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Multimodal therapy including electroacupuncture for the treatment of facial

nerve paralysis in a horse

Article · January 2014

DOI: 10.1111/eve.12042

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EQUINE VETERINARY EDUCATION
Equine vet. Educ. (2013) •• (••) ••-••
doi: 10.1111/eve.12042
Case Report
Multimodal therapy including electroacupuncture for the treatment
of facial nerve paralysis in a horse
C. de Fourmestraux*, C. Tessier and G. Touzot-Jourde
Surgery Department, Equine Clinic, ONIRIS, Nantes-Atlantique, National College of Veterinary Medicine, Food
Science and Engineering, Nantes, France.
*Corresponding author email: claire.de-fourmestraux@oniris-nantes.fr
Keywords: horse; anaesthesia; facial nerve paralysis; electrostimulation
Summary
This Case Report describes a 5-year-old Standardbred gelding
that was referred to the Equine Hospital of ONIRIS Veterinary
School of Nantes, France for a surgical procedure under
general anaesthesia. Anaesthesia was induced and
maintained intravenously and the horse was placed in left
lateral recumbency with a padded halter. On post operative
Day 1, a post anaesthetic distal facial nerve branch paresis
was diagnosed based on clinical signs. The horse was
discharged on post operative Day 2 with medical treatment
based on anti-inflammatory drug administration locally and
systemically. The horse was re-examined 2 weeks after the
surgery; the left partial facial paralysis was still present and
associated with amyotrophy of the muscles supplied by the
buccal branches of the facial nerve. In accordance with the
owner, the horse was hospitalised to start an electrostimulation
treatment. The horse was treated every day for the first 4 days,
then every 2 or 3 days during the following 3 weeks, for a total
of 11 sessions. At the end of the second week of treatment,
the horse was able to normally prehend the food and
atrophy seemed reduced. The horse was discharged from
hospitalisation at the end of the third week of treatment with
specific recommendations. One month after discharge from
the hospital just a slight asymmetry could be noticed at rest. Six
months later, the training season began and the horse was
able to perform. Facial paralysis due to nerve compression is a
well-known complication of anaesthesia. Gradual recovery of
function over the weeks of treatment suggests that
electroacupuncture may promote recovery and may hasten
time of recovery.
Introduction
Facial nerve paralysis has been identified in several domestic
species (DeLahunta and Glass 2009). The most common cause
in horses is a facial nerve traumatic injury, which can be a
consequence of direct trauma to the nerve or a result of local
inflammatory changes involving the nerve (Sumano et al.
1997; Rose and Hodgson 2000). It may improve over days,
weeks or months without treatment, but can also persist for
months to years and lead to inability to perform (Jeong et al.
2001; Smith and George 2009). In man, there is some evidence
to support acupuncture as a treatment for facial paralysis
(Dong and Xie 2002; Mayor 2007). Electroacupuncture has
been regarded as a therapeutic option for various muscular
and neurological conditions and may also be able to facilitate
the treatment of facial paralysis in horses (Sumano et al. 1997;
Fleming 2001; Kim and Xie 2009). Electroacupuncture elevates
neurotrophic factors such as neurotrophine 3 (NT-3) and level
1
of cyclic adenosine monophosphate in injured spinal cord
tissue (Ding et al. 2009). Neurotrophine 3 plays an important
role in nervous system development, neuronal survival and
differentiation, and neural repair. Elevated NT-3 expression can
improve the microenvironment of injured spinal cord (Yan
et al. 2011). In addition, a previous study reported that
electroacupuncture treatment can prevent the formation of a
glial scar after spinal cord injury (Yang et al. 2005). More
interestingly, regarding functional peripheral nerve
regeneration it has been shown that electroacupuncture
exerts a positive influence on motor recovery and reduced
pain related behaviour in mice after sciatic nerve crush injury
(Hoang et al. 2012). This clinical case reports the use of
electrostimulation in the treatment of traumatic partial facial
nerve palsy following a surgery under general anaesthesia in a
horse.
Case history
A 5-year-old Standardbred gelding was referred for surgical
release of an epiglottic fold entrapment to the Equine Hospital
of ONIRIS Veterinary School of Nantes, France. The surgery was
performed under general anaesthesia with the horse placed
in left lateral recumbency in a padded recovery box.
Anaesthesia was induced intravenously with diazepam
(Valium)1 at 0.05 mg/kg bwt and ketamine (Imalgene)2
at 2.2 mg/kg bwt after a romifidine premedication (Sedivet)3,
at 0.08 mg/kg bwt and maintained by administration of
a triple drip (guaifenesin 5%, ketamine 1 g/l, romifidine
0.05 g/l). The surgical site was accessed by the oral cavity and
the procedure was performed under endoscopic guidance.
No intraoperative complications were encountered. The
procedure lasted 18 min and the total recumbency duration
lasted 60 min. During the procedure, a padded halter was
kept on the horse in order to mobilise the head easily and was
left during recovery.
Clinical findings and diagnosis
On post operative Day 1, the horse presented a marked
muzzle deviation towards the right side, the left nostril was
collapsed and sagging inwards during inspiration. The lower lip
on the left side hung loosely from its attachment and the horse
had difficulty prehending food. The left eyelid and the left ear
did not show any weakness. Additionally, swelling was present
on the left lateral aspect of the masseter at the level of the
facial nerve buccal branches. A traumatic distal facial nerve
branch paresis was diagnosed based on clinical signs (Fig 1).
The initial treatment was comprised of a single i.v.
administration of dexamethasone (Dexadreson)4 at 0.1 mg/kg
© 2013 EVJ Ltd
2 Facial nerve paralysis and electrostimulation

