TCM Formulas and Acupuncture Protocols for Ramsey-Hunt Syndrome

Editor's Note: This is a case study regarding Ramsey-Hunt Syndrome, which is defined as an invasion of the 8^th nerve ganglia of the facial nerve by the herpes zoster virus, producing severe ear pain, hearing loss, vertigo and paralysis of the facial nerve.

The Case

The case involves a 49-year-old woman suffering from Ramsey-Hunt Syndrome, which began in January 2005. She came in for acupuncture treatments due to the overwhelming fatigue and vertigo secondary to this condition. Her previous treatments were listed as antivirals and rest. She was seen in a master's level intern clinic for six acupuncture treatments between Aug. 16, 2005 and Oct. 1, 2005.

With Ramsey-Hunt, vesicles can be seen in the external auditory canal along the distribution of the sensory branch of the facial nerve. Other cranial nerves can be involved and meningeal inflammation can be common. Lymphocytes might be in CSF, and its protein content increased. Hearing might be lost permanently or partially/completely recovered. Vertigo can last for days to several weeks. Facial paralysis might be transient or lasting.

Treatment

The Merck Manual states, "Althoughthere is no reliable evidence that corticosteroids, antivirals, or decompression makes a difference, they are the only possible useful treatments." It suggests corticosteroid therapy is the first choice and should be started right away - prednisone for 7-10 days; if acyclovir is added for 10 days, it might shorten the treatment. Codeine is used for the pain and diazepam for the vertigo. Finally, it suggests that decompression of the fallopian canal, after nerve excitability declines or when electroneurography demonstrates 90 percent decrement, occasionally can relieve facial paralysis.

Chief Complaint

The patient's chief complaint is Ramsey-Hunt syndrome, leading to additional complaints of exhaustion, vertigo, headache and neuralgia. Her condition was caused by, in this case, herpes zoster attacking cranial nerves 5, 7 and 8, causing symptoms similar to Bell's Palsy. It now continues to cause visual blurriness in her right eye, her balance is affected, which causes her to lean to the right, and she is extremely fatigued. She has a pain that begins at the right occipital area and radiates to the right eye, diagnosed as neuralgia. When the fatigue is prevalent, her face becomes very tight. She reports intense vertigo when she works at the computer professionally for relatively short periods of time. Her menstrual cycle is "normal" except that she gets migraine headaches one week prior to and one week after her period, which she also feels as starting from the right side of her head and radiating to the right eye.

She gets ringing in the ears when she is tired. There is a prior diagnosis of asthma, which she treats with an inhaler (listed below), and at the time of the first treatment she was coughing from an external attack a few weeks prior. She has difficulty falling asleep and she wakes up four to six times in the night. She has bilateral knee weakness, low back pain, frequent urination, and night sweats on her chest and inner thighs. Her appetite is poor and her overall energy level is low.

Medical History

• Surgeries: lymph node biopsy (1992).
• Other serious illnesses/injuries: henselae infection (1979) and asceptic meningitis (1991).
• Allergies: alcohol, bee stings, chocolate, dairy, penicillin, sulfa drugs, wheat.
• Medications: Famvir, 500 mg, three times daily; Advair, two puffs daily; previously prescribed acyclovir and prednisone.

Tongue/Pulse: The tongue is pale dusky; greasy white coating, dry; red dots front one-third; red tip; deep midline crack from front edge to middle; slightly deviated to right. The pulse is weak, deep, thin and slippery.

TCM Diagnosis:

1. Wind/Phlegm/Toxic obstructing local channel;
2. systemic qi xu;
3. kidney and liver yin xu with xu heat.

Western Medical Diagnosis: Ramsey-Hunt syndrome or herpes zoster oticus.

Treatment Principle: Expel Wind/Phlegm/Toxin, open orifice, tonify qi, nourish yin, clear xu heat.

Treatment: Six treatments were done by master's program interns, two under my direct supervision; a different herb formula and point protocol was added each time at treatments three to six.

Points

• Treatment One: GB-20, SJ-5, LI-10, ST-36, 40, LV-3, SP-3, 15, LU-7, Ren-12, 4.
• Treatment Two: LV-3, SP-3, 6, 15, ST-36, LI-10, Ren-12, 6, GB-31, 41, SJ-5, 4, Ear - Shen Men, Sympathetic.
• Treatment Three: K-3, 6, ST-6, 7, 40, LV-3, 8, GB-2, LI-4, right side only - GB-8, 40.
• Treatment Four: Right side: GB-14, SJ-23, St-1, 4, 6; left side: LI-11, SJ-5; bilateral: Tai Yang, SJ-17, ST-40, 36.
• Treatment Five: LV-2, 6, 8, ST-36, DU-20, SP-6, 9, ST-5 to ST-6, LI-4.
• Treatment Six: KD-3, 6, LV-3, 8, SP-6, ST-36, 6, 7, LI-4, 11, HT-7; right side - GB-2, 8, 40.

