Hemifacial spasm (HFS) is a peripheral (neuromuscular) movement disorder subtype. It is characterized by short-lasting, involuntary twitching of facial muscles on one side of the face supplied by the ipsilateral facial nerve (seventh cranial nerve). It is always almost unilateral except for a few cases where bilateral involvement of facial muscles is seen [1]. HFS is a rare condition with an estimated prevalence of 14.5 per 100,000 women and 7.4 per 100,000 men, suggesting that females are twice more prone to HFS than males [2]. Facial nerve compression resulting from ectatic blood vessels in the posterior cranial fossa is the leading cause of primary HFS. Secondary HFS is mainly due to trauma, bell’s palsy, brainstem lesions, and mastoid ear infections [1]. The affected person suffers excessively and tends to socially withdraw even though the disorder does not have life-threatening consequences [3].

The peculiar feature of HFS is progressive, irregular, involuntary, clonic, or tonic movements of the muscles innervated by the facial nerve [3]. At its onset, involuntary spasms occur in the region of the orbicularis oculi muscle, which later extends gradually into other parts of the affected half [3]. In pronounced cases, the platysma muscle will also get involved, and symptoms persist during sleep in most patients. Diagnostic evaluation is based on the clinical features, electromyography (EMG), and MRI. Symptoms will persist throughout life and over time if untreated [3]. The intensity of the spasm, frequency of the spasm, and the area affected is often progressive. Treatment options include medical management, botulinum toxin injection, and microvascular decompression surgery, which have drawbacks like short-term success, repeated administration, and surgical procedure risks [3].

Ayurveda plays a pivotal role in treating neurological disorders. In Ayurveda, a disease termed Vartma sankocha, characterized by eyelids spasms due to the affliction of Vata dosha (one among the bio humor), is co-relatable to the initial stage of HFS [4]. Electro-acupuncture (EA) is gaining importance worldwide for its excellent effectiveness and advantages in treating a few neurological conditions like trigeminal neuralgia and facial paralysis [5]. Hence, we report this case which was treated with an integrative approach and showed an improvement in HFS and quality of life.

A female patient aged 57 years complained of brief, intermittent twitching in the right eye and contraction of the face’s right side for four years (Fig. 1). Four years ago, a sudden twitching of the right eyebrow continued for a week, gradually extending to the right lower lid. A couple of days later, she also noticed a deviation of the face towards the right side during the twitching spells. She consulted a neurologist and was diagnosed with HFS (code G51.31 in the International Classification of Diseases 10th Revision) and was prescribed Zeptol- 100 mg 0.5 tablet BID for two weeks. This involuntary twitching persisted even during sleep. Finding not much improvement, she was administered two sittings of botox injection within a gap of 1 year. She was symptom-free except for watering in the eyes post-botox injection. Since it was not cost-effective and she had to get it repeatedly injected every 3-6 months, she quit the treatment.

Figure 1. The hemifacial spasm of the patient.

Despite undergoing folk medicines followed by Ayurveda medications for the past year, she developed a brief, intermittent involuntary twitching on the right side of the face that involved the right eyebrow, cheeks, and lips. The complaint of twitching recurred two months ago in a much more severe form which aggravated even during sleep and led to sleep disturbance. This condition compelled her to approach integrative management (Table 1).

EA = electro-acupuncture; HFS = hemifacial spasm..

&md=tbl&idx=1' data-target="#file-modal"">Table 1

Depicting the timeline of events.

Time	Patient status
2017/01/14	Sudden twitching of the right eyebrow
2017/01/21	Twitching extended to the right lower eyelid
2017/01/28	Deviation of the face towards the right side during twitching spells
2017/01/29	Diagnosed with HFS and started with Zeptol 100 mg tablet 0.5 BID for two weeks
2017/07/15	First try of botox injection
2018/08/12	Second tri of botox injection
2019/09/15	Twitching symptoms commenced in a much more severe form. She took some folk medicines for six months, but found not much relief
2020/04/18	Symptoms of twitching persisted, and hence consulted an Ayurveda physician and underwent the medications for six months. Relief was found only during medication, and the symptoms recurred once the medication was discontinued
2020/10/26	The complaint of twitching recurred two months ago in a much more severe form which aggravated even during sleep and led to sleep disturbance
2021/01/15	She underwent integrative approach management with EA and Ayurveda

EA = electro-acupuncture; HFS = hemifacial spasm..

