Acupuncture Continuing Education

Acupuncture and Herbs Quiet Tinnitus

tinnitus

Researchers find acupuncture and Traditional Chinese Medicine herbs effective for the treatment of tinnitus (ringing of the ears). Tinnitus is often a pernicious and intractable disorder. In this article, we will review the important research on acupuncture and herbs that demonstrates significant positive patient outcome rates. Take a close look at the results achieved by Dongzhimen Hospital researchers. Their use of electroacupuncture produces significant positive patient outcomes. First, let’s go over a few basics about ringing in the ears. 

 

About Tinnitus
Tinnitus is characterized by the perception of sound that is not caused by external acoustic stimuli. The condition is often accompanied by other disruptive symptoms such as anxiety, insomnia, and lack of concentration. Tinnitus patients may experience hearing loss or dizziness. Tinnitus and related symptoms negatively impact patients’ psychological health, sleep, and daily life activities. [1] Research shows that approximately 8% of tinnitus patients suffer from sleep problems, and about 1% experience severe repercussions in their work and everyday life. [2] The sound may be loud or soft, of high or low pitch, and experienced in one or both ears. According to the National Institutes of Health online publication on the topic of tinnitus, in the past year alone, roughly 25 million USA residents—approximately 10% of the adult population—have experienced tinnitus lasting at least 5 minutes.

 

Usual Care
Usual care tinnitus treatments often include vasodilator drugs to increase cochlear blood supply and inner ear tissue metabolism. [3] Long term consumption may have adverse effects such as lethargy and anxiety. Drugs for chronic tinnitus, such as lidocaine, demonstrate limited efficacy. [4] The use of glucocorticoids has also been investigated, but results have not been substantiated. [5] This has prompted researchers to explore the therapeutic effect of Traditional Chinese Medicine (TCM) on tinnitus. Specifically, the TCM modalities of acupuncture and herbs have been investigated in multiple research studies. 

 

Chinese Medicine
Several independent studies were conducted to investigate the various effects of acupuncture on different types of tinnitus based on TCM differential diagnoses. One finds that acupuncture boosts the efficacy of herbs for uprising liver heat tinnitus. Another study demonstrates that acupuncture is effective as a standalone therapeutic modality for treating kidney essence deficient (jing xu) tinnitus. Another study finds electroacupuncture a more powerful treatment option than conventional acupuncture for excess liver and gallbladder heat tinnitus.

 

Differential Diagnostics
The researchers provide a theoretical TCM background in their investigations. According to TCM principles, tinnitus results from one or more imbalances. Common excess-type imbalances include rising liver heat, phlegm-fire stagnation, and excessive liver and gallbladder heat. Common deficiency-type imbalances include kidney essence deficiency and blood-qi deficiency. A combination of excess and deficiency is not an unusual presentation in patients.

 

Local Points
Generally, acupoints located near the ear such as Ermen (TB21), Tinggong (SI19), and Tinghui (GB2) are used to treat tinnitus by licensed acupuncturists. From an anatomical perspective, they are acupoints rich in blood vessels and nerves. The anterior superficial temporal artery, anterior superficial temporal vein, auriculotemporal nerve, and great auricular nerve pass through these acupoints.

Other acupoints are applied based on individual conditions. It is worth noting that abdominal acupuncture has been shown to effectively treat nervous tinnitus (caused or exacerbated by anxiety) and improve quality of life. [6] Electroacupuncture has also shown significant clinical effects. Electrical stimulation of acupoints around the ear stimulates local muscle contractions, increases ear blood supply, and promotes nerve fiber regeneration. [7–8]

 

Excess Heat Acupoints and Herbs
Rising liver heat tinnitus responds well to treatments that are based on clearing liver heat and unblocking the acupuncture channels innervating the ear. Historically, herbal formulas such as Long Dan Xie Gan Tang are used for this type of tinnitus. The herbal formula Long Dan Xie Gan Tang has been documented to have a 97.6% treatment efficacy rate for rising liver heat tinnitus. [9] This is predominantly for acute cases and subacute flare-ups. Acupuncture point Taichong (LV3) clears liver heat and regulates qi flow (source point and shu-stream point of the liver) and is often used for liver heat related tinnitus. [10]

 

Kidney Deficiency
In TCM literature, there are many records showing kidney essence (jing) deficiency as a cause of tinnitus. This is closely related to the theory that the ears are the surface openings of the kidneys. Acupuncture on kidney meridian acupoints like Shangqu, Yindu, and Taixi nourish the kidneys and regulate the twelve major meridians. Many abdominal acupoints are also important in treating kidney essence deficiency. For example, Qihai and Guanyuan replenish and strengthen yuanqi, while Zhongwan and Xiawan strengthen the spleen and reinforce qi. These reinforcements fortify the body and increase kidney essence.

