Abstract
Abstract
Background:
Trigeminal neuralgia is a common neuralgia condition. Most data available relate to primary trigeminal neuralgia, but little has been published about secondary trigeminal neuralgia treated with Chinese medicine.
Objective:
To describe a case of secondary trigeminal neuralgia treated with acupuncture and Chinese herbal decoction.
Design and Patient:
Case report of an Australian woman who presented in August 2005 with severe symptoms of trigeminal neuralgia (diagnosed in 2002). She had undergone carbamazepine treatment for 3 years. She also presented with sinusitis with polyposis.
Intervention:
Acupuncture needles were applied with manual methods to the affected ophthalmic branch and maxillary branch of the trigeminal nerve. Acupoints selected were ST 7 (Xiaguan), SI 19 (Tinggong), Ex-HN5 (Taiyang), GB 14 (Yangbai) (all right side), and LI 4 (Hegu) (both sides). De Qi was elicited every 3 minutes in a 20-minute session. Acupuncture was performed once a week for 12 sessions. Also, an individually designed Chinese herbal decoction was used as a coordinated approach for the treatment of sinusitis with polyposis.
Main Outcome Measures:
Resolution of trigeminal neuralgia symptoms and improved symptoms of sinusitis.
Results:
The severe trigeminal neuralgia gradually disappeared within 7 days after the first session of acupuncture treatment. This result was maintained during a 12-session acupuncture treatment course as well as during an herbal treatment period. Most importantly, this result has been maintained for more than 3 years. The patient's sinusitis was also resolved.
Conclusions:
The combination of acupuncture and Chinese herbal decoction treatment led to a complete disappearance of symptoms of trigeminal neuralgia (after a 3-year course of carbamazepine, which became ineffective 2 months prior to acupuncture). This approach may offer a new treatment and supports the necessity for further research to evaluate Traditional Chinese Medicine in the treatment of trigeminal neuralgia and sinusitis.
Introduction
Diagnosis is by a careful record of the history, 2 location, and characteristics of the pain, and few neurological signs. 4 There are few investigations that are of value in this condition. 2 Pharmacological management is the first line of treatment.3,5,6 Drugs demonstrated to be efficacious in trigeminal neuralgia include carbamazepine, phenytoin, clonazepam, and valproic acid. Carbamazepine is usually suggested as the drug of first choice.7,8 Surgical options include peripheral or central (intracranial) procedures, which may be considered if medical treatment fails or cannot be tolerated.4,9 Other therapies such as cryotherapy 10 and gamma knife radiosurgery 11 are among the common therapeutic approaches documented.
Trigeminal neuralgia can be divided into primary and secondary causes.4,9 The majority of articles focus on primary trigeminal neuralgia, evidenced by nearly 6,000 articles recorded in February 2009 in PubMed, EMBASE, Cochrane Library, SpringLink, AcuBrief, and AMED. In contrast, secondary trigeminal neuralgia treatment has been rarely documented, especially in terms of acupuncture and Traditional Chinese Medicine (TCM) treatments. Many Chinese clinical trials demonstrate the usefulness of acupuncture in treating trigeminal neuralgia.12–15
Case Report
The case presented herein is of secondary trigeminal neuralgia caused by sinusitis with polyposis treated with acupuncture and a Chinese herbal decoction.
Patient History
A 47-year-old woman presented at M. Modern Traditional Chinese Medical Clinic in Victoria, Australia. Her main complaint was severe pain around the right side of her forehead, eye, nose, cheek, and upper lip for 2 months. The pain started as paroxysms of stabbing, flashing, radiating, and burning around the above-mentioned area and lasted many seconds or a few minutes. It was characterized by a recurrence of similar pains in the same area, which were triggered by light pressure or touch on the right side of the nose or cheek and sometimes by teeth brushing, face washing, or the turning of her head.
The patient was diagnosed with trigeminal neuralgia by a neurologist in 2002. A dentist had ruled out a dental cause. The condition was affecting the ophthalmic branch and maxillary branch of the trigeminal nerve. Carbamazepine was prescribed and the patient had taken it for 3 years. Trigeminal neuralgia occurred, coinciding with missed doses of carbamazepine, during those 3 years. She reported persistent but tolerable facial pain while taking the carbamazepine. In general, the pain was fairly well-controlled for 3 years—until 2 months prior to presenting to our clinic. At presentation, paroxysmal episodes of the pain occurred from once every 1–2 hours to once every few minutes, despite the fact that the patient was taking carbamazepine at 800 mg/d in 2 divided doses.
