Clinical Case StudiesReal Patients, Real Medicine


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.

  • Acute Cholecystitis

    Acute Cholecystitis

    70-year-old female presents with acute abdominal, chest and scapular pain, vomiting and diarrhea. At the local hospital, she was diagnosed with acute cholecystitis via labs and ultrasound

    Read More
  • Ankylosing Spondylitis

    Ankylosing Spondylitis

    25-year-old male presents with low back and sacroiliac pain, beginning approximately 15 months prior to consultation at this clinic, for which he had received a diagnosis

    Read More
  • Atrophic Vaginitis with Recurrent Urinary Tract Infections

    57-year-old post-menopausal female presents with constant burning uterine and bladder pain for 3 years. Allopathic care has been unsuccessful in diagnosing and providing relief of symptoms

    Read More
  • Autism Spectrum Disorder

    Autism Spectrum Disorder

    20-year-old male patient presents with decreased mental capacity, which his mother states has been present since birth. He lacks verbal communication skills and his mother states

    Read More
  • Bell’s Palsy (Facial Paralysis)

    Bell’s Palsy (Facial Paralysis)

    A 50-year-old female with Bell’s palsy presents with hemi-facial paralysis involving the eye and the mouth. After 5 weeks, 10 acupuncture treatments and 2 months of

    Read More
  • Bilateral Hip and Low Back Pain

    19-year-old male presents with trauma-related chronic hip and low back pain with limits in range-of-motion that interferes with daily life. After 24 acupuncture treatments over the

    Read More
  • Bilateral Leg Weakness and Paralysis

    Bilateral Leg Weakness and Paralysis

    42-year-old female presents with an inability to walk due to slow-onset, partial bilateral leg paralysis occurring over a 15 year time span. After 23 treatments focusing

    Read More
  • Candidiasis and Vaginal Discharge (Type II Diabetes)

    Candidiasis and Vaginal Discharge (Type II Diabetes)

    63-year-old female presents with chronic purulent vaginal discharge, pruritus vulva and tingling in the extremities. Test results show hyperglycemia of RBS 540 mg/dl as well as

    Read More
  • Cervical and Lumbar Spondylosis

    Cervical and Lumbar Spondylosis

    70-year-old male presents with severe cervical and lumbar pain, neuropathy of the arms, hands, legs and feet, incontinence of bowels and anal rash. His doctor has

    Read More
  • Chronic Abdominal Pain

    Chronic Abdominal Pain

    31-year-old male presents with chronic abdominal pain. The patient has suffered from abdominal pain for the past 11 years, but has had a worsening of symptoms

    Read More
  • Chronic Gastritis

    Chronic Gastritis

    52-year-old female presents with chronic, burning epigastric pain accompanied by acid reflux, nausea, belching and decreased appetite. The patient also experiences daily headaches and dizziness. With

    Read More
  • Chronic Gastritis with Inflammatory Bowel Syndrome: Crohn’s Disease

    Chronic Gastritis with Inflammatory Bowel Syndrome: Crohn’s Disease

    40-year-old male presents with chronic, burning gastrointestinal pain with accompanied acid reflux, belching, fullness, diarrhea, weight loss and occasional rectal bleeding. The patient also experiences

    Read More
  • Chronic Headache (Typhoid Fever Sequela)

    Chronic Headache (Typhoid Fever Sequela)

    43-year-old female presents with a severe headache. 9 months ago, the patient contracted Typhoid fever. During the illness, she had a headache that covered her entire

    Read More
  • Chronic Non-Healing Ear Ulcers

    Chronic Non-Healing Ear Ulcers

    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

    Read More
  • Chronic Obstructive Pulmonary Disease with Osteoarthritis

    Chronic Obstructive Pulmonary Disease with Osteoarthritis

    65-year-old female presents with dyspnea and continuous cough. The patient also presents with chronic, severe pain and inflammation of all joints of the hands and feet.

    Read More
  • Chronic Vomiting

    Chronic Vomiting

    80-year-old male presents with vomiting 20 minutes after each meal for 2 years. At the time of initial visit, patient was vomiting undigested food and water

    Read More
  • De Quervain’s Syndrome

    57-year-old female presents with hand tingling and severe wrist pain that began 9 months prior to visiting the clinic. Both wrists are affected. Patient reports pain

    Read More
  • Dupuytren’s Contractures

    Dupuytren’s Contractures

    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

    Read More
  • Emotional Depression

    Emotional Depression

    40-year-old woman presents with depression, emotional stress and dream-disturbed sleep. She presents with a secondary complaint of chronic ringing in her ears. 2 months ago her

    Read More
  • Facial Paralysis (Bell’s Palsy)

    Facial Paralysis (Bell’s Palsy)

    35-year-old female presents with left-sided facial twitching and paralysis. After 7 acupuncture treatments, the patient regained over 50% of her facial functioning with 80% of the

    Read More
  • Febrile-Induced Cerebellar Ataxia

    Febrile-Induced Cerebellar Ataxia

    58-year-old male patient presents with ataxia, severe dizziness, vertigo and slurred speech. Symptoms started after a severe febrile illness in November 2012, and appear to be

    Read More
  • Ganglion Cyst

    Ganglion Cyst

    11-year-old female presents with large lump over left radial artery at radial styloid process, causing pain to the local area. She had minor surgery to remove

    Read More
  • Hemiplegia (Stroke Sequelae) with Acute Lung Consolidation

    Hemiplegia (Stroke Sequelae) with Acute Lung Consolidation

    81-year-old female presents with complete left-sided hemiplegia following ischemic stroke 2 months ago. Over the course of 7 weeks of acupuncture treatment, the patient regained limited

    Read More
  • Hemiplegic Stroke Sequelae with Aphasia

    Hemiplegic Stroke Sequelae with Aphasia

    Patient presents with right-sided paralysis of his upper and lower limbs due to an ischemic stroke 9 months ago. Additional sequela includes speech impairment with the

    Read More
  • Hemorrhagic Stroke Sequelae

    Hemorrhagic Stroke Sequelae

    53-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

    Read More
  • Huntington's Disease

    Huntington's Disease

    38-year-old female presents with a 4-year history of involuntary spasming throughout her entire body. The patient does not have any available medical records and the cause

    Read More
  • Ischemic Cerebrovascular Incident

    Ischemic Cerebrovascular Incident

    60-year-old male presents with sudden onset of motor deficit of right hand, tingling and weakness of right foot, as well as marked changes in function of

    Read More
  • Juvenile Rheumatoid Arthritis

    Juvenile Rheumatoid Arthritis

    10-year-old female presents with active phase of Juvenile Rheumatoid Arthritis (JRA) as demonstrated by multiple articular bony joint deformities, severely limited range-of-motion in all affected joints,

    Read More
  • Low Abdomen Pain due to Roundworm and Urinary Infection

    Low Abdomen Pain due to Roundworm and Urinary Infection

    30-year-old female presents with lower abdominal pain, burning urination and shortness of breath for the last 5 months. With the discovery and treatment of a parasitic

    Read More
  • Low Back Pain with Radiation

    Low Back Pain with Radiation

    30 year old male presents with severe back and left leg pain, exhibiting postural deviation as a way to relieve pain from an L5/S1 disc herniation.

    Read More
  • Low Back Pain with Urinary Difficulties

    Low Back Pain with Urinary Difficulties

    32-year-old woman presents with constant low back pain and burning urination. She has been diagnosed with severe hydronephrosis in the right kidney and, due to pain,

    Read More
  • Lumbar Stenosis due to Osteoartritis

    Lumbar Stenosis due to Osteoartritis

    36-year-old female with lumbar spinal stenosis presents with severe low back pain with referred pain down the posterior left leg and anterior right thigh. The patient

    Read More
  • Massage for Chronic Back Pain Associated with Spondylosis of the Spine

    Massage for Chronic Back Pain Associated with Spondylosis of the Spine

    70-year-old male referred for massage treatments for pain associated with spondylosis of the spine and neuropathy. The patient is simultaneously receiving ongoing acupuncture treatments. At the

    Read More
  • Neck Pain with Radiation

    Neck Pain with Radiation

    40-year-old male presents with right-sided neck pain, without nerve radiculopathy, down the arms bilaterally. He has seen his physician who diagnosed him with nerve impingement and

    Read More
  • Outer Ear Infection

    Outer Ear Infection

    52-year-old male presents with right-sided, burning head and ear pain, right-sided hearing loss and anosmia. It is determined, after an initial ear examination with an otoscope,

    Read More
  • Painful Ulcerations of the Throat with Chronic Sinusitis

    28-year-old male presents with chronic sinusitis, nasal blockage, throat pain and ulcerations for 18 months. The patient also presents with gastric pain. After 9 acupuncture treatments

    Read More
  • Palliative Care of Parkinson’s Disease

    Palliative Care of Parkinson’s Disease

    62-year-old male was diagnosed with Parkinson’s disease 8 years ago and has been receiving treatment in this clinic since 2009. This case explores the positive role

    Read More
  • Palliative Management of End-Stage Emphysema

    Palliative Management of End-Stage Emphysema

    71-year-old male presents with cough and severe shortness-of-breath, caused by emphysema. Initially, patient was stabilized during an emergency home visit. At patient’s request, palliative home care

    Read More
  • Parkinson’s Disease

    Parkinson’s Disease

    72-year-old female presents with left hand tremors that extend up the arm and into her neck and jaw. Tremors have been present for 2 to 3

    Read More
  • Primary Hypertension

    Primary Hypertension

    3 patients present with stage 2 essential hypertension (HTN), 1 of which is a female (76 yo) and 2 of which are male (61, 50 yo).

    Read More
  • Psoriasis with Neck and Shoulder Pain

    Psoriasis with Neck and Shoulder Pain

    45-year-old male presents with psoriasis for 5 years, possible psoriatic arthritis for 2 years, and idiopathic neck pain and stiffness for 2 months. After 17 treatments

    Read More
  • Rheumatoid Arthritis

    Rheumatoid Arthritis

    35-year-old female presents with multiple bilateral joint pain beginning 18 months previously and had received a diagnosis of rheumatoid arthritis at the Arthritis & Rheumatic Diseases Treatment

    Read More
  • Sequelae of Osteoarticular Tuberculosis

    Sequelae of Osteoarticular Tuberculosis

    Rachael Haley BAppSci (TCM)December 2014 OVERVIEW A 58-year-old man, of rural Nepal, presents with left hip pain, reduced strength and mobility in his left hip and

    Read More
  • Spastic Quadriplegic Cerebral Palsy

    Spastic Quadriplegic Cerebral Palsy

    Severely malnourished and non-ambulatory 11-year-old female presents with increased tone and spasticity in all extremities, frequent seizures, and currently requiring assist for all mobility. Patient was s

    Read More
  • Spinal Trauma Sequelae with Osteoarthritis of Right Knee

    60-year-old female presents with spinal trauma sequela consisting of constant mid- to high grade pain and restricted flexion of the spine. In conjunction with the treatment

    Read More
  • Stroke Sequela

    Stroke Sequela

    50-year-old male presents with post-stroke sequelae symptoms manifesting as severe right-sided paralysis. After 10 treatments starting in September 2012, the patient exhibited improvement in his condition

    Read More
  • Typhoid Fever Induced Paralysis

    Typhoid Fever Induced Paralysis

    32-year-old female presents with left-sided paralysis of upper and lower limbs. At age 12, the patient suffered from a fever due to Typhoid that caused convulsions

    Read More
  • Ulcerative Colitis

    Ulcerative Colitis

    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

    Read More
  • 1

Compendium of Clinical Case Studies

clinical case studies

Download our entire collection of clinical case studies.

View FlipbookDownload PDF

Your Donations Help

In addition to volunteering their time and energy, our practitioners are required to raise the money it takes to support their efforts at our clinic. Please consider helping them by making a tax deductible donation in their name.

DONATE NOW

Support our work

Donate Volunteer Get in Touch

Support Us