Cara O. Frank, L.OM.
The following is an excerpt from one of the chapters of my forthcoming book on TCM Case Histories: Eye, Ears, Nose and Throat Disorders.
Vertigo Due To Auricular Illness encompasses vertigo as well as Ménière’s disease. Vertigo is defined as the illusion of motion. It can include chronic or intermittent sensations of loss of balance. The causes of vertigo include benign paroxysmal positional vertigo (BPPV), inflammation in the inner ear, migrainous vertigo, acoustic neuroma and Ménière’s disease. Rarely, it can be a symptom of aserious neurological problem such as a stroke, brain hemorrhage or multiple sclerosis[i].
Ménière’s disease is an inner ear disorder that is characterized by severe dizziness, tinnitus, hearing loss and a sensation of congestion in the ear. Usually unilateral, the dizziness is episodic and the attacks often come on suddenly or after an episode of tinnitus. The causes of Ménière’s disease are unclear[ii] and frequently idiopathic. It resembles many other diseases and is often conclusively diagnosed when other pathologies are ruled out. It has been theorized that excess fluid in the labyrinth (hydrops) is the cause of Ménière’s disease. It is also hypothesized that the membranous labyrinth becomes filled with endolymph that stimulates receptors as the body moves. The receptors send signals to the brain, which affect proprioception. In the cochlea, fluid is compressed in response to sound vibrations, which stimulates sensory cells that send signals to the brain. The endolymph buildup in the labyrinth interferes with normal balance and hearing signals between the inner ear and the brain. This abnormality causes vertigo and other symptoms of Ménière’s disease. Recent theories, however, center on immunologic causes such as autoimmune thyroiditis[iii]. Migraines may also be a cause of Ménière’s disease.
Attacks may be separated by long periods, or they may be clustered close together over days or weeks. The vertigo may be so extreme that patients lose their balance. It most commonly occurs in people from 40-60 years old; however, it can occur at any age. The National Institute on Deafness and Other Communication Disorders reports that approximately 615,000 people in the United States have been diagnosed with Ménière’s disease and that 45,500 cases are newly diagnosed each year[iv].
Diagnosis is usually based upon the patient’s medical history and the presence of at least two episodes of vertigo lasting at least 20 minutes each, tinnitus, temporary hearing loss and a sensation of fullness in the ear. To rule out other diseases, magnetic resonance imaging (MRI) or computed tomography (CT) scans of the brain may be performed.
Treatment consists of medications to manage the dizziness and accompanying nausea. For BPPV, the main treatment is canalith repositioning. Drugs such as meclizine, diazepam, and lorazepam can help relieve dizziness and shorten the attack. Salt restriction and diuretics may help some people control dizziness by reducing the amount of fluid the body retains, which may help lower fluid volume and pressure in the inner ear. Some people may benefit from restricting caffeine, chocolate and alcohol.
Gentamicin injections into the middle ear helps control vertigo, but significantly raises the risk of hearing loss because gentamicin can damage the microscopic hair cells in the inner ear. Refer to the chapter on Hearing Loss due to Pharmaceutical Toxins for further discussion of this topic. Injections of corticosteroids are also an option to reduce dizziness with no risk of hearing loss.
In TCM, Vertigo Due To Auricular Illness is a condition caused by pathology of the ear orifice. It is characterized by carsickness and a spinning sensation in the head. There are different theories regarding the etiology of this condition. For example, there is the theory that dizziness relating to wind always belongs to liver. While this is true, dizziness can also be caused by phlegm, as well as by weakness. It can present in both deficient and excessive patterns; however, it has a deficient root and an excessive manifestation. The classic text Records of Following Others in Medicine (Yī Xué Cóng Zhòng Lù, 医学从众录) by Chen Xiu-yuan of the Qing dynasty, states that: “Deficiency belongs to the root while excess refers to the pathological manifestation”.
In the clinical setting, Vertigo Due To Auricular Illness often presents as a combination of deficiency and excess, with a pattern of deficient root and excessive branch. Deficiency is often from the kidneys and spleen, while excess is usually due to external pathogens, such as phlegm turbidity, liver yang, and a cold quality of water rising to disturb the clear orifices.
COMMON CLINICAL PATTERNS
Attack of external wind pathogens
Phlegm turbidity blocking the center
Liver yang rising
Cold water flooding upwards
Deficiency of the sea of marrow
Central qi deficiency
Female, age 45. Initial Visit: June 3, 2006.
Chief Complaints: Paroxysmal vertigo with recurrent visual rotation for 2 months before treatment.
