EARS AND EYES

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Chapter 42

imageEARS AND EYES

HOW WE ASK

When asking about tinnitus it is important to express this symptom in terms patients can understand. I generally ask them whether they experience any ‘ringing in the ears’. It is important to let the patient understand that even an occasional ringing in the ears has clinical significance.

In general terms, the ears may be affected by a pathology of Deficiency (usually of the Kidneys but also of Lung and Heart) causing tinnitus, hardness of hearing or deafness, or by one of Fullness, usually due to Heat or Phlegm.

The main deficiency patterns affecting the ear are:

The main Full patterns affecting the ears are:

Tinnitus

Symptoms and Signs, Chapter 57

Tinnitus is caused either by a failure of Qi to rise to the ears (Empty type) or by an excess of Qi in the ears (Full type). In order to differentiate between the Empty types and the Full types, we need to consider the onset, the pitch, the duration and the reaction to pressure of the tinnitus.

A sudden onset suggests a Full condition, which may be internal such as Liver-Fire or Liver-Wind, or external such as Heat in the Lesser Yang. A gradual onset suggests an Empty condition, which may be due to a deficiency of the Kidneys, Lung or Heart.

A loud, high-pitched, ringing noise like a whistle indicates Liver-Yang rising, Liver-Fire or Liver-Wind, whereas a low-pitched noise like rushing water indicates a Kidney deficiency.

Tinnitus of short duration is usually due to an external invasion of Wind-Heat affecting the Lesser Yang channels. Chronic tinnitus of long duration is due to either a Kidney deficiency or a Liver pathology (Liver-Yang rising, Liver-Fire, or Liver-Wind).

If the tinnitus is aggravated by pressing one’s hands on the ears, this suggests a Full condition; if it is alleviated it suggests an Empty condition.

Case history 42.1 illustrates a pattern of tinnitus caused by Yin deficiency.

Case history 42.1

A 56-year-old woman had been suffering from tinnitus for 3 years. The onset had been slow and gradual and the ear noise was low in pitch. She also suffered from poor memory, lack of concentration, blurred vision, dizziness and hot flushes (flashes). On asking her, it transpired that she also experience a dry mouth, anxiety and palpitations. Her urine was dark. She also said that she startled easily.

She also experienced occasionally a dull ache in the chest, with the pain sensation extending up to the neck like a ‘steel band’.

Her periods had stopped 2 years previously. Her tongue was Red, with a redder tip, entirely without coating and dry. Her pulse was Weak on both Rear positions and very slightly Wiry but Fine on the left.

Diagnosis:

This patient presents with very clear manifestations of Kidney-Yin deficiency (dark urine, tinnitus, dizziness, blurred vision, hot flushes) and Heart-Yin deficiency (poor memory and concentration, palpitations, anxiety and propensity to be startled). The condition of Yin deficiency is shown very clearly by the absence of coating, and the redness of the tongue (combined with the lack of coating) clearly indicates Empty-Heat. I interpreted the dull ache in the chest extending to the neck as a symptom of rebellious Qi of the Penetrating Vessel, a common complicating factor in menopausal problems. The Wiry quality of the pulse on the left supports this diagnosis.

Box 42.1 summarizes the patterns underlying tinnitus.

BOX 42.1   TINNITUS

Deafness

Symptoms and Signs, Chapter 57

The diagnostic criteria of deafness or hardness of hearing are similar to those of tinnitus: an acute onset points to Fullness, whereas a gradual onset points to Deficiency. The main Excess causes of deafness or hardness of hearing are Liver-Fire, Liver-Yang rising and Phlegm-Fire affecting the Liver channel.

The main Empty cause of deafness or hardness of hearing is a Kidney deficiency (the most common cause in the elderly). However, the Kidneys are not the only organ that influences the ears; hardness of hearing may also be caused by Heart-Blood, Heart-Yin, Lung- or Heart-Qi deficiency, or deficiency of the Gathering Qi (Zong-Qi) or Yang-Qi. In all these cases, hardness of hearing is due to Qi or Blood not flowing upwards to the ears.

Box 42.2 summarizes the patterns underlying deafness.

