Cara O. Frank, L.OM.
The following is an excerpt from my forthcoming book TCM Case Histories: Eye, Ear, Nose and Throat Disorders. This chapter discusses common early stage middle ear infections. I will follow up with excerpts on suppurative otitis media at a later date. The full chapter includes other case scenarios as well as discussions of other formulas. I hope that you find it helpful.
Non-suppurative otitis mediarefers 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.
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
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)
Male, age 17. Initial Visit: July 9th, 2001
Chief Complaint: Distention, oppression and a sensation of obstruction in both ears along with a deterioration in hearing for one week prior to treatment.
History: The patient suffered from a cold one week prior to treatment. Since then, symptoms of distention, oppression and a sensation of obstruction in the both ears, mild pain, tinnitus, autophony, decreased hearing ability, a stuffy and running nose, headache, cough, fever and an aversion to cold appeared. Self-administration of antibiotics relieved these symptoms somewhat, but the stuffy, swollen and obstructed sensation persisted along with a cough and no improvement in hearing.
Signs and Symptoms: Tinnitus was present and sounded like wind, accompanied by autophony and decreased hearing ability. The patient’s appetite and sleep were fair. Urination and bowel movements were normal. The tongue was pink with a thin yellow coating and the pulse was wiry and rapid.
Examination: Both auricles were normal with no discharge found in bilateral external auditory canals. Both eardrums were intact with mild hyperaemia and some fluid collection in the tympanic cavity. There was obvious hyperaemia in the nasal membrane and mild swelling of the right nasal concha. The nasal cavity airway was normal with some discharge in the inferior nasal meatus.
This case began with external wind invading the lung, which congested the channels of the ear, causing the mild distending pain. The subsequent stagnation of the ear orifice resulted in the inability of clear qi to reach the ear. Wind heat attacking upward caused mild hyperaemia of the eardrum that blocked the clear orifice, hence the wind-sound type of the tinnitus. Wind heat attacking the lungs resulted in impaired lung depuration and the dysfunction of nutrient qi and defensive qi. This, in turn, caused swelling of the nasal membrane, nasal congestion, headache and aversion to cold and fever. All of these are symptoms of wind heat attacking the lungs causing ear congestion, hence the accumulated fluid in the tympanic cavity. Evil stagnation, ear orifice congestion and clear qi insufficiency resulted in the sunken eardrum. The accumulation of fluid in the tympanic cavity indicated dampness and yin evil congestion. The ear congestion caused the blockage of external sound entering the ear, hence the autophony and decrease in hearing.
The origin of this condition was in the lung. It belonged to the excessive patterns of impaired lung depuration, lung qi stagnation and blockage in the channels of the ear orifice.
WM diagnosis: Non-suppurative otitis media
TCM diagnosis: Ear distention and block due to external pathogenic wind attacking and channel qi blockage
The cause of this condition was an attack of external pathogenic wind coupled with channel qi blockage. Treatment should focus primarily on coursing wind and dissipating heat, and then, as the supplementary treatment, dissipating pathogens and opening the blockage.
Principle: Disperse wind, dissipate pathogens, diffuse the lung and open the orifices
Formula: ModifiedYín Qiào Săn (Lonicera and Forsythia Powder) and Tōng Qì Săn (Qi-Freeing Powder)
|金银花||jīn yín huā||15g||Flos Lonicerae Japonicae|
|连翘||lián qiào||15g||Fructus Forsythiae|
|荆芥||jīng jiè||15g||Herba Schizonepetae|
|薄荷||bò he||10g||Herba Menthae|
|淡豆豉||dàn dòu chĭ||10g||Semen Sojae Praeparatum|
|桔梗||jié gĕng||10g||Radix Platycodonis|
|淡竹叶||dàn zhú yè||6g||Herba Lophatheri|
|芦根||lú gēn||15g||Rhizoma Phragmitis|
|石菖蒲||shí chāng pú||5g||Rhizoma Acori Tatarinowii|
|桑白皮||sāng bái pí||12g||Cortex Mori|
|路路通||lù lù tōng||15g||Fructus Liquidambaris|
|柴胡||chái hú||10g||Radix Bupleuri|
|川芎||chuān xiōng||10g||Rhizoma Chuanxiong|
|泽泻||zé xiè||10g||Rhizoma Alismatis|
|甘草||gān căo||6g||Radix et Rhizoma Glycyrrhizae|
Yín Qiào Săn is the primary formula. It consists of acrid, cool and exterior-resolving medicinals. It expels wind and clears heat. It mainly treats patterns of externally contracted wind heat. Yín Qiào Săn combines well with Tōng Qì Săn, which diffuses qi in the shaoyang channels and guides the medicinals to the site of disease.
