The Treatment of Nasal Dryness in TCM

The Treatment of Nasal Dryness in TCM

Cara O. Frank, L.OM.

The following is an excerpt from my chapter on the treatment of nasal dryness from my upcoming book on case histories of EENT disorders.

The nose is the gateway of moist air to the lungs. The nose and the lungs need moist air to function optimally. The normal exchange of oxygen and carbon dioxide from the lungs to the blood and back depends upon moist lung tissue. Dry air can easily damage lung tissue. Dry membranes are unable to dissolve these gases. Therefore, the body’s mechanism for insuring that the lungs receive moist air depends upon the health of nasal turbinates. The turbinates are 3-4 inch ridges that protrude in the nasal airways. The tissue that lines them is elastic and moist. It secretes mucus and water, which moisturizes the air that is inhaled. Further, they have a sticky quality, so dust, dirt, pollen, bacteria, or viruses are filtered by and adhere to the turbinates.[i] Usually these particulates will be excreted with the mucus.

A normal protective measure of the turbinates when they are excessively dry is to swell which temporarily closes the nasal air passage. This is normal and allows the membranes to clean and remoisturize themselves. This occurs on a daily basis and is called nasal cycling. When the humidity is over 50%, most people will not notice their nose becoming congested as the turbinates only swell moderately. Other causes of nasal obstruction, such as a deviated nasal septum, nasal polyps, or a thin nose anatomy, become totally blocked even with this normal nasal cycling. If the room humidity is below 50%, the turbinates can swell severely causing severe nasal congestion.

Nasal dryness is characterized by dryness and reduced fluid in the nasal orifice with epistaxis, but no nasal atrophy or dysfunction of the sense of smell. It is often accompanied by a burning and itchy sensation inside the nose, a small number of dry scabs in the anterior inferior turbinate and mucosal erosion of the nasal septum. It frequently occurs in adolescents, especially during the fall and winter seasons. It is usually due to dry cold or dry hot weather, a dusty environment and over indulgence in smoking and alcohol consumption.

In TCM, the basic etiology of this condition is damage to the nasal orifice resulting from lack of fluid. It is related to the patterns of pathogenic dryness, yin deficiency, qi deficiency and congested heat. Over indulgence in smoking, alcohol consumption and spicy hot foods can cause congested heat in the lung and stomach. Following the pathway of the channels, pathogenic congested heat invades upward resulting in fluid injury and nasal dryness. Additionally, spleen and stomach deficiency causes an inability to generate qi and blood, which results in metal not being generated by earth. Chronic illness, lung and kidney deficiency, deficient heat burning upward cause injury to lung fluids and malnourishment of the nasal orifice. Dry cold or dry hot weather as well as dusty environments can result in fluid damage in the lungs. All these factors can result in lung qi deficiency and malnourishment of the nasal orifice.

Common Clinical Patterns:

    <p>
          ·Congested heat in the lung and stomach
    </p><p>
          ·Spleen deficiency and lung dryness
    </p><p>
          ·Dryness damaging the nose
    </p></ul><p>
    <strong>CASE STUDY</strong></p><p>
      Male, age 8.</p><p>
    <strong>Chief Complaint:</strong> Nasal dryness and chronic itchiness for 3 years.  Symptoms became aggravated 20 days prior to treatment.</p><p>
    <strong>History:</strong> No obvious causes. Prior treatments yielded poor results.</p><p>
    <strong>Signs and Symptoms:</strong> The patient’s symptoms occurred mainly during summer and fall. Examination showed a pink nasal mucus, dryness and hyperemia in the anterior inferior parts of the nasal septum with mild erosion and bleeding spots on the right side. His face was pale. The tongue body was pale with a slightly yellow coating and root. The pulse was thin and slow.</p><p>
    <strong><u>Diagnostic Analysis</u></strong></p><p>
    <strong>Analysis of Pattern Differentiation:<u></u></strong></p><p>
      Spleen deficiency, lung dryness, an inability of clear yang and fluids to rise and subsequent malnourishment of the nose lead to the nasal dryness, pale complexion and reduced body fluids. Qi deficiency results in an inability to dissolve pathogens causing nose congestion, which causes symptoms of dry itchiness, a sensation of a foreign body and burning inside the nose or dry scabs. The systemic symptoms tongue and pulse signs all indicated patterns of spleen qi deficiency.</p><p>
      The location of this disease is at the nose. It belongs to the patterns of spleen deficiency and lung dryness. A pattern of mixed deficiency and excess with deficiency predominantly.</p><p>
    <strong>Diagnosis:<u></u></strong></p><p>
    <strong>TCM:  </strong>Nasal dryness</p><p>
    <strong>WM: </strong>Nasal dryness due to Spleen deficiency and lung dryness</p><p>
    <strong>Clinical Treatment<u></u></strong></p><p>
      The etiology of this case was spleen deficiency and lung dryness. Therefore, the treatment should focus on strengthening the spleen and moistening dryness. Strengthening the spleen creates sufficient fluids to benefit the nasal orifice.</p><p>
    <strong><u>Principles:</u></strong> Benefit qi, strengthen the spleen, clear heat and transform dryness.</p><p>
    <strong>Formula:</strong> Modified<em> Huáng Qí Bái Zhú Tāng</em> (Radix Astragali and Rhizoma Atractylodis Macrocephalae Decoction)</p><p>
      [黄芪白术汤加味]</p>

    黄芪

    huáng qí

    9g

    Radix Astragali

    白术

    bái zhú

    9g

    Rhizoma Atractylodis Macrocephalae

    神曲

    shén qŭ

    10g

    Massa Medicata Fermentata

    麦芽

    mài yá

    10g

    Fructus Hordei Germinatus

    地骨皮

    dì gŭ pí

    10g

    Cortex Lycii

    黄芩

    huáng qín

    9g

    Radix Scutellariae

    麦冬

    mài dōng

    10g

    Radix Ophiopogonis

    木通

    mù tōng

    6g

    Caulis Akebiae

    桑白皮

    sāng bái pí

    10g

    Cortex Mori

    茅根

    bái máo gēn

    10g

    Rhizoma Imperatae

    甘草

    gān căo

    3g

    Radix et Rhizoma Glycyrrhizae

    <strong></strong></p><p>
    <strong>Formula Analysis:</strong></p><p>
    <em>Huáng qí, bái zhú, shén qŭ </em>and <em>mài yá </em>supplement the qi and strengthen the spleen.</p><p>
    <em>Dì gú pí, huáng qín </em>and <em>sāng bái pí </em>clear and sedate lung heat.</p><p>
    <em>Mài dōng </em>nourishes the yin and moistens the lung.</p><p>
    <em>Bái máo gēn</em> cools the blood and stops bleeding.</p><p>
    <em>Mù tōng </em>guides heat downward.</p><p>
    <em>Gān căo </em>harmonizes the other medicinals.</p><p>
      The formula supplements the qi, strengthens the spleen, clears the lung, moistens dryness, cools the blood and stops bleeding.</p><p>
    <strong><u>External Treatment:</u></strong> Blow <em>shēng dà huáng </em>(Raw Radix et Rhizoma Rhei) powder into the nasal cavity and apply tetracycline paste on the septum mucus, 2-3 times per day.</p><p>
    <strong><u>Second Visit</u></strong></p><p>
        After three packs of medicinals, the epistaxis stopped, the appetite improved, itchiness inside the nasal cavity disappeared, the dry sensation was reduced, and the dryness and hyperemia in the nasal septum mucus was significantly improved. Lung heat was reduced, but spleen deficiency remained with insufficient rising of clear yang.</p><p>
    <strong><u>Principles:</u></strong> Supplement the middle, benefit qi, raise the clear yang and moisten dryness.</p><p>
    <strong>Formula: </strong>Modified<em> Bŭ Zhōng Yì Qì Tāng Jiā Jiăn</em> Middle-Supplementing and Qi-Benefiting Decoction</p><p>
    <strong>[</strong>补中益气汤加减]</p>

