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Efficacy of Diode GaAs (940 nm) in treating Facial Paralysis and Replacing Steroids: Case Report

George Isac Ezzat Yacoub

Misr University for Science and Technology – MUST’s Laser Center, in collaboration with Genoa University faculty of Dentistry.

George Isac Ezzat Yacoub,

BDS Misr University for Science and Technology, Egypt
Fellowship in Laser Dentistry from Genoa University.

Tel: +2 012 845 351 5
George.isac.jj@gmail.com

ABSTRACT

Low-Level Laser Therapy (LLLT) was used to accelerate and allow the recovery process for a 60-year-old male patient who suffers from severe Facial Paralysis on one side caused by an ear infection “Malignant Otitis”

The low-level laser source used was a gallium aluminum arsenide semiconductor diode laser device (940 nm).
The laser hand-piece used is tip-less and noncontact (defocusing). The duration of a laser session was between 16 to 20 minutes. Light was applied twice for 60 seconds per point on maximum number of 8 points, where the entire affected (left) side is irradiated. The whole duration of the treatment was only one month. No steroids were given to the patient. Vit B12 was prescribed as injection.

Results: The treatment resulted in improvement of facial movement and motor functions of the facial nerve and preventing further inflammation and deterioration to happen to the facial nerve because of the Malignant Otitis. 

Conclusions: LLLT has a prospering future in treating complicated cases of Facial Paralysis, but yet, it still has a long way of investigations to go.

KEY WORDS:  Diode Laser – Facial Paralysis – LLLT – PBM- Malignant Otitis Externa – Bell’s palsy.

CASE HISTORY

A 60-year-old male suffers from severe facial paralysis, asymmetry in the face and contraction of the muscles on the left side.
There was dropping of the eyebrow, incomplete closure and excessive tearing of the eye on the same side. There was difficulty in mastication because of accumulation of food on the paralyzed side. There was dripping of liquid during drinking; the patient described it as a line of liquid appears on the glass or his chin after drinking. There were also problems related to speech and phonetics. All the previous problems inhibited the patient to perform his professional and social life normally which had negative psychological impact on him. The patient had been on oxygen and physical therapy for two months, but without any significant result. A Nerve Conduction Test was made showing that the patient suffers from severe Bell’s palsy with bad prognosis and an expected longtime for recovery. Also, a clinical evaluation of the degree of severity of the facial paralysis on day 1 was evaluated as a House-Brackmann, Grade 5. The patient’s score at the Facial Disability Index was 53/200 (23.5%) and his score at the Yangihara 40-point scale was 9/40 at the first session.

MEDICAL HISTORY

The patient had been suffering from Malignant Otitis externa for 4 months prior the treatment, with pus loculation and suspected focal meningeal irritation with skull bone erosions, which is the main reason of the facial paralysis as it caused an inflammation in the 7th cranial nerve as well as the 6th cranial nerve. The patient had been on antibiotics for 4 months. Steroids were contraindicated as the patient is uncontrolled diabetic. Important to mention that the patient has a history of treated Bell’s Palsy 10 years ago.

LIGHT SOURCE AND IRRADIATION PROCEDURE

The patient was treated using laser therapy with the continuation of the physical therapy. Vitamin B12 injection was prescribed to help the support of healthy nerve function and red blood cell formation. To document the progress, the patient pictures were captured after each session. The low-level laser source used was a gallium aluminum arsenide semiconductor diode laser device (wavelength: 940 nm). The laser hand-piece used was tip-less (Gaussian mode), noncontact with focusing and defocusing technique. LLLT applied to the superficial roots of the facial nerve of the affected side [1] (Fig.1). In the 1st round, the average power was 1 watt for 60 seconds for each point, delivering 60 joules of energy. The 2nd round, the average power was 0.8 watt for 60 seconds for each point delivering another 48 joules of energy with a total of 108 joules per point. Except the point targeting the trunk of the facial nerve, I delivered another 1 watt for 60 seconds in the 2nd round as it is deeper in the fascia (nearly 20 mm deep). The laser beam was delivered in a continuous emission mode in indirect contact with the facial area.