a) b)

Fig 1a) and b): The horse with distal facial nerve palsy associated with a marked muzzle deviation towards the right side and the lower lip
on the left side hung loosely.

Facial nerve
Dorsal buccal
branch
Ventral buccal
branch

3
1 Zygomaticus
Levator
nasolabialis
Levator 5
labii 4
7 Buccinator
superioris
Caninus
6 Depressor labii
2 inferioris
Orbicularis
oris

Fig 2: Superficial structures of the head; the course of the facial nerve and muscles supplied by its buccal branches.

bwt and local application twice a day of a topical gel
containing dimethyl sulfoxide and prednisolone. The horse
was discharged on post operative Day 2. The owner was
instructed to administer a 5-day course of phenylbutazone
(Equipalazone)4 at 2.2 mg/kg bwt per os s.i.d., to rest the horse
for 2 weeks (1 week of box rest and 1 week in the paddock),
and to return for follow-up.
The horse was re-examined 2 weeks after the surgery for a
post operative evaluation of the upper airway and the facial
paralysis. The left partial facial paralysis was still present and a

© 2013 EVJ Ltd

C. de Fourmestraux et al.
Fig 3: The electroacupuncture unit, IC-1107+.
discrete amyotrophy of the muscles supplied by the buccal
branches of the facial nerve (levator nasolabialis, orbicularis
oris, levator labii superioris, caninus, depressor labii inferioris,
buccinator, zygomaticus) was noted by comparative
palpation of the muscles on both sides of the face (Fig 2). Food
impaction in the left cheek and drooling on the left side of the
lips had worsened. Cranial nerve testing did not reveal any
additional abnormalities apart from the left distal facial nerve.
Muscle tone and movements of the left eyelid and the left ear
were deemed normal. Endoscopic examination of the upper
airway including the left guttural pouch did not show any
abnormality and confirmed the resolution of the epiglottic
entrapment with normal healing at the surgical site.
Treatment
Due to a lack of spontaneous recovery of the paresis and the
identification of muscle atrophy, the horse was hospitalised to
start an electrostimulation treatment.
The acupuncture points were selected in accordance to
veterinary literature and adapted to the course of the facial
nerve on this horse (Fleming 2001; Jeong et al. 2001; Mayor
2007). The electroacupuncture unit used was an IC-1107+5
(Fig 3) that has 3 output channels device, an adjustable
frequency 0–500 Hz, an asymmetric biphasic pulse shape with
a phase duration of 100 ms on low voltage (0–10 V) and a low
current amplitude (0–20 mA). Needles (Serein 0.25 ¥ 40 mm)6
used were single-use, sterile, silicon coated individually
packaged acupuncture needles. They were inserted just
under the skin or directly into the muscle. Needles were
3
attached by lead clip to the electroacupuncture unit. The
thinness of the skin facilitated the palpation of the buccal
branches. For the first 3 sessions, the acupoints TH17, ST4, 6 and
7 were used bilaterally (Table 1). Extra needles were inserted
subcutaneously along the dorsal and the ventral buccal
branches on the left side and intramuscular needles were
inserted in the levator labii superioris, the caninus and the
depressor labii inferioris muscles (Fig 4). In the following
sessions, TH17 and ST7 were treated bilaterally. Two or 3 points
along each buccal branch were selected on only the left side.
Three leads were used for the electrostimulation (ITO ES-130):
one lead on each facial buccal branch and one lead in the
