Cara Frank, L.OM.
Acute tonsillitis is a common inflammatory pharyngeal disease that is caused by bacterial or viral infections. It is characterized by a sore throat, red swollen tonsils with yellow or white pus on the surface, along with fever and is among the most frequently occurring diseases seen in the clinical setting. The majority of tonsillitis is caused by viral infections. Western medical treatments for viral tonsillitis may include corticosteroids and IV fluids to manage the swelling and maintain hydration. Bacterial infections, such as streptococcus, are treated with antibiotics. The throat may be swabbed and cultured to determine if the infection is bacterial. 1 It often occurs in children and adolescents. It mostly occurs in the spring and fall. Other treatments include comfort measures, such as salt-water gargles, throat lozenges and warm beverages. Untreated tonsillitis takes 1-3 weeks to resolve.
In TCM, acute tonsillitis is referred to as jírǔ é(急乳蛾, babymoth). It usually presents with a pattern of excessive heat. It is often caused by wind-heat pathogen attacking a weakened body, as well as fire-heat toxins congested in the throat. External wind-heat attacking with lung qi unable to diffuse, and wind-heat in the lung channel attacking upward, results in pathogen congestion in the throat. Alternately, excessive external pathogen invading inward, along with excessive heat in the lungs and stomach, and fire heat steaming upward to burn the tonsils, results in acute tonsillitis.Qi and blood stasis then combine with the pathogenic factor, binding in the throat and resulting in tonsillitis.
COMMON CLINICAL PATTERNS AND FORMULAS
Wind-heat in the lungs: Shū Fēng Qīng Rè Tāng (Wind-Coursing and Heat-Clearing Decoction)
Excessive heat in the lungs and stomach: Qīng Yān Lì Gé Tāng (Throat-clearing Diaphragm-Disinhibiting Decoction)
Female, age 27. Initial Visit: June 12th, 2008
Chief Complaints: Sore throat and fever for three days.
History: The patient had a dry and itchy throat after catching a cold three days ago. The sore throat started afterward and felt worse when swallowing. A fever (39.3℃) accompanied the sore throat with a slight aversion to wind, headaches, lower back soreness and weak extremities. Urination and bowel movements were normal. After being treated with roxithromycin and antipyretic medication, the fever receded, but the sore throat and other symptoms remained.
Signs and Symptoms: A sore throat aggravated by swallowing, along with fever, a slight aversion to cold, a cough with phlegm, headaches, sore joints, weak extremities, short voiding of dark urine. Bowel movements were normal. The tongue tip was red with a thin yellow coating. The pulse was floating and rapid.
Physical Examination: Fatigue and a sick facial complexion. Body temperature 38.6℃, pulse rate 94 beats/min.
Local Examination: Obvious hyperaemia of the pharyngeal mucosa, hyperaemia and 2nd degree enlargement of the tonsils bilaterally with a small amount of yellowish white discharge on the surface. The submandibular lymph nodes were enlarged, swollen and painful upon palpation.
Laboratory Examination: CBC: WBC 12.3×109/L, N81.7%.
The throat is a clear and empty and is associated with the lung channel. It is very easily attacked by wind pathogen and often presents with exterior symptoms. The patient’s illness started with a dry and itchy throat, fever and a slight aversion to cold, showing a pattern of external wind-heat pathogen attack. The wind-heat pathogen congested in the throat and burned the tonsils, causing qi and blood stagnation along with blockage of the collaterals. This caused the dry and itchy sore throat with red, swollen tonsils. The fire heat was mild in the early stage of the disease, which is why only a small amount of discharge appeared on the tonsil surface. A red tongue with a thin yellow coating and a floating rapid pulse were signs of an exterior wind-heat pattern.
The location of this disease was the throat. The etiology was lung heat from an external wind-heat attack, a pattern of lung heat. It was an exterior pattern.
