Case Studies

Case Studies

Chronic Non-Healing Ear Ulcers


Tiffany Forster LAc
March 2015
OVERVIEW

chronic ear ulcers case study

15-year-old female presents with purulent, non-healing ulcers in the right ear canal. After 20 treatments, using an integrative approach that included Chinese herbal medicine, acupuncture and antibiotics, the patient experienced a reduction of pus, reduced pain and itchiness. However, the condition did not resolve. The treatment and investigation became directed towards possible skin staphylococcus, otomycosis (a skin fungal infection), skin tuberculosis and acquired cholesteatoma. A referral for further investigation is necessary for a definitive diagnosis. 

Subjective

15-year-old patient presents with non-healing, suppurative ulcers of the right, external ear canal. The patient reports she has an 8-year history of upper respiratory tract infections (URTI) and ear infections with the ear ulcers. With the use of an unknown quantity of antibiotics and eardrops, there has been no resolution of the ulcers. The ulcers developed to this severe stage 1 year ago and have gotten continually worse. She reports intermittent pain and itchiness with constant, copious amounts of thick, sticky pus. The hearing in the right ear is diminished. The submandibular glands are occasionally swollen bilaterally. She suffers from intermittent headaches. The patient does not show any symptoms of an acute infection, as there is no fever, intense pain, painful swollen glands or an acute sore throat. 

Objective

On first inspection of the ear canal, an accumulation of chronic, inflammatory cells are evident with a copious amount of pus being produced. Initially, the tympanic membrane is not visible.

The location of the ulcers are a third of the way down the ear canal at 5 o’clock with a bigger ulcer half way down at 12 o’clock. They are inflamed, suppurative and crater-like with a definite circumference. 

With consistent treatment, the less deep ulcers clear to expose a larger ulcer at the end of the ear canal at 1 o’clock. It appears to be partially covering the tympanic membrane. It is unclear if the tympanic membrane is affected. Upon asking if the patient can taste the vinegar being used to alter the environment of the ear, she claims she cannot, indicating tympanic membrane is intact.

Upon inspection of the left ear, no redness is observed, nor associated pain or itchiness noted. The tympanic membrane is intact.

TB mantoux test and TB sputum test – both negative; For a definitive result, a skin biopsy and pus culture is necessary. The pus culture determines which bacteria is present in order to find the antibiogram, which can determine a bacteria’s sensitivity to an antibiotic. 

Initially, when cleaning the debris in the ear, up to 10 cotton swabs were necessary. After 15 treatments, only 2-4 cotton swabs were used, indicating a significant reduction in pus secretion.

Assessment

DX: Non-healing, suppurative ulcers of the right external ear canal

The body’s ability to heal the ulcers is compromised due to the location at the deep end of the external ear canal, poor visibility and difficult access, and the chronic nature of the disease. The ulcers respond to the antibiotics and antifungals, but do not heal completely. Possibly, the wound has become antibiotic-resistant over the years. An infection of the middle ear cannot be ruled out, as it is impossible to investigate under the circumstances. 

Possible cutaneous staphylococcus infection: A culture is required to identify. 

Otomycosis: Fungal infection of the external ear canal; Malodorous discharge, inflammation, scaling, severe discomfort and itchiness with minimal pain characterize fungal infections. A culture is required to identify for exact diagnosis and appropriate treatment.

Skin TB: Non-healing wound is the main symptom of skin TB. Characteristic histopathological features on skin biopsy and pus culture confirm the diagnosis. 

The patient experiences a combination of all of the above symptoms at differing times. Further testing is required for complete and accurate diagnosis.

Acquired cholesteatoma: Cholesteamtoma can give rise to a number of appearances. If there is substantial inflammation, the tympanic membrane may be partially obscured by an aural polyp. The presentation of this disease penetrates into the middle ear and should be considered. Further analysis is recommended to rule out potential for this condition 

TCM DX: Chronic, turbid, damp-heat in the external ear canal 

It is most likely that the ulcers began with a channel pathology of an external invasion. Over time, the chronic and damp nature of the condition has become more systemic.