 

Liver-Gallbladder Heat
Excessive liver-gallbladder heat is another imbalance treatable by acupuncture. The gallbladder meridian is connected to the liver meridian and travels past the ear, therefore excessive liver-gallbladder heat easily traverses the meridian and manifests in the ear. Tinghui is a crucial acupoint for treating this type of tinnitus as it is both part of the gallbladder meridian and located near the ear. Fengchi, another gallbladder meridian acupoint, is also useful as it is connected to the vertebrobasilar arterial system. Electrostimulation of Fengchi stimulates the development of collateral circulation thereby improving labyrinthine arterial blood flow. Electroacupuncture at Fengchi also stimulates neck muscle contraction, and the resulting pump effect causes an increase in inner ear blood supply. [11]

 

Hubei Huangshi Traditional Chinese Medicine Hospital
Research conducted at Hubei Huangshi Traditional Chinese Medicine Hospital by Chen Guang finds acupuncture an important an effective complementary treatment modality to Chinese medicinal herbs. [12] The research is specific to rising liver heat type tinnitus patients.

The clinical trial compared two groups of patients, both receiving Long Dan Xie Gan Tang, but one group also received acupuncture. Results document that acupuncture raised the clinical efficacy of TCM herbs in improving patients’ hearing acuity, ringing severity, and depression. Three indicators were used to evaluate clinical efficacy: hearing threshold, degree of ringing, depression.

Hearing threshold refers to the lowest level that sound can be heard 50% of the time. Using electroaudiometry, the average hearing threshold for frequencies of 0.25 – 4 kHz was determined. [13] Based on the threshold, hearing acuity was classified into 3 tiers:

  • Grade 1: 26 – 40 dB mild deafness.
  • Grade 2: 41 – 70 dB moderate deafness.
  • Grade 3: ≥71 dB severe deafness.

The degree of ringing was graded on a 6-tier scale:

  • Level 1: Extremely slight ringing, faintly detectable.
  • Level 2: Slight ringing, definitely detectable. Only occurs in quiet environment. No impact on daily life and work.
  • Level 3: Moderate ringing, detectable in normal environment. No observable impact on daily life and work.
  • Level 4: Ringing detectable in any environment. Sleep and concentration are affected. Slight impact on work.
  • Level 5: Loud and noisy ringing. Sleep and work are severely affected. Signs of slight anxiety, irritability, depression, or other psychological issues.
  • Level 6: Extremely loud ringing. Constantly affected by ringing. Inability to sleep and work. Major signs of anxiety, irritability, depression, or other psychological issues.

Degree of depression was assessed using the Hamilton Depression Rating Scale (HAM-D), a multiple item questionnaire. Scores increase with the severity of depression. A score of <7 indicates the absence of depression, and a score of >29 indicates severe depression. [14] In addition to the above three indicators, the overall treatment efficacy was also surveyed. [15] By comparing symptoms before and after treatment, the treatment efficacy for each patient was categorized into 1 of 4 tiers as detailed:

  • Clinical recovery: Absence of ringing. Normal hearing acuity. No relapse throughout 1-month follow-up.
  • Significantly effective: Ringing no longer affects work and sleep, only occurs at night or in quiet environment. Ringing frequency improved from constant to occasional. No major hearing difficulties.
  • Effective: Ringing no longer affects work and sleep, only occurs in noisy environment. Alternatively, ringing no longer occurs in noisy environment, only occurs in quiet environment. Ringing frequency improved from constant to intermittent.
  • Ineffective: No improvement, or worsening, of ringing.

 

Rising Liver Heat Results
The treatment effective rate for each group was derived with the following formula: [Clinical recovery + Significantly effective + Effective] / [Total number of patients in group] * 100%. The treatment effective rates were 91.9% for the acupuncture and herbs group and 78.9% for the herbs-only group. The rates are reflective of the overall efficacy of the treatments, and here they show that acupuncture greatly improves treatment response to TCM treatment (P<0.01). The results for the 3 indicators below demonstrate the ways in which acupuncture complements herbs for tinnitus.

The acupuncture with herbs group had a mean pre-treatment hearing threshold of 50.29 ±4.02 dB, which lowered significantly (P<0.01) to 26.45 ±3.51 dB after treatment. Similarly, the herbs-only group had a mean pre-treatment hearing threshold of 49.53 ±3.68 dB and achieved significant improvement (P<0.01) to 31.26 ±2.97 dB after treatment. This tells us that the two treatments were effective in improving hearing acuity. However, comparing the post-treatment results, acupuncture with herbs outscored herbs-only (P<0.05). As a result, the researchers concluded that acupuncture boosts the efficacy of herbs in improving hearing acuity.