WM diagnosis: Acute tonsillitis
TCM diagnosis: Baby moth due to wind-heat in the lung channels
The throat is the upper orifice of the lungs and stomach. All diseases of the throat will always be associated with these channels. Treatment should be determined based on the presenting symptoms focusing on clearing lung heat or suppressing and clearing the stomach. This case was caused by an external wind-heat pathogen attack, causing lung heat and wind-heat pathogen to congest in the throat and burn the tonsils. The location of the disease was on the top of the body.
According to Zheng Mei-jian, in the Jade Key to the Secluded Chamber (Chóng Lóu Yù Yào, 重楼玉钥), the treatment principles should follow this theory: “When using herbal medicine, the most effective method is to first attack the disease from within and expel them outward. Secondly, eliminate phlegm and attack the [pathogens in the] upper body, and lastly, precipitate the pathogen. When there is excessive heat, the treatment should eliminate the internal heat. Use medicinals that have an ascending nature to block wind-heat pathogen and prevent it from penetrating the body. This is a good treatment strategy; otherwise, the disease can enter into the stomach and diaphragm. If it enters into heart and lung, it will progress into other diseases.” Therapeutic treatment should focus on coursing wind, raising and dissipating the pathogen, benefiting the throat and dispersing swelling. Medicinals should course wind and cool heat. In accordance with the theory of “treating the upper burner like a feather with a light nature”, the medicinals selected should have a clearing and ascending action.
Principles: Course wind, clear heat, benefit the throat and disperse swelling
Formula: Modified Shū Fēng Qīng Rè Tāng (Wind-Coursing Heat-Clearing Decoction)
|荆芥||jīng jiè||6g||Herba Schizonepetae|
|防风||fáng fēng||6g||Radix Saposhnikoviae|
|金银花||jīn yín huā||10g||Flos Lonicerae Japonicae|
|连翘||lián qiào||6g||Fructus Forsythiae|
|桑白皮||sāng bái pí||6g||Cortex Mori|
|赤芍||chì sháo||6g||Radix Paeoniae Rubra|
|黄芩||huáng qín||6g||Radix Scutellariae|
|牛蒡子||niú bàng zĭ||6g||Fructus Arctii|
|玄参||xuán shēn||9g||Radix Scrophulariae|
|浙贝母||zhè bèi mŭ||9g||Bulbus Fritillariae Thunbergii|
|马勃||mă bó||3g||Lasiosphaera seu Calvatia|
|桔梗||jié gĕng||3g||Radix Platycodonis|
|甘草||gān căo||3g||Radix et Rhizoma Glycyrrhizae|
Jīng jiè and fáng fēng course wind and relieve the exterior.
Jīn yín huā and lián qiào course wind and clear heat.
Mă bó eliminates the rotten discharge.
Niú bàng zĭand jié gĕng correct the qi dynamic and expel the pathogen.
Sāng bái pí, chì sháo and huáng qín clear lung heat.
Xuán shēn and zhè bèi mŭ transform phlegm, dissipate nodules and benefit the throat.
The formula as a whole courses wind, clears heat, benefits the throat and disperses swelling.
Main points: LI 4 (hé gŭ), ST 44 (nèi tíng), LI 11 (qū chí)
Supplementary points: RN 22 (tiān tū), SI 1 (shào zé), LU 10 (yú jì)
Method: Select 2-4 points each time. After obtaining the needle sensation, retain all needles for 20-30 min, 1-2 times per day.
Techniques: Needle with drainage method.
Insufflation method: Directly blowing the Zhū Huáng Qīng Chuī Kŏu Săn (Pearl Yellow Green Mouth-Blowing Powder) on the tonsils bilaterally, 4 times per day to clearheat, resolve toxin, disperseswelling, stop pain, eliminate putridity and benefit the throat.
Rinse method: Rinse the mouth with Yín Péng Sù Kŏu Yè (Lonicera and Borax Mouthwash) and let it sit for a few minutes, 3-4 times per day to relieve toxins, disperse swelling and eliminate the sticky phlegm.
After three days of treatment, the sore throat was almost relieved. Swallowing was normal, with a slightly itchy throat and a slight cough. The redness and swelling on both tonsils had receded, the superficial purulent discharge was eliminated, the submandibular lymph nodes had shrunk. The tongue body was red with a thin coating and the pulse was slow.