Lung qi and wei qi are affected due to the history of URTI. The Lung system is the most exterior organ and is the first internal organ typically affected by external pathogens. The Lung system includes the skin and is associated with wei qi. As the wei qi becomes weakened, the body’s ability to have a strong defense becomes negatively affected.

Spleen and Stomach qi deficiency due to the chronic nature of the condition. One of the Spleen’s functions is to identify the turbid and to transform and transport this pathogen. The Spleen also produces and stores white blood cells that clean bacteria from the blood. This function is important in tissue regeneration and in stimulating an immune response in the body. The cold nature of antibiotics damages the Spleen and thus the ability to be effective in healing the chronic nature of the ulcers.  

Prognosis

Poor prognosis without the skin biopsy and pus culture to identify the pathogen as bacterial, fungal, skin TB or drug-resistant skin TB. Infection is the single most likely cause for the delay in healing. The inflammatory phase has become prolonged because of the chronic nature of the condition. With ineffective, yet consistent treatment, both internally and externally, surgery is recommended because of the excessive granulation of the tissue that is hindering the re-epithelialization of the local area. Alternatively, with the confirmation of skin TB, the healing will occur with the use of appropriate medication. The potential for a good prognosis is possible if the above recommendations are followed. 

Treatment

Due to the chronic nature of the ear ulcers, therapy is adjusted throughout the process. Treatment is according to the nature of what the patient is reporting and how they present over the course of 1 month. Below is an outline of the sequential treatments. 

The following is done at every treatment from the beginning.

- Acupuncture: Ear tacks applied every 2- 3 days to San Jiao 17 and 21, Gallbladder 2 and Small Intestine 19. These points are used locally to activate circulation and decrease inflammation. 

The following occurred at the same time. The pus decreased before plateauing and never fully resolved. 

- Internal antibiotic Chinese herbal medicine (CHM) Huang Liang Jie Du Tang 7 days

- External antibiotic CHM Huang Liang Jie Du Tang mixed with Neosporin 10 days alternating days

- Aural saline flush on alternate days for 7 days

After the above stopped working, the following was prescribed. 

– Azithromycin, 500mg PO for 5 days

– Aural vinegar flush on alternate days for 8 days

– Cloxacillin, 1gm TID for 7 days 

Once the antibiotics stopped working, a fungal approach was taken. 

– Antifungal ear drops 4 drops TID for I month

– Fluconazole 150 mg PO once per day for 3 days, then once per week for 3 weeks 

The following was prescribed to support the digestive system.

– Internal CHM Si Jun Zi Tang taken over the 4 weeks of treatment

The following was prescribed at the end of the treatment plan to help boost the immune support and aid the ear.

– 50% colloidal silver/50% rubbing alcohol ear flush, 4 times per week for 2 weeks 

– Multi vitamin and 500mg vitamin C taken daily – long term 

Outcome

After the initial 5 treatments, it became obvious that the ulcers were difficult to heal and would require different approaches in the attempt. Through the observation of changes over a series of 20 treatments, the plan was adjusted 3 times. The patient reported decreased itchiness, pain and discharge. As soon as the medicines were completed, however, the itchiness reappeared, but to a lesser degree. The discharge also increased, but to a lesser degree than when she initially started treatment. All of this was indicative that the ulcers were still present.

Ongoing Treatment

The patient and her family were informed that further investigation was necessary. With the consistent treatment that she had been receiving, to act on the referral that had been given would ensure the resolution of the non-healing ulcers. To continue using the antifungal eardrops, taking a multi-vitamin and extra vitamin C would be beneficial in the support of her immune system. 

Conclusion

This has been an interesting and important case, as it not only demonstrates the efficacy of using an integrative approach, but it also highlights the ability of acupuncture to serve as an initial access point of care in which the patient received regular treatments and the opportunity to closely follow her progress and therefore prognosis. Significant improvement has been achieved, clearing the way for the definitive understanding that a referral to the appropriate hospital is necessary. A referral for investigation and/or surgery has been written bringing attention to the patient’s lower income status. This is imperative for the family so they are not subjected to unnecessary financial burden. This can, otherwise, have a significant effect on the family not following through with the investigation necessary for the ulcers to resolve.

