TREATMENT OF THROAT AND VOICE DISORDERS WITH CHINESE MEDICINE

TREATMENT OF THROAT AND VOICE DISORDERS
WITH CHINESE MEDICINE

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

BACKGROUND

The throat is subject to a number of disorders including infections, hoarseness, vocal cord polyps and nodules, irritation (sometimes the result of gastric reflux and postnasal drip), and cancer. In Chinese medical texts, throat (Chinese:yan or hou) disorders are mentioned secondarily to other syndromes, such as common cold or a feverish disease, but are not a focus of specific discourse. Therefore, information about treatments for throat disorders must be culled from sparse sources, including medical reports from specialists and recommendations from texts devoted to modern medical specialties, such as otolaryngology, each providing some clues that may be useful in understanding the treatment principles.

There is a traditional Chinese herb formula that has become well-known in modern times for treating throat disorders as a result of Japanese research efforts: Pinellia and Magnolia Combination (Banxia Houpu Tang). It was presented in theJingui Laoyue (1), a treatise composed at the end of the Han Dynasty (ca. 220 A.D.). The text addresses miscellaneous disorders, mostly those suffered by women. It includes this brief statement: "A woman who feels as if a piece of broiled meat is stuck in her throat should takeBanxia Houpu Tang." This statement has been interpreted to mean that the woman is suffering from globus hystericus, the feeling of a lump (globus) resulting from hysteria (a state of mind originally thought to be associated with the uterus). The Chinese later described the sensation as that of a plum pit caught in the throat. The plum commonly used in China and Japan, known by the local nameswume and umeboshirespectively, has a small pit that can become lodged in the throat; it has rough edges that contribute to the sensation being described. The syndrome is called "plum pit qi" (meihe qi), indicating that bound-up qi feels like a plum pit. Its cause was attributed to the emotions coupled with stagnation of phlegm (20).

The applications of Pinellia and Magnolia Combination have been expanded to include both the sensation of a lump that is without obvious physical cause and several physical disorders, such as esophageal spasms or difficulty swallowing. Expanding the applications of traditional formulas is a common procedure, based on the concept that the formulas address the basic pattern of symptoms and associated conditions (in this case, qi stagnation) and not necessarily the specific cause of the disorder as understood in modern terms. As a result, formulas designed for acute ailments that may have arisen from infections, climatic influences, or emotional disorders may be applied, for example, to the treatment of chronic diseases that are understood today to be related to metabolic, genetic, circulatory, or other disorders.

In Japan, where traditional formulas from the Han Dynasty form a large part of the modern prescription range (in what is called Kampo Medicine), Pinellia and Magnolia Combination is frequently prescribed for numerous throat disorders in both men and women, not just for plum pit qi. The book Commonly Used Chinese Herb Formulas with Illustrations (2) presents the Kampo indications for the formula, which include esophageal spasms and hoarseness due to the common cold. In two recent studies conducted in Japan, the formula was proclaimed beneficial in treating swallowing difficulty in the elderly. It was used to improve the swallowing reflex in those who suffered from aspiration pneumonia (3), stroke (19), and progression of Parkinson's disease (4). The mechanism of its action in these cases remains to be established.

PINELLIA AND MAGNOLIA COMBINATION AND THE THROAT

In modern Chinese texts, Pinellia and Magnolia Combination is classified with the qi regulating formulas, even though none of the herb ingredients are classified in the materia medica as having the primary property of being qi regulators. A typical presentation of its ingredients and quantities is (5):

Pinellia and Magnolia CombinationPinellia12 gHoelen12 gMagnolia9 gFresh ginger9 gPerilla6 g

From the traditional Chinese point of view, both magnolia bark and perilla leaf regulate the flow of qi (as secondary properties) and this is attributed to their fragrant components that have a dispersing effect. These herbs alleviate the neurotic and depressive syndromes that lead to plum pit qi. The qi regulating formulas in general, and the ingredient perilla leaf in particular, are recommended in China for treatment of depression and anxiety. In a recent laboratory evaluation, Pinellia and Magnolia Combination was reported to have antidepressant activities (6), confirming this application.