After the above first treatments, the main symptoms had been resolved, but a mild sore and itchy throat, cough and floating pulse remained, indicating that a remnant of the pathogen lingered. The treatment principles followed the previous one, which was to scatter wind, clear heat and eliminate the remaining pathogen.
Principles: Scatter wind, clear heat and benefit the throat
Formula: Modified Sāng Jú Yĭn (Mulberry Leaf and Chrysanthemum Beverage)
|桑叶||sāng yè||6g||Folium Mori|
|菊花||jú huā||10g||Flos Chrysanthemi|
|金银花||jīn yín huā||10g||Flos Lonicerae Japonicae|
|连翘||lián qiào||10g||Fructus Forsythiae|
|玄参||xuán shēn||10g||Radix Scrophulariae|
|浙贝母||zhè bèi mŭ||10g||Bulbus Fritillariae Thunbergii|
|桔梗||jiĕ gĕng||6g||Radix Platycodonis|
|甘草||gān căo||3g||Radix et Rhizoma Glycyrrhizae|
All the symptoms were resolved after two days of the above follow-up treatment. The tongue body was pink with a thin coating and the pulse was slow.
COMMENTARY AND DISCUSSION
The primary case featured in this chapter depicts a woman with a painful sore throat, fever and body aches. The symptoms of a dry and itchy throat at the onset were signs and symptoms of wind, as opposed to heat. Later, the disease transformed to heat and the throat became painful. In clinical practice, this kind of staging is important because the patterns in acute infectious diseases transmute quickly. In order to achieve optimal results, the disease should be differentiated with care. In this case, because bowel movements were normal, the disease was still relatively superficial.
The illness progressed rapidly. In a Wēn Bìng (warm disease) model of heat penetration, a wei (defensive) level disease progresses to the qi level. The treatment strategy is effective and preventative. Not only is the tonsillitis alleviated, the physician has also prevented heat from penetrating internally to the stomach and diaphragm.
Using light, cool medicinals that dispel wind and heat combined with cold, bitter medicinals that drain heat, the physician selects Shū Fēng Qīng Rè Tāng. Despite the fact that the patient’s disease process is several days old, the heat is relatively superficial. It can be said that the heat is without form. The selected formula is broad and practical. Although its actions are to clear heat, the thermal nature of the overall formula construction is not excessively cold. Despite the treatment guidelines to use medicinals “like a feather with a light nature”, several medicinals also have a descending nature. The up and down dynamic of the formula might be divided this way: jīng jiè, fáng fēng, jīn yín huā, lián qiào, mă bóand jié gĕng are ascending and light in nature, while sāng bái pí, huáng qín, niú bàng zĭ, xuán shēn and zhè bèi mŭ are generally heavier and descending. Thus, the formula is balanced in both its thermal and its directional nature. Jīn yín huā, lián qiào, niú bàng zĭand mă bó are also grouped in the Wēn Bìng formula Yín Qiào Mă Bó Săn (Lonicera, Forsythia and Puffball Fruiting Body Powder), which clears heat toxin and drains lung heat. Mă bó has an important relationship with xuán shēn. The pair clears heat, stops pain and eases the throat[i]. It is specifically indicated for the treatment of wind-heat causing Hóu Bì (throat impediment). It also treats severe sore throats with pain upon swallowing. Another noteworthy relationship within this formula is xuán shēn and zhè bèi mŭ. The combination features in the formula Xiāo Luŏ Wán (Scrofula-Dispersing Pill), which treats phlegm-fire nodules, illustrating its usefulness in this formula.
The external therapies are practical and, even if unavailable in a Western clinic, worth replicating. Watermelon Frost Spray Powder can be substituted for Zhū Huáng Qīng Chuī Kŏu Săn (Pearl Yellow Green Mouth-Blowing Powder) with similar results.