Dupuytren’s Contractures

Debbie Yu MS EAMP LAc
March 2015
OVERVIEW

 

58-year-old male presents with persistent contraction of 3rd, 4th and 5th fingers of right hand. He reports it began insidiously 3 years ago, and that it might be due to a leech bite from 25 years ago. After just 3 treatments using electro-acupuncture and manual therapy, passive and active range-of-motion have improved by 35%. To be limited in hand dexterity in this rural country is traumatic and debilitating. Acupuncture is a quick-acting and cost-effective alternative to surgery. This is especially important for this case where health care access and financial resources are limited. 

Read more ...

Hemorrhagic Stroke Sequelae


Joy Earl, LAc, MAcOM
November 2013
OVERVIEW

Acupuncture Case Study53-year-old male presents with right-sided hemiplegia following a hemorrhagic stroke 1 year ago. Patient complaints include decreased range-of-motion, pain, numbness and weakness of his right side including the shoulder and arm. Concluding 10 treatments, comprising of acupuncture with electrical stimulation and Chinese herbs, the patient reports decreased pain, improved range-of-motion (ROM), increased sensation in limbs, and greater muscle strength.

SUBJECTIVE

53-year-old patient presents with right-sided hemiplegia after suffering a hemorrhagic stroke 11 months ago. On the day of the stroke, patient experienced muscle weakness along with headache and seeing red. Patient entered shower to pour cold water over his head when he began to feel sensations of insects crawling up the left side of his body. The feelings began at his toes, ascending up his lateral and anterior legs, left hypochondriac region, lower and upper arms, side of his neck and then to his head, where he felt pressure in the parietal region, and lost consciousness. When he regained consciousness, he experienced paralysis on his right side. Patient was sent to Chitwan Medical Teaching Hospital in Bharatpur where he was hospitalized for 2 weeks. After the hospitalization, he attended physical therapy sessions including electrical current therapy for 2 weeks. Patient reports having received several medications unknown to him, and he did not undergo any surgical procedure. 12 months prior to the stroke, he was prescribed blood pressure medication, though was not consistently compliant. While hospitalized during the first 3 days after incident, his blood pressure (BP) was 240/120.

On initial visit to the clinic, patient complaints include a heavy feeling and numbness on the right side of his body, pain in the right shoulder near deltoid attachment, especially with grasping or rotating of arm, pain in upper right side of the neck with movement of his arm, pain in right thumb and wrist especially when grasping, an inability to move shoulder, and accompanying pain with active and passive rangeof-motion. He also complains of overall body stiffness, inability to move toes 2, 3 or 4, feeling of coldness in the toes and limping while walking.

Secondary complaints include problems with concentration and with speech when speaking fast, trembling of right hand with certain activities, as well as the inability to dress himself without assistance.

The patient reports that he is currently taking Amlod, a calcium channel blocker, and Losartan/Hydrochlorothiazide, a diuretic, for maintenance of hypertension.

Bowel movements are normal with no complications regarding digestion. The patient reports frequent and urgent urination, nocturia at a frequency of 3-4 times per night, and water intake of 3-4 glasses per day.

OBJECTIVE

Patient seems solemn and reserved.

Pulse is wiry and thin on the right side, and wiry, thin and slippery on the left.

Tongue presents as thin and pink with a thin, white coat and stagnation of sublingual veins. Initial blood pressure is 160/100.

ROM in the right arm and shoulder exhibits an inability to actively adduct without causing severe pain to upper shoulder and neck. Lateral flexion of the neck 35 degrees to the right induces pain to the right shoulder proximal to the AC joint. Supination of forearm, beyond 90 degrees, creates moderate to severe pain in anterior shoulder near AC joint. Patient is able to extend leg to full range with no difficulty or pain. Patient is able to move each individual finger, but demonstrates an inability to contract toes completely. The second, third and fourth toes on the right foot are permanently contracted in dorsiflexion. Strength/grasp test of the right hand indicates 30% less strength than left hand.

Sharp/dull sensory testing indicates deficits in the following dermatomes: C5, C6 and S1. They show no sensitivity to stimulation, while the dorsal aspect of foot and toes 2, 3 and 4 experience dull sensation, regardless of sharp stimulation.