In a Japanese report on treatment of 45 patients with abnormal sensations in the throat (sense of pressure, swelling, or, in most cases, something stuck in the throat), relayed by Dr. Hong-yen Hsu (20), 21 of the patients of "weak" constitution were given Pinellia and Magnolia Combination, while 13 patients of "firm" constitution were given Bupleurum and Dragon Bone Combination (Chaihu Jia Longgu Muli Tang). A few patients received miscellaneous other formulas. Bupleurum and Dragon Bone Combination is categorized as a sedative formula and is commonly administered for neurotic disorders. It includes pinellia, hoelen, and ginger in common with Pinellia and Magnolia Combination.

Pinellia, hoelen, and ginger are the ingredients of another formula from the same original text: Pinellia and Hoelen Combination (Xiao Banxia Jia Fuling Tang). This prescription is administered for a condition of phlegm-damp accumulation in the stomach, leading to tendency to have vomiting or gastric reflux. Reflux of stomach acid is one of the potential irritants to the throat; it can cause the sufferer to frequently try to clear the throat, even though there is nothing there to expectorate. This formula is prescribed in Japan for the morning sickness of pregnancy that involves lack of appetite and vomiting (7). Its function, from the traditional viewpoint, is to clear the dampness and to lower the stomach qi that is pushing upward, rejecting food. This three-herb formula was later transformed into the most widely used of the prescriptions for phlegm-damp: Citrus and Pinellia Combination (Erchen Tang; with the addition of citrus and licorice, and sometimes including mume, the plum).

Throat polyps, from the Chinese view, are lumps in the throat that have a phlegm-damp quality (soft masses fit this broad category). The cause of the lumps is thought to be stagnation of the qi circulation, usually secondary to overuse of the throat. Hence, Pinellia and Magnolia Combination is also a potential treatment for that condition, though other treatments have been devised recently, as will be presented below. Throat nodules, somewhat harder lumps that may occur as the result of overuse of the voice, are classified as blood stasis masses, and are thus treated not by Pinellia and Magnolia Combination, but by formulas that vitalize blood circulation and crack static blood.

THROAT HERBS

The herbs in Pinellia and Magnolia Combination treat a syndrome that can affect the throat, but the individual herbs are not depicted as being specific for throat disorders. By contrast, there are some herbs used by Chinese herbalists that have developed a reputation as being more specific for treating the throat area, as displayed in Table 1, relying on information from Oriental Materia Medica(8). These herbs may make up the foundation of formulas for throat disorders or may be added to formulas that are aimed at treating the syndrome that causes or includes a throat disorder. The herbs are listed in the table according to the Materia Medica category that they belong to, with four basic categories, plus miscellaneous others.

TABLE 1. Individual herbs noted for their effect on throat disorders.

Herb Name (Common; Pinyin)Indications Related to ThroatSurface Relieving Herbschive (congbai)sore throatarctium (niubangzi)sore throatcicada (chantui)aphonia, laryngitiscimicifuga (shengma)sore throateriocaulum (gujingcao)laryngitismentha (bohe)sore throatHeat Clearing Herbsgardenia (shanzhizi)esophagitis, tonsillitisgypsum (shigao)dry throatphragmites (lugen)dry throatrehmannia, raw (shengdi)sore throatscrophularia (xuanshen)swollen and sore throatgentiana (longdancao)swollen and sore throatabrus (xiangsizigen)swollen and sore throatandrographis (chuanxinlian)tonsillitisisatis leaf (daqingye)pharyngitisisatis root (banlangen)swollen and sore throatbelamcanda (shegan)swollen and sore throatbidens (xianfengcao)swollen and sore throatlashiosphaera (mabo)pharyngitis, sore throatoldenlandia (baihuasheshecao)laryngitis, tonsillitisscutellaria (banzhilian)sore throatsubprostrata (shandougen)painful swelling in throatYin Tonicsadenophora (nanshashen)dry and sore throatasparagus (tianmendong)dry throatyu-chu (yuzhu)dry throatPhlegm Resolving and Antitussive Herbssterculia (pangdahai)aphonia due to sore throattrichosanthes root (gualougen)sore throatcentipeda (shihusui)sore throatgleditsia fruit (zaojia)sore throatplatycodon (jiegeng)sore throattussilago (kuandonghua)sore throatoroxylum (muhudie)aphoniaegg shell lining (fenghuangyi)hoarseness due to sore throatMiscellaneous Otherslicorice (gancao); qi tonicsore throatsilkworm (baijiangcao); wind calmingpainful swelling in throat; aphoniaterminalia (hezi); astringentaphonia due to prolonged cough

