The first part of this discussion, which appeared in the April 2006 issue of Acupuncture Today, focused on the pathophysiology of acute otitis media (AOM) in children and the problems stemming from antibiotic treatment of this condition. Part two attempts to guide the practitioner through the treatment of the various patterns of AOM that can manifest.
Three Most Common Patterns
As a parent/practitioner active in both classroom and daycare settings, I have had the opportunity to treat many cases of AOM. Typically, the child with AOM will present with a common wind-heat pattern, or there will be cold damage turning to heat in either the tai yang or shao yang channels. All three of these patterns can be treated successfully with a single formula.
The best formula I have found for the routine treatment of pediatric AOM is a modification of three common formulas: yin qiao san, xiao chai hu tang and bi min gan wan. The first of these, yin qiao san, has a strong action to dispel wind-heat and resolve toxin. The second, xiao chai hu tang, is a shao yang-stage formula. Since the shao yang channel enters the ear, the inclusion of xiao chai hu tang can help direct the rest of the formula to the middle ear. The third formula, bi min gan wan, opens and drains the sinuses and other orifices in the head, which can help restore the balance of pressure between the nasopharynx and the Eustachian tube.
This combination was reduced to its therapeutic essentials and augmented to focus its actions specifically on ear infections. When using this formula, relief of ear pain is usually experienced in two hours or less, with complete resolution in one to three days.
Below is a full list of ingredients for a day's treatment of AOM with this formula. Amounts are based on a 25- to 40-pound child. If the AOM pattern is one of the common three mentioned above, doubling or tripling this formula can usually treat the entire course of AOM (two to three days).
Most parents report significant improvement in their child within the first two to three hours after administration of the initial dose. After the pain has subsided significantly and fever has dropped, you may reduce frequency to every four hours. If fever becomes very mild and no pain is present, you may continue with the same-size dose, but administered only three to four times a day.
A normal course of treatment during a moderate infection looks something like the following:
Modifications
Generally, the first two ingredients (agastache and poria) are emphasized slightly in order to focus the formula on relieving pressure in the ear canal and resolving pain. Usually, less zingiberis is used than the other ingredients. It is important to harmonize and protect the middle warmer during the treatment course, but one must take care not to make the formula too warm for a child with a wind-heat condition. If RSV (respiratory syncytial virus) is suspected, augment the forsythia; for vomiting, augment the pinellia and coptis. If symptoms differ from a typical wind-heat pattern, consider one of the other formulas mentioned below.
This formula destroys pathogens and reduces inflammation. It resolves phlegm in the head, supports digestive function and preserves the wei qi (defensive qi) to prevent recurrence. It contains ingredients shown to possess essential antibacterial and antiviral action,1-4 and which also are beneficial for treating other signs and symptoms of the pattern. Poria, chrysanthemum and peucedanum all can reduce edema in the ear.5-7 Coptis, chrysanthemum and forsythia have strong anti-inflammatory action.8 Pressure in the ear can cause distress and pain for children; red peony root and angelica9 both have an analgesic property with an affinity for the head. Bupleurum and pinellia10 each have a mood regulating action. Poria and fritillaria work together to guide pathogens out of the body through the urine.11
This AOM formula can be administered to prevent an initial infection from developing into otitis media. If the child has a recently developed mild fever, a red tympanic membrane that is not yet bulging, or sinus congestion in which the heat factor is more pronounced than the congestion, this formula can be used to prevent this condition from developing into AOM.
Other Patterns/Formulas
Though wind-heat is the most common TCM pattern of true AOM, it is important to distinguish between the wind-heat pattern and other conditions and patterns.