Patient exhibits no difficulty in reciting the vowel sounds a, e, i, o, u, cha and la. His face appears symmetrical with no drooping of eyes and lips, or deviation of the tongue. No slurring is noticed upon speaking. His signature is precarious with significant trembling.

ASSESSEMENT

DX: Cerebrovascular accident d/t cerebral bleed; CVA indicates a hemorrhagic stroke leading to post-stroke sequelae with right-sided hemiplegia

TCM DX: Blood and qi deficiency with blood stasis causing blockage of channels and collaterals with internal wind

PROGNOSIS: Good; Although a complete recovery of motor and sensory skills is unlikely, prompt action following incident, including physical therapy, coupled with his overall constitutional health, significantly improves this prognosis. It is expected that acupuncture will continue to improve this patient’s condition.

PLAN

Treatment principles: Move blood, tonify qi, open channels, extinguish wind.

Acupuncture: 3 times per week for 5 weeks with a reevaluation at the 10th treatment; Focus on stimulating Yangming channels (Stomach and Large Intestine), as well as Gallbladder and Triple Burner channels on affected side. The unaffected side should have a constitutional focus of tonifying qi and blood while clearing any residual wind and phlegm.

Standard treatment comprised of electrical stimulation with leads connecting LI15 to TB5, LI11 to LI4, ST34 to ST41 and GB34 to LV3 at a continuous frequency of 5/100 for 20 minutes; Additionally, left-sided motor scalp line and leg motor and sensory lines are needled to stimulate the right side. Alternating pi ci treatments are performed with needles inserted 1 cun (1”) apart down entire Large Intestine channel from LI16 to LI2 and Stomach channel from ST34 to ST44.

Herbal formula, Bu Yang Huan Wu Tang, is prescribed at a dosage of 8 tablets BID, along with increased water intake of at least 8 glasses a day.

Patient is instructed to sign his name before each treatment to analyze trembling

OUTCOME

Patient was compliant with treatment plan, attending every appointment, and becoming increasingly more energetic and outgoing with each visit.

Patient reported a 50% overall improvement including complete resolution of the thumb, neck and shoulder pain. He reported the ability to straighten toes, as well as increased sensation and feeling of warmth in the toes and upper and lower legs where he had initially experienced numbness. Patient also described increased strength and less shaking in upper and lower leg.

Patient reports that he was now able to remove his shirt by himself. His blood pressure dropped to 130/90.

His signature was more developed, even and distinguishable with a 30% decrease in trembling.

CONCLUSION

Currently, the patient has had 11 treatments and is responding very well. His mental and physical states have greatly improved. He reports that before treatments, he had a feeling of numbness and heaviness all over his body. Now, on the day following a treatment, he feels a sensation of lightness in his body and spirit. He often mentions, “I feel great” and has become more cheerful since his first treatment.

The patient continues to maintain a treatment plan of acupuncture 3 times per week. Patient needs to continue this plan for 2 or more months. Following this time, a healthy and active lifestyle is important for maintenance of hypertension, as well as continued improvement.

It has been communicated to the patient that, with many post-stroke cases, the odds of a full recovery are not good. However, due to his diligence and compliance with treatments and care, both at the clinic and initially following incident, his chances for recovery are greater than most. He is reminded to maintain his motivation to recover, surround himself with encouragement, and believe in the mind’s ability to help the body heal.

Ulcerative Colitis


Patty McDuffey, LAc, MAcOM, Dipl OM
November 2013
OVERVIEW

Acupuncture Case Study

70-year-old female patient presents with urgent, frequent diarrhea. No enteropathogenic organisms are present, however blood is found in the stool. Allopathic care has been unable to resolve her symptoms. After 17 acupuncture treatments and the use of Chinese herbal medicine, the patient has experienced 75% reduction in symptoms since the initial onset 14 weeks ago.