muscle (alternating every 5 min between the caninus,
orbicularis, levator labii superioris and depressor labii inferioris
muscles), for the first 3 treatments. Once nerve conduction
had fully returned (Treatment 4), stimulation of each buccal
branch was used to elicit muscle contractions of the nostril,
upper and lower lips (Fig 4). Electrostimulation lasted 20 min
with alternating frequencies every 5 min between 5 and
200 Hz with a low current intensity. A frequency of 1.5 Hz was
used for repeated muscle contractions for periods of 2–3 min 3
times during the treatment. Each treatment from the fourth
session onward included a few short provoked tetanic
contractions (1–2 s, <10 in a row) of the nostril-upper lip and the
lower lip by stimulation of each branch. Needle insertion
was always very well tolerated as well as low intensity
electrostimulation. Induced tetanic contractions elicited a
large head movement during the first applications but slowly
increasing the intensity of stimulation resolved the initially
observed discomfort. The horse was treated every day for the
first 4 days, then every 2 or 3 days during the following 3 weeks,
for a total of 11 sessions. During the second week, physical
therapy was used in conjunction with the acupuncture
therapy; presenting hay to the left side of the mouth at least 3
times a day to stimulate active mobilisation of the left side of
the lips for 10 min and daily grazing in the paddock facilitated
mobilisation of the affected muscle (Table 2).
Outcome
After the 4 first treatments, the horse exhibited an improved
ability to drink and feed with less cheek impaction and
reduced drooling at the left commissure. Weak spontaneous
movements of the upper lip were noticed at the end of the first
week and facial asymmetry diminished progressively over the
3-week course of treatment. At the end of the second week of
treatment, the horse was able to normally prehend the food
with his left side of the lips. Atrophy seemed reduced and the
food impaction had disappeared. The horse was discharged
from hospitalisation at the end of the third week with
instruction to keep promoting food prehension on the left side
of his lips twice daily for one month. One month after
discharge from the hospital, a slight asymmetry could be
noticed at rest but disappeared while the horse was mobilising
his lips. The horse’s training season began 6 months after the
treatment and no exercise intolerance was observed.
Furthermore, the left nostril appeared to dilate normally at
exercise.
Discussion
In horses, traumatic facial paralysis is a well-known
complication of abnormal pressure applied to the face over
the track of the facial nerve. Predisposing factors include
© 2013 EVJ Ltd
4 Facial nerve paralysis and electrostimulation

TABLE 1: Description of acupuncture points used

Point, Chinese name Meridian Location area

ST4, Di Cang Stomach meridian Caudal to the corner of the mouth, at the ‘V’ junction of the levator nasolabialis
m. and zygomaticus m., on the outer margin of the orbicularis muscle.
ST6, Jiache Stomach meridian In the centre of the masseter muscle belly, just dorsal to the ventrolateral aspect
of the jaw. Located in a depression when the jaw is opened (where the ring
halter is).
ST7, Xia Guan Stomach meridian At the temporo-mandibular joint, ventral to the zygomatic arch, caudodorsal to
the lateral canthus, in the masseter m.
TH17, Yi Feng Triple heater Posterior to the ear in depression between the mandible and mastoid process.