    黄芪

    huáng qí

    6g

    Radix Astragali

    党参

    dăng shēn

    6g

    Radix Codonopsis

    白术

    bái zhú

    6g

    RhizomaAtractylodis Macrocephalae

    玄参

    xuán shēn

    6g

    Radix Scrophulariae

    麦冬

    mài dōng

    6g

    Radix Ophiopogonis

    葛根

    gĕ gēn

    6g

    Radix Puerariae Lobatae

    陈皮

    chén pí

    3g

    Pericarpium Citri Reticulatae

    升麻

    shēng má

    3g

    Rhizoma Cimicifugae

    当归

    dāng guī

    3g

    Radix Angelicae Sinensis

    酒炒黄柏

    jiŭ chăo huáng băi

    3g

    Wine- Fried Cortex Phellodendri

    炙甘草

    zhì gān căo

    3g

    Radix et Rhizoma Glycyrrhizae Praeparata cum Melle

    <strong></strong></p><p>
    <strong>Formula Analysis:</strong></p><ul>
    <p>
          ·<em>Huáng qí, dăng sh</em><em>ē</em><em>n, bái zhú, d</em><em>ā</em><em>ng gu</em><em>ī</em><em>, chén pí, sh</em><em>ē</em><em>ng má, gĕ g</em><em>ē</em><em>n </em>(to replace <em>chái hú </em>- Radix Bupleuri) and <em>zhì g</em><em>ā</em><em>n căo </em>supplement the center, benefit qi and raise clear yang.
    </p><p>
          ·<em>Xuán shēn </em>and <em>mài dōng </em>nourish yin and moisten dryness.
    </p><p>
          ·Wine-Fried <em>huáng băi</em> clears and subdues yin fire.
    </p></ul><p>
    <strong><u>External Treatment: </u></strong> Same as above.</p><p>
    <strong>COMMENTARY</strong></p><p>
      Dryness is an interior/exterior phenomenon: Dryness in the external environment will deplete body fluids resulting in internal dryness. Internally, fluid deficiency exacerbates sensitivity to environmental dryness. Further, any defect in the mechanisms of fluid distribution in the body will also exacerbate dryness. The primary case in this chapter centers on this pathodynamic.</p><p>
      The discussion describes a case of nasal dryness that is exacerbated by seasonal changes. Internally, the patient, while not exhibiting overtly spleen qi deficient symptoms <em>per se,</em> has a pale face and tongue body along with a thin and slow pulse.</p><p>
      Two important points of pattern differentiation should be noted. First, although there are symptoms of nasal dryness, there are few symptoms of either internal or external heat. Secondly, the tongue body is not dry. Therefore, for this case, the physician can rule out pathogenic dry heat and internal yin deficiency as probable causes. The only symptom of heat is the sensation of burning and irritation in the nose.</p><p>
      Normal fluid metabolism is a cyclic, unending process of organ functions that are choreographed in a dynamic and interwoven way between nearly all the<em> zang</em> and <em>fu</em> organs of the body ultimately to be distilled into <em>jin</em> and <em>ye </em>fluids. The spleen exerts its influence on many of these processes. After the spleen receives the pure essence of food and fluids from the stomach, it separates the purest part and distributes it to the lungs. The purest part of the fluids is circulated with a boost from the <em>sanjiao</em>. One common outcome of spleen deficiency is the development of dampness. Another consequence is dryness in other parts of the body, not from lack of fluids, but from a lack of normal distribution of fluids. This mechanism is so important to the health of the body, that many of Chinese medicines most enduring formulas correct this defect. Li Dong-yuan devoted his career to this topic.</p><p>