This patient received a total of 9 sessions, only one session in the first week followed by two sessions per week till the end of the treatment. The length of the laser treatment session varied from 16 to 20 minutes. The total treatment time was 29 days. Each application includes points that target the superficial roots of the branches of the facial nerve. The laser treatment should not be applied close to the eyes without proper eye protection. During the laser therapy, it is recommended to use specific glasses goggles targeting the same wavelength of the used machine.

LLLT should be used within hours following the onset of BP. The earlier the irradiation is started, the faster and better are the results.

IMG_9118.PNG

Fig. 1 Points of laser application used in treatment of Bell’s Palsy (adapted from Bernal 1993)[1]

OUTCOME MEASURMENTS

Four measurements had been used to assess the progression of the recovery, starting with Nerve Conduction Test before the first session and after the last one. Also, The House-Brackmann System (HBS) was used to assess the nerve damage. The Facial Disability Index (FDI) was used to evaluate the physical and social functions. And at last, the Yanagihara 40-point Score was used to monitor the evolution of the facial expressions. Photographs were taken after every session, always using the same camera. Treatment was completed after a total number of 9 sessions with good –not complete- recovery. There were 2 sessions per week.

OUTCOME

An obvious improvement was noted during the course of the treatment: a marked development of the left facial muscle strength and a progressive attenuation of the facial asymmetry. After every session, the overall improvement of different facial expressions were rated and scored using the Yanagihara 40-point score. By the end of the treatment, Patient restored the ability to masticate with no accumulation of food on the affected side and with minimal Liquid dripping while drinking. Patient restored sensation on the 2/3 of the tongue. The Quality of speech increased. Complete Closure of the eye on the affected side. The Patient restored his ability to work and to practice his social life normally. The facial expressions of the patient had seen 42.5% improvement. Patient restored Physical and Social function by (46.5%).

First: Facial Disability Index (FDI): to assess the physical and social function of the patient:

The patient’s score was 26.5% in the first session and increased to 73% in the last session. (Fig. 2)

Second: Yanagihara 40-point Score: to assess facial expressions as (static, wrinkle forehead, blink, close eyes, close eyes strongly, wink, wrinkle nose, whistle, grin, protrude lip)
The patient;s score was 9/40 at the first session and increased to 26/40 in the last session. (Fig. 3-4)

Third: House-Brackmann Scale (HBS): to assess the degree of nerve damage.
The patient transitioned from Grade 5: Severe Dysfunction to Grade 3: Moderate Dysfunction.

The treatment had stopped according to the request of the patient and to focus on the treatment of the Malignant Otitis.

Follow-ups are made 1, 6 and 12 months after the end of treatment. The patient is still maintaining the progress achieved after treatment.

Fig. 2 Comparison between the patient’s FDI score in first and last session

Score in Last SessionScore in Sixth SessionScore in First Session                                            Movement
321Static
210Wrinkle Forehead
320Blink
321Close Eyes
431Close Eyes Strongly
444Wink
221Wrinkle Nose
321Whistle
220Grin (Smile Broadly)
330Protrude Lower Lip
29239Total

0: Complete Paralysis, 1: Severe Paralysis, 2: Moderate Paralysis, 3: Slight Paralysis, 4: Intact