History: 2 months before treatment, sudden vertigo occurred after the patient had a family dispute at home. Symptoms remained unchanged after resting. Dizziness and tinnitus appeared the next day and the patient came to the hospital. After being injected with Salviae via IV and taking Merislon Pills orally, the patient felt better. Since then, vertigo, tinnitus and dizziness recurred frequently. Symptoms were often aggravated by mood and irritability. During the onset of disease, the vertigo was accompanied by decreased hearing. The patient also frequently experienced a bitter taste in her mouth, a dry throat, a red face, red eyes, irritability and anger.
Signs and Symptoms: Vertigo, dizziness along with a fear of rotating the head, nausea, decreased hearing and paroxysmal tinnitus along with a bitter taste in the mouth, a dry throat, red face and eyes, and bitterness and fullness in the hypochondriac region. The tongue body was red with spots and a yellow coating. The pulse was wiry and rapid.
Past History: Unremarkable.
Physical Examination: Blood pressure 130/80 mmHg, thin body type, in supine position, fearful of rotating the head.
Special Examination: There was no blockage in the external ear canal. The tympanic membrane was intact with clear marking signs. Involuntary nystagmus one degree, which was faster on the left.
In this case, the vertigo occurred after emotional distress, indicating that the binding of liver qi had transformed into fire, leading to wind-fire rising upward and disturbing the clear orifices. The liver prefers free flow rather than stagnation, and liver qi stagnation can cause irritability and anger. Liver qi stagnation transforms fire into wind, and wind-fire rising upward can disturb the clear orifices. All these factors resulted in vertigo, tinnitus, hearing loss, a red face and eyes. Qi depression caused fullness in the chest and hypochondriac region, and liver fire injured fluids, leading to the bitter taste in the mouth and dry throat. The red tongue body with spots and a yellow coating and the wiry, rapid pulse indicated heat. The wiry pulse is a sign that indicates liver disease.
The location of this condition was the clear orifices. It was caused by liver yang rising and was an excessive pattern.
WM Diagnosis: Vertigo due to auricular illness
TCM Diagnosis: Vertigo due to liver yang disturbing upward
The vertigo in this case was due to emotional distress causing liver qi stagnation, and liver yang ascending disturbing the clear orifices. The clinical manifestation of this case was in the liver, while the root cause lay in the kidneys. Liver and kidney deficiency resulted in liver yang rising. Treatment, therefore, should focus on calming yang, extinguishing the wind, nourishing yin and subduing yang. The patient should rest in bed during the acute onset and maintain quiet.
Treatment Principles: Calm the liver, extinguish the wind, nourish the yin and subdue the yang.
Formula: Modified Tiān Má Gōu Téng Yĭn (Gastrodia and Uncaria Decoction)
|天麻||tiān má||30g||Rhizoma Gastrodiae|
|钩藤（后下）||gōu téng (add at the end)||15g||Ramulus Uncariae Cum Uncis|
|石决明||shí jué míng||30g||Concha Haliotidis|
|黄芩||huáng qín||10g||Radix Scutellariae|
|栀子||zhī zĭ||10g||Fructus Gardeniae|
|龙胆草||long dăn căo||5g||Radix et Rhizoma Gentianae|
|丹皮||dān pí||15g||Cortex Moutan|
|牛膝||niú xī||15g||Radix Achyranthis Bidentatae|
|杜仲||dù zhòng||10g||Cortex Eucommiae|
|桑寄生||sāng jì shēng||10g||Herba Taxilli|
|益母草||yì mŭ cáo||30g||Herba Leonuri|
|夜交藤||yè jiāo téng||15g||Caulis Polygoni Multiflori|
Formula AnalysisTiān má, gōu téng and shí jué míng calm the liver, subdue yang and extinguish the wind.
Huáng qín and zhī zĭ clear liver heat.
Niú xī, dù zhòng, sāng jì shēng and yì mŭ căo nourish the liver and kidney.
Yè jiāo téng calms the spirit and stabilizes the mind.
Lóng dăn căo and dān pí clear the liver and sedate fire, which is indicated by the prickles on the side of the tongue, a sign of excessive liver fire.
Modifications: If there are obvious symptoms of photophobia and nystagmus, the condition belongs to the pattern of liver yin deficiency and deficient wind causing pathological eye movement. Add jú huā (Flos Chrysanthemi), jué míng zĭ (Semen Cassiae), qīng xiāng zĭ (Semen Celosiae), shā yuàn zĭ (Semen Astragali Complanati) and bái jí lí (Fructus Tribuli) to calm the liver and brighten the eyes.
If there is a stiff neck and aggravated vertigo while turning the head, these are symptoms of liver channel congestion and liver wind stirring internally. For these cases, add sī guā luò (Retinervus Luffae Fructus), luò shí téng (Caulis Trachelospermi) and rĕn dōng téng (Caulis Lonicerae Japonicae) to open the channels and invigorate the collaterals.
