TREATMENT OF TINNITUS, VERTIGO, AND MENIERE’S DISEASE WITH CHINESE HERBS
by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon
TINNITUS
Chinese medical ideas about the cause and treatment of tinnitus and other hearing disorders were developed many centuries ago. In the Neijing Suwen (1), written around 100 B.C., several potential causes were mentioned. For example, it is stated: “Kidney qi communicates with the ears; when the kidneys are functioning well, the five types of sound can be heard.” The term kidney (shen), as used by ancient Chinese doctors, refers to a functional complex that is today difficult to link to specific organs, but can be suggested to involve not only the kidneys, but also the endocrine system. According to the traditional ideas, kidney qi weakens with aging (especially after age 50) and difficulty with hearing, as well as failings of the other senses, particularly vision, arises as a result. We know from modern investigations that tinnitus may arise in conjunction with the common old age disorders of anemia, heart and blood vessel disorders (e.g., hypertension, hyperlipidemia, arteriosclerosis), and the accumulated effect of numerous ear infections or exposures to very loud noise over many years.
There are specific strategies for rectifying the kidney qi deficiencies described by Chinese physicians, and these same strategies are also applied (with only slight modifications) to a number of aging-related problems, such as lowered immune function, reduced libido and sexual responsiveness, achiness in the lower back and joints, fatigue and sleep disorder, and impairment of memory. What is specific about tinnitus is the spontaneous aural activity, which the Chinese usually interpret as a type of movement, signifying an agitation of the yang energy that ought to be more settled by presence of adequate yin. Such yang agitation can also cause dizziness, insomnia, and headaches.
It is also said in the Neijing that “When the yin fails to contain the yang, the flow in the channels will become rapid, causing the yang qi to become excessive and reckless. If the yang qi is deficient and unable to counterbalance the yin, communication between the internal organs will be disrupted, and the nine orifices will cease to function....When yin and yang are balanced, the five visceral organs function appropriately together....vision is clear and hearing is acute.” According to this concept, both yang agitation (from yin deficiency) and yang deficiency can lead to disorders in hearing (the ears being two of the nine orifices; the eyes also being two of the orifices). In cases of yang deficiency, the body is overwhelmed by yin (substance) and the communication becomes blocked; organs don’t interact properly with each other or with their external manifestations, such as eyes and ears.
Another cause is indicated in the Neijing for cases of acute loss of hearing: “a case of sudden onset [of symptoms], where the patient may pass out, lose hearing, or experience obstruction of the bowel or urine, is usually induced by chaos of the qi and blood within.” In such cases, one must regulate the flow of qi and blood to restore normal functions. As to the cause of this chaos, the text continues: “Headaches, ringing in the ears, and obstruction of the nine orifices are usually caused by imbalances in the stomach and intestines.” By improving dietary practices and by using harmonizing therapy to improve and coordinate the stomach and intestine functions, these problems may be alleviated.
According to the Advanced Textbook on Traditional Chinese Medicine and Pharmacology (2), in approaching treatment of tinnitus, it is important to distinguish between recently acquired disorders (acute, sudden onset) and long-term disorders (displaying gradual development), between continuous and intermittent tinnitus, and also between excess-type (attributed to accumulation of pathogenic substances affecting the ear) and deficiency-type (attributed to inadequate nutritional status). Excess-syndrome tinnitus is often experienced in one ear only (or begins distinctly in one ear and later develops in the second ear to a lesser extent), while deficiency-syndrome tinnitus tends to develop in both ears and intermittently may improve, being less severe during the day and obviously worse at night. A combination of deficiency and excess syndromes is possible, especially in persons with other illnesses or with tinnitus that has persisted for several years.
The specific syndromes described in the textbook include four primary types, the first two are in the excess category and the last two are in the deficiency category. The disorders of the liver, gallbladder, kidney, and spleen mentioned in these descriptions apply to the traditional depictions of the organ systems and may not relate directly to the modern structural and functional connotations of the named organs.
Type 1. An excess syndrome defined as being due to hyperactive liver and gallbladder fire. This manifests as sudden onset of tinnitus, usually continual sound, which may be accompanied by symptoms of the excess syndrome, such as headache, flushed face, restlessness, irritability, insomnia, and constipation. Though there can be other causes, this syndrome is believed to be due mainly to the experience of anger, violent rage, or fright, and the tinnitus may arise soon after becoming embroiled in situation that causes much anger. Persons who frequently drink alcohol to excess are especially subject to this syndrome. The traditional remedy for hyperactive liver and gallbladder fire is Gentiana Combination (Longdan Xiegan Tang), which can be modified to treat tinnitus by adding moutan, ligustrum, and eclipta (these additions are intended to rectify the problem of extreme or persistent liver fire weakening the kidney water).
