Western Medicine

Picture of ear anatomy

• Eardrum, malleus, incus and stapes are hearing organs.
• Semicircular canal (labyrinth), vestibular nerve and cochlea are balancing organs.

(Stedmans's Medical Dictionary 27th edition copyright 1999)

Ménière's disease is a disease of the inner ear. Build-up of fluid in the inner ear creates excess pressure and causes damage to the sense organs that are responsible for balance and hearing. A patient with Ménière's disease typically presents with varying levels of hearing loss, a sense of fullness in the ears, tinnitus and episodes of vertigo.

The disorder is also known as endolymphatic hydrops. The cause is unknown, but it is a common ear, nose and throat (ENT) disease. The major clinical symptoms are frequent attacks of vertigo, tinnitus, degrees of hearing loss and a sensation of fullness in the inner ear. Symptoms will resolve with or without treatment. The disease is usually seen in the young and middle-aged adults, and approximately 75 per cent of cases occur in those aged 30 to 60 years. The incidence between the sexes is equal. A recent increase in the number of cases is probably related to the increasing risk of air pollution and chemical toxicity.

Chinese Medicine

TCM would classify Ménière's as a "dizziness" disease

Ménière's disease is a disorder of the fluid-filled semicircular canals of the inner ear (labyrinth).

Traditional Chinese medicine (TCM) practitioners focus on the dizziness that results from the disease and consider it to be ear related. The disorder is therefore categorized as "aural dizziness." Dizziness is a sensation of unsteadiness with a feeling of movement within the head. It is also referred to as giddiness or vertigo and there is often blurring of vision. In mild cases, the symptoms disappear when the eyes are closed. In serious cases, patients experience a whirling sensation and the feeling that things about them are turning. There is also then a tendency to loose balance and fall; this is commonly accompanied by nausea, vomiting and sweating.

Different TCM schools through the ages have varied in their theories on the etiology of this disease. The famous classic Huang Di Nei Jing (The Yellow Emperor's Medicine Classic) held that "Dizziness with trembling extremities is a syndrome caused by the stirring of liver-wind inside the body. It is also related to qi deficiency and deficit in the sea of marrow, etc."

Western Medicine

Ménière's disease can affect people of all ages, but is especially common in those in middle age or older. The incidence in men and women is equal.

Extensive research into the cause of this symptom complex has led to the present understanding that Meniere syndrome is not the result of any particular cause, but is the reaction of the inner ear to different offending agents that cause disruption of the normal balance of the ear's fluid system.

Recognized causes of the syndrome include:

• congenital inner ear deformities
• inflammation of the inner ear
• physical trauma to the head and ear
• injury caused by loud noise
• congenital or acquired syphilis
• allergic disorders
• autoimmune disorders, and
• disorders involving blood vessels, including diabetes and hypertension.

Most cases, however, arise from no known cause and these are labeled as Ménière's disease.

Chinese Medicine

Click here to see the causes of Ménière's Disease from a TCM perspective
The understanding in TCM is that the disease mainly stems from internal injuries to the liver, spleen and kidneys. This leads to loss of nourishment of the orifices and a deficit in the sea of marrow, resulting in dizziness. The causative factors of the organ damage include wind evil, fire evil and phlegm.
Excess of liver yang
The liver dominates the conduction and dispersal of qi movement. Liver-yang has the property of upward motion and causes qi or other things to ascend. Liver-yin, conversely, has the property of static motion and causes things to descend. Yin and yang mutually restrict and promote each other in order to maintain balance in the body. Hyperactivity of liver-yang or deficiency of liver-yin triggers the qi and blood to ascend to the brain. Moreover, the acceleration of qi movement also produces wind evil and leads to symptoms of dizziness or sudden blackouts.
Hyperactivity of liver-yang occurs in these situations:

• In individuals who are prone to a natural excess of yang, the excess yang periodically triggers the generation of wind evil.
• Emotional instability, especially long-term anger and depression, causes stagnation of the liver-qi. This results in the accumulation of fire evil in the body and the exhaustion of liver-yin. In turn, this activates the liver-yang and generates wind evil.
• Damage to the kidneys, for example as a result of indulgence, results in a depletion of kidney essence and affects the liver-yang. According to the theory of the five elements, the kidneys (representing water) nourish and promote the liver (representing wood).