The large number of heat-clearing herbs in this listing is associated with their ability to inhibit infections that can cause sore and swollen throat. A few of the herbs, such as gypsum (a mineral), scrophularia, raw rehmannia, and phragmites, have a moisturizing and soothing effect for dry throat rather than an anti-infection action; these, and the three yin tonic herbs listed separately, are often used to treat chronic and recurrent sore throats that are thought to arise from yin-deficiency heat syndromes. Surface relieving herbs are usually administered for acute ailments, though mentha and arctium are also used for chronic throat irritation that may not be related to infections. Phlegm resolving herbs play a role in normalizing the throat surface, presumably smoothing the flow of mucus over the throat tissues and alleviating irritation.

TRADITIONAL FORMULAS

Some traditional formulas are indicated for treatment of sore throat, dry throat, or other throat disorders as one of several potential applications. The formulas in Table 2 are indicated for throat disorders; the herb ingredients listed in Table 1 are specified and the indications are fromCommonly Used Herb Formulas with Illustrations.

Table 2. Formulas indicated for throat disorders.

Formula Name 
(Common; Pinyin)Ingredients from Table 1Indications Related to ThroatLonicera and Forsythia Formula 
(Yin Qiao San)arctium, mentha, phragmites, platycodon, licoricesore throat due to infectionBupleurum and Rehmannia Comb. 
(Chaihu Qinggan Tang)arctium, mentha, gardenia, platycodon, trichosanthes, licorice, raw rehmanniachronic tonsillitisArctium Combination 
(Qingyan Lige Tang)arctium, mentha, gardenia, scrophularia, platycodon, licoriceswollen, aching throat; laryngitis, tonsillitisForsythia and Rhubarb Formula 
(Liangge San)mentha, gardenia, licoricesore throatRehmannia and Lonicera Formula 
(Baidu San)arctium, mentha, raw rehmannia, scrophularia, platycodon, trichosanthes root, gypsum, licoricesore throat, laryngitisScute and Cimicifuga Combination 
(Puji Xiaodu Yin)mentha, arctium, cimicifuga, isatis root, lashiosphaera, scrophularia, platycodon, licoricesore throatGardenia and Mentha Combination 
(Qingliang Yin)mentha, gardenia, raw rehmannia, platycodon, licoricesore throat, tonsillitis, pharyngitisScrophularia and Ophiopogon Comb. 
(Zengye Tang)scrophularia, raw rehmanniadry throatPlatycodon and Fritillaria Comb. 
(Qingfei Tang)gardenia, asparagus, platycodon, licoricesore and itching throat, hoarsenessGasping Formula 
(Xiangsheng Podi Wan)mentha, platycodon, licorice, terminaliahoarsenessFritillaria and Trichosanthes Formula 
(Beimu Gualou San)trichosanthes root, platycodondry throatPlatycodon Combination 
(Jiegeng Tang)platycodon, licorice 
(only ingredients in formula)tonsillitisSchizonepeta and Forsythia Comb. 
(Jingjie Lianqiao Tang)mentha, gardenia, raw rehmannia, platycodon, licoricetonsillitis

The herbs used most consistently in these 13 formulas are mentha (included 9 times), platycodon (11 times), and licorice (11 times). Gasping Formula (Xiangsheng Podi Wan, literally: the pill for people whose voices sound like a broken whistle) is a prescription for hoarseness. In Kampo medicine it is often applied for speakers and singers who become hoarse due to overuse of their vocal cords. It contains these three ingredients plus the throat soothing and voice restoring herb terminalia; these four key herbs make up 60% (by weight) of a relatively small prescription (powdered herbs made into a pill). The complete formula is:

Gasping FormulaMentha15 gPlatycodon9 gLicorice9 gTerminalia3 gForsythia9 gCatechu6 gCnidium3 gCardamon3 gRhubarb3 g

A modern patent medicine used for throat swelling due to infection is Qingyan Wan, which includes platycodon, mentha, licorice, and terminalia, as in the above formulation. The patent also has anti-infection herbs (mainlyqingdai, a derivative of isatis, made by isolating the purple dye fraction, known as indigo) and other strong-acting herbs for treating swellings (borax, borneol, and calcite; these ingredients are often applied topically over the throat rather than taken internally). A therapy recommended for vocal edema (21) is to combine terminallia, platycodon, adenophora, and borax, make it into a honey pill and dissolve slowly in the mouth. It is classified as an external treatment, because it acts directly on the throat as the dissolved material is slowly swallowed.

A small Qing Dynasty text (Yihouqian Lun) on epidemic diseases that cause sore throat presents formulas that alleviate throat swelling. A typical formula is this one, that relies on mentha, platycodon, and licorice along with herbs for relieving the surface to treat acute diseases (10):

Qingyan Tang
(Throat Clearing Decoction)Platycodon5 gMentha3 gLicorice3 gArctium3 gApricot seed10 gSiler5 gSchizonepeta5 gChih-ko3 gSpirodela3 gPeucedanum5 gSilkworm6 gOlive3 seeds

A similar formulation is presented in the bookTraditional Chinese Treatment of Otolaryngologic Diseases (21):

Decoction for Sore ThroatPlatycodon6 gMentha9 gLicorice6 gArctium9 gFritillaria9 gTrichosanthes root15 gScrophularia15 gPhragmites15 gLonicera15 gForsythia15 gSchizonepeta9 gPeucedanum9 gSilkworm9 gTussilago9 g

In the treatment of vocal cord polyps, the principle of removing dampness is relied upon. As an example:

Vocal Cord Polyps FormulaHoelen15 gAtractylodes9 gAlisma15 gPolyporus9 gCoix30 gGinseng9 gScrophularia15 gSterculia9 gCicada4.5 gLicorice6 g

The first five herbs listed are moisture dispelling agents, and ginseng aids the spleen in dispersing moisture; the remaining four herbs are specific for treatment of throat distress, listed in Table 1. Unlike Pinellia and Magnolia Combination, this formula is not aimed at treating emotional disturbance, but only the fluid accumulation in the form of a polyp, the excess fluid resulting from weakness of the lung and spleen. For nodules, the moisture resolving herbs alisma, polyporus, and coix are deleted, replaced by blood vitalizing herbs, such as tang-kuei, cnidium, red peony, persica, and carthamus.

Chinese herbs are also applied in treatment of post-surgical throat symptoms, mainly hoarseness, from removal of vocal cord polyps or from other vocal cord surgeries (e.g., separation of vocal cord adhesions). In a report on treatment for post-surgical vocal cord swelling and/or congestion or incomplete closure of the glottis, the following base formula that includes terminalia, platycodon, and licorice was administered, with additions dependent on particular signs and symptoms (16):

Codonopsis9-15 gAstragalus9-15 gHoelen9 gTerminalia5-9 gEgg shell lining5-9 gPlatycodon5 gLicorice5 gCitrus5 g

The herbs were administered in decoction form daily for 15-16 days to obtain notable improvements in the condition of the vocal cords, while some individuals had to be treated for up to two months to gain satisfactory results. The combination of codonopsis, astragalus, hoelen, and citrus was included to tonify qi to help the repair mechanisms; these herbs are not specific for throat disorders.