1. Clinical profile in the first visit

The patient was afebrile. The pulse was 72 beats/min. Her blood pressure was 130/80 mmHg. The functioning of the respiratory, circulatory, and digestive systems was normal. The score of HFS grading scale [6] was 9, and that of quality of life scale for HFS [7] was 20. Her brain magnetic resonance imaging showed no abnormal variations. Her random blood sugar level was 143 mg/dl. The Ayurveda therapeutic interventions, EA, and international medicine used in her are summarized in the Tables 2-4 [8-12]. Several different treatment modalities were provided over a total of 24 weeks (Fig. 2). The progress of treatment was evaluated on the HFS grading scale and quality of life scale for HFS at the first visit, 3 weeks, and 24 weeks, respectively.

Table 2

Ayurveda therapeutic intervention given to the patient.

Procedure	Description	Medicine and dose	Duration
Nasya	Therapy in which medicines mainly having the oil base are instilled in the nose in a comparatively higher dose	Ksheerabala Taila 101 avarti [8] - six ml in each nostril	21 days
Ksheera Dhooma [9]	The Vapour of the boiling milk was administered over the face after the Nasya treatment	Ksheera (~milk)	21 days
Pratimarsha Nasya	Kind of nasya therapy in which medicines mainly having the oil base are instilled in the nose in a lower dose	Ksheerabala 101 one ml in each nostril twice daily	Six months

Table 3

Description of acupuncture treatment performed to the patient.

Item	Detail
1. Acupuncture rationale	1a) Style of Acupuncture: Electro-acupuncture
	1b) literature sources: Relevance of Acupuncture [10].
2. Details of needling	2a) Number of needle insertions per subject per session: 9
	2b) Names of points used: GV20, GB14, EX-HN5, ST3, ST4, ST6, TE17, LI4, GB34- Unilateral (Right side)
	2c) Depth of insertion, based on a specified unit of measurement, or on a particular tissue level: 2-3 cm
	2d) Response sought: TE17, ST2, ST3, ST4- muscle twitch; Rest points: De qi
	2e) Needle stimulation: Electrostimulation with the frequency of 2 Hz with an intensity of ~1-2 mA
	2f) Needle retention time: 25 mins
	2g) Needle type (diameter, length, and manufacturer or material): Needle type: Filiform needles, 0.5 cun, 1 cun, 2 cun sized needles (cloud and dragon company)
3. Treatment regimen	3a) Number of treatment sessions: 3 sittings of 21 days course
	3b) Frequency and duration of treatment sessions: 2nd sitting was planned 30 days after the commencement of the first 3rd sitting was done six months after the first
4. Other components of treatment	Ayurveda treatment
5. Practitioner background	MD, President of the Indian Association of acupuncturists and have 22 years of acupuncture experiences
6. Control or comparator interventions	Not applicable

Table 4

Internal medication given to the patient.

Medicine	Duration	Dose
Ekangaveera rasa [11]	90 days	One tablet (250 mg) after food twice daily
Ksheerabala capsules [8]	90 days	One capsule after food twice daily
Rasona navaneetha (Garlic and butter) [12]	48 days	Three grams crushed with twelve grams of butter to be consumed on an empty stomach in the morning

Figure 2. Chronological figure showing the external and internal treatment modalities.

1. Outcome measures and follow up

After completing the first sitting of EA, Nasya, and oral medications, the patient was assessed for the HFS in terms of HFS grading and quality of life scale and was noted as 6 and 16, respectively. The subsequent follow-up was done after six months, wherein the HFS grading and quality of life scale were 4 and 10, respectively (Table 5). No adverse events were found throughout the treatment course and during follow-up. There were no issues with intervention adherence and tolerability for Ayurveda and EA, which were assessed by daily case-taking.