Herbs

• Treatment Three: An herb formula (50 gm powder) also was recommended: shi chang pu (12 gm); chen pi, jing jie, chai hu, gou teng, gan cao (6 gm); chuan xiong, huang qin, qin jiao, dang shen, bai zhu, cang zhu, bai shao, bai fu zi (9 gm).
• Treatment Four: 50 gm powder; huang qi (45 gm); dang gui wei, chi shao, di long, chuan xiong (6 gm); hong hua, tao ren (3 gm).
• Treatment Five: 50 gm powder; mu li (15 gm); chai hu, dang gui, bai shao, gou teng, fu ling, mu dan pi, niu xi (12 gm); bai zhu, tai zi shen, yu jin, da zao (9 gm).
• Treatment Six: 50 gm powder (modified from treatment three formula); bai zhu (12 gm); chuan xiong, qin jiao, bai fu zi, bai shao (9 gm); chen pi, fang feng, jiang can, di long, gou teng, gan cao (6 gm).

Recommendations: Treatment One: Begin mild exercise. Treatment Four: Massage right-side facial muscles with warm towel.

Progress

• Patient reports light improvement in overall feeling of energy by treatment six. First three SOAP notes report same symptoms, with no record of improvement.
• Treatment Four: Patient reports that energy improved greatly after the third treatment; still trouble falling sleep, but then sleeping better. The right-side HA remains present, tinnitus has increased,but vertigo is mild.
• Treatment Five: Symptoms were the same as first three visits. She states that it felt like the treatment four formula did not help.
• Treatment Six: Patient reports that energy has improved, able to sleep through the night, although it isn't restful sleep (difficulty falling asleep, early awakening, some slight night sweating).
• Overall, symptoms improved.

Discussion

This was a challenging case because, among other reasons, Ramsey-Hunt Syndrome was a rare diagnosis/condition to work on with acupuncture and herbs. Also, the patient was a first-time acupuncture patient and her condition was moderately severe. Due to the relatively long duration of her affliction (eight months) before seeking treatment from TCM modalities, even six treatments probably would not be enough to begin to see definitive results. When she first came to us, her daily functioning was debilitated due to pain and vertigo, and her energy was very low. She also had a history of a number of strong diseases, including asthma, which might have previously taxed her immune system and therefore her ability to fight off the present attacks.

It is interesting to note that her condition was able to be improved in the six treatments, even though the specific treatment protocols and focus were not exactly the same. The supervisor and/or the intern were different at each visit because of changes in the patient's schedule. The treatments were prescribed by four supervisors and executed by four interns, each of varying levels of experience, and yet it is probably safe to say there was an improvement in the patient's condition, particularly in regards to her energy level and sleep. Overall, there was general improvement across the board of her complaints in terms of reducing the intensity of all of the aggravating symptoms. This lends credence to the notion that in TCM, there are many possible methods to choose from when approaching a problem; the "best" one is then a matter of taste decided on by "mutual consent." We also should add that sometimes it takes more than one treatment to begin to get a positive effect.

Resources

1. Beers MH, B. R. (1999). The Merck Manual, 17^th Edition. Whitehouse Station, NJ: Merck Research Laboratories. 679-80.
2. Bensky, Dan. S. C., Stoger, Erich. (2004). Materica Medica: Chinese Herbal Medicine, 3^rd Edition. Seattle: Eastland Press, Inc.. pp. 933-935.
3. Hijikata, Y. Yasuhara, A. and Sahashi, Y. (2005). Effect of an herbal formula containing ganoderma lucidum on reduction of herpes zoster pain: a pilot clinical trial. Am J Chin Med;33(4):517-23.
4. Verhulst, E., Van Lammeren, M., and Dralands, L. (2000). Diplopia from skew deviation in Ramsey-Hunt syndrome. A case report. Bull Soc Belge Ophtalmol;(278):27-32.
5. Johnson W. G. (1981). The clinical spectrum of hexosaminidase deficiency diseases. Neurology;31(11):1453-56.