infections that become reactivated by trauma or environmental factors. Bells Palsy can also be the result of a brain tumor, skull fracture, diabetes, chronic otitis media, or hypertension.

Symptoms have a range of severity. [ii] Diagnosis is easily made by the patient’s facial appearance. Treatment in Western medicine depends on the cause of the paralysis, but corticosteroids are frequently prescribed to reduce the swelling and inflammation. Antibiotics are required for bacterial infections, such as Lyme disease. Anti-viral medications will be used if there is a herpes infection. The eye may be unable to close, and normal blinking is not possible; therefore, it is crucial to protect the eye with lubricating eye drops and eyeshades to prevent corneal damage and improve comfort.

The prognosis for recovery is mostly excellent. The extent of nerve damage determines the extent of recovery. Recovery times vary based on the degree of nerve damage. With or without treatment, most people begin to recover within two weeks after the initial onset of symptoms, and most will recover completely within 3 to 6 months.

According to Chinese medical theory, Bell’s Palsy is a condition caused by an attack of external wind pathogen to the ear and subsequent blockage of the collaterals. It is mainly characterized by a deviation of the eyes and mouth. In Western medicine, Bell’s Palsy is also known as a mononeuropathic paralysis, involving only one facial nerve, or Bell’s Pattern.

This condition is often caused by a deficiency of zhèng qi, empty and deficient collaterals, which allows for the invasion of wind pathogens, qi and blood blockage, and slow sinews. During the early stages, Bell’s Palsy is often due to an upward attack of wind-cold pathogens. The symptoms often present with facial collateral blockage. Treatment should focus on eliminating wind, resolving toxins, opening the channels, and correcting the deviation. In chronic cases or among elderly patients, the disease is often characterized by excessive symptoms concurrent with an underlying qi and blood deficiency, or an upward attack of deficient wind to the facial orifices. Treatment should focus on benefiting qi, invigorating the blood, transforming stasis, and opening the channels.

COMMON CLINICAL PATTERNS

• Wind evil blocking the collaterals
• Qi deficiency and blood stasis

CASE STUDY

Female, age 62. Initial Visit: July 27th, 2007.

Chief Complaint: Numbness in the left side of the face along with a deviation of the mouth for four days before treatment.

History: 4 days prior to Chinese medical treatment, the patient was hospitalized due to second-degree hypertension, along with dizziness and type II diabetes. The patient’s condition stabilized after being treated with medication. The patient noticed discomfort on the left side of her face four days later, upon waking up. She drooled while brushing her teeth and had difficulty closing her left eye. A CT scan of the head showed normal muscle tension.

Past History: The patient’s past medical history included diabetes with high lipids for 15 years. Despite oral intake of hypoglycemic medication, the blood sugar remained uncontrolled. The patient suffered from diabetic neuropathy for three years, including numbness and stabbing pain in the lower extremities when she was examined. Hypertension was present for seven years; despite oral administration of Amlodipine Besylate tablets, the patient’s blood pressure was still hard to control. BP reached 200/125mmHg at its highest level.

Physical Examination: Blood pressure: 190/116 mmHg, overweight, alert. Normal pupil size, the left frontal lines were shallow, an inability to close the left eyelid, disappearance of the left lip groove, an inability to close the left corner of the mouth when blowing, mouth deviation towards the right, normal motor and sensory function of the four extremities. The patient had a pale face, chest tightness, and shortness of breath, aggravated by exertion and discomfort at the anterior chamber of the heart. The tongue body was dusky with spots at the tip with a sticky, white coating. The pulse was thin, difficult, and weak.

• Laboratory Examination: Lipids: triglycerides 7.8mmol/L, cholesterol 12.6mmol/L, HDL 3.6mmol/L. Blood sugar: on an empty stomach 10.5mmol/L, after a meal 16.5mmol/L.
• Diagnostic Analysis

The patient was overweight with a healthy appearance, but her qi was weak. Spleen qi deficiency caused a failure of transportation, leading to dampness that further failed to transform and caused turbid phlegm stagnation within the body. External wind invading the collaterals disturbed internal phlegm, which traveled through the face causing stagnation in the channels. Qi and blood failed to nourish the channels, leading to facial discomfort on the affected side, with an inability to close the eye. The left side nasolabial fold was flattened. The eye and mouth deviated towards the healthy side. The chronic nature of the patient’s illness injured qi and blood. Qi leads blood; qi deficiency caused weak movement of blood. The channels, therefore, failed to receive nourishment from qi and blood, leading to the deviation of the mouth and eye and dull facial expression. The tongue body was dusky with spots at the tip and a white, sticky coating. The pulse was thin, choppy, and weak. Both are signs of blood stasis.

The location of the condition was the heart and spleen. It belongs to patterns of qi deficiency, blood stasis, and wind phlegm blocking the collaterals; this is a root deficiency with branch excess.