Main Points: DU 20 (băi huì), ST 8 (tóu wĕi), GB 20 (fēng chí), DU 16 (fēng fŭ), HT 7 (shén mén), PC 6 (nèi guān).
Supplementary Points: LV 2 (xíng jiān), GB 43 (xiá xī), UB 18 (gān shū).
Method: Select three main points along with 1-2 supplementary points per treatment, alternating the points every day. Needles should be retained for 20 minutes after obtaining needle sensation, once per day.
Techniques: Sedating technique applied mainly.
After 3 days of treatment, the vertigo improved. The redness in the face, red eyes, the bitter taste and fullness in the chest area were eliminated, indicating that smoothing of liver qi stagnation and a reduction of liver fire had occurred. A dry throat, thirst, irritability, insomnia, and vexing heat in the heart accompanied by mild vertigo remained. The tongue body was red with little fluid and a yellow coating and the pulse was thin and rapid. This indicated that damaged yin remained despite bringing the liver yang under control.
Treatment Principles: Nourish the yin, enrich fluids, calm the liver and subdue the yang.
Formula: Modified Qí Jú Dì Huáng Wán (Lycium Berry, Chrysanthemum and Rehmannia Pill)
|熟地黄||shú dì||15g||Radix Rehmanniae Praeparata|
|山茱萸||shān zhū yú||10g||Fructus Corni|
|山药||shān yào||10g||Rhizoma Dioscoreae|
|泽泻||zé xiè||15g||Rhizoma Alismatis|
|丹皮||mŭ dān pí||10g||Cortex Moutan|
|枸杞子||gŏu qí zĭ||10g||Fructus Lycii|
|菊花||jú huā||10g||Flos Chrysanthemi|
|夜交藤||yè jiāo téng||15g||Caulis Polygoni Multiflori|
Liù Wèi Dì Huáng Wán (Six-Ingredient Rehmannia Pill) nourishes the yin and fluids.
Gŏu qí zĭ and jú huā calm the liver and subdue the yang.
Yè jiāo téng calms the spirit, stabilizes the mind and helps sleep.
COMMENTARY AND DISCUSSION
In TCM, vertigo encompasses two aspects that refer to sensations of discomfort in the head: xuàn yūn, dizziness and a faint sensation. The term xuàn refers to a sensation in the eye characterized by dim blinding, which is the sensation of fainting. Yūn refers to a sensation of continuous motion in the head. Both symptoms can occur concurrently or independently. This combination of symptoms can also be referred to as Ěr Xuàn Yūn, or Auditory Vertigo
Diagnosing and treating dizziness, vertigo, and Ménière’s disease is complex. Every case will present with both excessive and deficient symptoms. Historical literature, from The Yellow Emperor’s Inner Classic to the Basic Questions, refers to liver wind as a causative factor, while the Spiritual Pivot[v] lists eight references to dizziness, ranging from evil affecting the heart and the kidneys, to heat in the yangming channels, sea of marrow deficiency and qi not reaching the head.
In the Ming dynasty, Zhu Dan-xi[vi] detailed summer heat and phlegm as a cause of dizziness. According to him, dizziness is caused by phlegm above with fire below. The fire updrafts the phlegm, causing dizziness and vertigo accompanied by nausea. He treats qi-deficiency dizziness with a combination of Èr Chén Tāng (Two Matured Substances Decoction) and Sì Jūn Zĭ Tāng (Four Gentlemen Decoction), which together create the formula Liù Jūn Zĭ Tāng (Six Gentlemen Decoction). He modifies it with huáng qí (Radix Astragali), chuān xiōng (Rhizoma Chuanxiong) and jīng jiè (Herba Schizonepetae). In the case of Wind-Phlegm dizziness, he uses Èr Chén Tāng plus huáng qín (Radix Scutellariae), cāng zhú (Rhizoma Atractylodis), fáng fēng (Radix Saposhnikoviae) and qiāng huó (Rhizoma et Radix Notopterygii). No doses are given. For excessive cases with dry-bound stools, use Dà Chéng Qì Tāng (Major Purgative Decoction), which connects to the yang-ming reference from the Líng Shū.
The Ming dynasty text Symptoms, Causes, Pulses and Treatment Zhèng Yīn Mài Zhì provides a detailed list of symptoms and treatments of dizziness due to summer-heat pattern.
The pattern of Cold Water Flooding Upwards is rarely discussed in historical literature. Based on the discussion above, the physician would diagnose this pattern as a Zhēn Wŭ Tāng (True Warrior Decoction) presentation of kidney yang deficiency with excessive water accumulation. This is a pattern of pathogenic yin excess. The treatment focuses on warming the kidney and spleen yang and strengthening the spleen qi to transform and drain fluids. Zhēn Wŭ Tāng has a wide realm of applications, all relating to various presentations of excessive water accumulation.