Fig. 3-4 Improvement according to Yangahira 40-point Score

IMPORTANT REMARKS

It was discovered then that the Malignant Otitis that the patient suffers from had been treated with wrong antibiotic targeting the wrong bacteria and it wasn’t until after the laser treatment when the patient started to take the right medication and truly treating his infection. Keep in notice that, the patient’s paralysis got better despite of that. That increases support for the assumption that the LLLT can’t only treat severe cases of facial paralysis caused by the infection, it also prevents the spreading of the bacteria that causes more damage to the nerves, in cases –like this one- when the infection is not being treated during the LLLT and causes it to subside. Then we can consider using LLLT as a prophylactic treatment to prevent facial paralysis in cases related to Malignant Otitis or Ramsey-Hunt Syndrome, especially when steroids are contraindicated, as in diabetic patients, epilepsy, liver damage, recent heart attacks, and breast feeding ……. Etc

DISCUSSION

Generally, a treatment combination of physical therapy and LLLT can be more efficient than physical therapy alone and in shorter duration of time.

The field of LLLT should be broadened to include Facial paralysis treatment side by side with the physical therapy. A lot of features of bio-stimulation effects related to LLLT are urgently needed in cases related to nerves specifically.

Photobiomodulation has remarkable effect on nerves generally in cases of paresthesias [2]. LLLT’s objectives in cases related to neural regeneration and neuromuscular recovery can be mentioned in the ability of the light to change the chemical components in the cell into a form of energy. The bio-modulation effect of lasers helps the Mitochondria inside the cell to synthesis faster and more ATPs that work as fuel for living cells and main factor that increases the speed and efficiency of healing especially in tissues that show difficulty and longevity in healing as nerves [3][4]. Moreover, the photo-thermal effect of medical lasers which has decontamination effect reducing any pathogens and preventing the diffusion of more especially in case where the facial paralysis is related to an infection as in this case or cases like Ramsey-Hunt Syndrome [5].  Also, LLLT has effect on the muscles innervated with the damaged nerve to continue function normally [6]. Moreover, its ability to eliminate pain in such painful conditions [7]. Also, Studies showed that Photobiomodulation (PBM) can be alternative for steroids without the steroids’ side effects as an anti-inflammatory drug [8] [9]. In my opinion, LLLT will have a great role replacing steroids in facial paralysis caused by infection cases where steroids are contraindicated as in diabetes mellitus, such as this case. But further investigation is needed in that aspect.


REFRENCES

[1] Mohamed Alayat, Amir Abdel-Raouf Alfiky, Ahmed Mohamed Elsodany (2013)  Efficacy of high and low level laser therapy in the treatment of Bell’s palsy: A randomized double blind placebo-controlled trial.
https://www.researchgate.net/publication/236940120

[2] Robert A. Convissar: Principles and Practice of Laser Dentistry, Chapter 15: Photobiomodulation in Dentistry 263-264, 2010

 [3] Patrícia M. de Freitas and Alyne Simões, Lasers in Dentistry Guide for Clinical Practice, Chapter 4: Cellular Mechanism of Photobiomodulation, Signaling Pathways: Role of ATP 37-38, 2015

[4] Robert A. Convissar: Principles and Practice of Laser Dentistry, Chapter 15: Photobiomodulation in Dentistry, Mechanisms 251-252, 2010.

[5] Patrícia M. de Freitas and Alyne Simões, Lasers in Dentistry Guide for Clinical Practice, Chapter 29: Traditional Chinese Medicine and Laser Therapy 244, 2015

[6] Patrícia M. de Freitas and Alyne Simões, Lasers in Dentistry Guide for Clinical Practice, Chapter 38: Nerve Repair by Light 297-304, 2015

[7] Robert A. Convissar: Principles and Practice of Laser Dentistry, Chapter 15: Photobiomodulation in Dentistry, Stimulation/Inhibition 253 & Pain 263, 2010.

[8] Robert A. Convissar: Principles and Practice of Laser Dentistry, Chapter 15: Photobiomodulation in Dentistry, Inflammation 260-262, 2010.

[9] Patrícia M. de Freitas and Alyne Simões, Lasers in Dentistry Guide for Clinical Practice, Chapter 5: Low level laser therapy – mechanism of action: Inflammatory process 40-45, 2015.

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