BOX 42.2   DEAFNESS

Earache

Symptoms and Signs, Chapter 57

With the exception of Qi and Blood stagnation, earache is usually due to Heat; this can be an invasion of Wind-Heat affecting the Lesser-Yang channels (which is very common in children, and accompanied by aversion to cold and fever), Damp-Heat in the Liver and Gall-Bladder channel or Liver-Fire. A yellow discharge from the ear may accompany an invasion of Wind-Heat or Damp-Heat in the Liver and Gall-Bladder. Earache from Liver-Fire is accompanied by headache, a red face and a bitter taste in the mouth. The chronic earache from Qi and Blood stagnation is not common and is usually seen only in the elderly.

Box 42.3 summarizes the patterns underlying earache.

BOX 42.3   EARACHE

HOW WE ASK

‘Blurred vision’ is not an expression most patients are familiar with. I generally ask them whether their vision is sometimes ‘not clear or somewhat obfuscated’, stressing that the condition at issue is quite apart from their being short sighted or not. ‘Floaters’ is another expression most patients are not familiar with and I generally ask whether they ever see ‘black or white spots floating in the field of vision’.

Eye pain

Symptoms and Signs, Chapter 61

Full or Empty character of eye pain

Table 42.1 and Figure 42.1 summarize the Full and Empty characteristics of eye pain.

Table 42.1

Full and Empty characteristics of eye pain

  Full/Yang Empty/Yin
Onset Sudden Gradual
Time Day Night
Time of day Morning Afternoon
Constancy Chronic and persistent Chronic on and off
Swelling With swelling Without swelling
Intensity Severe, unbearable Dull, mild
Inflammation Inflamed, red and hot Not red, not hot
Pressure Worse with pressure Better with pressure
Temperature Worse with heat, better with cold Worse with cold, better with heat
Irritability Pain with irritability (Liver) Pain without irritability (Yang deficiency)
Character of pain Pain like needles Mild pain
Food Worse after eating Better after eating, worse when hungry
Two excretions (urination and defecation) Redness, excretions affected No redness, excretions not affected
Eyeball movement With moving eyeballs Eyeballs not moving

Eye pain of internal or external origin

Eye pain can first be differentiated into internal and external types (Fig 42.1); secondly internal eye pain can be differentiated into Full and Empty as indicated in Table 42.1.

Eye pain of external origin is mostly due to invasion of Wind-Heat and is characterized by a sudden onset, sticky eyelids and streaming eyes, with an aversion to cold and a fever.

Eye pain from a Full condition is often accompanied by swelling and redness.

Box 42.5 summarizes the patterns underlying eye pain.

BOX 42.5   EYE PAIN

Streaming eyes

Observation, Chapter 6; Symptoms and Signs, Chapter 61

Streaming eyes may be due to Heat of the Full or Empty type. In particular, it may be due to Full-or Empty-Heat of the Lung or Stomach.

Other causes of streaming eyes include external Wind-Heat, Liver-Fire and Liver-Blood deficiency associated with Liver-Heat. In some cases, streaming eyes may be due to Liver-Blood deficiency and general Qi deficiency or to Kidney-Yang deficiency: these two types of streaming eyes are called ‘cold streaming’.

Box 42.7 summarizes the patterns underlying streaming eyes.

BOX 42.7   STREAMING EYES

Blurred vision

Symptoms and Signs, Chapter 61

‘Blurred vision’, called Mu Xuan in Chinese, indicates not only blurring of vision and floaters but also includes a slight dizziness.

Although blurred vision is a relatively common complaint, when asked whether they suffer from it most patients will either answer negatively or not know what we mean. Thus, this question should be asked in a different way, such as ‘Do you have any problems with your vision?’ or ‘Is your vision sometimes unclear?’

First of all, it should be remembered that the eyes are under the control not only of the Liver but also of the Gall-Bladder and Kidneys; especially in the elderly, a Kidney deficiency is often at the root of eye problems and blurred vision.

Among the Deficiency types, the most common causes of blurred vision are Liver-Blood or Liver-Yin deficiency. If blurred vision is associated with dryness of the eyes, this suggests either Liver-Yin deficiency or Liver- and Kidney-Yin deficiency, which is common in the elderly.

Blurred vision may also be due to Excess patterns such as Gall-Bladder Heat, Liver-Yang rising (a common feature in migraine), Liver-Fire and Phlegm. Phlegm, in particular, is not often recognized as a possible cause of blurred vision; however, it may cause a blurring of vision with muzziness and dizziness because it obstructs the clear orifices of the head, including the eyes (for the same reason, Phlegm may cause tinnitus).

Box 42.9 summarizes the patterns underlying blurred vision.

BOX 42.9   BLURRED VISION

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