At the follow-up visit, the symptoms have improved yet the pulse is still floating, suggesting that the patient is still fighting an external pathogen. Jīng jiè, fáng fēng, niú bàng zĭand mă bóare omitted and sāng yè and jú huā are added. Xuán shēn, jiĕ gĕng and gān căo, serve as a key trio to soothe the throat and alleviate painful swelling.
The prognosis for this case is good. If there is recurrent tonsillitis with difficulty healing, it can result in lesions and local or systemic complications. Local complications include ear distention, pharyngitis and throat abscess. Systemic complications include low-grade fever, bì syndromes, palpitations and edema.
What details warrant attention regarding the patient care for this case?
In clinical practice, acute tonsillitis is a frequently occurring, recurrent disease. In the classical book Jade Key to the Secluded Chamber (Chóng Lóu Yù Yào, 重楼玉钥) by Zheng Mei-jian, it is written that among all throat diseases, single and bilateral tonsillitis is the most commonly seen. Even though the onset is mild, it is difficult to resolve quickly. Therefore, at the acute onset of this condition treatment should be given immediately. Appropriate care should be offered after recovery to prevent reoccurrence and complications. The patient should exercise to boost the immune system and eat a proper diet with little hot spicy foods to prevent congested heat in the spleen and stomach. Fever can damage yin fluids, so choose medicinals such as xuán shēn (Radix Scrophulariae), jié gĕng (Radix Platycodonis), zàng qīng guŏ (Fructus Chebulae Immaturus), shè gān (Rhizoma Belamcandae) and shēng gān căo (Radix et Rhizoma Glycyrrhizae) to decoct and drink. This will benefit the qi, nourish the yin, generate fluids and prevent or decrease the onset of this condition. Have the patient rest well and avoid overworking to prevent deficient heat. During the acute onset of this condition, be sure to resolve it completely to avoid delayed and difficult healing. Maintain good oral hygiene and treat any diseases of the surrounding area.
In TCM, tonsillitis is referred to as Rŭ É (baby moth) or Hóu É (throat moth). Pharyngitis is referred to as Hóu Bì (throat impediment). According to the Practical Dictionary of Chinese Medicine, Rŭ É is the term that describes redness and soreness of the throat nodes (tonsils) with a yellowish white discharge on the surface. 3 There are three main patterns:
Lung-stomach heat congestion with a fire toxin steaming upward
Qi stagnation with blood stasis combined with old phlegm and liver fire, binding to form malign blood
Liver and kidney yin-fluid deficiency with empty fire flaming upwards
Lung-stomach heat congestion with fire toxin steaming upward is a hybrid, organ-channel syndrome, in which surface symptoms of wind-heat appear concurrently with signs of yangming heat presenting with or without form. Symptoms include a sensation of heat and irritability, throat pain, difficulty swallowing and constipation. The treatment principle is to course wind, diffuse the lungs, disperse the swelling and resolve toxins. The selected formula for this pattern was first recorded in the Qing Dynasty text Precious Collection for Throat Diseases(Hóu Kē Zĭ Zhēn Jí, 喉科紫珍集).
Formula: Qīng Yān Lì Gé Tāng(Throat-Clearing Diaphragm-Disinhibiting Decoction)
|荆芥||jīng jiè||4.5g||Herba Schizonepetae|
|防风||fáng fēng||4.5g||Radix Saposhnikoviae|
|金银花||jīn yín huā||10g||Flos Lonicerae Japonicae|
|连翘||lián qiào||2.5g||Fructus Forsythiae|
|牛蒡子||niú bàng zĭ||6g||Fructus Arctii|
|薄荷||bò he||4.5g||Herba Menthae|
|玄参||xuán shēn||2.5g||Radix Scrophulariae|
|桔梗||jié gĕng||4.5g||Radix Platycodonis|
|甘草||gān căo||2.5g||Radix et Rhizoma Glycyrrhizae|
|黄芩||huáng qín||4.5g||Radix Scutellariae|
|黄连||huáng lián||4.5g||Rhizoma Coptidis|
|栀子||zhī zĭ||2.5g||Fructus Gardeniae|
|大黄||dà huáng||2.5g||Radix et Rhizoma Rhei|
Jīng jiè, fáng fēng, jīn yín huā, lián qiào, niú bàng zĭand bò he dispel wind and clear heat.
