deafness1.pngTinnitus and Deafness (Ĕr Míng Ĕr Lóng)


Er Ming: “ear ringing” (e.g., cicadas, ocean tides)
Er Long: “deafness; decline or loss of hearing”

Clinically, tinnitus and deafness may or may not present simultaneously. Although they have different manifestations, their pathogenesis in TCM terms is virtually identical, which is why they are discussed together.

Deafness

Hearing loss can be divided into 2 main categories:
Conductive hearing loss (CHL): occurs because of some mechanical problem in the external or middle ear. The three tiny bones of the ear (ossicles) may fail to conduct sound to the cochlea or the eardrum may fail to vibrate in response to sound. Fluid in the middle ear can cause CHL.
Sensorineural hearing loss (SNHL): results from a dysfunction of the inner ear. It most often occurs when the tiny hair cells (called cilia) that transmit sound through the ear are injured. This type of hearing loss is sometimes called "nerve damage," although this is not accurate.

deafness2.pngGeneral Etiology

-Occupational/Noise-induced
-Age-related (a.k.a. presbycusis)
-Infectious (e.g. otitis media)
-Toxic (e.g., aminoglycoside antibiotics, aspirin, quinine)
-Genetic (e.g., otosclerosis)
-Congenital (e.g., otosclerosis)
-Traumatic
-Other (physical obstruction such as earwax, Meniere’s disease, acoustic neuroma, autoimmune)

Conductive hearing loss
-Obstruction of external ear canal (for example, with wax, a tumor, or pus from an infection)
-Middle ear infection (otitis media)
-Chronic middle ear fluid (otitis media with effusion)
-Cholesteatoma (noncancerous tumor in the middle ear caused by an ear infection)
-Otosclerosis (bony overgrowth of the ossicles from genetic or congenital factors)
-Perforated eardrum

Sensorineural hearing loss
-Aging (a.k.a. presbycusis)
-Loud noise
-Certain drugs (e.g., aminoglycoside antibiotics, aspirin)
-Viral infection of the inner ear (labyrinthitis)
-Childhood infections (mumps, meningitis)
-Congenital infection (toxoplasmosis, rubella, cytomegalovirus, herpes, syphilis)
-Genetic
-Meniere's disease
-Brain tumors
-Congenital abnormality
-Demyelinating diseases (diseases that destroy the myelin sheath covering nerves)
-Sudden pressure changes from flying, diving, and strenuous exercise

Statistics

-More than 28 million people in the United States are deaf or have hearing loss.
-Older people are the most affected: 30 to 40% of people aged 65 and older have significant hearing loss.
-Every year, about 1 out of 5,000 people develops sudden deafness. Sudden deafness is severe hearing loss, usually in only one ear, that develops over a period of a few hours or less.

Age-related Hearing Loss (a.k.a. Presbycusis)
Age-related hearing loss first affects the highest pitches (frequencies) and only later affects lower pitches. Loss of the ability to hear high-pitched sounds often makes it more difficult to understand speech. Although the loudness of speech appears normal to the person, certain consonant sounds—such as the sound of letters C, D, K, P, S, and T—become hard to distinguish, so that many people with hearing loss think the speaker is mumbling.

Rinne Tuning Fork Test
-A screening test that helps distinguish between conductive from sensorineural hearing loss by comparing how well a person hears sounds conducted by air with how well the person hears sounds conducted by the skull bones.
-To test hearing by air conduction, the tuning fork is placed near the ear. To test hearing by bone conduction, the base of a vibrating tuning fork is placed against the head so the sound bypasses the middle ear and goes directly to the nerve cells of the inner ear.
-If hearing by air conduction is reduced but hearing by bone conduction is normal, the hearing loss is conductive. If both air and bone conduction hearing are reduced, the hearing loss is sensorineural or mixed. People with sensorineural hearing loss may need further evaluation to look for other conditions, such as Meniere's disease or brain tumors.