Jīn yín huā and lián qiào clear heat, resolve toxins, lightly diffuse and expel pathogens.
Jīng jiè, bò he and dàn dòu chĭ have an acrid quality, dissipate external pathogens and expel heat.
Dàn zhú yè, zé xiè and sāng bái pí clear heat and promote urination.
Shí chāng pú and lù lù tōng have afragrant quality and dissipate pathogens, open the orifices and enhance hearing ability.
Jié gĕng clears the lungs and guides the medicinals upward.
Lú gēn and chái hú clear heat and dissipate pathogens; chái hú also guides the formula into the shaoyang channels.
Chuān xiōng eliminates wind, opens the channels and enhances the hearing.
Gān căo harmonizes the formula.
Nasal drop therapy: 1% ephedrine nasal drop solution for the distended ear (make sure the solution reaches the pharyngeal opening of auditory tube).
Ear drop therapy: 1%-3% phenol glycerol ear drops for inner ear distention and pain (contraindicated in cases of eardrum perforation).
Eustachian tube self-inflation therapy: This method can be applied once the redness and swelling in the eardrum have dissipated leaving only ear distention. Be cautious in cases of nasal congestion and profuse nasal discharge. Instruct the patient to squeeze tightly the alae of the nose on both sides, with the mouth closed, to create a closed cavity between the nasopharyngeal part, the mouth and the nasal cavity. Then exhale which increases pressure in the cavity to push open the eustachian tube. Instead of the breathing method, the patient can also use the swallowing technique to decrease the pressure in the cavity, thus increasing pressure in the middle ear and pushing the eustachian tube open.
Tympanic membrane puncture to extract fluid:Patients with significant fluid accumulation under the tympanic membrane and no improvement in the distending ear pain should try this method.
Main points: SI 19 (tīng gōng), GB 2 (tīng huì), SJ 21 (ĕr mén)
Supplementary points: LI 20 (yíng xiāng), GB 20 (fēng chí), LU 5 (chĭ zé), SJ 5 (wài guān), SJ 3 (zhōng zhŭ), GB 41 (zú lín qì)
Method: Needle both sides simultaneously. Select 1-2 main points each time along with 2-4 supplementary points. Needles should be retained for 15-20 min after obtaining needle sensation, once per day.
Techniques: Sedating technique applied for the first week of the treatment, then even technique thereafter.
After 14 packs of medicinals, the patient’s hearing was greatly improved, ear obstruction was significantly reduced and the tinnitus was alleviated during the day with mild recurrence at night. The autophony remained along with fatigue and a pale face. An examination revealed reduced redness in the eardrum, eradication of fluid and a clear nasal passage. The tongue was pale with teeth marks and a white coating. The pulse was thin.
At this point, the case was sub-acute and the patient’s hearing had improved greatly and the pathogenic wind-heat had receded. More signs of spleen deficiency and combined symptoms of deficiency and excess were now evident.