        The formula selection is a surprise. Usually, if the diagnosis were lung dryness, then the key action of the primary formula would be to moisten dryness. Thus, a formula such as <em>Sāng Xìng Tāng</em> (Mulberry Leaf and Apricot Kernel Decoction) or <em>Yăng Yīn Qīng Fèi Tāng </em>(Yin-Nourishing and Lung-Clearing Decoction) might be selected. Here, the physician selects a formula to address the central root issue of spleen deficiency. <em>Huáng Qí Bái Zhú Tāng </em>is modified with <em>dì gú pí</em> and <em>sāng bái pí </em>of <em>Xiè Bái Săn </em>(White-Draining Powder), which drains lung heat. Many formulas, especially in the ophthalmology chapters, use the combination of <em>sāng bái pí </em>and <em>huáng qín </em>to clear lung heat. <em>Shén qŭ </em>and <em>mài yá</em> introduce a kind of enzymatic dynamic, strongly emphasizing the spleen strengthening action of the formula. <em>Mù tōng </em>drains dampness and opens the channels and collaterals of the head.</p><p>
      At the follow-up second visit, the patient’s symptoms have improved. The treatment strategy shifts focus from benefitting qi, strengthening the spleen, clearing heat and transforming dryness to supplementing the center, benefitting qi, raising the clear yang, and moistening dryness. While similar, the differences in the treatment principles are significant. Because the first includes the principle of strengthening the spleen, medicinals that improve digestive strength, such as <em>bái zhú, shén qŭ </em>and <em>mài yá</em> must be included. For the follow-up treatment strategy, the emphasis is on raising the clear yang. This suggests that medicinals such as <em>Huáng qí, shēng má </em>and <em>chái hú</em> from <em>Bŭ Zhōng Yì Qì Tāng </em>should be included. In this case, <em>chái hú </em> is replaced with<em> gĕ g</em><em>ē</em><em>n. </em> This is a wise modification: Both medicinals have an ascending action, yet <em>chái hú </em>is drying and enters the <em>shao yang</em> channels making it more suitable for ear conditions while <em>gĕ g</em><em>ē</em><em>n </em> generates fluids and enters the <em>yang ming </em> channels making it more suitable for conditions of the nose.</p><p>
      Perhaps the most important historical reference is another of Li Dong-yuan’s’ formulas: <em>Qīng Shŭ Yì Qì Tāng </em>(Summerheat-Clearing Qi-Boosting Decoction) which includes <em>Huáng qí, dăng sh</em><em>ē</em><em>n, bái zhú, d</em><em>ā</em><em>ng gu</em><em>ī</em><em>, chén pí, sh</em><em>ē</em><em>ng má, gĕ g</em><em>ē</em><em>n, huáng băi </em>and <em>zhì g</em><em>ā</em><em>n căo</em> from this formula plus <em>zé xiè (</em>Rhizoma Alismatis), <em>shén qū </em>(Massa Medicata Fermentata), <em>qīng pí </em>(Pericarpium Citri Reticulatae Viride), <em>wŭ wèi zĭ </em>(Fructus Schisandrae Chinensis) and <em>cāng zhú </em>(Rhizoma Atractylodis). The formula is then modified with <em>xuán shēn </em>and <em>mài dōng</em> which, along with <em>shēng dì </em>(Radix Rehmanniae_ in the formula <em>Zēng Yè Tāng</em> Humor-Increasing Decoction. Another medicinal relationship is <em>huáng băi </em>and <em>mài dōng </em>which together enrich the yin and downbear fire</p><p>
    <em>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. </em><em>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 <a href="http://sixfishes.com.php54-1.ord1-1.websitetestlink.com/about/staff/cara-frank">bio</a> or schedule an <a href="http://sixfishes.com.php54-1.ord1-1.websitetestlink.com/contact">appointment.</a></em></p><hr>

    [i] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3199822/?tool=pmcentrez

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