Type 2. An excess syndrome defined as being due to retained hot phlegm (phlegm-fire syndrome). This typically manifests as intermittent ringing in the ears, like the chirping of cicadas, sometimes accompanied by the sensation that the ears are blocked, thus impairing hearing. Possible accompanying symptoms may include stuffiness in the chest, excess sputum production, dizziness, nausea, and difficulty in urination or defecation (these symptoms reflect the blockage, retention, and accumulation). This syndrome is believed to be due to improper diet, especially if there is much fatty and/or spicy food that is consumed regularly. A standard remedy for phlegm-fire syndrome is Bamboo and Hoelen Combination (Wendan Tang), and this formula is modified for treating tinnitus by adding pearl, haliotis, and uncaria in cases accompanied by hyperactive liver; or by adding lapis, scute, rhubarb, and aquilaria (Lapis and Scute Formula; Mengshi Guntan Wan) for cases of stuffiness in the chest, excessive sputum, and difficulty defecating. If the fire is not a major concern, but phlegm accumulation is evident, Pinellia and Gastrodia Combination (Banxia Baizhu Tianma Tang) may be used alone or with Bamboo and Hoelen Combination.
Type 3. A deficiency syndrome defined as being due to insufficient kidney yin (essence). This is a gradually worsening tinnitus (though it may reach a certain constant level and get no worse after that) which is accompanied by deficiency type symptoms such as dizziness, back ache, and weakness of the knees, sometimes accompanied by deficiency-heat symptoms, such as hot sensation of the palms/soles and facial flushing. This syndrome is often caused simply by the aging process (accumulated stress, lack of adequate nourishment, insufficient exercise, chronic depression, etc.), and may be worsened by experience of certain diseases (especially chronic or debilitating diseases). The standard remedy for kidney yin deficiency is the Rehmannia Six Formula (Liuwei Dihuang Wan), which is modified to treat tinnitus by adding magnetite and schizandra. In more severe cases, one may add tortoise shell, gelatin, dragon bone, oyster shell, ligustrum, and morus fruit to further nourish yin and settle agitated yang (that is not controlled by the yin, blood, and essence).
Type 4. Deficiency syndrome defined as failure of clear qi to ascend. This manifests as intermittently occurring tinnitus that is alleviated by rest and aggravated by stress. Other possible symptoms of the deficiency include lassitude, poor appetite, and loose stools. This syndrome is caused by a yang deficiency affecting the spleen system, which may result from stress and worry, inadequate nutrition, or poor eating habits. The standard remedy for failure of clear qi to ascend to the head is Ginseng, Astragalus, and Pueraria Combination (Yiqi Chongming Tang), which was developed for treatment of auditory difficulties, mainly deafness and tinnitus, and for treatment of reduced visual acuity; it was first reported in the Yuan Ji Qi Wei (1370 A.D.).
In an article on treating sensorineural hearing loss (3), Sun Aihua gives the following background information on tinnitus and hearing loss, taking a somewhat different, but overlapping, perspective compared to the textbook definitions:
According to TCM theory, deafness and tinnitus are related to dysfunction of kidney, heart, liver, gallbladder, and spleen. Feebleness of kidney qi, deficiency of kidney yin, vertigo or facial tic due to dysfunction of the liver [i.e., liver yang agitation], stagnation of liver qi, deficiency of heart qi, and diminished vitality of spleen are the causes of deafness and tinnitus. Ye Tianshi, a noted Qing Dynasty physician, pointed out that the ear was connected with the kidney, heart, and gallbladder in various ways. He stressed heart and kidney in treating deafness in the feeble, but in deafness due to harmful environmental factors he stressed the gallbladder channel in treatment, concluding that the main principles to follow were “clearing the upper and suppressing the lower parts of the body.” The actual methods of treatment were “reinforcing kidney, invigorating heart, purging gallbladder, etc.” Recent investigations on the pathophysiology of sensorineural hearing loss have generally pointed to disorder of microcirculation of the inner ear as a main disturbance. “Promoting blood circulation and relieving stasis” is, therefore, a method of choice in correction.
In this depiction, there are two ideas mentioned beyond those listed in the Advanced Textbook: an old concept of deficiency of heart qi (which is not pursued in modern clinical practice) and the newer finding of disruption of normal blood circulation (which several Chinese physicians pursue in treatment of deafness and tinnitus, along with the traditional methods).
Sample Clinical Trial
In the Chinese Journal of Integrated Traditional and Chinese Medicine (4),a clinical trial for treatment of tinnitus was described. A basic formula was designed, which would be modified for different types of tinnitus. The basic formula contained:
polygonatum (huangjing)40 grams
epimedium (yinyanghuo)10 grams
cynomorium (suoyang)10 grams
hu-chang (huzhang)30 grams
persica (taoren)10 grams
earthworm (dilong)10 grams
This formula, which primarily treats the deficiency of spleen and kidney with a heavy dose of polygonatum, differs from those described in the Advanced Textbook by adding tonification for yang deficiency (epimedium, cynomorium) as well as herbs for vitalizing circulation of blood (persica and earthworm). Hu-chang helps treat heat and dampness, as occurs in excess-type disorders; it is also used to promote blood circulation, and it has been recognized as a remedy for tinnitus since ancient times, having been mentioned for that purpose in the 7th century book Qianjin Yaofang. These adjustments reflect the modern physician’s view that tinnitus often arises from a combination of yin and yang deficiency and that the damage to the ear involves a blood stasis syndrome (a disorder emphasized in Chinese clinical practice during the past century, and mentioned by Sun Aihua).
