Case History: Acute Sinusitis

Case History: Acute Sinusitis

By Cara Frank, L.OM.

The following is an excerpt of a chapter from my upcoming book on EENT Case Histories from China.

Nasosinusitis is an acute condition resulting from a bacterial, viral or fungal sinus infection. The term acute nasosinusitis is used frequently in Chinese medical literature. In the West, the condition is commonly referred to as acute sinusitis, or acute sinus infection.

Colds, allergies, polyps and a deviated nasal septum can predispose one to sinusitis. It is characterized by nasal discharge, sinus congestion and headaches. Sinusitis is acute when the symptoms are less than 4 weeks old. Subacute infections have lasted from 4-12 weeks and chronic sinusitis refers to infections that have endured for more than 3 months[i]. Factors that increase the likelihood of developing sinusitis include smoking, swollen adenoids, attending day care, sinus allergies, cystic fibrosis and compromised immunity.

In TCM, this acute condition is usually caused by external wind-heat or external wind-cold that transforms into heat. Pathogenic heat congested inside the body injures the lungs, stomach, liver and gallbladder. It belongs to the patterns of wind-fire and excessive heat.

COMMON CLINICAL PATTERNS

    ·Wind-heat in lung channel

    ·Excessive heat in lungs and stomach

    ·Liver and gallbladder fire

CASE STUDY

Male, age 44.

Chief Complaints: Nasal congestion and discharge with pain in the forehead and cheeks for 7 days.

History: the patient contracted a cold 10 days prior to treatment. The patient was treated with antibiotics with no result. the symptoms were not resolved and were accompanied by pain in the forehead and cheeks. Afraid of the nasal puncture procedure of western medicine, the patient came to the TCM clinic.

Signs and Symptoms: Constant nasal congestion with yellow and foul smelling nasal discharge, pain in the forehead and cheeks, along with a dry mouth and slight thirst and a poor appetite. The tongue body was red with a sticky yellow coating. the pulse was slippery and rapid.

Physical Examination: Thick, sticky and yellow nasal discharge was observed. The symptoms were worse on the left side with red and swollen nasal membranes. The lower left eye socket had distending pain in the superior maxillary sinus.

Diagnostic Analysis

As the orifice of the lungs, the nose belongs to the yangming channel, which governs the stomach. Based on the symptoms and the examination, this condition is a pattern of excessive heat. Heat in the lungs and stomach with congested fluid combines with a heat pathogen, resulting in nasal congestion with a profuse yellow discharge. Internal congestion of excessive heat, along with qi and blood stagnation, block the yangming channels to cause frontal headaches. Congested turbid nasal discharge belongs to the pattern of damp-heat with injury to the spleen and stomach, which results in a dry mouth and poor appetite. The tongue and pulse reflect the pattern of damp-heat congestion.

The location of this condition was the nose and its etiology concerns the lungs and stomach. It was a pattern of excessive heat in the lungs and stomach, a pattern of excess.

Diagnosis

WM Diagnosis: Acute nasosinusitis

TCM Diagnosis: Acute nasosinusitis due to lung and stomach excessive heat

Clinical Treatment

Acute nasosinusitis is a pattern of excessive heat in the lungs and stomach. In this case, both the root and surface show patterns of excess. The root treatment strategy should focus on clearing and sedating the lungs and stomach, while resolving toxins and eliminating the sinus infection should be the surface treatment. The condition will recover once the pathogen is eliminated and the right qi is consolidated.

Treatment Principles: Clear and sedate the lungs and stomach, resolve toxins and eliminate the infection.

Formula: Modified Shēng Má Jiĕ Dú Tāng (Rhizoma Cimicifugae Toxin-Relieving Decoction)

[升麻解毒汤加味]