HFS = hemifacial spasm..

&md=tbl&idx=5' data-target="#file-modal"">Table 5

The treatment results of this case.

Diagnostic criteria	During the first visit	After three weeks	After 24 weeks
HFS grading scale	9	6	4
Quality of life scale for HFS	20	16	10

HFS = hemifacial spasm..

2. Patient perspective

I visited this hospital outpatients department in January 2021 for constant twitching on the left side of my face, which I have been suffering from for the past four years. I underwent various medications and therapies for these complaints but found little relief. I started feeling very low and avoided all public gatherings. The most distressing part was that I could not read or concentrate on my regular religious prayer/ Sloka reading nor talk freely with anyone. After my treatment course began in this hospital, I found drastic relief in my twitching. Within a month, the twitching spells reduced, and I could perform my routine prayer happily. Even though I did not have a complete cure for my symptoms, this treatment benefited me greatly in reducing the twitching compared to the previous therapies.

This case report suggests the positive effect of the integrative approach using Ayurveda and EA in managing HFS, which is evident in the improvement in the HFS grading scale and the quality of life scale for HFS. Since its etiology is unknown, it is difficult to state the exact mode of action of different therapeutic procedures including Nasya and internal medicines used. An article has correlated neural activity to Vata dosha function, and mainly the eyelid movement is attributed to a Vata subtype- Vyana Vata [13]. So HFS could be considered a Vyana Vata dysfunction which, as per ayurvedic treatment principles, has to be managed by Shamana measures (Vata pacifying measures) [14]. Hence various Vata pacifying measures were adopted in this case.

Among different pharmacological types of Nasya, Brimhana Nasya (Nasya with tissue nourishing effect) is mentioned explicitly in Akshi sankocha (HFS-like feature of twitching in eyes) and was thus selected [15]. The medicine Ksheerabala used for Nasya is Indriya Rasayana (nourishing the sense organs) [16]. It is also reported to be an effective remedy for neurological disorders [16]. Ksheerabala 101 is the potentiated form of this medicine, which contains Bala (S.cordifolia), Ksheera (cow’s milk), and Tila Taila (Sesamum oil) that making it a potent anti-inflammatory and antioxidant. Also, S. cordifolia is used in treating neurodegenerative disorders [14]. Ksheera dhooma pacifies Vata dosha causing motor afflictions in the face due to cranial nerve palsy [9]. Ekangaveera rasa is administered in Vata kaphaja [11] disorders, and here it helped in pacifying Vata dosha. Garlic as a neuroprotective is emerging as a recent health benefit. The three interrelated anti-atherogenic, antioxidant and anti-apoptotic properties are accredited for their neuroprotective action [17]. Acupuncture in HFS works by regulating humoral immunity and auto cell immunity and hence is believed that it may be an effective and safe treatment for HFS with no definitive conclusion [5]. This novel integrative approach was administered on the HFS patient based on the results derived from a case of post covid parosmia with a similar approach [18]. Hence this study gives way for further study on this approach in treating various disorders with lesser known side effects.

Supplementary data to this article can be found online at https://doi.org/10.51507/j.jams.2023.16.2.65

jams-16-2-65-supple.pdf

This study received no funding.

Akshatha K Bhat - Conceptualization, Methodology, Validation, writing original draft; Krishna Kumar - Conceptualization, Resources, Writing – Review & Editing; Jim Daniel Johnson - Conceptualization, Resources, Writing – Review & editing.

This research complied with the guidelines for human studies and was conducted ethically, following the World Medical Association Declaration of Helsinki. Written informed consent was obtained from the patient to publish this case report and any accompanying images.

All data generated or analyzed during this study are included in this article [and/or] its supplementary material files. Further enquiries can be directed to the corresponding author.

The authors declare no conflict of interest.