Sinusitus & Ear Pain: A Case Study

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The patient was successfully treated for acute sinusitis and ear pain using herbal medicine.

July 2015

Male, 38

Brief Synopsis Of History Taken At Visit:

The patient reported 4 day history of nasal discharge, facial pressure, and chest discomfort.   The pain began after water became trapped in his ear while swimming.  As per the patient, the nasal discharge is profuse in quantity with a yellow color. There was also a productive cough with phlegm. In addition the patient reports “pressure” in his cheeks, temples, and ears. The patient notes a history of sinus infections typically treated with antibiotics in the past.

Pulse: thin, choppy 

Tongue: Large, moist, no coat, pink/red in color, puffy sides

TCM Diagnosis: Bi Yuan

Herbal Treatment:

-Herbs Are Granules Of 5x Concentration 

8 Scoops, 2 x Day for 3 days(1g of granules approx. equals 5g of raw herb).

Xin Yin Hua                        Chai Hu

Cang Er Zi                          Huang Qin

Bai Zhi                                 Zhi Ban Xia

E Bu Shi Cao                      Sheng Jiang

Chuan Xiong                     Zhe Bei Mu

Zhi Shi                                 Jie Geng

Yi Yi Ren                             Huang Lian 

Results:       

Follow up  3 days later

The patient reported that while his frontal sinuses had improved greatly that the ear pain and pressure had increased and the patient felt that he might have an ear infection on his left side. As per patient he is experiencing some hearing disturbance on his left side. Pt. reports L sided gum inflammation as well. Pt. is not feverish but tends to run warm. On exam, pt. has submandibular lymph nodes present, approx. 1 – 1.5 cm, soft, slightly tender.  Pulse:  Wiry, Moderate  Force

The following herbs were given in granules, and the patient was instructed to contact myself , his primary care, or ENT if the hearing problems worsened.

Herbs Are Granules Of 5x Concentration (1g of granules approx. equals 5g of raw herb).

10 Scoops, 2 x Day for 4 days. Total Daily Granule Dosage:        

Chai Hu                      .5g                                     Xuan Shen           3g

Huang Qin (Jiu)          2g                                   Sheng Di Huang 3g

Huang Lian            1.5g                                      E Bu Shi Cao       1g

Long Dan Cao        .75g                                      Bai Zhi                 1g

Ban Lan Gen            2g                                        Xin Yi                  1g

Lian Qiao                .5g                                            

Jin Yin Hua              1g

Shi Chang Pu         2g

Zhu Ru                     .75g

Follow up 15 days later 

The patient reported that he took the herbs as directed and that the ear pressure had resolved.  The gum inflammation it turned out was due to a tooth that needed extraction. 

Overall, the sinusitis and ear pain cleared over a week period.

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