Obstruction of orifices by phlegm and dampness
Orifices are the openings on the body's surface to the five internal organs. Phlegm and dampness evil are heavy and turbid (viscous) in nature. They tend to cause obstructions in the places where they accumulate. When these evils are brought up by qi and reach the head, they lodge easily in the orifices and cause dizziness.
In TCM, it is believed that phlegm and dampness evil accumulate under the following conditions:

• Consumption of an improper diet, such as an excess of fat and alcohol, irregular meal times, and excessive concentration and stress lead to malfunction of the spleen and stomach. The organ damage facilitates accumulation of dampness evil, which can then turn into phlegm.
• Impaired functioning of the lungs, resulting in a failure to regulate and distribute fluid throughout the body, leads to a build-up of dampness evil.
• When the kidneys fail to perform their vaporization function (removal of metabolic waste), excessive fluid will remain in the body.

Deficiency of the kidneys
The kidneys are responsible for storing essence and producing the marrow of which the brain is composed. The kidneys therefore nourish the brain. In kidney deficiency, the brain loses this supporting nourishment and dizziness results.

TCM holds that impaired functioning of the kidneys or loss of kidney essence happens in the following conditions:

• in individuals with congenital (inherited) weakness who do not care for themselves properly
• aging
• chronic disease
• indulgence.

Western Medicine

Patients with Ménière's disease experience periodic attacks of disabling symptoms of loss of hearing and balance. The disease is progressive, but in between attacks patients are usually free of symptoms. Attacks tend to occur in clusters over a few weeks and they can last for up to two or three days. There may be periods of remission between attacks of weeks or even months. During the acute episode the following symptoms are commonly experienced:

Vertigo
This is a sudden sense of loss of equilibrium, or dizziness, often described as if "everything seems to be going around" or "the whole room seems to be spinning." Vertigo may appear without warning at any time and is not usually associated with a change in position. It may make sitting or walking difficult. Any head motion, even when lying flat, may aggravate the sensation. These spells of dizziness may last from five minutes to 72 hours. The spells may stop gradually or very suddenly. Sufferers are usually obliged to lie down with their heads placed in the position of greatest comfort.

Nausea
Nausea usually accompanies the vertigo because of stimulation of nerves in the ear that affects the nerve supply to the stomach and intestines. Any head movement may aggravate nausea. As a consequence, the head is usually held rigidly to one side. Vomiting may be violent or prolonged for hours.

Ear fullness
The sensation of ear fullness may precede other symptoms by several days or occur abruptly with tinnitus and hearing loss.

Tinnitus
Tinnitus is described as a sudden roar, whistling, ringing, cricket hum, or rushing sound deep within the ear that is unremitting and constant. Pulsating or throbbing tinnitus does not occur with Ménière's disease and its presence suggests a disorder of the blood vessels. The tinnitus may improve or disappear as the attack subsides. However, in more than 50 per cent of patients, the tinnitus continues after the first attack and may rival vertigo as the most severe symptom.

Loudness sensitivity
Loudness sensitivity is known as "recruitment." Recruitment is an abnormally rapid increase in the sense of loudness as sound intensity increases. The comfortable range of hearing becomes narrow and patients become intolerant of sounds barely above their hearing threshold.

Hearing loss
Sudden profound hearing loss may occur with the first attack. It may persist, but hearing usually returns and fluctuates close to normal. Hearing loss becomes progressive with each attack. Characteristically, low-tone loss develops, followed by high-tone loss as repeated attacks occur. The hearing may become useless for normal conversation as pure-tone and speech discrimination levels decline. Total deafness for all sounds is rare. Hearing may improve suddenly as nausea and vomiting occur.

Impaired vision
Patients may experience blurred or "jerky" vision, created primarily by the rapid, involuntary stimulation from the inner ear. This can be constant during the first few hours of the attack. The entire room may seem to be in rotation from the vertigo also.