Biomedical Tx

-Obstruction of the canal from debris or wax: a doctor can vacuum (wash) the canal or recommend over-the-counter drops that dissolve ear wax
-Fluid in the middle ear: tympanostomy (a small tube placed in the eardrum to drain and prevent fluid accumulation)
-Deafness: Biomedical Tx
-Corticosteroids: for autoimmune causes or sudden hearing loss
-Surgery: otosclerosis, tumors
-Hearing Aids
-Cochlear Implants

Prevention of Deafness

-Limiting exposure to loud noise (music played through headphones can be particularly damaging)
-For occupational or firearm exposure, the use of hearing protectors, such as plastic or foam rubber plugs in the ear canals or glycerin-filled muffs over the ears, is essential

TCM Etiology and Pathogenesis

Tinnitus: Differentiating Repletion from Vacuity
Repletion patterns characterized by sudden onset, loud and high-pitched ringing
Vacuity patterns characterized by gradual onset and soft, low-pitched sounds
Note: The pitch or loudness of tinnitus should not be taken as a sure indicator of repletion or excess; always corroborate these sx’s with patient’s other sx’s to determine the pathology and pattern.

TCM Pattern Differentiation

Wind-Heat Invasion

Symptoms: common Wind-Heat symptoms including sore throat, fever, aversion to cold, headache, dry mouth, possible red tongue tip, thin, yellow tongue coating, floating and rapid pulse, with additional manifestation of distention and obstruction within the ears with possible earache leading to tinnitus and impairment of hearing
Treatment Principles: Disperse Wind, clear Heat, open the orifices
Herbal Treatment: Yin Qiao San
Jin Yin Hua 10-30g
Lian Qiao 10-30g
Dan Dou Chi 10g
Niu Bang Zi 10g
Bo He 10g
Jing Jie 10g
Jie Geng 5g
Lu Gen 10g
Gan Cao 3g
Note: children are less likely to complain of tinnitus or loss of hearing, but will complain of earache
Wind-Heat Invasion

Liver and Gallbladder Fire

Main Symptoms: sudden onset of loud tinnitus or deafness with the tinnitus resembling ocean waves or claps of thunder; onset of symptoms or increase in severity of symptoms with anger or frustration;
Additional Symptoms: headache, dizziness and vertigo, epistaxis, earache, distending sensation of the ears, flushed complexion, red eyes, dry mouth, bitter taste in mouth, irritability, irascibility, restlessness, insomnia, distention and pain of the chest and hypochondria, constipation, dark urine
Tongue: red with yellow coating
Pulse: rapid, wiry, forceful
Liver and Gallbladder Fire
Treatment Principles: Drain Liver and Gallbladder Fire, open the orifices
Herbal Treatment for Liver and Gallbladder Fire: Long Dan Xie Gan Tang
Long Dan Cao 10-15g
Huang Qin 10g
Shan Zhi Zi 10g
Ze Xie 10g
Mu Tong 6g
Dang Gui 10g
Che Qian Zi 10g
Sheng Di Huang 10g
Chai Hu 6g
Gan Cao 6g
Herbal Treatment for Liver Depression transforming to Heat (less pronounced Fire: Jia Wei Xiao Yao San
Chai Hu 10g
Bai Shao 10g
Dang Gui 10g
Bai Zu 10g
Fu Ling 10g
Zhi Gan Cao 6g
Pao Jiang 6g
Bo He 6g
Zhi Zi 10g
Mu Dan Pi 10g

Binding Depression of Phlegm-Fire

Main Symptoms: tinnitus and deafness accompanied by dizzy spells, sensation of heaviness of the head
Additional Symptoms: oppression in the chest, profuse phlegm, bitter taste in the mouth, irregularity of urination and bowel movements
Tongue: red with greasy, yellow coating
Pulse: slippery, wiry or rapid, slippery pulse
Treatment Principles: Drain Fire, transform Phlegm, open the orifices
Herbal Treatment: Huang Lian Wen Dan Tang Jia Wei
Zhu Ru 10g
Zhi Shi 10g
Ban Xia 10g
Chen Pi 6g
Fu Ling 10g
Huang Lian 5g
Gan Cao 6g
Sheng Jiang 3pcs.