Diagnosis

WM Diagnosis: Bell’s Palsy

TCM Diagnosis: Bell’s Palsy due to qi deficiency, blood stasis, wind pathogen blocking the collaterals

Clinical Treatment

This condition belonged to the patterns of root deficiency and branch excess. The root etiologies were qi deficiency, blood stasis, and wind evil blocking the collaterals. Treatment should focus on benefiting qi, invigorating blood, eliminating wind, and transforming phlegm. Root and branch should be treated at the same time.

Treatment Principles: Benefit qi, invigorate blood, eliminate wind, and transform phlegm.

Formula: Modified Bŭ Yăng Huán Wŭ Tāng (Yang-Supplementing and Five-Returning Decoction) and Qiān Zhèng Săn Jiān Jiăn(Symmetry-Correcting Powder)

[补阳还五汤合牵正散加减]

生黄芪  shēng huáng qí  30g Radix Astragali

当归 dāng guī 15g Radix Angelicae Sinensis

赤芍 chì sháo 15g Radix Paeoniae Rubra

地龙 dì lóng 10g Pheretima

川芎 chuān xiōng 8g Rhizoma Chuanxiong

红花 hóng huā 6g Flos Carthami

桃仁 táo rén 10g Semen Persicae

丹参 dān shēn 30g Radix et Rhizoma Salviae Miltiorrhizae

白僵蚕  bái jiāng cán 15g Bombyx Batryticatus

白附子  bái fū zĭ 6g Rhizoma Typhonii

全蝎 quán xiè 10g Scorpio

甘草 gān căo 6g Radix et Rhizoma Glycyrrhizae

Formula Analysis

Shēng huáng qí tonifies and benefits the source qi. Its purpose is to boost qi and move blood, eliminate stasis, and open the channels.

Dāng guī, chì sháo, chuān xiōng, táo rén, hóng huā, and dān shēn invigorate blood, eliminate stasis and open the channels.

Dì lóng opens the channels throughout the body and improves the effectiveness of the medicinals.

Bái fū zĭ enters the yangming channels, circulates qi in the head and face, eliminates wind, and transforms phlegm in the head and face.

Bái jiāng cán and quán xiè transform phlegm and stop spasms.

Gān căo harmonizes the formula.

Acupuncture

Main Points: ST 4 (dì cāng), ST 6 (jiá chē) (both sides), SJ 17 (yī fēng), GB 20 (fēng chí), LI 4 (hé gŭ), ST 40 (fēng lŏng)

Supplementary Points: ST 36 (zú sān lĭ), SP 6 (sān yīn jiāo), LV 3 (tài chōng)

Method: Select 4 main points each time with 1-2 supplementary points. Treat once daily. 10 times constitute one course of treatment.

Techniques: Needle all points with even supplementation and drainage.

Moxibustion

ST 4 and ST 6 for 15-20 minutes each time, once daily. 10 sessions constitute one course of treatment.

Follow Up

A week after the treatment commenced, the patient’s blood pressure and blood sugar reached normal levels. The tightness in her chest and shortness of breath had greatly improved. The stabbing pain in the lower extremities had decreased; the left frontal lines re-appeared. The left eyelid was able to close but blinked slowly. The left nasolabial groove looked shallow. The left corner of the mouth was able to close while blowing; however, the mouth still deviated towards the right. The patient still suffered from constant dizziness, along with nausea. The tongue coating was slightly yellow and sticky. The pulse was wiry and slippery.

Through the above treatment, the symptoms of chest tightness and shortness of breath had greatly improved, indicating improvement of the root deficiency pattern. The branch manifestations are associated with damp-phlegm.

Treatment Principles: Dry dampness, benefit the spleen, transform phlegm and open the channels

Formula: Modified Bŭ Yăng Huán Wŭ Tāng (Yang-Supplementing and Five-Returning Decoction) and Qiān Zhèng Săn Jiān Jiăn(Symmetry-Correcting Powder)

[补阳还五汤合牵正散加减]

生黄芪  shēng huáng qí  30g Radix Astragali
当归 dāng guī 15g Radix Angelicae Sinensis
赤芍 chì sháo 15g Radix Paeoniae Rubra
地龙 dì lóng 15g Pheretima
川芎 chuān xiōng 8g Rhizoma Chuanxiong
红花 hóng huā 6g Flos Carthami
桃仁 táo rén 10g Semen Persicae
丹参 dān shēn 30g Radix et Rhizoma Salviae Miltiorrhizae
白僵蚕  bái jiāng cán 15g Bombyx Batryticatus
白附子  bái fū zĭ 6g Rhizoma Typhonii
全蝎 quán xiè 10g Scorpio
陈皮 chén pí 10g Pericarpium Citri Reticulatae
苍术 cāng zhú 10g Rhizoma Atractylodis
甘草 gān căo 6g Radix et Rhizoma Glycyrrhizae

Formula Analysis

Chén pí and cāng zhú dry dampness, transform phlegm, and strengthen the spleen.