Headache
About one in every four patients experiences generalized vague headache, even between attacks. This may be accentuated with attacks and persist to a lesser degree almost daily. The mechanism of this headache is unclear, but it may be related to constriction of blood vessels common to the inner ear and other cerebral vessels. In some patients this is the most distressing part of the disease.

An acute episode typically follows this course:

• Warning symptoms of pressure sensation or fullness in one ear, which feels "blocked," precede an attack.
• Hearing then becomes impaired, accompanied by a loud roaring tinnitus.
• Vertigo soon follows and lasts from a few minutes to many hours, rarely lasting as long as 24 hours. The interval between the onset of symptoms and the peak of vertigo varies from a few minutes to a full day or so.
• Depending on the severity of the vertigo, patients may experience nausea, vomiting or diarrhea.
• Pallor and cold sweat are common.
• The patient may feel weak and unsteady for one or two days following a severe attack. Recurrence of the attacks is a fundamental feature of the disease. The attacks are of unpredictable frequency. At first, patients may have one attack per year. Then attacks may occur more frequently, once a week or even daily.

Chinese Medicine

TCM practitioners will examine a sufferer and categorize symptoms under special syndrome groups known as "disharmony patterns." Certain disharmony patterns are present at different stages of a disorder. In Ménière's disease these can be classified into the following types:

Deficit in the sea of marrow
Individuals present with frequent attacks of dizziness accompanied by severe ringing in the ears and obvious hearing loss. Other symptoms include listlessness, soreness and weakness in the back and knees, insomnia and irritability, nightmares, spermatorrhea, poor memory, and a hot sensation in the chest, palms of the hands and the feet.

Deficiency in qi and blood
During the dizziness attacks, individuals look pallid, are fatigued or sleepy, lack emotion and are reluctant to speak. Other symptoms include loss of appetite, diarrhea, shortness of breath, and wheezing and palpitation on exertion.

Flood of cold-dampness
Individuals experience forceful palpitations during attacks, accompanied by an aversion to cold, a low body temperature and the spitting-up of large amounts of thin, clear sputum. Other symptoms include pain and a sensation of cold in the loin area, listlessness and lack of affect (emotion), frequent nocturnal urination, and production of large volumes of clear urine.

Disturbance of liver-yang
These episodes usually happen after an emotional disturbance and are accompanied by impetuosity and irritability, headache, a flushed face and blood-shot eyes. Other symptoms include a bitter taste in the mouth, a dry throat, and a feeling of fullness and discomfort in the chest and below the ribs. Insomnia and nightmares may occur.

Obstruction by viscous phlegm
Individuals experience heaviness and distension in the forehead during dizzy spells. Chest discomfort, nausea and sometimes severe vomiting can accompany these symptoms. Other symptoms include the production of large amounts of saliva and sputum, palpitation, poor appetite and fatigue.

Western Medicine

Diagnosis is usually evident from the symptoms and the history given by the patient.

Symptoms that affect the ear, such as tinnitus, fullness of the ear and hearing loss, contribute most to making a diagnosis. Hearing tests (audiograms) will confirm any low-frequency sensory nerve hearing loss. Repeated audiograms reveal the fluctuating nature of the loss.

Computed tomography (CT) and magnetic resonance imaging (MRI) usually reveal no physical abnormalities.

Chinese Medicine

Diagnosis in TCM places importance on determining the circumstances and manifestations of a disease through inquiry and symptom observation. Diagnosis is based on the traditional four examination techniques:

1. Questioning The TCM practitioner will establish the medical history of both the patient and his family.
2. Observation Examination of the physical features of the body, such as the face, tongue, hair, nails, sputum (mucus that is coughed up), and location of pain, all offer clues to the problem. The tongue is a particularly useful indicator of the functioning of the internal organs.
3. Listening and smelling The smelling of sputum and breath and listening to the sounds produced by the chest offer additional clues to the patient's health.
4. Touching Feeling the pulse is a cornerstone of TCM diagnosis and gives the practitioner much information about any bodily imbalance.