Subjective

70-year-old female patient presents with urgent diarrhea with initial onset 2 months prior to 1st visit. She suffers from frequent, watery diarrhea 12 times per day that occurs upon waking in the morning, after eating, and throughout the night. Mucus and undigested food are present in the stool. The stool is reported to be red, black, yellow and white in color with a strong odor. Patient was admitted twice to the Chitwan Medical College Teaching Hospital in Chitwan, Nepal and reports no change in symptoms with allopathic medicine, nor does the patient understand the cause. Patient's appetite is poor with little water intake (2-3 glasses per day), and a subjective sinking sensation. She does not have a fever, nor does she experience abdominal pain, but does report feeling cold. Previous to the onset of diarrhea, she reports having a history of normal bowel movements.

OBJECTIVE

Patient is very soft-spoken, but alert with full mental capacity. She has a gentle, optimistic spirit and appears to be in relatively good health for her age and environment.

Hospital lab tests run at Chitwan Medical College Teaching Hospital 15 days after initial onset of symptoms show an initial diagnosis of dysentery. Complete Blood Count (CBC) shows Eosiniphil Sedementation Rate (ESR) value of 46 Mm/Hr (normal range 0-20). Urinalysis indicates urine pH 5.0 (slightly acidic), potassium level of 2.58 Mmol/l (normal range 3.5-5.5) and urea 14 mg/dl (normal range 20-40). Stool culture shows a RBC (Red Blood Cell) count of 2-4, indicating blood is present in the stool, a pus count of 6-8 with mucus present on physical examination, and no enteropathogenic organisms after 48 hours of incubation. No pain on abdominal palpation, nor abdominal masses, are found. Slight gurgling is detected in the lower left quadrant of the abdomen on palpation. Hands and feet are cold to the touch.

While at the hospital, the patient was given the following medications at an unknown dosage and duration:

Cifran: Ciproflaxacin - broad-specturm antimicrobial
Metron: Metronidazole - antibacterial and antiprotozoal
Ondem: Serotonin type 3 receptor antagonist, typically used for nausea/vomiting associated with cancer and post-operative treatment
Pantop: Proton-pump inhibitor for gastroesophageal reflux disease (GERD)
Bifilac: Probiotic
Dometic: Domperidone - antiemetic
Codophos: It is not clear which medication was administered; either Odophos, which is an iron mineral supplement, or Colophos, which is a laxative.
Potclor: Potassium electrolyte supplement
Enterogermina: Probiotic/anti-diarrheal
Doxobid: Doxofylline - anti-asthmatic

Upon discharge from hospital, the patient was administered the following meds:
Dometic 10mg PO TID (3 days)
Pantocid 40mg PO BID (10 days)
Codophos 15mg PO TID (2 days)
Enterogermina 1 Tab PO QD (7 days)
Potclor 15ml PO TID (5 days)
Doxobid 400mg PO BID (10 days)
Cifran 500mg PO BID (5 days)
Metron 400mg PO TID (5 days)
Seroflo 250mcg PO BID (continuous); Fluticasone Propionate is a corticosteroid used for asthma. The patient has a history of asthma.

Pulse is slippery, and the tongue is red and moist with a thin, white coat.

ASSESSMENT

DX: Ulcerative colitis

Differential DX: Colorectal cancer; Diverticular bleeding

Due to the presence of pus and blood in the stool, another diagnosis could be colorectal cancer. This diagnosis seems less likely because the abdominal scan is negative for masses, nor is occult blood present in the stool. Another possibility is diverticular bleeding.

This is more likely than colorectal cancer as diverticular bleeding becomes more common with age. However, it often causes major bleeding, which is not present in this case. Ulcerative colitis is the most likely culprit, with frequent bloody diarrhea being the primary symptom. Systemic symptoms are often absent or mild. It can also be aggravated by NSAID's.

TCM DX: Primary - Spleen and Kidney yang deficiency with sinking Spleen qi; Damp-heat present in the Stomach and Large Intestine

PROGNOSIS: Good recovery is expected due to her overall good health and relatively short duration of symptoms.

 INITIAL PLAN

Electrolyte salt pack is administered on first visit for rehydration.

Acupuncture and moxibustion 3 times per week for 3 weeks before reevaluation. Focus on lifting Spleen qi, nourishing the Spleen and the Kidney and clearing damp-heat from the intestines. Use of moxa is intended to replenish pure yang energy in the Kidneys. Herbal treatment of Bu Zhong Yi Qi Tang 2 pills TID to nourish and lift Spleen qi. Diet recommendations include the elimination of dairy and the inclusion of more high fiber foods such as fruits and vegetables, meat and warming (aromatic) foods to address nutritional deficiency. Increase liquids to at least 1 liter water per day. If symptoms do not continue to improve over the 1st course of treatment, further lab tests will be ordered.