SPECIALTY FORMULAS DEVELOPED IN JAPAN

Workers in Japan have developed some small prescriptions for treating throat disorders. The main ones are:

Pinellia and Gardenia Combination (Lige Tang) formulated by Genyi Nagoya (2). It contains three ingredients: pinellia, gardenia, and aconite, and is used for treatment of esophageal stenosis, esophageal polyps, esophageal spasms, and throat obstruction. Keisetsu Otsuka suggests combining this formula with licorice and dry ginger (20).Platycodon and Gypsum Combination (Jiegeng Shigao Tang) formulated by Nagakura, who founded one of the famous herb medicine factories of Japan (2). It contains just the two herbs mentioned in the formula name. The formula is indicated for pharyngitis.Gardenia and Licorice Combination (Zhizi Gancao Tang), a recommendation of Keisetsu Otsuka, made with the two herbs in a ratio of 2.5:1. This is for difficulty swallowing resulting from esophagitis and constriction of the esophagus (20).

These formulas include the herbs gardenia, gypsum, platycodon, and licorice, which are known for their effects on the throat. The combination of aconite and pinellia in the first formula is a pair of herbs that are believed to "clash" and be somewhat toxic, so it is to be used for a short time to yield dramatic effects.

SUMMARY AND CONCLUDING REMARKS REGARDING HERB THERAPIES

A relatively small number of formulas, incorporating certain herbs repeatedly, are used to treat a range of common throat disorders of various origins. Of the three dozen herbs listed in Table 1 as being specifically described as effective for throat disorders, only about a dozen ingredients appear repeatedly in traditional and modern formulas that are specified as treating throat diseases, namely mentha, arctium, gardenia, gypsum, phragmites, raw rehmannia, scrophularia, trichosanthes root, platycodon, terminalia, and licorice. In addition, pinellia (an ingredient of Pinellia and Magnolia Combination) is found in some of the formulas, particularly those that resolve phlegm accumulation disorders. While Pinellia and Magnolia Combination is the only formula that has been subjected to several clinical evaluations, the other herbs mentioned here may be of substantial value.

In Western medicine, mentha (peppermint), in the form of its main active component, menthol, is an approved ingredient for over-the-counter sore throat lozenges and syrups. Licorice is well known worldwide for its throat soothing effects. The combination of menthol and licorice is made into a popular over-the-counter remedy for cough and sore throat (called Fisherman's Friend, produced in England). Gardenia, raw rehmannia, and scrophularia all contain iridoid glycosides that may be responsible for anti-inflammatory actions that could affect the throat (as well as other parts of the body). Trichosanthes root, platycodon, and licorice all contain triterpenes that may smooth the flow of mucus and reduce inflammation. The calcium compounds (oxides, sulfates and others) in gypsum and the fatty acids in arctium may soothe the throat by providing substances that aid the formation and flow of mucus. Thus, there are some promising therapies among the Chinese herbs and traditional formulas for improving throat conditions.

ACUPUNCTURE FOR THROAT DISORDERS

Just as there are herbs that are deemed to have specific therapeutic benefits for the throat area, certain acupuncture points are selected when the throat has been affected by some adverse influences. The principal points are local points, those that are on the neck, but there are certain distal points that are said to influence the throat because the meridians on which they are found pass through the throat or because they resolve factors that contribute to throat disease. Following is a review of recent medical reports on acupuncture for throat disorders; these treatments should only be performed by experienced acupuncturists.

Shen Canruo (11) promotes the use yansixue (= throat four points) that are located around the laryngeal protuberance (Adam's apple). They are not traditional acupuncture points, but they are located near the stomach meridian. These points are 2 cun lateral to the Adam's apple (the stomach meridian is 1.5 cun from the Adam's apple) and are the same as or near the extra points qiangyin (strong sound) and zengyin (increase sound), designated as head-neck extra points 25 and 26 respectively. Those extra points are indicated for aphasia due to diseases of the vocal cords, but are deemed useful for other throat and vocalization disorders.