A Chinese doctor feeling a patient's pulse

In Ménière's disease, the procedures used in TCM to differentiate between disharmony patterns can be explained as follows:

Deficit in the sea of marrow
This syndrome group is the result of kidney deficiency. When kidney essence becomes depleted, production of brain marrow declines. The brain loses nourishment and the result is dizziness. Furthermore, the ear is the surface opening of the kidney and as the kidneys also produce marrow for bones, ringing in the ears and soreness of the back and knees develop concomitantly.

On examination, the tongue is red with scanty fur. The pulse is thready, fine and rapid.

Deficiency in qi and blood
As defective qi circulation causes a disturbance to the function of the brain and insufficiency of blood leads to a lack of nourishment, the result to the brain is dizziness. Exertion consumes more qi and so triggers an attack. Other presentations of qi deficiency include fatigue, a reluctance to speak, sleepiness and lack of appetite.

On examination, the tongue is pale. The pulse is fine and rapid.

Flood of cold-dampness
The syndrome results from the retention of coldness and dampness evils, and damage to the kidneys. The evils not only obstruct the orifices in the head, leading to dizziness, they also bring manifestations of patterns of cold, such as a low body temperature, fatigue and lack of affect (emotion). Kidney damage is usually involved in this condition, so the individual may experience pain and a cold sensation in loin area, or frequent urination at night.

On examination, the tongue is pale, and coated with white and moist fur. The pulse is deep, weak and fine.

Disturbance of liver-yang
This pattern is usually triggered by an emotional disturbance, which gives rise to hyperactivity of liver-yang and generates wind evil. The symptoms that result include dizziness, headache, insomnia and nightmares. Moreover, due to yang excess, individuals can also experience heat symptoms, such as a flushed face, blood-shot eyes, a bitter taste in the mouth and a dry throat.

On examination, the tongue is red and coated with yellow fur. The pulse is taut and rapid.

Obstruction by viscous phlegm
When phlegm remains in the head and causes obstruction of orifices, normal qi flow will be affected. The individual experiences dizziness, fatigue, and heaviness and throbbing in the forehead. When phlegm stays inside the organs, symptoms such as chest discomfort, nausea, vomiting and poor appetite develop.

On examination, the tongue is pink, and coated by white and greasy fur. The pulse is uneven and slippery, or may be taut.

Note: If a TCM practitioner suspects a serious problem that Chinese medicine alone cannot treat, he or she will recommend the individual to see a Western doctor for further follow-up.

Western Medicine

Treatment comprises management of symptoms; when this fails, surgery or chemical ablation (destruction) can be considered.

Medical management

Medical treatment is usually tried first, but the many categories of medical management indicate how difficult it is to treat this disorder. The aims of treatment are to reduce symptoms and to prevent hearing loss. The following are currently used:

• sedatives
• anticholinergic agents
• vitamins
• agents that increase blood flow
• histamine desensitization
• antihistamines
• control of body fluid
• allergy management
• metabolic therapy
• endocrine (hormone) therapy
• physical therapy, and
• various combinations of these.

Bed rest is essential. Controlled trials of the efficacy of any treatment of an acute attack have been difficult to complete because of the unpredictable and variable nature of the disease.

Surgical treatment

About 20 per cent of patients fail to respond to medical management and need surgery to relieve disabling vertigo. Patients who have lost hearing respond well to an operation that removes the inner ear (labyrinthectomy). This involves the complete removal of the vestibular (balance) end-organ. For patients who still have serviceable hearing, removal of the vestibular nerve is the procedure of choice, offering a 90 to 95 per cent success rate in vertigo control while preserving hearing.

Anatomy of the Ear
In a chemical labyrinthectomy gentamicin can be administered through the eardrum.
(Stedmans's Medical Dictionary 27th edition copyright 1999)

Chemical labyrinthectomy

Patients who are either not suited for or refuse surgery, but yet fail to respond to medical treatment, may benefit from an injection of gentamicin sulfate given into the ear. This injection is carefully administered and allows gentamicin to be absorbed through the eardrum to create a chemical labyrinthectomy whilst preserving hearing.