Typical treatment: ST36, ST25, CV12, CV6 and LI 0 with 1" deep needle insertion

Alternate treatment: SP3, SP4, DU20, LI4, SP15 and ST37

Treatments include abdominal indirect moxa at the periumbilical region near ST25, SP15, CV12 and CV6. Particular emphasis is placed on the herbal formula as patient needs to receive daily care and nourishment to fully recover.

OUTCOM

After the 3rd treatment, little change was seen with Bu Zhong Yi Qi Tang, so the formula was changed to Fu Zi Li Zhong Wan (8-10 pills, TID) alternating with Li Zhong Wan (3 pills, BID). More emphasis was placed on tonification of the Kidney yang energy. At the 6th treatment, the patient reported that the stools were more soft than watery. Mucus and undigested food in the stool were still present.

At the reevaluation (9th visit), the patient was having 7-9 bowel movements per 24-hour period, approximately a 40% improvement from the initial visit. Her appetite was better and she was eating a wider variety of foods 3 times per day. Though mucus was no longer seen in the stools, there was still a strong odor and the patient continued to experience urgency to use the toilet. A high fiber, low fat diet was recommended. At this treatment, the patient reported feeling dizzy since the initial onset of symptoms 3 months ago.

The patient took a minor fall sometime in the days after the 9th treatment, injuring her left medial knee joint. As a result, ibuprofen was administered to decrease inflammation. An increase in bowel movements to 10-11 per day coincided with the administration of ibuprofen, suggesting that the NSAIDs were irritating the mucosal membranes.

After cessation of the ibuprofen (13th visit) the patient reported only 3-4 bowel movements per 24-hour period for the previous 4 days. However, she still experienced days with as many as 8 bowel movements. Stools still alternated between soft and watery with strong odor and yellow in color, but were not always urgent.

Ten weeks (15th visit) after initial acupuncture treatment began, an herbal formula was added to further help clear heat from the intestines: Qing Wei San 6 pills TID. Fu Zi Li Zhong Wan was reduced to 6 pills TID. After the addition of Qing Wei San, the patient's stools reduced to 3-4 per day with a formed consistency. At this time, a follow-up stool analysis and CBC was ordered. Pus cells were no longer found in the stool with the RBC count in the stool reduced to 0-1 HPF.

Treatment plan was modified to continue with 1 acupuncture and herbal treatment once per week for 2 additional weeks before requesting another stool analysis and CBC. If blood is still present in the stool or if symptoms return, a colonoscopy will be ordered to determine further course of action.

CONCLUSION

Over the course of treatment, the patient experienced significant improvement in symptoms and arrived for each appointment optimistic about her progress. Due to her age, recognizing the role and good health of the Kidneys in her treatment prognosis is critical to her well-being. 2 critical points in the treatment plan were the switch from focusing on the Spleen to focusing on the health of the Kidney yang energy and the addition of the heat clearing formula to stop bleeding in the intestines. When little results had been achieved from the formula, Bu Zhong Yi Qi Tang, the treatment approach was changed to more strongly nourish the Kidneys. The formula was switched to a Kidney-based formula in the Li Zhong Wan family. When the stool analysis showed that there was still blood present in the stool, Qing Wei San was added to help cool the gastrointestinal tract and stop bleeding. Diarrhea can be an especially dangerous symptom for the elderly. With acupuncture, Chinese herbs, supportive care and allopathic testing, I am optimistic that the patient’s health will continue to improve. A colonoscopy would confirm the diagnosis of ulcerative colitis at which point a more accurate management plan and prognosis could be made. At this point in her progression, I expect that the patient will need to continue care at the clinic for an additional month, focusing on herbal and dietary therapy to resolve her condition. As a member of the elderly community in a small, rural village in Nepal, the improvement in my patient's health is a significant contributing factor to the health, well-being and sustainability of her community.

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