The yansixue points are needled with perpendicular insertion of the needles to a depth of about 0.5 to 1.2 cun, having the needles retained for 20-30 minutes, with manipulations (low frequency twirling) performed every 3-5 minutes. There are certain precautions to follow, including avoiding needling into the carotid artery (especially with the upper point). It is necessary to avoid excessive needle depth (causing facial reddening or coughing, in which case the needles need to be withdrawn far enough to eliminate these reactions) or excessively strong or fast manipulation (which can cause needle pain). In the article about Shen's application of this treatment, three cases are mentioned: dysphonia due to radiotherapy for cancer, paralysis of the vocal cord, and hoarseness due to overuse of the voice (number of daily treatments for these cases was 40, 15, and 1, respectively). In each case, yansixue points were needled along with some distal points, mainly the large intestine points quchi (LI-11) and hegu (LI-4), the lung pointchize (LU-5), and the kidney point zhaohai (KI-6). The lung point lieque (LU-7) was also recommended as useful.

A similar example of use of local points is needling kaiyin yihao xue (= open the voice, acupuncture point number one). This point is recommended by Xie Qiang (12, 22), a specialist in eye-ear-nose-throat (ENT) disorders. It is located 0.5 cun lateral torenying (ST-9), hence 2 cunlateral to the Adam's apple, and close by qiangyin. Needling is towards the aryepiglottic plica. The yansixue and kaiyin yihaopoints are located along the margin of a band of cartilage, referred to as the thyroid cartilage. As an adjunctive point for treatment of vocal cord nodules, hegu (LI-4) was also needled and an herb formula was administered orally while another herb formula was prepared hot and used as a source of vapors to be breathed in through the mouth (see Appendix for formula details).

The use of a local point to promote circulation through the throat area is illustrated also by treatment of a type of plum-pit qi syndrome, referred to by the author as hysteric aphonia (in this, case, the person is unable to speak, as the apparent result of emotional factors). Dr. Shen Xiaolei (13) reported on use of acupuncture to treat this disorder, relying mainly on futu(LI-18), a point on the neck located lateral to renying (ST-9), but 3 cun from the Adam's apple, at the posterior margin of the sternocleidomastoid muscle. Secondary points used in the treatments were jingqu(LU-8) and xingjian (LV-2) for cases of qi stagnation dominant, or taiyuan LU-9 andzusanli (ST-36) for cases of qi deficiency dominant.

In the treatment of bulbar and pseudobulbar palsy, a disorder of the throat functions (speech, swallowing) that occurs because of a stroke or injury to the brain, a local point recommended is tiantu (CV-22), located at the base of the neck. The traditional functions of this point are described as (18): "facilitates and regulates movement of lung qi, cools the throat, and clears the voice." The authors of a report on treating the disorder, describe their selection of points this way (14):

TCM hold that the pathogenesis [of bulbar palsy] is stagnation of wind, phlegm, qi, and blood which obstructs the channels and collaterals, giving rise to unsmooth circulation of qi in the lung channel, and resulting in such symptoms as dysphonia, cough, choke, and vomiting on drinking and eating....Acupuncture attiantu (CV-22) may eliminate the obstruction and improve local circulation of qi and blood; the reducing maneuver used will instantly open the laryngeal orifice and eliminate stagnation of phlegm and blood; and hence taintupoint is located at an important position, the needle should not be retained. Lieque (LU-7) is one of the eight confluence points, communicating at the throat and middle part of the gastric cavity with the conception channel. Theyinqiao channel originates from zhaohai [KI-6, another one of the eight confluence points; located at the ankle] and runs directly to the throat. Acupuncture at the latter two points in combination can treat diseases of the throat, lung, diaphragm, and chest. Reinforcing maneuver should be adopted and performed for supplementing qi, nourishing yin, soothing the chest, promoting the action of the diaphragm, and dredging the laryngeal orifice.

For polyps and nodules of the vocal cord, the local acupuncture points renying (ST-9), suitu (ST-10), tiantu (CV-22) and lianquan (CV-23) are recommended in the bookTraditional Chinese Treatment of Otolaryngologic Diseases (21). Distal points recommended include fenglong(ST-40), a point on the leg that is used for phlegm accumulation disorders, zhaohai (KI-6), specifically indicated for treatment of throat disorders, and hegu (LI-4), used to clear heat and swelling in the neck and head areas.

