Ear Discomfort in Children
Of the many difficult chief complaints that we face as health care providers, earaches in children can be particularly challenging. Over the years of clinical practice, I have treated these complaints many times and would like to share my experience with you.
An understanding of the unique nature of children's physiologies from the TCM perspective is essential in both diagnosing the specific nature of these clinical pictures, and in putting together an effective treatment strategy. It is also important to distinguish between acute and chronic ear conditions, as these are treated differently.
When considering TCM treatment to restore ear health, it is essential to remember that the Spleen is immature in children under 10 years old, which results in a tendency for young bodies to produce excess phlegm. Addressing this issue first is important for effective treatment. Keep in mind that the Spleen likes to be warm and dry, and therefore frequent use of cold and bitter antibiotics can further impair the Spleen's normal functioning. This can also lead to imbalance in the healthy microbial flora in the sinuses, nasal passages, and intestines.
Acute Ear Discomfort
The TCM pattern for acute earache is Wind Heat (Fēng Rè Dú 风热毒). Initial symptoms include itchiness, minor pain, pressure and a stuffy feeling inside the ear. Occasionally a loss of auditory acuity is present. There may also be typical symptoms of external Wind Heat. The ear canal may appear red upon examination. Fluid build-up inside the ear canal can also increase discomfort.
Initial onset of this condition is caused by external Wind Cold invasion of the head and neck. Cold stagnation then causes impairment of Qi and Blood circulation and weakens the Wei Qi. As a result of local Qi and Blood stagnation, Toxic Heat (Rè Dú 热毒) can develop in the ear, leading to increased swelling and the formation of phlegm. If not treated early, and appropriately, it is the formation of Phlegm and Heat together that can cause these cases to become chronic.
It should be noted that the inner ear, by virtue of its anatomical location and its association with the Gall Bladder and San Jiao channels, can be considered as part of the Shao Yang region. Therefore, some TCM practitioners may also include harmonization of the Shao Yang channel with Xiao Chai Hu Wan.
Treatment Principle:
Clear Wind Heat, open sinus and nasal passages, dispel Phlegm, and eliminate Toxic Heat.
Herbal Medicine treatment
To support our treatment principle, I recommend combining these three individual prescriptions together.
Yin Qiao Jie Du Pian
Wu Ju-Tong's Yin Qiao San, first published in Systematic Differentiation of Warm Pathogen Disease in 1798, continues to be one of the most relied-upon prescriptions for initial stage of external Wind Heat invasion. In contrast with Sang Ju Yin, also a prescription of Wu Ju-Tong's which addresses External Wind Heat attack of the Lung, Yin Qiao San addresses Wind Heat affecting the head, eyes, nose and throat. Jin yin hua and Lian qiao specifically treat the initial stage of Toxic Heat and disperses Wind Heat on the exterior.
Dosage: 2-4 pills, 2-3 times daily, depending on patient's age and weight.
Cautions: Do not use in cases of Wind Cold.
Bi Yan Pian
Though this formula is primarily used for Phlegm Heat in the sinus and nasal passages, Bi Yan Pian is equally effective in addressing the same condition in the inner ear. Cang er zi, Xin yi hua, Fang feng, Bai zhi, Jing jie, Ye ju hua and Wu wei zi work together to eliminate congestion and open blockage of the inner ear and ear canal. Zhi mu, Wu wei zi, Lian qiao, Ye ju hua and Gan cao combine to reduce swelling and fluid accumulation of the tissue through their cold, sour and bitter natures.
Dosage: 2-4 pills, 2-3 times daily, depending on patient's age and weight.
Cautions: Use with caution in Yin deficiency.
Ban Lan Gen Pian
This modern formulation was developed specifically to provide a strong Toxic Heat clearing treatment. Nan ban lan gen, Pu gong ying and Zi hua di ding work together to clear heat, reduce swelling, and eliminate Toxic Heat. Pu gong ying and Zi hua di ding, are a classic Dui Yao herb pair. Pu gong ying eliminates heat, clears Toxic Heat, and dispels accumulations on the Qi level, while Zi hua di ding clears Toxic Heat in the deeper Blood level. Nan ban lan gen also clears Toxic Heat, cools the Blood and reduces swelling and accumulations.
Dosage: 2-4 pills, 2-3 times daily, depending on patient's age and weight.
Cautions: Use with caution in Spleen deficient patients.
Treatment Note: Combined together, these three formulas can treat all aspects of occasional acute earache. Dosages of each individual prescription is adjusted to focus treatment on the more predominant aspect of the individual case presentation. For convenience, I have listed the herbal formulas in pill form, but treatment can also be formulated with herb granules or whole herbs in decoction form. It's been my experience that it's easier to treat children with pills or granule formulations in capsule form.
Recurrent Ear Discomfort
Recurrent earaches result from lack of treatment, or incorrect treatment during the first occurrence. As mentioned above, acute earache is the result of the external Toxic Heat pathogens becoming trapped in the middle ear. Under the influence of unresolved Heat and Toxin, the thin, healthy mucus that moistens the membranes of the nasal passages, sinuses and middle ear can become thicker and more copious, leading to further accumulation of Phlegm. This syndrome is inherently more stagnant and intractable. In addition, due to the immature nature of the Spleen this process is further aggravated. This condition is slightly more common in children from 6 to 10 years old.