Patients’ degree of ringing saw marked improvement with both treatments (P<0.05). For the acupuncture with herbs group, these are the number of patients in each ringing level (from level 1–6) before treatment: 0, 3, 10, 15, 6, 3. After treatment, the respective numbers were: 4, 8, 12, 10, 2, 1. For the herbs group, these are the number of patients in each ringing level (from level 1–6) before treatment: 0, 2, 11, 16, 5, 5. After treatment, the respective numbers were: 1, 8, 15, 10, 2, 2. After treatment, both groups of patients improved—they experienced less frequent and quieter ringing. Acupuncture with herbs patients outperformed herbs-only patients. The researchers conclude that although herbs-only treatment is effective, acupuncture further alleviates the severity of tinnitus. 

Both patient groups also experienced less depression after treatment (P<0.01). Before treatment, the HAM-D score for the acupuncture with herbs group was 11.12 ±2.04, which fell to 5.54 ±1.06 after treatment. The HAM-D score for the herbs group fell from 11.64 ±1.31 before treatment to 7.89 ±1.22 after treatment. As with the previous two indicators, the addition of acupuncture effectively augmented the clinical efficacy of TCM herbs (P<0.05), in this case for lessening depression from tinnitus.

 

Design
The study was set up as a double-arm clinical trial. A total of 80 patients from the Neurology Division of Hubei Huangshi Traditional Chinese Medicine Hospital participated in the study. They were diagnosed with tinnitus from rising liver heat. The following selection criteria were applied in choosing trial participants: [16]

  • Fulfilled diagnostic criteria for rising liver-heat tinnitus as described in “Otolaryngology – Head and Neck Diagnoses and Differential Diagnoses”. [17]
  • TCM clinical presentation of rising liver-heat tinnitus.
  • Tinnitus as main symptom, recurring for ≥1 month or continuously occurring for ≥5 days.
  • Aggravated by exertion or agitation.
  • Accompanied by hearing loss, headache, irritability, insomnia, chest/rib fullness, red tongue with yellow coating.
  • Eardrum slightly hyperemic or normal.

The following exclusion criteria were applied:

  • Organic damage due to external injury or infection.
  • Tinnitus due to tumors or systemic diseases.
  • Severe cardiac, liver, or renal primary diseases.
  • Complete deafness with tinnitus.
  • Duration of illness ≥2 years.
  • Failed to complete or comply with prescribed treatment.

Patients were randomly divided into the treatment group and the control group. Both groups had equivalent demographics (P>0.05) to ensure fairness of comparison. Excluding patients who were disqualified during the study, the treatment group recorded 37 patients:21 males, 19 females, mean age 32.5 ±8.1 years, mean duration of illness 8.9 ±3.7 months. The control group recorded 38 patients: 18 males, 22 females, mean age 31.2 ±8.7 years, mean duration of illness 8.4 ±4.3 months.

Both groups received a modified Long Dan Xie Gan Tang decoction and the treatment group received acupuncture as an additional therapy. One treatment cycle was administered and a 1-month follow-up was conducted. The following acupoints were selected for the treatment group: [18–19]

  • Scalp acupuncture vertigo and hearing area (bilateral insertion)
  • Ermen (TB21)
  • Tinggong (SI19)
  • Tinghui (GB2)
  • Yifeng (TB17)
  • Hegu (LI4)
  • Taichong (LV3)

 

Acupuncture Technique
For acupuncture, the needles had a total length of 1.5 inches. For the vertigo and hearing area, a needle was inserted using the Feizhen technique: the needle was rotated rapidly for 1 minute, at a rate of 200 rotations/minute, then retained for 1 hour. During needle retention, the same rotation technique was repeated once every 20 minutes.

For the other acupoints, needles were inserted based on standard protocols and retained for 30 minutes. During needle retention, needles were manipulated once every 10 minutes using lifting, thrusting, and rotation. Attenuation was applied for excess conditions. [20] One treatment cycle comprised 10 consecutive days. One acupuncture session was conducted per day. [21]

From an acupuncture continuing education standpoint, this is important. In the United States, treatment appointments are often 1–3 per week. This is often due to norms of behavior, insurance company limitations, cost, and access to care (including work schedule limitations and transportation issues). However, the research indicates that one robust treatment per day is required. This distinction requires a rethinking of the delegation of acupuncture care in the 1–3 treatments per week protocol.

For modified Long Dan Xie Gan Tang, different ingredients were added according to Traditional Chinese Medicine differential diagnoses. For mood swings, the following herbs were added to the base formula:

  • Yujin
  • Hehuanpi

For insomnia, the following herbs were added:

  • Lingcishi
  • Yuanzhi
  • Duanlonggu
  • Duanmuli

The results indicate that rising liver heat type tinnitus responds well to acupuncture and herbal medicine. However, adding acupuncture to the herbal medicine protocol increases the efficacy over using only herbs. Let’s take a look at another investigation.

 

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