In several countries the most common cause of death in young people is cancer. Patients with head and neck cancer often have complications after cancer treatment. Radiation therapy can cause oral trismus, which is related to high doses of radiation. Although acupuncture is reported to be effective and is widely used for the treatment of peripheral facial paralysis by promoting an improvement of motor functions, few reports in the literature demonstrate its effectiveness. We report a case in which the symptoms of a patient with facial paralysis after surgical cancer treatment associated with chemotherapy and radiotherapy improved after laser treatment at acupuncture points. Ten weekly sessions of laser therapy were conducted, using the Twin laser device, applied to systemic acupuncture points (LR3, LI4, LI18, LI19, LI20, SI17, SI19, ST4, ST6, ST7, GV20), together with 10 weekly sessions of auricular acupressure. Significant improvement of the trismus was seen, confirmed by the increase in mouth opening from 33.26 to 53.3 mm. The patient's family also noted reduced anxiety and hyperactivity. These results suggest that laser acupuncture and auricular acupressure for trismus and facial paralysis following cancer treatment is worth further investigation.
Statistics from Altmetric.com
Medulloblastoma is a type of cancer of the central nervous system which is considered the most common paediatric tumour.1 Treatment, consisting of surgery, chemotherapy and radiotherapy, improves the survival rates of children affected.2 Although radiotherapy is often used, it increases the risk of trismus as a complication.3 Acupuncture may result in significant relief of painful symptoms and improvement of motor functions.4 Thus, we report a case study of a boy with moderate facial palsy, trismus and anxiety, resulting from treatment of medulloblastoma, whose health was helped by laser acupuncture and auricular acupressure.
Description of patient
The patient, a boy aged 5 years and 9 months, attended for dental treatment at the Center for Training of Specialised Human Resources of Dental Services to Special Patients of the School of Dentistry of Ribeirão Preto, University of São Paulo (CAOPE—FORP/USP). This study was submitted and approved by the committee for ethics in research with human beings of the School of Dentistry of Ribeirão Preto, University of São Paulo (process No 165.589).
Presentation and history of presenting condition
The patient had undergone medulloblastoma oncological treatment 15 months before his dental appointment. The tumour, which was discovered at 2 years and 6 months of age, was located in the lower left cerebral lobe. Since then, the patient has been treated by the oncology service of the Clinical Hospital of Campinas, where he received surgical treatment at 2 years and 9 months and associated treatment with chemotherapy and radiotherapy. On presentation to us, the family reported that the patient had hyperactivity, anxiety, low concentration, learning difficulties, cognitive deficit and difficulties in speech, oral hygiene and mastication.
During the clinical evaluation, moderate facial palsy of the side affected by the tumour was seen, with loss of sensitivity in the face, difficulties in speech, laxity of the muscles of the face and trismus with mouth opening limited to 33.36 mm, which was documented with the aid of a digital calliper (Digimatic Caliper/code number 071-467B, Mitutoyo, Suzano, Brazil) (figure 1A–C). Measurements were performed with the fixed end resting on the base of the nose and the mobile end within the limit of the lower lip, and a photograph was taken (Cyber Shot DSC-717, Sony Corporation, Japan).
The patient complained of pain on the left side of the face, which might have been temporomandibular joint pain, but the panoramic radiography allowed us to verify that the patient did not have any detectable problem in the joints.
During intraoral dental examination, which was difficult to carry out owing to his limited mouth opening, it was found that the patient did not have caries and had a low risk of disease, so preventive treatment was recommended, which consisted of instructions for oral hygiene, dietary guidance, prophylaxis, topical fluoride application and application of sealants in the first permanent molars only.
Conservative dental treatment was undertaken since the patient was systemically healthy, although the oncologist indicated that a careful examination should be made if any surgical dental treatment was needed, because of the increased risk of osteoradionecrosis.
Laser acupuncture and auricular acupressure
The patient's low-level laser treatment started on 28 March 2011 in local and systemic points of acupuncture, without any other drug intervention, with a total of 10 sessions, given weekly. Periodic measurements of the mouth opening were recorded.
The dentist–acupuncturist conducted active laser acupuncture therapy. The low-level laser source used was a gallium aluminium arsenide semiconductor diode laser device (Twin-Laser; MmOptics Industry, São Carlos, SP, Brazil), which had the following specifications: wavelength 780 nm, output power 70 mW, beam spot size area 0.04 cm2 and aperture about 1 mm diameter. The time of irradiation was 60 s at each point, with an energy density of 105 J/cm2 per point, during each of the first 10 sessions. The acupuncture points used included the following three sets: (1) on the face—SI17, SI19, LI19, LI20, ST4, ST6 and ST7, (2) on the upper extremity—LI4, LI18 and GV20 and (3) on the lower extremity—LR3. The laser beam was delivered in a continuous emission mode in direct contact with the points. During the laser sessions, glasses for specific use were worn by the patient and by the professional, following the recommendations of the manufacturer.
Treatment with auricular acupressure, indicated from reports of the family about the child's anxious and hyperactive behaviour, was suggested as a complementary method, with the aim of treating the emotional problems of the patient. The treatment was carried out weekly, alternating the ears, stimulating the ear points by mustard seeds, stuck onto the ear with adhesive tape (Micropore, 3M do Brasil Ltda, Sumaré, São Paulo, Brazil). The proposed protocol for the treatment of anxiety was the stimulation of points Shenmen, SNV, Brainstem, ST, anxiety and tension.