Toxic heat. Profuse suppuration and high fever indicate the presence of toxic heat. Severe headache may be part of the pattern. To treat successfully, you will need to add huang lian jie du tang to the pediatric ear formula. This is a serious condition and, in rare cases, can lead to deafness. Treat quickly and with care. (Note: When combining these two formulas, you should decide upon one to use as the lead formula and the other as its assistant. The lead formula can be given at full strength; the assistant at one-half to three-quarter strength. To determine the lead formula, determine whether there is an underlying condition of toxicity that led to the AOM, or whether the AOM developed into a toxic condition. In the case of underlying toxicity, huang lian jie du tang should be your lead, while the pediatric ear formula guides it to the auditory canal and sinuses. If the AOM was contracted entirely from the exterior and developed into a toxic condition, the ear formula will be your lead and the huang lian jie du tang will be used at one-half or three-quarter strength to augment the lead formula.)
Wind-cold attacking the outer ear. This is often misdiagnosed due to an apparent lack of heat in the child. I strongly suggest purchasing an otoscope if you plan on treating children with ear infections. The key for diagnosing wind-cold attacking the outer ear is ear pain with absence of swelling and redness in the tympanic membrane, plus a slight blue or purple color change in the cartilage of the ear. If there is ear pain causing a headache with only slight or no fever, a runny nose with clear discharge, and you are unable to detect any heat or swelling in the middle ear, then clearing wind-heat will be of little value. A cold pathogen has invaded from the exterior of the ear and has been conducted to the middle ear. For the least invasive treatment of this pattern, try warming the outer ear with a tiger warmer or indirect moxa at GB 2. A TDP lamp can be helpful, if the child can be trusted to lie still. If these methods are too risky for younger children, a hot water bottle or heating pad, carefully monitored by the parent, may do the trick in mild cases. In more stubborn cases, or where there is an underlying deficiency of yang, using dang gui si ni san (tang kuei and jujube combination) combined with chuan xiong cha tiao san (ligusticum & tea formula) can warm both the core and the head from the inside to dispel the cold, and relieve ear pain and headache.
Liver and gallbladder fire. Onset of pain will be rapid, as in a wind-heat condition, but pain may be mild and chronic, with a sudden trigger for acute, severe pain. Yellow discharge is likely. The child probably will have a ringing in the ear that accompanies the pain and have a bitter taste in his or her mouth. The recent history will not necessarily include a viral exposure. Though bacteria will show up in the exudates, the underlying cause is not viral or bacterial, but induced by stress and diet. In the days leading up to the acute attack, the child will likely appear irritable or nervous. He or she will have a thick, yellow, greasy tongue coat and/or a diet high in fat and/or sugar. The best formula to treat this is long dan xie gan tang.
Caution: Long dan xie gan tang is very cold, not unlike antibiotics. If given to younger children (under age 7), inappropriately prescribed, or given to children with already weakened digestion, the formula can damage the spleen qi. The damage is usually not as severe as antibiotics. Yeasts are killed by this formula, too, so the chance of a yeast infection developing as a result of using long dan xie gan tang is small. When there is a question about the child's digestive strength and this formula is otherwise appropriate for the condition, combine with a digestion-strengthening formula such as bu zhong yi qi wan or liu jun zi tang.
If you can learn to treat children's ear infections properly, you will have great success with your younger patients, and their parents will be most grateful.
Notes
Chronic pain afflicts over 20% of the adult population. Sadly, most MDs have essentially no education in treating pain, beyond offering a few toxic medications. Then they tend to steer people with pain away from those health practitioners who are trained. This puts the acupuncture community on the front lines for addressing this epidemic.
When the body is going through a stressful event, the sympathetic system is activated. This activation will help the body with a life-threatening situation. If this state is activated for prolonged periods of time, it starts to consume energy. These traumatic events that generate stressors in the autonomic nervous system (ANS) will eventually become internalized.
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One of the things that makes acupuncture so difficult to measure is that the medicine actually does contain some esoteric aspects. There have been numerous studies that demonstrate the neurochemical reasoning behind why acupuncture points stimulate the autonomic nervous system to enact change However, not all the benefits of TCM can easily be measured by randomized, controlled trials. But does that make them fundamentally and definitively untrue?
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