Cara O. Frank, L.OM
The following is an excerpt and re-working from the chapter on the treatment of Non-suppurative otitis media from my book TCM Case Studies, Eye, Ear, Nose and Throat Disorders, from Peoples Medical Publishing House. The book also contains chapters on acute suppurative otitis, chronic suppurative otitis. If you find this information helpful, I encourage you to study the entire chapter, as it contains case studies and other helpful information.
Non-suppurative otitis media refers to the first phase of a middle ear infection. Many cases occur after a common cold and are part of the sequelae of an upper respiratory infection. 1 Most cases are viral in nature. Symptoms include mild pain that is worse at night along with a sensation of popping in the ears and deafness. Treatment consists of pain management with non-steroidal anti-inflammatory drugs (NSAIDS). Since most cases are viral, antibiotics generally don’t improve outcomes and are associated with side effects. Tympanostomy tubes may also be placed in the eardrum if there are more than three episodes in six months. 2
In TCM, otitis media falls into the category of ěr zhàn (耳胀, ear distention) or ěr bì (耳闭, ear block), an otolaryngological condition caused by external pathogenic invasion or retention of pathological toxins. It is characterized by symptoms of distention, fullness and a sensation of blockage inside the ear, accompanied by tinnitus with a deterioration of hearing. Classical texts define it as wind-type hearing loss, sudden hearing loss or hearing loss due to qi blockage. It is equivalent to non-purulent otitis media in Western medicine.
This is an extremely common complaint in clinical practice. the condition is very responsive to treatment with Chinese medicine.
There is close relationship between ear distention and ear block. Ear distention is seen in the initial onset of the infection and exhibits excessive-type symptoms. Usually caused by external pathogenic invasion and obstruction of channel qi, it is characterized by a feeling of distention in the ear with pain specific to the auricular region. In comparison, ear block is a chronic condition, often caused by retention of pathogenic toxins. It is related to spleen and kidney deficiency, and exhibits symptoms of deficiency-excess complex patterns. It is characterized by a sensation of blockage inside the ear, with impaired hearing. If treatment of ear distention is delayed, it can develop into ear block.
COMMON CLINICAL PATTERNS AND FORMULAS
The following are the main patterns of the differential diagnosis and treatment, however there are more choices in the pattern descriptions.
External pathogenic wind invasion with channel qi obstruction: ModifiedYín Qiào Săn (Lonicera and Forsythia Powder) or Sān Ào Tāng (Rough and Ready Three Decoction)
Liver-gallbladder damp-heat steaming the auricular orifice: Modified Lóng Dăn Xiè Gān Tāng (Gentian Liver-Draining Decoction)
Spleen deficiency and damp congestion with damp turbidity encumbering the ear: Modified Shēn Líng Bái Zhú Săn (Ginseng, Poria and Atractylodes Macrocephalae Powder)
Accumulation of toxins with qi and blood stagnation: Modified Tōng Qiào Huó Xuè Tāng (Orifice-Freeing Blood-Quickening Decoction)
1.External pathogenic wind invasion with channel qi obstruction resulting in impaired diffusion and downbearing of the lung and obstruction of the ear orifice:
The middle ear belongs to the lung system. Wind-cold or wind-heat attacks the exterior and hides in the lungs, leading to impaired diffusion and downbearing of the lung and pathogenic qi congestion in the clear orifice. The wind-cold type can be accompanied by a stuffy nose, clear nasal discharge, sneezing and headache or whole body soreness. The tongue coating will be thin and white with a floating, tight pulse. The treatment principle is to course wind, dissipate coldness, diffuse congestion and open the orifices. The formula should be Sān Ào Tāng (Rough and Ready Three Decoction) modified with jīng jiè (Herba Schizonepetae), fáng fēng (Radix Saposhnikoviae) and shí chāng pú (Rhizoma Acori Tatarinowii).