Bilateral Ménière's disease

Patients with active Ménière's disease in both ears are treated with systemic injections of streptomycin sulfate. The injection is given daily with close monitoring of vestibular (balance) function; treatment is stopped after the first signs of toxicity to the balance function and before the onset of hearing loss.

Chinese Medicine

TCM treatment of Ménière's disease is based on two principles:

• Elimination in conditions of excess; and tonifying in conditions of deficiency.
• Dealing with symptoms in the acute stage; and dealing with the origin of the disorder when it is chronic.

Chinese Medicine

Deficit in the sea of marrow

Therapeutic aim: To nourish yin, tonify kidneys, replenish essence and benefit marrow.

Prescription:

A Chinese patent medicine such as Qiju Dihuang bolus is recommended as it can nourish yin and tonify the kidneys.

Deficiency in qi and blood

Therapeutic aim: To replenish qi and blood, reinforce the spleen and calm the mind.

Prescription:

A Chinese patent medicines such as Guipi bolus is recommended to reinforce the spleen, benefit qi and promote blood production.

Flood of cold-dampness

Therapeutic aim: To warm the kidney yang, eliminate coldness evil and promote diuresis (elimination of fluid from the body by urination).

Prescription:

A Chinese patent medicine such as Fugui Bawei bolus is recommended. This warms the kidneys and reinforces the yang part of body.

Disturbance of liver-yang

Therapeutic aim: To smooth the liver, expel wind evil, nourish the yin and depress the yang component.

Prescription: Tianma Gouteng drink

A Chinese patent medicine such as Longdan Xiegan bolus is recommended. This clears heat and fire evils, promotes liver function and detoxifies.

Viscous phlegm obstruction

Therapeutic aim: To reinforce the spleen and liver, expel dampness evil and phlegm.

Prescription:

Acupuncture and moxibustion

The use of acupuncture and moxibustion can be helpful, for alleviating symptoms like vertigo and tinnitus. Treatment is conducted as follows:

• When applying general methods, the usual acupuncture points are:
  Bai-hui, shen-ting, shen-men, er-men, nei-guan, shen-mai, he-gu, zu-shan-li, feng-long, pi-shu, shen-shu, guan-yuan, feng-chi, xing-jian and zhong-wan.
  Three or four acupoints are stimulated each time.
• When applying otopuncture therapy, the acupuncture points are:
  Forehead, heart, shen-men, kidney, occipital and inner ear.
  Two to three acupoints are stimulated each time.
• When applying acupoint injection, the recommended acupuncture points are:
  He-gu, zu-shan-li, tai-chong, yi-ming or nei-guan, feng-chi and si-du.
  Two to three acupoints are stimulated each time. Injections can include danshen, ginseng and Chinese angelica.

Western Medicine

No consistently valuable preventive measures are known. Patients should follow a low-salt diet, consuming no more than 2 g a day, as fluid imbalance is the basic cause of physiologic disturbance.

Low salt diet

Chinese Medicine

An improper diet, stress and emotional instability are the common trigger factors for Ménière's disease. In the prevention and management of the disorder, it is therefore important to live a balanced lifestyle, maintain a proper diet and exercise regularly.

A balanced lifestyle

• Pay attention to climatic changes to avoid the invasion of exogenous pathogens.
• Eliminate stress and always retain an optimistic frame of mind.
• Regular exercise helps to reinforce the body's constitution and resistance.
• During episodes of the disorder, stay in bed to avoid unnecessary accidents.
• The living environment should be quiet, sunny, warm and well ventilated.

Dietary management
Individuals should maintain a low-salt and light diet. Fried and greasy food should be avoided. As certain food can promote the functions of the organs, you should ask your TCM practitioner for recommendations.

Spiritual management
Individuals should avoid mental over stimulation and stress. Proper understanding of the disease is important. Always remain in an optimistic frame of mind and be relaxed. During remission periods, individuals are recommended to follow traditional Chinese exercise, such as the tai chi or eight-length brocade exercise. All of these measures can reduce the frequency of attacks.

Western Medicine

Chinese Medicine