Dì lóng’s dosage was increased to 15g to reinforce its function of transforming phlegm and opening the channels.

Two 2 weeks after the follow-up visit, the facial paralysis had recovered entirely, and the symptoms of dizziness had disappeared. Zhì shŏu wū (treated Radix Polygoni Multiflori) 20g was added to the original formula. The patient took another 14 packs of medicinals to consolidate the treatment result.

COMMENTARY AND DISCUSSION

In traditional Chinese medicine, Bell’s Palsy can be referred to in several interrelated ways. The first term is Zhēn Zhòng Fēng, or “true wind stroke,” to describe a pattern associated with externally contracted wind. [iii] Another is Lèi Zhòng Fēng, or “wind-like stroke,” which refers to a pattern of internal wind. Although Bell’s Palsy is not the same as a stroke, the symptoms and presentation are similar. Both patterns include deviation of the eyes and mouth, one-sided symptoms, difficulty speaking, and drooling. Obviously, Bell’s Palsy is not a cerebral vascular accident, and there will not be sudden clouding collapse (loss of consciousness). In chapter 5 of Essentials from the Golden Cabinet[iv], Zhang Zhong-jing discusses several manifestations of Zhòng Fēng: The overarching theory is that external evil wind invades and lodges in the body and is not discharged. He then differentiates the patterns according to the depth that the wind penetrates. The first, zhòng luò, wind-strike involving the collaterals, most closely matches the symptoms of Bell’s Palsy.

This chapter’s primary case describes at an attack of Bell’s Palsy in an older woman who suffers from chronic health issues: hypertension, hyperlipidemia, diabetes, and diabetic neuropathy. All of her conditions were under poor control. Her constitution reflects that of many patients who are encountered in clinical practice. That despite her large body, the physician makes a point that she is not strong.

When we diagnose and treat diseases of wind, no matter how robust a person may seem, wind tracks and enters the body where the body is most weakened. There will always be some aspect of surface deficiency. Most cases will present with mixed excess and deficient patterns. This case presents a complex mixture of qi deficiency, blood stasis, and wind phlegm obstructing the channels. Therefore, in addition to the treatment principles outlined above — benefitting qi, invigorating the blood and transforming phlegm—we can add in the principles of dispelling wind and unblocking the collaterals.

Bŭ Yăng Huán Wŭ Tāng is combined with Qiān Zhèng Săn Jiān Jiăn with only dān shēn added to harmonize the blood. The selection of dān shēn over other blood-harmonizing medicinals is likely because it is commonly used in formulas that treat cardiac disease. Dì lóng has dual functions in context as it opens the channels and is a vasodilator, which reduces blood pressure.

At the follow-up visit, the patient has improved. However, dizziness and nausea are now the predominant symptoms. Chén pí and cāng zhú are added to the formula to transform damp-phlegm and relieve nausea. What is not mentioned is the possibility that the nausea is a result of the formula; patients with spleen deficiency and dampness are predisposed towards adverse digestive reactions. The formula contains a large quantity of insects as well as 30 grams of shēng huáng qí, which, because of its upbearing nature, can exacerbate nausea. The dosage of dì lóng is also increased to enhance the formula’s channel-opening action.

The patient recovers and then takes the formula for another two weeks to consolidate the effect. Another 20 grams of zhì shŏu wū is added. This, presumably, is based on her western medical history as the medicinal lowers serum cholesterol levels.

[i] http://www.ninds.nih.gov/disorders/bells/detail_bells.htm

[ii]Page 646, Kasse, et al. (2003) Clinical data and prognosis in 1521 cases of Bell’s Palsy. International Congress Series (2003) Issue Vol.1240 Page no. 641-647 ISSN 05315131

[iii] Pg. 964, Bells Facial Paralysis, Clinic of Traditional Chinese Medicine, Vol. II, Practical English Chinese Library of Traditional Chinese Medicine. Shanghai College of Traditional Chinese Medicine, 1990.

[iv], Pg. 110, Yuk-ming Suk, Understanding the Jin Gui Yao Lue, A Practical Textbook, Peoples’ Medical Publishing House, 2008

About Cara Frank, L.OM.

• Cara Frank, L.OM., was raised in a health food store in Brooklyn, NY. When she was 8, she cartwheeled 5 miles from Greenwich Village through Soho and Chinatown and across the Brooklyn Bridge. For nearly 40 years, she has had the same crazy passion for Chinese medicine. At 17, she had her first acupuncture treatment. At 20, she enrolled in acupuncture school. In1998 she went to China to study where she fell deeply in love with herbs and has never recovered. 
• Cara is the founder of Six Fishes Healing Arts in Philadelphia, where she maintains a busy acupuncture practice. She is the president of China Herb Company, and she was the founding Academic Director of the Department of Chinese Herbology at the Won Institute of Graduate Studies. You can read her full bio or schedule an appointment.