developed in this horse and was probably a result of keeping

TH17
ST7
ST6
ST4
Fig 4: Electroacupuncture treatment of a horse with left distal facial
paralysis and localisation of the acupuncture points used in the
treatment.
anatomic features in the horse, such as the nerve passing
over prominent facial bony structures (rim of the ramus
mandibulae, supraorbital ridge) and nerve location in thin
subcutaneous tissue as well as prolonged periods of complete
lateral recumbency on hard surfaces or wearing a halter with
large buckles and thick leather or fabric (DeLahunta and Glass
2009; Smith and George 2009). Despite padding precautions
and a short duration of recumbency, facial paralysis
a large, thick and insufficiently padded halter on the head.
The World Health Organisation has included Bell’s palsy in
its list of diseases for which acupuncture therapy is indicated
and a wide variety of human facial paralyses are commonly
treated by acupuncture and electroacupuncture (Dong and
Xie 2002; Mayor 2007). Point selection based on traditional
acupoints has been shown to be more effective when it is
adapted to the anatomical distribution of the facial nerve
branches and anatomical location of muscles targeted for
stimulation (Fleming 2001; Jeong et al. 2001; Mayor 2007). In
the treatment of various problems including paralysis,
electroacupuncture, as compared to simple needling, has
been shown to allow for more rapid, more intense and longer
lasting results (Mayor 2007). While experimental data have
supported the benefit of electrical nerve stimulation for axonal
regeneration following nerve trauma (Shi et al. 2000), direct
stimulation of denervated muscles has been a subject of
controversy. Excessive stimulation and movement of muscles
with reduced circulation is thought to increase fibrosis and
delay nerve regrowth and reconnection to muscles (Mayor
2007). However, electrical stimulation by its beneficial effects
on microcirculation and inflammation can improve tissue
nourishment and healing as well as delay atrophy and fibrosis.
Selection of electrical parameters based on intrinsic firing
characteristics of motor units themselves like in trophic
electrical stimulation (low frequencies and amplitudes)
appears to be less fatiguing and more able to maintain muscle
tone by altering metabolism rather than muscle fibre training
(Mayor 2007). Low frequency and low intensity stimulation for
short periods of time were therefore initially used to obtain
weak contractions of atrophied muscle in this horse. Once
nerve conduction had been regained, alternating high and
low frequency stimulation at low amplitude was used as it has
been shown to be more efficacious than a continuous
stimulation at a set frequency (Mayor 2007). This constitutes a
difference with the stimulation mode used by Sumano in his 12
clinical cases.
When the injury is mild, clinical signs often disappear in a
few days/weeks and it is thought that no nerve degeneration
occurs, only interruption of nerve conduction (neuropraxia).
The myelin sheath is temporarily damaged causing a focal
demyelination and a partial denervation of the muscles, which
can still be excited by stimulation of the motor nerve (Mayor
2007). If the lesion is more severe (neurotmesis), a complete
denervation leads to muscle degeneration and fibrosis starting
within 1–2 weeks of the nerve injury and is completed in about
3 years. In this sort of clinical case, the muscle fibres need to be
directly stimulated to contract. The severity of the lesion was
not clearly established; however, absence of spontaneous

© 2013 EVJ Ltd

C. de Fourmestraux et al. 5

TABLE 2: Therapeutic table

Type of Day after

treatment surgery Detailed description

Medical D1 Dexamethasone (Dexadreson, i.v.)4 at 0.1 mg/kg bwt, s.i.d.