The wind-heat type includes symptoms of a stuffy nose, thick nasal discharge, headache and a sore throat. The tongue coating will be thin and yellow. The pulse is floating and rapid. The treatment principle is to course wind, dissipate heat, diffuse the lungs and open the orifices. The formula is modified Liù Wèi Tāng (Six-Ingredient Decoction) or Yín Qiào Săn (Lonicera and Forsythia Powder). If the patient’s tympanic cavity also has fluid, it is often due to impaired diffusion and downbearing of the lung from fluid stagnation. The treatment principle should focus on coursing wind and diffusing the lungs. Add medicinals for further lung diffusion, water dispersal and resolution of dampness such as tíng lì zǐ (Semen Lepidii; Semen Descurainiae), ché qián zǐ (Semen Plantaginis) and zé xiè (Rhizoma Alismatis).
2.Pathogens blocking the shaoyang channels with ear orifice obstruction:
The three yang channels of hand and foot plus the hand jueyin pericardium channel all cross the ear. The hand and foot shaoyang channels have the closest relationship with the ear. This condition is often caused by the external contraction of the six excesses, with pathogens entering shaoyang channel, leading to channel qi stagnation and pathogen blockage of the ear. It mainly manifests as auricular swelling and obstruction accompanied by a bitter taste in the mouth and a dry throat. The tongue coating is thin and yellow, and the pulse is wiry. The treatment principle should be to clear and diffuse shaoyang, open the orifices and nourish the ear. The formula selection for this pattern is Xiăo Chái Hú Tāng (Minor Bupleurum Decoction) or modified Tōng Qì Săn (Qi-Freeing Powder) from the Correction of Errors in Medical Works (Yī Lín Găi Cuò, 医林改错). In this condition, patients will not present with the typical symptoms of lung dysfunction such as cough, nasal discharge or a floating pulse.
3.Phlegm turbidity stagnation and ear orifice obstruction:
This pattern is mainly characterized by fluid accumulation in the tympanic cavity. It can reoccur often and last for long periods without typical symptoms of exterior patterns. Usually due to impairment of splenic movement and transformation, it results in disorders of fluid metabolism, leading to water-dampness retention in the ear. The treatment principle should focus on percolating water and resolving dampness by using modified Zhū Líng Tāng (Polyporus Decoction) or Zé Xiè Tāng (Alisma Decoction). Choose modified Shēn Líng Bái Zhú Săn (Ginseng, Poria and Atractylodes Macrocephalae Powder) if spleen deficient patterns are more prominent. If the patient has sticky accumulative fluid or thick fluids glued to the ear, then qi-moving, dampness-drying, phlegm-dissolving and nodule-dissipating medicinals should be added. Examples of such medicinals are bàn xià (Rhizoma Pinelliae), xuán shēn (Radix Scrophulariae), mŭ lì (Concha Ostreae) and zhè bèi mŭ (Bulbus Fritillariae Thunbergii).
With an accumulation of heat caused by phlegm turbidity, huāng qín (Radix Scutellariae), jīn yín huā (Flos Lonicerae Japonicae) and mŭ dān pí (Cortex Moutan) should be added to clear heat and eliminate pathogens, or clear heat and dissolve toxins. This type of pattern may be diagnosed in Western medicine as a low-grade infection of the middle ear cavity. Western medical theory attributes this condition to allergic response or endocrine dysfunction. Therefore, in the case of recurrent fluid accumulation without resolution, high doses of huáng qí (Radix Astragali), dăng shēn (Radix Codonopsis) and bái zhú (Rhizoma Atractylodis Macrocephalae) should be added to fortify the spleen and drain dampness. Alternately, add fù zĭ(Radix Aconiti Lateralis Praeparata), bā jǐ tiān (Radix Morindae Officinalis) and suŏ yáng (Herba Cynomorii) to warm the kidney and spleen. These medicinals may play an important role in regulating the endocrine system and ameliorating the allergic response.
4.Congealing of phlegm and stagnant blood congestion, and blockage in the ear orifice:
Due to the tendency of this condition to become chronic, the patient will often present with signs of stagnation, such as a tongue body with stagnant spots and a dusky, purplish color. There may also be obvious sticky discharge glued to the ear from the tympanum, thickening and becoming more turbid in the tympanic membrane, with decreased mobility. Treatment should focus on invigorating blood, transforming stasis, eliminating phlegm and dissipating nodules. Select modified Èr Chén Tāng (Two Matured Substances Decoction) and Bŭ Yáng Huán Wŭ Tāng (Yang-Supplementing and Five-Returning Decoction).