Significant improvement was seen in the trismus, confirmed by measurement of mouth opening with a digital calliper. Initially, the mouth opening was 33.26 mm and at the end of 10 sessions the opening reached 53.34 mm (figure 2A,B), allowing completion of the dental sealant application. The patient was followed up for 24 months and mouth opening was maintained after low-level laser acupuncture. According to family reports, increasing the mouth opening led to improvement in speech and facilitated feeding and oral hygiene. We also noted an increase in the tonicity of the muscles of the face. Auricular acupressure also seems to have contributed to improvement of the patient's behaviour, since the family observed reduced hyperactivity and increased concentration on school activities.
Medulloblastoma is classified as a primitive tumour of neural ectoderm, originating from precursors of granular cells of the cerebellum.1 A recent study showed that among 1043 cases of central nervous system tumours in South India, a medulloblastoma was the second most common tumour, with a prevalence of 11.4%. The incidence of brain tumours was about 20%, most of them in boys and an average age of discovery of about 8 years.5
Owing to the extremely invasive treatment of medulloblastoma, many sequelae appear soon after treatment, such as facial paralysis, loss of hearing, mucositis, candidosis, radiation caries, osteoradionecrosis, necrosis of soft tissues, periodontal disease, trismus and xerostomia.1 ,6 In children in the first year of life, the treatment is particularly difficult owing to the high immaturity of the brain, increasing the risk of cognitive deficit.2 Our patient presented cognitive deficit, facial paralysis and trismus, resulting in feeding, speech and oral hygiene impairment, and also difficulties in school learning and even in socialising.
Trismus is defined as a tonic contraction of the muscles of mastication, resulting in limitation of mouth opening. Several methods have been used to define limitation of mouth opening to diagnose trismus.7 Some studies classify gradually into mild, moderate and severe,8 others define it as a limitation of mouth opening <20 mm9 or <40 mm.10 A clinical trial showed that about 50% of patients treated with chemotherapy and radiotherapy presented trismus, with mouth opening limited to <36 mm, and in eight patients to <20 mm.3 A mouth opening ≤35 mm should be considered as trismus in patients with head and neck cancer.7 Our patient had a mouth opening of 33.26 mm.
Radiotherapy increases the risk of trismus as a complication, since the high dose of radiation used causes damage to, and fibrosis of, the masticatory muscles, resulting in abnormal proliferation of fibroblasts.11 Trismus is directly associated with significant morbidity, with significant implications for the health3 ,11 and quality of life6 of patients, including reduced nutrition due to chewing deficiency, speech disorder and impaired oral hygiene.3 ,11 Patients with trismus have limitations on mastication and muscle tension, which occur in a more severe form (incidence 38%) after 6 months of treatment.12 The impairment of quality of life of our patient owing to trismus was illustrated by difficulties in speech, mastication and in oral hygiene. In addition, the initial visit for dental treatment was difficult owing to limitation of mouth opening.
During acupuncture's long history, the original techniques for stimulation of acupuncture points have been modified in line with technological developments. In addition to the use of needles, low-level laser therapy has been employed since 1970 to stimulate the acupuncture points.13 This method offers important additional opportunities for acupuncture, mainly for children and patients with special needs. Another modern development of acupuncture is auricular acupuncture or acupressure, which is based on the supposed existence of points in the ear, which are used for the diagnosis or treatment.14
Reports on the treatment of trismus with acupuncture are scarce. This study used appropriate points for the analgesic properties and facial musculature activity of the area. Irradiation of LR3 was performed because it is supposedly a ‘relaxation’ point, indicated to treat anger, irritability, anxiety, owing to energy contained within the upper part of the head/body that can cause psychological symptoms and headache.
The use of low-level laser therapy when applied at acupuncture points appears to exert equivalent effects to needle acupuncture. In our case, after low-level laser application at acupuncture points, a reduction in trismus was seen together with an increase in oral opening, improvement of muscular tone of the facial region, oral hygiene and speech, as well as facilitation of dental treatment. According to reports of the family, socialising and school learning also improved.
Auricular therapy, proposed by Dr Nogier, is based on the understanding that the ear represents a simulation of an inverted fetus. Each point corresponds to an organ of the human body.15 It is a quick technique, relatively easily applied, safe and minimally invasive, being well accepted by children. In our study, auricular therapy was performed with seeds and this led to satisfactory improvement, seen both clinically and by reduced hyperactivity and increased concentration at school.
Thus, application of laser acupuncture and auricular acupressure, as complementary therapies, might assist in the treatment of sequelae arising from treatment of medulloblastoma, such as trismus and facial paralysis. Reduced anxiety and hyperactivity were also seen, after the use of auricular acupressure by a dentist competent in the technique.
Contributors DCAF treated the patient; CPT and RG were the dentists–acupuncturists; DCAF, CPT, ADR and AMdQ obtained the references for the paper; DCAF, FWGP-S, ADR and AMdQ prepared the text.
Competing interests None.
Patient consent Obtained.
Ethics approval Committee for ethics in research with human beings of the School of Dentistry of Ribeirão Preto, University of São Paulo (process No 165.589).
Provenance and peer review Not commissioned; internally peer reviewed.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.