During the consultation, concern about the current symptoms and her history of sinusitis was raised. The patient had a large amount of light green sputum daily, either discharged from the nose or running down the back of the throat. This disappeared for about 2 weeks in June 2005 (2 months before the TCM consultation) during 2 courses of antibiotics. The patient reported sinusitis since 2001 and had been taking antibiotic treatment several times a year during the last 5 years. In July 2004, a septoplasty, bilateral ethmoidectomy, and antrostomy was performed by an otolaryngologic surgeon and 1 month later, on review, her nasal obstruction had been removed and budesonide spray was prescribed by the surgeon.
The x-ray computed tomographic (CT) scans the patient had June 20, 2001 and March 20, 2002, fairly prominent ethmoidal sinusitis was noted. Referring to the brain scan, the apical areas of the petrous temporal bone with respect to the trigeminal ganglion appeared normal.
In addition to x-ray CT scans, magnetic resonance imaging (MRI) was performed on August 18, 2005 (13 days before TCM consultation), showing that mucus had filled all the right maxillary sinus, combined with up to 4 polyps of considerable sizes which occupied nearly 5/6 of the space of the sinus. There was only 1 smaller polyp with a small amount of mucus in the left maxillary sinus.
Diagnosis and TCM Assessment
Two diagnoses of this patient were established by specialists: sinusitis and trigeminal neuralgia, although a more accurate diagnosis, rather than sinusitis, would be sinusitis with sinus polyposis. From all the symptoms and evidence collected, the final diagnosis was secondary trigeminal neuralgia caused by sinusitis with polyposis.
Facial pain 16 was the first or symptomatic TCM category assessment. One of the main causes was the fact that Wind pathogen invaded the facial area of meridians and blocked Qi and Blood of the related meridians. Nose Yuan was the second or chief TCM category assessment. 17 Wind/Hot pathogens invading Lung meridian in the nose region was the main cause of this condition.
Methods
The patient was advised to stop taking carbamazepine while she began TCM treatment because of its latest ineffectiveness. She had not taken any medicines prior to the consultation. The acupuncture treatments were performed at the aforementioned clinic. Disposable single-use needles were used: Kun Lun, classical style, 0.25 mm in diameter and 30 mm in length (Kun Lun acupuncture needles, Australian Registered Therapeutic Goods, 148643).
Acupoints selected were ST 7 (Xiaguan), SI 19 (Tinggong), Ex-HN5 (Taiyang), GB 14 (Yangbai) (all on the right side), and LI 4 (Hegu) (both sides). After obtaining De Qi immediately after the insertion, turning and twisting manipulations were used to obtain the status of De Qi every 3 minutes in a 20-minute session. Acupuncture treatment was performed once a week for 12 sessions.
Meanwhile, a raw Chinese herbal decoction was used as a coordinated approach for the treatment of sinusitis (Nose Yuan). This herbal decoction is a modified form (individual flexibility under the documented classical TCM treatment principle) of 1 of the commonly used herbal prescriptions for the treatment of sinusitis. 17 The details of the herbs are described and used as daily dosages: Huang Qin 10 g (Scutellaria baicalensis), Pu Gong Yiong 15 g (Taraxacum mongolicum), Jin Yin Hua 9 g (Lonicera japonica), Huo Xiang 10 g (Pogostemon cablin), Bai Ji 10 g (Angelica dahurica), Jie Geng 6 g (Platycodon grandifolrum), and Gao Cao 6 g (Glycyrrhiza uralensis). (All the herbs were obtained from Winner Trading Herbs Pty. Ltd., Victoria, Australia. All the herbs were registered as therapeutic herbs in the Therapeutic Goods Administration, Australia.) This decoction was used 7 days every week during a scheduled 3- or 6-month treatment period (depending on the symptoms of chronic sinusitis with polyposis).
Results
The patient noticed less typical pain or attacks after 2 days of commencing the first acupuncture treatment. All the symptoms of trigeminal neuralgia gradually disappeared in 7 days, during which treatment involved only 1 session of acupuncture treatment plus 7 days of the Chinese herbal decoction. She had more noticeable sputum running from the nose or running down the back of the throat after commencing this treatment regimen.
There were no further acupuncture treatments after the completion of 12 acupuncture sessions which focused on both of her conditions, chronic sinusitis and symptoms of trigeminal neuralgia. The herbal decoction was continued for another 3 months, plus used during the first 3 months of the acupuncture treatment period for a total of 6 months, and stopped when no further sputum was discharged.
At the follow-up consultations at 12, 24, and 36 months later, there were still no signs of any recurrence of trigeminal neuralgia.