Blood Stasis

Main Symptoms: persistent tinnitus and/or hearing loss, possibly associated with black discharge from the ear or dark matter mixed with ear wax; possible earache
Additional Symptoms: dark complexion; possible HA
Tongue: purple or purple spots with thin coat
Pulse: wiry or choppy and thready
Treatment Principles: Quicken the Blood, eliminate stasis, open the orifice
Herbal Treatment: Tong Qiao Huo Xue Tang (best when stasis confined to head)
Tao Ren 10g
Hong Hua 10g
Chi Shao Yao 10g
Chuan Xiong 9g
She Xiang 0.15g
Cong Bai 3g
Sheng Jiang 3 pcs
Da Zao 7 pcs

OR

Xue Fu Zhu Yu Tang (selected when Blood stasis is more systemic)
Tao Ren 12g
Hong Hua 10g
Chuan Niu Xi 10g
Dang Gui 10g
Chi Shao Yao 6g
Chuan Xiong 6g
Zhi Ke 6g
Jie Geng 6g
Chai Hu 6g
Gan Cao 3g




Note: this pattern usually follows upon some trauma to the head or injury to the ear, including exposure to loud noise or sudden pressure changes. It can also complicate other chronic patterns of tinnitus or hearing loss

Kidney Essence Depletion
Main Symptoms: gradual onset of tinnitus or hearing loss/deafness associated with aging or chronic illness; tinnitus resembles the buzzing of cicadas, may be intermittent and is often worse at night
Additional Symptoms: dizziness and vertigo, insomnia, weak, aching low back and knees, seminal emission
Tongue: red with scanty coating
Pulse: thin or rapid, thin pulse
Treatment Principles: Supplement the Kidneys, secure the Essence
Herbal Treatment: Er Long Zuo Ci Wan
Shu Di Huang 24g
Shan Zhu Yu 12g
Shan Yao 12g
Mu Dan Pi 9g
Ze Xie 9g
Fu Ling 9g
Shi Chang Pu 6g
Wu Wei Zi 6g
Ci Shi 30g

SP and ST Qi Vacuity(Center Qi Fall)

Symptoms: tinnitus and deafness aggravated by overwork, sensation of emptiness and coolness within the ears, accompanied by tiredness, fatigue, poor appetite, loose stools, epigastric distention after eating and a sallow, withered complexion, pale tongue with white coating, weak pulse
Treatment Principles: Strengthen the Spleen and Stomach, boost Qi
Herbal Treatment: Bu Zhong Yi Qi Tang
Huang Qi 10-60g
Dang Shen 10g
Bai Zhu 10g
Dang Gui 10g
Chen Pi 10g
Sheng Ma 5-15g
Chai Hu 5g
Zhi Gan Cao 3g

Acupuncture and Moxibustion Treatment

Excess Patterns

Primary Points: TE 3, TE 17, TE 21, SI 19, GB 2, GB43
Modification Based on Pattern:
Wind-Heat: TE 5, LI 4, LI 11
LV/GB Fire: LV 2, LV 3, GB 34, GB 41
LV depression Heat: LV 3, LI 4, PC 6, GB 20
Phlegm-Fire: ST 40, PC 8
Blood Stasis: LV 3, LI 4, SP 10, SP 6, BL 17

Vacuity Patterns

Primary Points: TE 3, TE 17, TE 21, SI 19, GB 2
Modification Based on Pattern:
Kidney Essence Depletion: BL 23, KI 3, SP 6, CV 4, GV 4
SP/ST Qi Vacuity: BL 20, BL 21, ST 36, SP 6, CV 6