A local point on the back of the neck, opposite the Adam's apple, has also been used to treat vocal cord ailments, including congestion, edema, nodules, hypertrophy, early polyps, and inadequate muscular tonicity (15). Chen Peifang, working at the Shanghai Conservatory of Music, treated the yangsheng(raise the voice) point in 110 cases of voice ailments, the largest group (41 of the performers) having hypertrophic protuberances as the cause of the disorder. The point is located 1 to 1.5 cunlateral (about 1-1.2 cun for women and 1.2 to 1.5 cun for men, since men have broader necks) to the interspinal space between C6 and C7. To access the point, the person sits with head bent forward about 25 degrees. The needle is inserted to a depth dependent on the thickness of musculature of the neck, generally 1.5 cun for women and 2 cun for men.

The needle is twisted and rotated in small amplitude movements to get the typical acupuncture needle sensation (deqi) but not to produce excessive pain or tenderness in the neck muscles. The needle is retained for 20 minutes, and six daily sessions is a course of treatment. Some improvements are expected within the first six sessions. It is recommended that at least six sessions be utilized, even if a marked improvement occurs more quickly, to assure continued relief afterward.

Needling therapy in the neck area often makes the patient nervous (23), so it is recommended to limit the number of throat points needled at one time and to have the patient lie down if nervous to prevent possible fainting. Pillows can be used to make sure the head and neck are in the proper position, and patients should be advised about the nature of the expected needling sensations for points on the meridians. For example, at futu (LI-18), typical sensations are tingling and numbness transmitted from the neck to the shoulder and forearm; sensation of electrical shock passing from the neck through the shoulder and arm to the thumb and index finger; and sensation of distension radiating from the neck into the chest. In addition, all of these feelings may be transmitted from the site of needling to the Adam's apple. For persons who do not like the acupuncture therapy, massage therapy may be substituted, so long as the practitioner is experienced in this method.

Gu Lide, at the Department of Laryngology of Artists Hospital of Shanghai, pointed out that laryngeal massage had been used at their hospital since about 1960 in treating singers (24). In the treatment of incomplete closure of the glottis, which causes disruption of singing quality, he described the following massage technique and its potential effects:

The patient lies supine with a pillow under the shoulders so that the neck is well extended and the head slightly inclined backward. The doctor uses one finger massage and up and down kneading to massage the bilateral renying (ST-9) andshuitu (ST-10) points upward and down for 10-15 minutes. The patient is then asked to sit upright while the doctor, using both hands, employs one finger massage on both sides of the fengchi points (GB-20) for 3-5 minutes. The same method is used to massage fengfu (GV-16) andyamen (GV-15) points for another 3-5 minutes. Finally, the fengchi point is massaged and the sternocleidomastoideus muscles of both sides are kneaded up and down for 2-3 minutes....Massage may relax spasm, promote blood circulation, enhance metabolism, relieve fatigue, increase mucus secretion, lubricate the vocal cords, and invigorate the elasticity and mobility of muscles and ligaments. It gives patients a feeling of well being, relaxes the laryngeal muscles, improves the voice quality, and eases phonation.

These treatments were given in courses of six sessions each, with patients receiving from 2 to 18 courses of therapy. The author cautions that: "laryngeal massage should be performed briskly, gently, yet powerfully and persistently, but never roughly....If a patient shows no apparent improvement after one or two courses of massage [e.g., 6-12 sessions], it is advisable to consider combining massage with other therapeutic measures or shifting over to other therapy."

Chen Peifang also described the use of massage therapy for the voice ailments (17). The massage includes local treatments in the front and back of the neck, and whole body treatments, but especially massage of the arms near the points that have been recommended for acupuncture therapy, such as the large intestine points quchi (LI-11) and hegu (LI-4) and the lung points chize (LU-5) and yuji (LU-10). He emphasized the following:

Massage is useful in cases of extra- or intra-laryngeal muscular spasm due to excessive or improper use of the vocal cords.Voice-care massage before going on to the stage promotes flexibility of the laryngeal muscles and coordination of antagonistic muscles necessary for good singing effects. Massage after the performance relieves fatigue of the throat.Massage along the channels dredges the channels and promotes circulation of qi and blood, thus clearing the throat for satisfactory singing.During massage, special emphasis is placed on tender points of the neck. This relieves pain from exertion of the laryngeal muscles, eliminates inflammation due to accumulation of waste material in the muscles, and facilitates repair of wear and tear in the laryngeal muscles.Massage on the cricothyroid articulation and muscles helps reduce the distance between the cricoid and thyroid cartilages to facilitate utterance of high pitch voices, while it indirectly increases the length and tonicity of the vocal cords. Massage on the arytenoid region is conducive to proper approximation of the vocal cords.The vocal organs in the throat are tender structures that demand gentle manipulations and avoidance of abrupt excessive pressure during massage.