Niú bàng zĭ, bò he, xuán shēn, jié gĕng and gān căo alleviate throat inflammation.
Huáng qín, huáng lián, zhī zĭand dà huáng clear heat and alleviate toxicity.
Dà huáng and pò xiāo clear heat by freeing the stool.
The structure of the formula resembles others that release interior-exterior excess, notably Fáng Fēng Tōng Shèng Săn (Ledebouriella Sage-Inspired Powder) as well as the prepared formula Huáng Lián Shàng Qīng Wán (Coptis Upper-Body-Clearing Pill), all of which have similar clinical applications.
According to the Practical Dictionary of Chinese Medicine, the guiding formula for Rŭ É patterns due to liver fire is Zhǐ Mí Fú Líng Wán(Pathfinder Poria Pill) from Selected Formulas(Băi Yī Xuăn Fāng, 百一选方). There are several formulas with similar names. It is often referred to as Fú Líng Wán (Poria Pill).
Formula: Zhĭ Mí Fú Líng Wán(Pathfinder Poria Pill)
|枳壳||zhĭ qiào||15g||Fructus Aurantii (bran-fried)|
|半夏||bàn xià||60g||Rhizoma Pinelliae|
The actions of the formula are to dry dampness, regulate the qi, transform phlegm and soften masses. It treats phlegm accumulation in the upper jiao that obstructs the flow of qi in the four limbs. It is indicated for sore, painful and numb upper arms, fatigue and weakness of the four limbs, nausea and plum pit qi.
Structurally, it is similar to many formulas that treat phlegm patterns, including Èr Chén Tāng (Two Matured Substances Decoction) and Wēn Dăn Tāng (Gallbladder-Warming Decoction). Both formulas use the key pair bàn xià and fú líng, which treats phlegm-damp patterns. The addition of zhĭ qiào smoothes the qi dynamic of the middle jiao, which assists in the transformation of phlegm. The pivotal medicinal in Zhǐ Mí Fú Líng Wánthat differentiates it from other similar formulas is pò xiāo. Pò xiāo is most familiar when used in concert with dà huáng (Radix et Rhizoma Rhei) to clear heat and free the stool. Here, the medicinals’ secondary functions, clearing heat and reducing throat swelling and ulcerations, take precedence.
The last pattern, Xū Huŏ Rŭ É(deficiency-fire tonsillitis), is treated with Zhī Băi Dì Huáng Wán (Anemarrhena, Phellodendron and Rehmannia Pill). This modification of Liù Wèi Dì Huáng Wán (Six-Ingredient Rehmannia Pill) adds bitter, cold and draining zhī mŭ (Rhizoma Anemarrhenae) and huáng băi (Cortex Phellodendri Chinensis) to enrich the yin and clear deficiency fire.
Finally, this, and all formulas that treat acute tonsillitis can be modified with medicinals and formulas that clear fire toxin from the throat. Examples of medicinals are qīng dài (Indigo Naturalis) and shè gān (Rhizoma Belamcandae). An example of a formula that might treat acute tonsillitis is Qiāng Lán Tāng (Notopterygium and Isatis Root Decoction). This formula is more of an herbal pairing, and thus could modify any of the formulas that have been discussed in this chapter.
1. Clarence T. Sasaki. Tonsillopharyngitis, The Merck Manual for Health Care Professionals, Updated 2012. Available from: http://www.merckmanuals.com/professional/ear_nose_and_throat_disorders/oral_and_pharyngeal_disorders/tonsillopharyngitis.html?qt=&sc=&alt=
2. Dan Bensky, Steven Clavey. Chinese Herbal Medicine: Materia Medica, 3rd Edition. Stoger Eastland Press, 2004: 124
3. Nigel Wiseman, Feng Ye. Practical Dictionary of Chinese Medicine. Paradigm Publications, 1998: 14