Auricular Acupuncture: Subcortex, Endocrine, Liver, Kidney, Inner Ear, Shen Men
Scalp and Electroacupuncture Tx of Tinnitus and Deafness:
Insert 3 needles along Jiao Auditory Line (a 4.0 cm horizontal line, with the midpoint 1.5 cun directly above the apex of the ear; at about GB8). Needle the two end points and the middle point obliquely downward, angled towards the apex.
With a thin copper wire (it cannot be too thick), start at one of the end needles, encircle it once, then encircle the middle needle once, and do the same with the last needle, making sure the wire is efficiently wrapped without much slack. Attach the wire around the middle of the handle and not at the top.

Attach the negative lead to SI19 and the positive lead to the middle needle on auditory line, above the wire.
Use intermittent wave with 1/2 or 1/3 frequency. Use your best judgement as to how strong, but not so much as to cause the patient any discomfort.
Use this technique on both ears for 25 minutes and add supplemental points according to the pattern.
This treatment protocol comes from Shandong University of TCM.
Note: GB12 is often used in this hospital for head disorders of all sorts.

Herbs For Ear Disorders

Ci Shi
Dong Chong Xia Cao
Ge Gen
He Shou Wu
Long Dan Cao
Mu Li
Nu Zhen Zi
Shan Zhu Yu


Homeopathic Remedies for Tinnitus

Cimicifuga 6c: for people sensitive to noise who tend toward depression
Carbo Vegetabilis 6c: for tinnitus accompanied by vertigo and nausea
Graphites 6c: for tinnitus with associated hearing loss
Chinium Sulfuricum 30c: for tinnitus resulting from ingestion of quinine tablets (common among elderly for nighttime leg cramps)
Homeopathic Remedies for Tinnitus
Salicylic Acid 30c: for tinnitus resulting from ingestion of high dosage of aspirin
Natrum Salicylicum 30c: may be beneficial if tinnitus present as a low, dull hum; loss of hearing and vertigo may also be present
Lycopodium 6c: may be beneficial to tinnitus present as humming and roaring along with impaired hearing
Supplements for Tinnitus and Hearing Loss
Cobalamin (vitamin B12): patients with tinnitus and noise-induced hearing loss have demonstrated significant vitamin B-12 deficiency

Shemesh, Z., Attias, J., Ornan, M., Shapira, N., Shahar, A. (1993). Vitamin B12 deficiency in patients with chronic-tinnitus and noise-induced hearing loss. American Journal of Otolaryngology, 14, 94-99.
Magnesium: low levels of magnesium are associated with noise-induced hearing loss; supplementation with magnesium has been shown to prevent noise-induced hearing loss

Attias, J., Weisz, G., Almog, S., Shahar, A., Wiener, M., Joachims, Z., Netzer, A., Ising, H., Rebentisch, E., Guenther, T. (1994). Oral magnesium intake reduces permanent hearing loss induced by noise exposure. American Journal of Otolaryngology, 15, 26-32.
Supplements for Tinnitus and Hearing Loss
Determination of vitamin B12 status in individuals with tinnitus and noise-induced hearing loss is warranted. If low, supplement with 2,000 mcg daily for 1 month, followed by 1,000 mcg daily thereafter (sublingual methylcobalamin is preferred form). Take with folic acid.
200 mg of magnesium daily (as magnesium aspartate) is safe and effective in preventing noise-induced hearing loss.
Supplements for Tinnitus and Hearing Loss
Vinpocetine, an extract of the Periwinkle plant, has shown possible benefit in the treatment of tinnitus. For more info.:
http://www.bixby.org/faq/tinnitus/treatmnt.html#vinpocetine
http://www.vinpocetine.net/Articles/vin_aug2000. htm

Other Tx Alternatives for Tinnitus

Use of low-pitch sound to mask high-pitch tinnitus:
http://www.hearinglossweb.com/Medical/Tinnitus/ low.htm

Basic Gemmotherapeutic Treatment: Sorbus Domestica