5.Qi deficiency resulting in dysfunction of the ear orifice
In this category, the patient presents with exudative type otitis media along with typical symptoms seen in spleen qi deficiency patterns. This is mostly seen in chronic cases and characterized by cloudy and sunken eardrums without any obvious fluid accumulation. The formula selection is modified Shēn Líng Bái Zhú Săn (Ginseng, Poria and Atractylodes Macrocephalae Powder) or Bŭ Zhōng Yì Qì Tāng (Center-Supplementing and Qi-Boosting Decoction), with added shí chāng pú (Rhizoma Acori Tatarinowii) to open the orifice. For patients with qi deficiency along with externally contracted cold symptoms, pathogen-eliminating medicinals such as chái hú (Radix Bupleuri), chuān xiōng (Rhizoma Chuanxiong), jīng jiè (Herba Schizonepetae) and bái zhĭ (Radix Angelicae Dahuricae) should be added. For patients presenting with kidney deficiency, medicinals such as bā jǐ tiān (Radix Morindae Officinalis), tù sī zĭ (Semen Cuscutae) and bŭ gŭ zhī (Fructus Psoraleae) should be added.
MODIFY LIKE A BOSS
For all patterns, in addition to the primary formula, be sure to include chái hú, which acts as an envoy to direct the formula to the shaoyang channels that surround the ear.
- Because the disease usually involves pain, include medicinals that
regulate the qi, such as chái hú, xiāng fù (Rhizoma Cyperi) and chuān xiōng.
- To open obstruction in the channels, consider medicinals that unblock the channels and quicken the collaterals, such as shí chāng pú, dì lóng, lù lù tōng andbái jiāng cán(Bombyx Batryticatus).
- Because the infection and inflammation is in the upper body, consider medicinals that clear fire toxin that are also light and diffusing in nature, such as jīn yín huā, lián qiào, jīng jiè and bò he. The first two are especially important as they expel pus and clear wei-level fevers.
- When there is fire toxin or damp heat from liver and gallbladder, use bitter cold medicinals that downbear fire, such as huáng qín (Radix Scutellariae) and lóng dăn căo (Radix et Rhizoma Gentianae). Huáng qín is especially important because of its relationship with chái hú, which, as discussed above, guides medicinals to the ear via its shaoyang channel relationship.
- Damp-obstruction is a major disharmony that must be resolved. This can be treated with many of the medicinals detailed in the above. However, three stand out as being especially effective: Huáng qí (Radix Astragali) not only boosts the qi and stabilizes the exterior, it also expels pus. Yì yĭ rén drains dampness and expels pus. Shí chāng pú is effective for opening the orifices to improve hearing.
- The final key: if the otitis media is chronic with persistent discomfort, consider the possibility that there is blood stasis. This diagnosis is made not because there is ear trauma, but rather it reflects the chronicity of the case. Medicinals such as dāng guī (Radix Angelicae Sinensis), chuān xiōng and chì sháo (Radix Paeoniae Rubra) are important in this situation. The former medicinal has a relationship with huáng qí in the formula Dāng Guī Bŭ Xuè Tāng (Chinese Angelica Blood-Supplementing Decoction). The actions of the formula are to expel pus and resolve abscesses. Another formula to consider is Bŭ Yáng Huán Wŭ Tāng (Yang-Supplementing and Five-Returning Decoction) that includes all the medicinals listed above. Its action is to boost the qi and promote the circulation of blood in channels. Furthermore, the more chronic the otitis media, the more the practitioner should consider medicinals that reduce nodulation by resolving phlegm and invigorating the blood.
Tan Jing-shu’s approach:
Modern TCM has accumulated extensive clinical experience in treating this condition. Professor Gan Zu-wang of the Nanjing University of Chinese Medicine especially emphasized treating the lungs by using a modified Sān Ào Tāng (Rough and Ready Three Decoction). The late, famous integrative otolaryngopharyngeal expert Tan Jing-shu advocated the practice of integrating TCM and Western medicine etiology and pathology. The pathological characteristics of this condition are infection and allergic reactions in the middle ear in terms of Western medicine, and qi stagnation and blood stasis in terms of TCM. Based on this theory he developed a formula known as the “Anti-Exudates Ear Formula” which yielded good clinical results. For patients with cumulative fluids in the middle ear, the theory focused on promoting urination and orifice opening.