This pattern can recur for months or years, and wax and wane over time. Standard medical treatment with antibiotics for ear infections may also impair the healthy circulation of Qi and Blood in the middle ear and weaken the Spleen, further aggravating the condition. Treatment must be focused on the local area of the ear, and also requires strengthening of the Spleen Qi in order to support the Spleen's ability to effectively regulate Phlegm and Dampness.
Symptoms include feelings of pressure in the ear, mild earache, trouble hearing, fluid draining from the ears, balance problems, trouble sleeping, irritability, mild fever, and in younger children tugging or pulling at the ear. In more serious cases, some patients may have drainage tubes surgically placed in the ear.
Treatment Principle:
Tonify Spleen Qi, Resolve Dampness and Phlegm, Circulate Qi and Blood, Clear Toxic Heat
Herbal Medicine Treatment
Xiang Sha Liu Jun Zi Wan
First cited in Discussions of Famous Physicians' Formulas Past and Present in 1675, this modification of Si Jun Zi Tang tonifies the Spleen Qi and drains Dampness via the Four Gentlemen, and also includes Ban xia and Chen pi to eliminate Phlegm, and Sha ren, Mu xiang and Sheng jiang to aromatically transform Dampness. Note that the first two components of our diagnostic treatment principle above can be applied via this compact classical prescription. Additionally, Xiang Sha Liu Jun Zi Wan resolves Dampness and Phlegm in the head when it is combined with our next formula.
Dosage: 2-4 pills, 2-3 times daily, depending on patient's age and weight.
Cautions: Contraindicated during early stages of acute illness, and in cases of excess heat or Yin deficiency.
Chuan Xiong Cha Tiao Wan
Originally developed to address minor headache, nasal, and sinus congestion associated with externally contracted Wind Cold, this prescription from Formulary of the Pharmacy Service for Benefitting People in the Taiping Era from 1107 is presently used for a much wider variety of etiologies than simple external Wind Cold. For example, this formula, with Chuan xiong, Bo he, Qiang huo, Bai Zhi and Jing Jie, is ideal to direct our overall prescription to the head, nasal passages and the inner ear. Chuan Xiong Cha Tiao Wan also circulates the Qi and Blood and resolves Dampness and Phlegm.
Dosage: 2-4 pills, 2-3 times daily, depending on patient's age and weight.
Cautions: Contraindicated for headaches due to Yin deficiency, Liver Yang rising, or other deficiency patterns.
Pu Ji Xiao Du Yin
This formula from Dong-Yuan's Tried and Tested Formulas from 1202 was developed specifically to treat seasonal external invasion of Toxic Heat. The prescription employs two treatment principles, namely dispersing Wind Heat and resolving Toxic Heat. It is a powerful formula, comprised of fifteen ingredients, and can be used to treat a wide variety of these conditions that specifically manifest in the neck and head. Huang lian and Huang qin are the dominant Toxic Heat clearing herbs in the formula, with Lian qiao, Xuan shen, Ma bo, and Ban lan gen assisting. For our purposes in treating chronic ear discomfort, only very small amounts of this formula are needed.
Dosage: 1-3 pills, 2-3 times daily, depending on patient's age and weight.
Cautions: Use with caution in hemorrhagic disorders and in patients on anticoagulant therapy.
Treatment Note: See notation under Acute Ear Discomfort.
Final Thoughts
For both acute and recurrent earache, Chinese herbal medicine can be quick and effective in resolving these clinical pictures. It is important to evaluate the relative proportions of the treatment principle objectives and adjust herbal medicine prescriptions accordingly. Careful attention should also be paid to dietary and behavioral factors that may be precipitating or aggravating these clinical pictures and recommending remedial action to reduce their influence. It is of particular importance to evaluate the child's intake of white flour, soy and dairy products, and sugar. Overconsumption of these damp and phlegm producing foods can be significant factors in precipitating and prolonging these clinical presentations.
References
- Bensky, D. & Barolet, R., Formulas & Strategies, Eastland Press: 1990.
- Bensky, D. et al., Chinese Herbal Medicine Materia Medica, 3rd ed., Eastland Press: 2004.
- Liu, Guohui, Warm Pathogen Diseases, A Clinical Guide, Revised edition, Eastland Press: 2005
- Chen, J. & Chen, T., Chinese Medical Herbology and Pharmacology, Art of Medicine Press: 2004.
- Maclean, Will, Clinical Manual of Chinese Herbal Patent Medicines, Pangolin Press: 2003
- Wrinkle, A. et al., A Practitioner’s Formula Guide, Elemental Essentials Press: 2008.
About the Author
Mark W. Frost, MSTCM, and licensed acupuncturist, was previously chair of the Herbal Medicine Department at the American College of Traditional Chinese Medicine in San Francisco, California where he taught in both the Masters and Doctoral Programs and served as a clinical supervisor in their Community Clinic. Mark has also been in private practice in San Francisco for more than 30 years. He is the author of numerous articles on Chinese herbal medicine and has presented at several TCM conferences since 2014.