The term Cold Water Flooding evokes an image of water everywhere. The term shuǐ qì, water qi, is used to describe the spreading, infiltrative nature of excessive water in the body, which can affect the entire body. For instance, if water affects the flesh, there will be superficial edema. If water is in the intestines, there will be watery diarrhea. If water obstructs the clear yang from ascending to the head, then it can obstruct the clear orifices, causing dizziness and vertigo. The tongue can be pale or dark, but it will be swollen with teeth marks, which indicates excessive fluid in the body.
Zhēn Wŭ Tāng is often used to treat edema, cardiac insufficiency, ascites and Ménière’s diseases. If the pattern of spleen yang deficiency dominates the presentation with symptoms of fullness in the chest and shortness of breath, then the guiding formula would be Líng Guì Zhú Gān Tāng (Poria, Cinnamon Twig, Atractylodes Macrocephala and Licorice Decoction). Another formula, perhaps even more useful for this presentation, is Wú Zhū Yú Tāng (Evodia Decoction), which warms the spleen and descends the stomach qi to alleviate nausea and stop vomiting.Compared to Zhēn Wŭ Tāng, this formula also is warming, but does not contain any medicinals to drain fluids. Therefore, it would be an excellent modifier for Zhēn Wŭ Tāng and Líng Guì Zhú Gān Tāng when vertigo with nausea and vomiting are the predominant symptoms.
The primary case in this chapter relates a case of Ménière’s disease with a diagnosis of liver yang ascending. The history of the case describes an algorithm similar to many of the ophthalmological cases: First, a decisive emotional experience causes anger, which results in symptoms of liver qi stagnation. The stagnation generates fire, which in turn causes wind-fire to ascend. If the person were predisposed to develop an eye disease, then perhaps the problem might manifest as conjunctivitis. In this case, the disease affects the clear orifices and manifests as vertigo. Similar to the ophthalmological cases, treatment begins with clearing excessive heat and fire. The following strategy focuses on clearing heat and nourishing the yin.
A modern formula created to treat hypertension resulting from liver yang ascending, the selected formula is a cleanly modified Tiān Má Gōu Téng Yĭn. Its construct is classic. There are medicinals to downbear ascendant liver yang, strengthen the liver and kidney yin and conduct blood away from the head. The only component missing is medicinals to clear liver fire. Thus simply adding long dăn căo and dān pí modifies the formula to clear liver fire. The key physical sign of this is the red prickles on the tongue, a clear sign of congested heat in the liver.
The first group of modifications the author suggests resembles many of the formulas that treat eye diseases. Of this group, all the medicinals clear the vision and are cool or cold with the exception of shā yuàn zĭ, which is warm.Jú huā, shā yuàn zĭ and jué míng zĭ have a sweet flavor, moisten the liver and improve vision. Qīng xiāng zĭ and bái jí lí (as well as jú huā and jué míng zĭ) clear wind and heat from the eyes with bitter and pungent flavors.
The second group of modifiers is unusual. Many formulas, including the primary one in this chapter, Tiān Má Gōu Téng Yĭn, include medicinals that sedate the liver, clear liver fire and eliminate wind to treat xuàn yūn. The treatment strategy and selection of medicinals is noteworthy for its perspective: The author uses sī guā luò, luò shí téng and rĕn dōng téng to eliminate wind from the liver channels and collaterals to alleviate the stagnation that causes vertigo. They are individually distinct in the following ways: Sī guā luò also transforms phlegm, luò shí téng is the best for promoting circulation in the collaterals, and rĕn dōng téng is most effective at clearing heat.
At the follow-up visit 3 days later, the patient has improved. The worst of the heat is resolved, and now there are sequelae of dryness and yin deficiency. The pattern that remains is referred to as Xū Fán Bù DéMián, Deficiency Vexation and Sleeplessness[vii], which describes a sensation or unease centered in the chest, along with insomnia and a dry mouth associated with residual heat. The treatment strategy is to enrich the yin and clear fire. The selected formula, Qí Jú Dì Huáng Wán, is modified with a single medicinal: yè jiāo téng, which calms the spirit and nourishes the heart blood. As a vine, yè jiāo téng creates an energetic symmetry with luò shí téng and rĕn dōng téng.
[i] http://www.mayoclinic.com/health/dizziness/DS00435/DSECTION=causes need full citations for WebPages
[v] Ling-Nuan, Wu, Ling Shu or The Spiritual Pivot, Asian Spirituality, Taoist Studies Series, the Taoist Center, Washington, D.C. 2011
[vi] Pg. 160, Shou-zhong, Yang, The Heart & Essence of Dan-xi’s Methods of Treatment. Blue Poppy Press, 1993
[vii] Pg 652, Wiseman, Ye, A Practical Dictionary of Chinese Medicine, 2nd edition, Paradigm Publications 1998
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 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.