D1–D5 Topical gel (dimethyl sulfoxide, prednisolone), b.i.d.
Phenylbutazone (Equipalazone)4 2.2 mg/kg bwt per os, s.i.d.
Acupuncture D16, D17, D18 Acupoints Extra needles Leads Mode and frequency
First week Bilaterally Left side Left side Treatment duration: 20 min
TH17, ST4, ST6, ST7 Subcutaneously One lead on needles placed Alternating every 5 min
Along the dorsal and the along left dorsal branch (5–200 Hz)
ventral buccal branches One lead on needles placed
Intramuscular needles along left ventral branch
(Levator labii superioris, One lead on intramuscular
caninus, depressor labii needles (levator labii
inferioris) superioris, caninus)
Second and D19, D21, D23, D25, TH17 and ST7 Along the dorsal and the One lead on needles placed Alternating every 5 min
third week D28, D31, D34, D37 ventral buccal branches along left dorsal branch (5–200 Hz)
with the proximal needle One lead on needles placed Low current intensity
just caudally to the origin of along left ventral branch 1.5 Hz for repeated muscle
the branches and the distal contractions for periods of
needle proximal to the 2–3 min, 3 times during the
rostral border of the treatment
masseter
Physical D23 to the end Hay presentation by hand of the left side to stimulate mobilisation of the affected muscles for 10 min, t.i.d. and
therapy all day grazing.

recovery and muscle atrophy seems to be in favour of
neurotmesis. Rapid recovery of nerve conduction as identified
by muscle contraction elicited by stimulation of the nerve on
the third treatment probably indicates a less severe lesion than
initially assessed. Electroacupuncture treatment is believed to
have been beneficial in this case as observed by the recovery
and improvement of clinical signs over time. No improvement
was seen during the first 2 weeks with the initial medical
treatment and facial muscle atrophy had begun. Gradual
recovery of function over the 3-week electroacupuncture
course suggests that it is a favourable treatment. Sumano et al.
(1997) reported successful outcomes with a similar treatment
course: first stimulation within the 10 days (2 weeks for this case)
following paralysis onset with a mean of 13 (7–17) treatments
done every other day over a course of 3–4 weeks (11 sessions
over 3 weeks for the present case). Progressive improvements
were seen over the course of the treatment and very visible
after the first or second treatment as in the present
case. Although the factors involved in the decision of
treatment termination are not clearly stated, owner
satisfaction seemed to have played an important role.
of the treatment was the most efficacious, although the
treatment success was assumed to be due to the combined
therapy (electroacupuncture and physical therapy) after
initial medical treatment failed. Finally, it is important to keep in
mind that facial paralysis might occur even after a short lateral
recumbency and halters should be always removed when
possible. Discussion about appropriate positioning and
padding to avoid nerve lesion is the primary way to avoid
facial paralysis in horses undergoing general anaesthesia.
Authors’ declaration of interests
No conflicts of interest have been declared.
Manufacturers’ addresses
1Roche, Boulogne-Billancourt, France.
2Merial, Lyon, France.
3Boehringer Ingelheim, Paris, France.
4MSD, Courbevoie, France.
5ITO, Tokyo, Japan.
6Seirin Corporation, Shizuoka, Japan.

Follow-up at 6 months showed no recurrence of clinical signs in

both case reports. Rehabilitation exercises were added to the
electroacupuncture for the present case during the second
week of treatment and likely also played a role in recovery.
Human and experimental data show that there are
advantages in combining electrotherapy and physiotherapy
(Angelov et al. 2007; Mayor 2007).
References
Angelov, D.N., Ceynowa, M., Guntinas-Lichius, O., Streppel, M.,
Grosheva, M., Kiryakova, S.I., Skouras, E., Maegele, M., Irintchev, A.,
Neiss, W.F., Sinis, N., Alvanou, A. and Dunlop, S. (2007) Mechanical
stimulation of paralyzed vibrissal muscles following facial nerve injury
in adult rat promotes full recovery of whisking. Neurobiol. Dis. 26,
229-242.

Conclusions
Distal facial paralysis in the horse as described in the present
case affects food prehension ability and nostril dilation. It can
result in dysphagia and inability to perform. Spontaneous
recovery can be long and incomplete, jeopardising
an athletic career. The use of electrotherapy seems
advantageous in promoting recovery and may hasten time of
recovery. However, as the amount of nerve injury was not
assessed before treatment and a multimodal therapeutic
approach was used, it is not possible to determine which part
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