Discussion
Carbamazepine, as the first-line medicine, was used for more than 3 years for the control of symptoms of trigeminal neuralgia in this patient. However, it had become ineffective; this is not usual. Carbamazepine had been helpful for controlling trigeminal neuralgia until 2 months before she presented to our clinic. Carbamazepine was then stopped 16 hours before beginning TCM treatment. The half-life through hepatic enzyme induction of carbamazepine averaged 16–24 hours. By contrast, there was a gradual reduction and disappearance of the patient's symptoms of trigeminal neuralgia in 7 days. Therefore, the discontinuation of carbamazepine was highly unlikely to be associated with the improvement of the symptoms.
From the information obtained from an MRI only 13 days before her initial TCM consultation, there was evidence that the number of larger polyps occupied most of the space in the right maxillary sinus. It is logical to conclude that these polyps increased in size, applying pressure to the inside walls of the sinus because of its limited space, thus being a constant trigger point causing severe symptoms.
Two courses of antibiotics used 2 months before the TCM consultation may have controlled the infection for a short while; nevertheless, it did not assist in relieving the symptoms of trigeminal neuralgia. This is understandable because sinus polyps respond to systemic oral steroids or intrapolyp steroid injection, 18 not antibiotics. Sinus polyps are caused by inflammatory tissue, which is allergy-type inflammation, and other pathogenic mechanisms remain unclear.19,20 Thus, steroids have become widely used in medical practice in the treatment of sinus polyps. 18 If applied, steroids would create further complications in addition to frequent sinus infections or perhaps chronic infections in this case. Indisputably, the use of antibiotics was necessary for the control of the sinus infections. However, it did not assist in the relief of symptoms of trigeminal neuralgia. For the rational design of treatment, it was practical to find a medicine with anti-inflammatory effects, including effects on allergy type of inflammation and with an anti-infection effect at the same time, and which could also be used long-term without risky or serious side effects. This herbal decoction was fitting for these treatment principles.
Acupuncture treatment may assist in the treatment of sinusitis due to allergy. 21 Thus, the rational design of 12 acupuncture sessions would be beneficial for the treatment of chronic sinusitis; more importantly, minimizing the chance of recurrence of trigeminal neuralgia due to its refractory and chronic status. In addition, the reduction of the degree of the inflammatory status of polyps may have taken some time in this treatment regimen (herbal decoction), as sinus polyps were the likely cause of the trigeminal neuralgia. The disappearance of symptoms of trigeminal neuralgia may not have lasted if the acupuncture treatment had stopped after only a few sessions; therefore, a longer-term acupuncture course over 3 months improved the chance of cure for trigeminal neuralgia.
We know that acupuncture treatments can relieve the symptoms of trigeminal neuralgia. The manipulation of the above-mentioned acupoints, especially GB 14 (Yangbai) and LI 4 (Hegu) every 3 minutes, could provide relatively stronger pain relief. However, the speed of this patient's response to pain relief was surprising. Thus, it is perhaps reasonable to deduce that the Chinese herbal decoction may have played an important role in relieving the pressure caused by sinus polyps. Reviewing the function of this herbal decoction may provide some information: it contained natural antibiotic agents and it reduced inflammation and relieved pain, assisting acupuncture treatment. 22 This herbal decoction is very complex in terms of its organic chemical compounds. For instance, for 1 of the key ingredients, Huang Qin (S baicalensis), the active chemical structures are as follows: baicalin (4–5.2%) and baicalein, wogonoside and wogonin, and skullcapflavone I, II. 23 Huang Qin has antibacterial as well as anti-inflammatory effects. 23 Other herbs with similar effects reinforce the effects of Huang Qin. Generally speaking, a combination of herbs has better therapeutic effectiveness compared with a single herb 22 and therefore creates a more complex combination. The decoction's assistance in the reduction of inflammation may have acted in a key role in relieving the degree of inflammation of the polyps. Consequently, less pressure was applied to trigger points in the maxillary area that were associated with trigeminal neuralgia. Most importantly, acupuncture and herbal decoction treatment effect was maintained for up to 3 years after the total of 6 months of treatment in this case.
Conclusions
The combination of acupuncture and Chinese herbal decoction treatment successfully led to a complete disappearance of symptoms of trigeminal neuralgia due to sinusitis and polyposis, and this outcome was maintained for up to 3 years. Little information exists regarding the outcome of medical management in secondary trigeminal neuralgia, especially in relation to sinusitis and polyposis. This case report is unable to establish causality as to whether acupuncture alone may have resulted in a cure, or the herbal treatment alone, or both. However, it emphasizes the direction that the approach described provides—a new way of treatment—and warrants further research, evaluation, and clarification in this area.
Footnotes
Disclosure Statement
No competing financial interests exist.