Anti-Exudates Formula (empirical formula from Tan Jing-shu)
Formula: Kàng Shèn Ěr Fāng (Anti-Exudates Formula)
|柴胡||chái hú||10g||Radix Bupleuri|
|香附||xiāng fù||10g||Rhizoma Cyperi|
|川芎||chuān xiōng||15g||Rhizoma Chuanxiong|
|石菖蒲||shí chāng pú||15g||Rhizoma Acori Tatarinowii|
|白术||bái zhú||15g||Rhizoma Atractylodis Macrocephalae|
|金银花||jīn yín huā||15g||Flos Lonicerae Japonicae|
|黄芪||huáng qí||30g||Radix Astragali|
|当归||dāng guī||12g||Radix Angelicae Sinensis|
|黄芩||huáng qín||12g||Radix Scutellariae|
|炮山甲||páo shān jiă||5g||Squama Manitis|
|泽泻||zé xiè||20g||Rhizoma Alismatis|
actions of this formula are to fortify the spleen, disinhibit water, transform stasis, unblock the collaterals, clear heat, dissolve toxins, move qi and open the orifices to treat difficult and chronic cases of exudative otitis media.
Bái zhú, zé xiè, fú líng and huáng qí fortify the spleen and resolve dampness to treat the root of accumulating fluid exudates from the middle ear.
Tōng Qì Săn from the Correction of Errors in Medical Works plus shí chāng pú, shuĭ zhì and páo shān jiă move qi, transform stasis and open the orifices to benefit the opening of the tympanic cavity.
Jīn yín huā and huáng qín clear heat, dissolve toxins and have anti-bacterial and anti-toxic effects.
Huáng qí, bái zhú and dāng guī benefit qi, nourish blood, support the upright qi and secure the root to regulate the immunity.
Tan Jing-shu’s Anti-Exudates Formula is like a hybrid of all the formulas that we have discussed in the chapter. The formula opens with Tōng Qì Tāng. Huáng qín and chái hú act as envoys to the ear, and from there, the formula incorporates bái zhú, huáng qí and fú líng to supplement the spleen qi. Fú líng also pairs with zé xiè to percolate dampness. Jīn yín huā clears fire toxin and expels pus. Dāng guī and huáng qí invigorate the qi and blood and expel pus. Going even further with this pair: if we add chuān xiōng and páo shān jiă (Squama Manitis), we then create the formula Tòu Nóng Săn (Pus-Expelling Powder). Summarizing the characteristics of Dr. Tang’s formula: its primary actions are to regulate the qi and blood, and expel pus using predominantly acrid flavors. In comparison to the primary case, both formulas include Tōng Qì Tāng; however, in the chapter’s primary case history it was combined withYín Qiào Săn to release exterior wind heat. In contrast, Anti-Exudates Formula is strictly a formula for internal patterns. 3
1.Ear Infections in Children. National Institute on Deafness and Other Communication Disorders,National Institute of Health, NIH Publication No. 13-4799, Updated February 2013.Available from:http://www.nidcd.nih.gov/health/hearing/earinfections
2.Otitis Media. National Institute of Health, NIH Publication 97-4216, Updated October 2000.Available from:http://www.nidcd.nih.gov/StaticResources/health/healthyhearing/tools/pdf/otitismedia.pdf
3.Li Fan-cheng, Xu Shao-qin. A Hundred TCM Clinical Masters in Modern China: Tan Jing-shu. Beijing: China Press of Traditional Chinese Medicine, 2007: 148-169
About Cara Frank, L.OM.
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 33 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. In 1998 she went to China to study where she fell deeply in love with Chinese herbs. Since then, she has devoted her life to studying and teaching the topic.
Cara is the founder of Six Fishes Acupuncture, Chinese Herbs and Massage in Philadelphia where she maintains a busy acupuncture practice and acts as the head fish of warm and lively office. She is also the president of China Herb Company. You can read her full bio or schedule an appointment.