升麻

shēng má

6g

Rhizoma Cimicifugae

葛根

gĕ gēn

15g

Radix Puerariae Lobatae

赤芍

chì sháo

12g

Radix Paeoniae Rubra

黄芩

huáng qín

12g

Radix Scutellariae

鱼腥草

yú xīng căo

12g

Herba Houttuyniae

生甘草

shēng gān căo

6g

Radix et Rhizoma Glycyrrhizae

蒲公英

pŭ gōng yīng

20g

Herba Taraxaci

桔梗

jié gĕng

10g

Radix Platycodonis

白芷

băi zhĭ

10g

Radix Angelicae Dahuricae

苍耳子

cāng ér zĭ

10g

Fructus Xanthii

辛夷花

xīn yí huā

10g

Flos Magnoliae

藿香

huò xiāng

10g

Herba Agastachis

 <strong></strong></p><p>
 <strong>Formula Analysis</strong></p><p>
 <em>Shēng Má Gĕ Gēn Tāng </em>(ModifiedRhizoma Cimicifugae Toxin-Relieving Decoction) clears heat toxins in the <em>yangming</em> stomach channel.</p><p>
 <em>Huáng qín, yú xīng căo </em>and <em>pŭ gōng yīng </em>clear and resolve heat toxin in the lung channel.</p><p>
 <em>Huò xiāng </em>combines with <em>bái zh</em><em>ĭ</em><em>, cāng ér zi </em>and <em>xīn yí huā</em> to transform turbidity and unblock the nasal orifice.</p><p>
 <em>Jié gĕng </em>raises the qi and eliminates infection.</p><p>
 <strong>External Therapy</strong></p><p>
 1% Ephedrine-based nasal drops, 1 drop, 3-5 times per day.</p><p>
 50% Herba Houttuyniae nasal drops, 2 drops, 3-5 times per day.</p><p>
 <strong><u><o></o></u></strong></p><p>
 <strong>Follow Up</strong></p><p>
 After 5 packs of the formula, the headache was gone. The white sticky nasal discharge was reduced and nasal congestion on the left was intermittent. Examination revealed bilateral middle nasal passage (-) and pink nasal membrane with no pain at the superior maxillary sinus. The tongue body was pink with a white sticky coating. The pulse was surging and slow.</p><p>
 The acute symptoms of the infection had subsided, but the heat was not fully resolved. There were also signs of qi deficiency. The current treatment should focus on benefiting qi and supporting the right qi by removing the heat-clearing medicinals. <em>Pŭ gōng yīng, gĕ gēn </em>and <em>huáng qín </em>were omitted,and <em>fú líng </em>(Poria) 10g, <em>dăng shēn </em>(Radix Codonopsis) 10g and <em>bàn xià </em>(Rhizoma Pinelliae) 10g were added to supplement the qi and resolve phlegm. All symptoms were resolved after another 5 packs of the formula.</p><p>
 The external therapy was unchanged but the dosage of the nasal drops was reduced to 2-3 times per day.</p><p>
 <strong>COMMENTARY AND DISCUSSION </strong></p><ul>

The chief case in this chapter presents a patient with Jí Xìng Bí Yuān,Acute Nasosinusitis. The pattern differentiation for this case is straightforward. Based on their location, many sinus diseases manifest with patterns of lung and stomach congested heat. The second most common pattern is liver and gallbladder fire a pattern of heat and excess. Both patterns present similarly, however, the chief difference between them is that in the case of liver and gallbladder excess, there will also be symptoms such as irritability and eye redness. According to the author of this chapter, wind-heat in the lung channel is rarely encountered in clinical practice as a causative factor in Bí Yuān,Deep Source Nasal Congestion.

For the treatment of sinus congestion due to lungs and stomach congested heat, most Chinese literature will suggest formulas such as Cāng Ér Zĭ Săn, (Fructus Xanthii Powder) or Xīn Yí Săn (Magnolia Flower Powder) modified with medicinals such as huáng qín (Radix Scutellariae), gé gēn (Radix Puerariae Lobatae), lián qiào (Fructus Forsythiae) and chì sháo (Radix Paeoniae Rubra). Thus, the author’s selection of modified Shēng Má Jiĕ Dú Tāng (Rhizoma Cimicifugae Toxin-Relieving Decoction) is surprising, reflecting a kind of “off-label” application of a classical formula. A careful analysis of the formula will show that, in fact, its selection is spot-on.

The formula is a modification of Shēng Má Gé Gēn Tāng (Cimicifuga and Pueraria Decoction), the classic formula for releasing the muscle layer and venting measles. The ingredients of the formula are shēng má, gĕ gēn, chì sháo and zhì gān căo (Radix et Rhizoma Glycyrrhizae Praeparata cum Melle). Within the formula, shēng má and gĕ gēn both enter the yangming channels raising the clear yang of the stomach. Together they release surface heat. Thus, the formula treats the Bing disease, which is lung and stomach congested heat. Furthermore, the formula acts as an envoy, directing the formula to the sinuses. In keeping with the idea of venting measles and rashes, the sinus infection can be thought of as presenting a kind of surface toxin. Shēng Má Gé Gēn Tāng uses zhì gān căo; however, the use of shēng gān căo in this practitioner’s formula is deliberate. It harmonizes the formula, yet its role is broader. It is a detoxicant, thus supporting the actions of shēng má and gĕ gēn to clear heat and alleviate inflammation.

The modified Shēng Má Jiĕ Dú Tāng is then fleshed out with huáng qín, yú xīng căo and pŭ gōng yīng to clear lung heat and reduce abscesses. Now, the entire arc of the diagnosis and treatment principle has been addressed. Finally, Cāng Ér Zĭ Săn plus huò xiāng deal with the symptom of nasal congestion by using aromatic medicinals that unblock the nasal orifices.

Jié gĕng’s role in the formula can also be expanded. In addition to its function of raising the qi and directing the actions of the formula to the upper body, it benefits the throat when combined with the shēng gān căo. It is easy to surmise that this combination would be soothing to sinus irritation. Jié gĕng also combines with huáng qín and yú xīng căo toexpel pus and resolve abscesses.

As expected, the patient recovers nicely. At the follow-up visit, the phlegm is less yellow and infected, thus the formula is modified to consolidate the treatment and support the right qi.

Cara Frank, L.OM. was raised by 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 over 30 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. 1n 1998 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. She is the president of China Herb Company and she is the Academic Director of the Department of Chinese Herbology at the Won Institute of Graduate Studies. You can read her bio or schedule an appointment.


[i]http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001670/

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Recharge your body and mind! – I first came to see Cara because she was highly recommended for her expertise in Chinese herbs. I was in need of a “body charge” for my autoimmune system and didn’t want the traditional medical approaches that had helped to get me in the condition I was in. Boy, did I get a REAL body charge when she combined her knowledge of herbs with acupuncture! When my session is complete, I often joke that I feel drunk. The truth is, my body feels completely relaxed and refreshed, my mind peaceful. Cara is amazing- she has helped me tremendously with my myriad of medical issues.

B.B.