Principles: Fortify the spleen and drain dampness, assisted by dispersing wind and opening the orifices
Formula: Modified Shēn Líng Bái Zhú Săn (Ginseng, Poria and Atractylodes Macrocephalae Powder) and Yù Píng Fēng Săn (Jade Wind-Barrier Powder)
|太子参||tài zĭ shēn||10g||Radix Pseudostellariae|
|白术||bái zhú||10g||Rhizoma Atractylodis Macrocephalae|
|防风||fáng fēng||10g||Radix Saposhnikoviae|
|辛夷||xīn yí||10g||Flos Magnoliae|
|石菖蒲||shí chāng pú||10g||Rhizoma Acori Tatarinowii|
|蝉蜕||chán tuì||10g||Periostracum Cicadae|
|蒲公英||pú gōng yīng||10g||Herba Taraxaci|
|薏苡仁||yì yĭ rén||30g||Semen Coicis|
|甘草||gān căo||5g||Radix et Rhizoma Glycyrrhizae|
|白芷||bái zhĭ||5g||Radix Angelicae Dahuricae|
The focus of this formula is to support the upright qi, dispel pathogens and expel them from the body.
Pú gōng yīng and yì yĭ rén drain dampness and expel pus.
Xīn yí and bái zhĭ arefragrant in nature, transform turbidity and open the orifices.
Chán tuì and dì lóng reinforce the formula’s ability to expel pathogens and open the orifices.
The formula fortifies the spleen and drains dampness without being overly drying.
COMMENTARY AND DISCUSSION
Auricular swelling and obstruction, or otitis media, is an extremely common complaint in clinical practice. It is clear from this detailed chapter that the pattern discrimination is well thought through and the condition is very responsive to treatment with Chinese medicine. In TCM, this disease falls into the category of ěr zhàn (ear distention) or ěr bì (ear block).
It is useful to briefly recap the patterns and offer pointers for effective treatment:
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.
The primary case in this chapter deals with an acute ear infection. The selection and treatment principles incorporate most of the guidelines above: Yín Qiào Săn is one of the world’s most commonly used formulas to dispel wind heat. It especially benefits the throat. In this case, the primary medicinals are guided to the ears by the formula’s modifiers, chái hú and chuān xiōng. The former is cool and the latter is warm. Other formulas that regulate the qi and blood use this combination, including Xuè Fŭ Zhú Yū Tāng (Blood Mansion Stasis-Expelling Decoction) and Chái Hú Shū Gān Săn (Bupleurum Liver-Soothing Powder). Other formulas that include this pair include Jīng Fáng Bài Dú Săn (Schizonepeta and Saposhnikovia Toxin-Resolving Powder) and Rén Shēn Bài Dú Săn (Ginseng Toxin-Resolving Powder). Another way to understand the formula is to focus on the flavors that predominate it; at the forefront are acrid flavors are included to eliminate wind, clear heat and toxins. The secondary group uses sweet and bland flavors that resolve toxins and drain heat and dampness through urination.
At the follow up visit, symptoms of acute heat are resolved and the patient’s symptoms of spleen deficiency become apparent. He still has mild discomfort. Because pain is always considered a sign of excess (as is dampness), the treatment strategy is to strengthen the spleen, resolve dampness, expel wind and open the orifices. Shēn Líng Bái Zhú Săn and Yù Píng Fēng Săn are modified in unique ways. Most striking is the inclusion of the wind-tracking, orifice-opening insects chán tuì and dì lóng. In a shift from the unmodified formula in which yì yĭ rén is used to dry dampness and stop diarrhea, the addition of pú gōng yīng shifts its focus to expel pus. Finally, warm, fragrant and acrid xīn yí and bái zhĭ are added to bust through phlegm obstruction in the ears. To redirect our attention again to the flavors of the formula, the majority of the formula consists of tonics and thus is sweet and bland. The second most dominant flavor is a tie between bitter and salty. In direct contrast to the first formula, predominantly composed of acrid medicinals that tend to disperse upwards and outwards, the flavors of this formula—bland, bitter and salty—have a draining and downbearing action. That said, the formula is still well balanced and not excessively drying.
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 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 where she maintains a busy acupuncture practice and acts as the head fish of the office. She is also the president of China Herb Company You can read her full bio or schedule an appointment.