For the tinnitus of type 1 described above, add to the basic formula:
chrysanthemum (juhua)10 grams
prunella (kuxingcao)15 grams
moutan (mudanpi)10 grams
vitex (manjingzi)10 grams
magnetite (cishi)30 grams
These herbs quell the liver and gallbladder fire and settle the agitated liver yang.
For the tinnitus type 2 described above, add to the basic formula:
pueraria (gegen)20 grams
morus leaf (sangye)10 grams
forsythia (lianqiao)15 grams
gardenia (zhizi)10 grams
cimicifuga (shengma)6 grams
These herbs clear heat and dry dampness (forsythia, gardenia), and open up the congested circulation to the head (pueraria, cimicifuga, morus leaf).
For the tinnitus type 3 described above, add to the basic formula:
rehmannia (dihuang)15 grams
asparagus (tianmendong)10 grams
ophiopogon (maimendong)10 grams
magnetite (cishi)30 grams
cimicifuga (shengma)10 grams
cyathula (chuanniuxi)15 grams
achyranthes (huainiuxi)15 grams
These herbs nourish the yin (rehmannia, asparagus, ophiopogon), and normalize the circulation of blood (cyathula, achyranthes) and the upward/downward flow of yang qi (cimicifuga, magnetite). The type 4 tinnitus was not mentioned in this article.
There were 38 persons treated, with tinnitus caused by infections, loud sounds, or accompanying hypertension, mental disorders, extreme fatigue, or drug side-effects. The herbs were decocted in the proportions indicated above and served as a tea once per day. Lidocaine was also administered to the patients by IV drip or by application to the tympanum. As a result of the treatment (one month), 9 of the patients were then free of the tinnitus, 22 were free of tinnitus during the day, but could still detect some during the quiet night time with varying degrees of threshold sound, and 7 of the patients did not respond.
In considering these results and the possible application of similar therapies in the West, the following should be considered:
a.The “types” of tinnitus represent general categories; most individuals will show a mixture of signs and symptoms that may seem to confuse the situation. The practitioner must use the differentiation of types of tinnitus merely as a guidepost to analysis and treatment. Note that the formulas used in the clinical evaluation included a mixture of the therapeutic principles.
b.The patients took a high dosage decoction daily. The herb combinations contained from about 170 to 200 grams of herbs, an amount that far exceeds what is often prescribed by Western practitioners. If the treatment results are dosage dependent, as is expected to be the case, then a lower dosage may yield a more modest result.
c.The lidocaine treatment is unlikely to be used here (especially its application by IV drip); its contribution to the effectiveness of the therapy is unknown.
Shao Nianfang, writing his personal experiences about treating tinnitus in his book Treatment of Knotty Diseases with Chinese Acupuncture and Chinese Herbal Medicine (5), has this to say about analysis of the disorder and the results of treatments:
In general, acute tinnitus and deafness pertain to excess. In cases due to wind-phlegm-fire invasion of the upper part, namely the sensitive orifices of the ear, it is proper to treat with the clearing and purging method of the liver and gallbladder, to extinguish wind, and resolve phlegm. A prompt recovery will usually ensue. Cases with gradual development of chronic tinnitus and deafness usually pertain to deficiency of essence, blood, and qi; in such cases it is suitable to replenish the essence and blood, reinforce the spleen and promote qi. Slow recovery is usually the case, so the therapist has to be patient in treating such cases. It is advisable to combine the use of acupuncture therapy [with the herb therapy]. In difficult and knotty cases, herbs that activate the circulation and meridians, such as cnidium, carthamus, persica, red peony, pangolin scales, liquidambar, earthworm, and silkworm, can be used to enhance the replenishing and stimulant action. No matter whether the disease is of the excess or deficiency type, it is important to add bupleurum, cimicifuga, acorus, curcuma, pueraria, or others as guiding herbs to lead the other ingredients to the proper channel to enhance the therapeutic effects.
In another clinical trial (6), 100 patients with type 1 tinnitus (persistent ringing of the ear, in one ear only) were divided into two groups, one receiving Chinese herbs and the other receiving Western medicine. The basic Chinese herb formula was markedly different than the one reported above:
rehmannia (shou dihuang)15 grams
ho-shou-wu (heshouwu)12 grams
salvia (danshen)20 grams
magnetite (cishi)30 grams
polygala (yuanzhi)12 grams
acorus (shichangpu)30 grams
cornus (shanzhuyu)30 grams
lycium fruit (gouqizi)12 grams
ligustrum (nuzhenzi)12 grams
morus fruit (sangshen)30 grams
This formula combines the principles of nourishing the kidney and liver (lycium fruit, ligustrum, morus fruit, ho-shou-wu, rehmannia, cornus), clearing phlegm-obstruction of the orifices (polygala and acorus), promoting microcirculation of blood (salvia), and settling agitated yang (magnetite). In addition, the traditional formula Suanzaoren Wan (Zizyphus Formula), which nourishes the liver and settles fire agitation, was given in pill form, 10 grams at a time, twice daily (at noon and before going to sleep). The treatment would be modified according to symptom presentation as follows: