Cara O. Frank, L.OM.
Acute laryngitis is a common clinical complaint caused by severe inflammation of the laryngeal mucous membranes. Symptoms include acute hoarseness, a sore throat, a cough, an aversion to cold, and fever. Most cases result from viral infections, including parainfluenza virus, influenza virus, rhinovirus, coronavirus, and echovirus. On rare occasions, it is caused by a bacterial infection, such as diphtheria. Acute laryngitis is especially common among people who overuse their voices.
In infants and children less than five years old, the larynx is both shorter and narrower. Therefore, when acute laryngitis occurs in children, it is usually more severe than in adults with more severe complications. Local swelling can obstruct the larynx. Patients of any age should seek emergency treatment if there is difficulty breathing, stridor, drooling, or a sensation of the throat closing.
In TCM, this disease is referred to as jí hóu yīn(急喉喑, acute loss of voice). It is usually caused by wind-cold attacking the lungs, with lung qi congestion making them unable to diffuse. The qi dynamic becomes inhibited, resulting in wind-cold pathogen congestion in the throat blocking the collaterals. This causes dysfunction of the glottis’ opening and closing, producing a sudden loss of voice and acute hoarseness. If wind-heat attacking lungs cause the disease, then symptoms of a sore, itchy throat, and a cough may be present.
Another pattern is phlegm-heat congesting the lungs with accumulated heat in the lungs and stomach. The contraction of wind-heat can compound this along with internal and external pathogenic heat congestion, which burns body fluids to form phlegm, resulting in phlegm-heat congestion with impaired diffusion and down bearing of the lungs.
Children’s zang-fu organs are particularly tender. Due to their narrowed larynx, this condition’s onset can easily result in blocked airways and develop into acute throat wind (acute epiglottitis).
COMMON CLINICAL PATTERNS AND FORMULAS
Wind-cold attacking the lungs: Modified Sān Ào Tāng (Rough and Ready Three Decoction)
Wind-heat attacking the lungs: Modified Shū Fēng Qīng Rè Tāng (Wind-Scattering and Heat-Clearing Decoction)
Phlegm-heat congested in the lungs: Modified Sāng Xìng Tāng (Mulberry Leaf and Apricot Kernel Decoction)
Female, age 31. Initial Visit: March 2nd, 2005
Chief Complaints: Hoarse voice for one day, along with an aversion to wind, a headache, and a mild sore throat.
History: Two days before the visit, due to overworking until midnight and napping in her clothes, the patient’s body felt cold with an aversion to cold, a headache, and a clear nasal discharge. The next morning, the patient felt hoarse and had a slightly sore throat, mild nasal congestion with a clear discharge, a cough, weak extremities, and an aversion to cold without sweat.
Sign and Symptoms: Hoarseness, a slight sore throat, a cough, an aversion to cold without sweat, and weak extremities. The tongue body was slightly pale and swollen with a thin white coating. The pulse was floating and tight.
Past History: Unremarkable.
Local Examination: Mild hyperemia of the pharyngeal mucosa. Indirect laryngoscopy revealed vocal cord edema with pale purple edges and improper closure of the glottis.
This case occurred during the early spring when the weather was cold. This fact, plus overwork, napping with clothes on, and late-night work, caused the defensive exterior’s insecurity. Wind-cold pathogen attacked the patient’s weakened body. Due to the congestion, the lung qi was unable to diffuse. Subsequently, wind-cold congested and blocked the throat, resulting in dysfunction of the opening and closing of the glottis and hoarseness.
Cold governs congealing, stagnation, contraction, and tautness. Cold pathogen invasion with qi and blood stagnation in the throat causes mild hyperemia of the pharyngeal mucosa, swelling of the vocal cords, and the glottis’ inability to open and close. Cold blocks the qi, blood, and collaterals, resulting in a slight sore throat. Wind attacks the lungs, causing an itchy throat and a cough. Impaired diffusion and down bearing of the lungs results in a loud cough.
The nose is the orifice of the lungs. When cold pathogens attack the lungs, it results in a clear nasal discharge. If wind-cold fetters the exterior depressing the defensive yang, it causes an aversion to cold, headaches, and weak extremities. The thin white tongue coating and the tight floating pulse reflect the exterior wind-cold pattern.
The location of this disease is the throat. The affected organ is the lung, and the pathogenic factor is wind-cold. It belongs to the pattern of wind-cold attacking the lung, an exterior pattern.
WM diagnosis: Acute laryngitis
TCM diagnosis: Acute loss of voice due to wind-cold attacking the lungs
Because this illness was due to wind-cold attacking the lungs, treatment should first focus on dispelling wind-cold. The patient should get adequate rest and protect the upright qi to expel the evil pathogen. Treatment can be internal and external and even be combined with acupuncture.
Principles: Course and dissipate wind-cold, diffuse the lungs and open the voice
Formula: Modified Sān Ào Tāng (Rough and Ready Three Decoction)
Formula: Modified Sān Ào Tāng (Rough and Ready Three Decoction)
|Semen Armeniacae Amarum
|Radix et Rhizoma Glycyrrhizae
|qīng bàn xià
|Radix Angelicae Dahuricae
|Rhizoma Zingiberis Recens
|mù hú dié
Má huáng courses wind and dissipates cold.
Xìng réndiffuses the lungs and downbears qi. It helps má huáng to diffuse the lungs and dissipate cold.
Gān căobenefits the throat and stops pain.
Ultrasonic atomization inhalation: #1 ultrasonic atomization formula of wind-elimination, cold-dissipation, and throat-benefiting medicinals. Inhale once per day.
Main points: ST 9 (rén yíng), ST 10 (shuĭ tū), RN 23 (lián quán)
Supplementary Points: LI 4 (hé gŭ), LI 11 (shào shāng).
Method: Sedation method. Retain all needles for 20-30 min, once per day.
Apply Vaccaria or magnet seeds on points including the throat (hóu), glottis (shēng dài), lung (fèi), large intestine (dà cháng), shenmen (shén mén) and endocrine (nèi fēn mì). Select 3-4 points each time, one treatment per day.
After three days of treatment, all of the symptoms disappeared, and the patient was cured.
COMMENTARY AND DISCUSSION
In TCM, acute laryngitis is referred to as bào yīn (sudden loss of voice) or jí hóu yīn(acute loss of voice). Many Chinese references refer to hóu yán, which simply means laryngitis. In contrast to the chapter on chronic hoarseness, where the spectrum of causative factors ranged from a mild cold to throat cancer, external pathogens are featured as the primary causative factor of acute laryngitis. Internal patterns tend to be caused by secondary factors.
This chapter’s primary case depicts a common scenario of a woman who caught a cold after becoming run down from overwork and lack of sleep. She presents with symptoms of wind-cold. The treatment principle and formula selection are straightforward. By choosing Sān Ào Tāng, the physician emphasizes the presence of a wind-cold pathogen. The highlight of the formula is the inclusion of light and floating mù hú dié and chán tuì. Both medicinals enter the liver and lung channels. Both benefit the throat and voice. Mù hú dié is superior for alleviating coughs, while chán tuì excels at dispelling wind-heat. They are a reliable pair that is used to treat acute sore throats and laryngitis.
The Practical English-Chinese Library of Traditional Chinese Medicine suggests using the formula Liù Wèi Tāng (Six-Ingredient Decoction) from A Handbook on Laryngology(Hóu Kē Zhĭ Zhăng, 喉科指掌 ), a Qing Dynasty Text by Zhang Zong-Liang, to treat acute laryngitis wind-cold.1 There are many formulas with the same name; however, the ingredients for this version are as follows:
Formula: Liù Wèi Tāng (Six-Ingredient Decoction)
|bái jiāng cán
|Radix et Rhizoma Glycyrrhizae
The second group of medicinals is also used together in Pŭ Jì Xiāo Dú Yĭn (Universal Relief Toxin-Removing Beverage), which can treat throat pain and inflammation due to epidemic toxins with wind-heat and phlegm. First recorded in the Yuan Dynasty text, Precious Mirror of Health(Wèi Shēng Băo Jiàn, 卫生宝鉴), it clears heat, eliminates fire toxin and disperses wind-heat.
Due to the restrictions in obtaining and using má huáng, this formula is a practical option. Mù hú dié and chán tuì would be suitable modifications for this formula as well.
For the treatment of wind-heat, the Practical English-Chinese Library of Traditional Chinese Medicine suggests Yín Qiào Săn (Lonicera and Forsythia Powder). Even when used unmodified, the formula effectively dispels wind-heat and benefits the throat. However, if modifications are called for, consider using mă bó (Lasiosphaera seu Calvatia) and xuán shēn (Radix Scrophulariae) to reduce pain and inflammation.
Although practitioners in the West may not have access to an ultrasonic nebulizer, simple inhalation steam can be made using 9g each of bò he, huò xiāng (Herba Agastachis), pèi lán (Herba Eupatorii), jú huā (Flos chrysanthemi), and jīn yín huā (Flos Lonicerae Japonicae). Decoct the medicinals and strain. Place the decoction in a large, wide bowl or cooking pot and have the patient sit with their face over the pot. Cover the head with a towel and inhale the herbal steam for 10-15 min, 2-3 times daily.
The main TCM empirical experiences in the differentiation of acute laryngitis include the following patterns:
(1)Wind-cold attacking with pathogens invading the throat: This pattern is often seen at the beginning of acute laryngitis. It is characterized by an aversion to cold, whole-body discomfort, a low voice, a thin white tongue coating, and a floating and rapid pulse. Treatment should focus on coursing wind, dissipating cold, diffusing the lungs, and opening the voice. The formula for this pattern is Sān Ào Tāng (Rough and Ready Three Decoction) plus bàn xià (Rhizoma Pinelliae), xì xīn (Radix et Rhizoma Asari) and shí chāng pú (Rhizoma Acorn Tatarinowii).
If there are obvious systemic symptoms due to severe cold pathogen attacking, select modified Xiăo Qīng Lóng Tāng (Minor Green Dragon Decoction).
If the condition is more chronic and coupled with depressive heat, add heat-clearing, toxin-resolving, throat-benefiting and voice-opening medicinals such as shè gān (Rhizoma Belamcandae), jīn yín huā (Flos Lonicerae Japonicae) and zàng qīng guŏ (Fructus Chebulae Immaturus).
For a cough, add medicinals that diffuse the lungs and transform phlegm, such as zĭ wăn (Radix et Rhizoma Asteris), qián hú (Radix Peucedani), and bái qián (Rhizoma et Radix Cynanchi Stauntonii).
(2)Yang deficiency with cold insulting the throat: This pattern is usually seen in acute laryngitis cases in a yang deficient patient. It is characterized by a recently contracted external pathogen, which causes hoarseness along with a pale face, a pale and swollen tongue body, and a deep and weak pulse. Treatment should focus on warming the yang, dissipating cold, diffusing the lungs, and opening the voice. The selected formula is modified Má Huáng Fù Zĭ Xì Xīn Tāng (Ephedra, Aconite, and Asarum Decoction).
If the pattern is accompanied by spleen yang deficiency and internally generated damp phlegm, and the patient presents a sticky, white-coated tongue and a slippery pulse, add gān jiāng (Rhizoma Zingiberis), bàn xià and fú líng (Poria).
If the case is chronic or is accompanied by a cold pathogen that has transformed to heat, then add heat-clearing medicinals such as huáng qín (Radix Scutellariae), guā lóu (Fructus Trichosanthis) and shí gāo (Gypsum Fibrosum).
(3)Cold fettering the exterior with depressive heat and pathogens attacking the throat: This pattern is seen in acute laryngitis due to an externally contracted disease. If resulting from an unresolved exterior pathogen with internal depressive heat, then the disease is more chronic. In an excessive body type, where the cold pathogen has not been resolved, but the internal heat is symptomatic, the disease onset will be shorter. It is characterized by symptoms of an exterior cold pattern combined with symptoms of a pattern of lung and stomach heat. Symptoms include whole body ache, an aversion to cold with fever, expectoration of yellow phlegm, yellow urine, and headache. The pulse will be floating, tight, or rapid. Clinical treatment should focus on releasing the exterior, dissipating cold, clearing heat, and opening the voice. The selected formula is modified Má Xìng Shí Gān Tāng (Ephedra, Apricot Kernel, Gypsum and Licorice Decoction).
(4)Wind-heat attacking with a pathogen invading the throat: This pattern is often seen in the early stage of acute laryngitis and is caused by externally contracted wind-heat. In patients with a constitution of depressive heat, this pattern can also be caused by externally contracted wind-cold that transforms into heat. The symptoms are fever, a slight aversion to cold, body aches, and a slight thirst. The tongue has a thin yellow coating. The pulse is floating and rapid. Treatment should focus on coursing wind, dissipating heat, diffusing the lungs, and opening the voice. The selected formula can be modified Shū Fēng Qīng Rè Tāng (Wind-Coursing and Heat-Clearing Decoction), which includes jīng jiè (Herba Schizonepetae), fáng fēng (Radix Saposhnikoviae), niú bàng zĭ (Fructus Arctii), gān cao (Radix et Rhizoma Glycyrrhizae), jīn yín huā (Flos Lonicerae Japonicae), lián qiào (Fructus Forsythiae), sāng bái pí (Cortex Mori), chì sháo (Radix Paeoniae Rubra), jié gĕng (Radix Platycodonis), tiān huā fĕn (Radix Trichosanthis), xuán shēn (Radix Scrophulariae), zhè bèi mŭ (Bulbus Fritillariae Thunbergii) and huáng qín.
(5)Externally contracted dry pathogen attacking the throat: This pattern is characterized by acute laryngitis due to a dusty and dry environment or autumn dryness. At the onset, the symptoms include hoarseness, a cough with scanty phlegm, slight thirst, a dry throat, and yellow urine. The tongue body is red with a thin, dry coating. The pulse is deficient, big, and slightly rapid. Treatment should focus on nourishing the yin, clearing dryness, diffusing the lungs, and opening the voice. The formula is modified Sāng Xìng Tāng (Mulberry Leaf and Apricot Kernel Decoction), which includes sāng yè (Folium Mori), xìng rén (Semen Armeniacae Amarum), shā shēn (Radix Adenophorae seu Glehniae), bèi mŭ (Bulbus Fritillaria), dòu chĭ (Semen Sojae Praeparatum), zhī zĭ (Fructus Gardeniae) and lí pí (pear skin). Qīng Zào Jiù Fèi Tāng (Dryness-Clearing Lung-Rescuing Decoction) can also be prescribed. This formula includes sāng yè, shí gāo, gān căo (Radix et Rhizoma Glycyrrhizae), rén shēn (Radix et Rhizoma Ginseng), huǒ má rén (Fructus Cannabis), ē jiāo (Colla Corii Asini), mài dōng (Radix Ophiopogonis), xìng rén and pí pá yè (Folium Eriobotryae).
(6)Externally contracted summerheat-damp with pathogen attacking the throat: This pattern is seen in acute laryngitis caused by external contraction of summerheat-damp. Characterized by an externally contracted pathogen in the summertime, it results in hoarseness, headaches, heavy body sensation, fever without sweat, irritability, fatigue, and short and yellow urination. The tongue has a greasy coating. The pulse is floating and rapid or soggy and rapid. Treatment should focus on aromatically transforming turbidity, diffusing the lungs, and opening the voice. The selected formula is Xiāng Rú Săn (Mosla Powder), which includes xiāng rú (Herba Moslae), biăn dòu (Semen Lablab Album) and hòu pò (Cortex Magnoliae Officinalis) modified with huò xiāng (Herba Agastachis) and pèi lán (Herba Eupatorii).
If internal heat is present, add huáng lián (Rhizoma Coptidis), fú líng and gān căo.
For spleen deficiency with insufficient middle qi, add medicinals that benefit the qi and strengthen the spleen, such as huáng qí (Radix Astragali), dăng shēn (Radix Codonopsis), bái zhú (Rhizoma Atractylodis Macrocephalae), and chén pí (Pericarpium Citri Reticulatae).
(7)Excess internal heat steaming the throat: Often seen in the middle and late stages of acute laryngitis, this pattern is usually due to an exterior pathogen invading the interior, which results in excessive heat in the lungs and stomach. Symptoms of this pattern are hoarseness, the expectoration of yellow phlegm, yellow urine, and constipation. The tongue body is red with a yellow or thick yellow coating. The pulse is rapid and strong or slippery and rapid. Treatment should focus on draining heat, relieving toxins, benefiting the diaphragm, and clearing the throat. The selected formula is Qīng Yān Lì Gé Tāng (Throat-Clearing and Diaphragm-Disinhibiting Decoction), which includes lián qiào, zhī zĭ, huáng qín, bò he (Herba Menthae), niú bàng zĭ, jīng jiè, fáng fēng, jīn yín huā, xuán míng fĕn (Natrii Sulfas Exsiccatus), xuán shēn, dà huáng (Radix et Rhizoma Rhei), gān căo, jié gĕng and huáng lián modified with chán yī (Periostracum Cicadae) and pàng dà hăi (Semen Sterculiae Lychnophorae).
(8)Heat injuring the yang collaterals with stagnation blocking the throat: This pattern is often seen in the early stage of submucosal hemorrhage of the vocal cord. It is characterized by hoarseness with bright red bleeding underneath the mucosa of the vocal cord. The selected formula is modified Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction).
In the early stage, with bright red blood from blood heat, add mŭ dān pí (Cortex Moutan), bái máo gēn (Rhizoma Imperatae), ŏu jié (Nodus Nelumbinis Rhizomatis), and pú huáng tàn (Pollen Typhae Carbonisatum).
In the late stage, the throat will have a dark red color, which belongs to the pattern of blood stasis. Add sān qī (Radix et Rhizoma Notoginseng) and dān shēn (Radix et Rhizoma Salviae Miltiorrhizae) to transform stasis and stop bleeding.
If the pattern presents with signs of qi deficiency, then select a modified Bŭ Yáng Huán Wŭ Tāng (Yang-Supplementing and Five-Returning Decoction).
(9)Damp-heat impediment with pathogen attacking the throat is an uncommon pattern not commonly seen.
The author’s discussion of the patterns associated with acute laryngitis reflects astute, nuanced clinical observation. Even when the patterns and formulas seem obvious, the modifications are specific and elegant. The range of possible pattern presentations is striking. Even though all of the patterns involve an attack of external pathogens, they are not limited to exterior patterns. There are several mixed external-internal patterns. This underscores the fact that even in the case of infectious pathogens, disease transformation is always in accordance with the patient’s constitution.
Many of the modifications are based on this clinician’s response to a rapidly changing clinical picture. The law of qi transformation and transformation of cold to heat is true for all diseases and is especially vivid when treating acute infectious diseases. Practitioners must actively assess and respond to each case from the symptoms as they present in the moment, not as they were at the onset of the disease and not as they are imagined to be in the future. Therefore, for each etiology described above, the formulas are flexibly adapted to integrate heat and cold transformation.
Many of the modifications described in this chapter would be suitable across several of the pattern categories. The following is a brief re-grouping of the modifications:
If there is phlegm in the throat, modify the formula with bàn xià (Rhizoma Pinelliae) and shí chāng pú (Rhizoma Acorn Tatarinowii).
For signs of heat or fire in the throat, modify the formula with shè gān (Rhizoma Belamcandae), jīn yín huā (Flos Lonicerae Japonicae) and zàng qīng guŏ (Fructus Chebulae Immaturus). This last medicinal is the immature hē zĭ (Fructus Chebulae). It has similar functions to the mature medicinal, but it is stronger. A detailed comparison of both medicinals is found in the chapter on chronic hoarseness.
If there is a cough, modify the formula with zĭ wăn (Radix et Rhizoma Asteris), qián hú (Radix Peucedani), and bái qián (Rhizoma et Radix Cynanchi Stauntonii).
It is also helpful to stage acute laryngitis to help identify the best treatment:
For early-stage wind-cold or taiyang patterns, select modified Sān Ào Tāng or Liù Wèi Tāng. Sān Ào Tāng is the best choice when chills and feverishness predominate. Liù Wèi Tāng is not as strong a diaphoretic, but it is better for alleviating throat inflammation.
For early-stage wind-heat or wei level patterns, select modified Yín Qiào Săn or Shū Fēng Qīng Rè Tāng (Wind-Coursing and Heat-Clearing Decoction). Yín Qiào Săn is the best choice when there is heat and inflammation. The latter formula, which is detailed above, is more appropriate when the patient complains of phlegm in the throat.
Middle and late-stage laryngitis will usually present with symptoms of lung and stomach heat. If the disease only affects the channels, then consider using modified Má Xìng Shí Gān Tāng (Ephedra, Apricot Kernel, Gypsum and Licorice Decoction). In this case, the diagnosis will be cold fettering with a pathogen attacking the throat. This can also be thought of as a mixed taiyang and yangming channel pattern. The formula for this pattern is Má Xìng Shí Gān Tāng.
If the heat has penetrated the yangming organs, then treat the patient with modified Qīng Yān Lì Gé Tāng (Throat-Clearing and Diaphragm-Disinhibiting Decoction), which is described above for excess internal heat steaming the throat.
Bleeding is a late-stage symptom. If heat continues unabated, it can injure the collaterals and result in bright red bleeding. In this case, the larynx and the mucosa of the vocal cords will be bright red. Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction) is the suggested formula; however, consider using shēng dì (Radix Rehmanniae) and chì sháo (Radix Paeoniae Rubra) along with the modifications suggested above. When crafting the formula, be sure to emphasize medicinals that clear heat and cool the blood. If the throat is dusky or dark red, then the diagnosis evolves to blood stasis. Use The same formula or choose modified Bŭ Yáng Huán Wŭ Tāng (Yang-Supplementing and Five-Returning Decoction).
A final grouping can organize laryngitis according to seasonal influences:
Sān Ào Tāng or Liù Wèi Tāng can treat cold pathogens
Several formulas can treat dry pathogens attacking the throat. Use Sāng Xìng Tāng (Mulberry Leaf and Apricot Kernel Decoction) for warm dryness. This formula gently disperses and moistens dryness. Qīng Zào Jiù Fèi Tāng (Dryness-Clearing Lung-Rescuing Decoction) or Sāng Jú Yĭn (Mulberry Leaf and Chrysanthemum Beverage) can be used with similar effects. Cool dryness is treated with Xìng Sū Săn (Apricot Kernel and Perilla Powder).
Summerheat-damp attacking the throat can be treated with modified Xiāng Rú Săn (Mosla Powder) or possibly a modified Sān Rén Tāng (Three Kernels Decoction).
Cold fettering and pathogen attacking the throat can be thought of as a mixed taiyang-yangming channel pattern. Another way to say this is: if there is lung and stomach heat, use Má Xìng Shí Gān Tāng. Alternately, other formulas could be modified with huáng qín (Radix Scutellariae), guā lóu (Fructus Trichosanthis), and shí gāo (Gypsum Fibrosum).
The diagnosis of seasonal and environmental patterns can be slippery. Due to the influence of air conditioning and central heat, patients can be exposed to exterior cold, heat, summerheat-damp, dryness, and damp pathogens in any season. Regardless of the season, do not become locked into the geographic location. The key is to discriminate the Biăo Lĭ Biàn Zhèng (Exterior-Interior Pattern Differentiation) to determine the best treatment principle and formula selection.
1.Zhang Engin, Editor-in-Chief. A Practical English-Chinese Library of Traditional Chinese Medicine: Clinic of Traditional Chinese Medicine, Volume 2.Shanghai: Publishing House of Shanghai College of Traditional Chinese Medicine, 1990: 1048
About Cara Frank, L.OM.
Cara Frank, L.OM. was raised in a health food store in Brooklyn, NY. When she was 8, she cartwheeled 5 miles from Greenwich Village through Soho and Chinatown and across the Brooklyn Bridge. For over 30 years, she has had the same crazy passion for Chinese medicine. At 17, she had her first acupuncture treatment. At 20, she enrolled in acupuncture school. In 1998 she went to China to study, where she fell deeply in love with Chinese herbs. Since then, she has devoted her life to studying and teaching the topic.
Cara is the founder of Six Fishes Healing Arts in Philadelphia, where she maintains a busy acupuncture practice and acts as the head fish of a warm and lively office. She is also the president of China Herb Company.
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