SUMMARY OF ACUPUNCTURE THERAPIES

Acupuncture therapies involve needling the neck to promote circulation of qi and blood in the immediate region. Some "extra points" have been selected for this purpose, mostly located 2 cun on either side of the Adam's apple (see Figure 1). The treatments are administered daily or every other day for chronic disorders, and effects of a single treatment or a series of just five or six treatments may be notable. Secondary points are mainlyhegu (LI-4), lung points on the forearm arm and hand (LU-5 through LU-11), and the leg points zhaohai (KI-6) andfenglong (ST-40). Massage therapy can also be used as an aid to treating and preventing vocal disorders, particularly those suffered by performers who use their voices for singing or acting (see Figure 2). Massage therapy can sometimes be administered under circumstances where acupuncture is not practical, so that the person with vocal disorders has several opportunities to get regular effective therapy.

REFERENCES

Hsu HY and Wang SY (translators), Chin Kuei Yao Lueh, 1983 Oriental Healing Arts Institute, Long Beach, CA.Hsu HY and Hsu CS,Commonly Used Chinese Herb Formulas with Illustrations, 1980 Oriental Healing Arts Institute, Long Beach, CA.Iwasaki K, et al., The traditional Chinese medicine banxia houpo tang improves swallowing reflex, Phytomedicine 1999; 6(2): 103-106.Iwasaki K, et al., The effects of the traditional Chinese medicine banxia houpo tang on the swallowing reflect in Parkinson's disease, Phytomedicine 2000; 7(4): 259-263.Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, vol. 2, 1993 Heilongjiang Education Press, Harbin.Luo L, et al., Antidepressent effects of banxia houpo tang, a traditional Chinese medicinal empirical formula, Journal of Ethnopharmacology 2000; 73(1-2): 277-281.Karazawa Yosuke, Morning sickness of pregnancy and Pinellia and Hoelen Combination, Bulletin of the Oriental Healing Arts Institute, 1982; 7(1): 9-17.Hsu HY, et al., Oriental Materia Medica: A Concise Guide, 1986 Oriental Healing Arts Institute, Long Beach, CA.Xu Xiangcai (chief editor),English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, vol. 5, 1990 Higher Education Press, Beijing.Wen JM and Seifert G, Warm Disease Theory, 2000 Paradigm Publications, Brookline, MA.Yao Wenlong, ProfessorSheng Canruo's experience in acupuncture treatment of throat diseases with yansixue, Journal of Traditional Chinese Medicine 2000; 20(2): 122-125.Yang Shurong, Clinical observations on 109 cases of vocal nodules treated with acupuncture and Chinese drugs, Journal of Traditional Chinese Medicine 2000; 20(3): 202-205.Shen Xiaolei, Acupuncture treatment of hysteric aphonia-A report of 27 cases, Journal of Traditional Chinese Medicine 1998; 18(4): 253-255.Liu Laili, Acupuncture treatment of bulbar palsy-a report of 54 cases, Journal of Traditional Chinese Medicine 2001; 21(1): 30-32.Chen Peifang, Acupuncture at yangsheng point for treatment of voice ailments in 100 cases, Journal of Traditional Chinese Medicine 1991; 11(4): 261-262.Ni Heye, Clinical observation on application of Chinese materia medica after intrlaryngeal microsurgery, Journal of Traditional Chinese Medicine 1994; 14(2): 101-104.Chen Peifang, Massage for the treatment of voice ailments, Journal of Traditional Chinese Medicine 1991; 11(3): 209-215.O'Connor J and Bensky D (translators), Acupuncture: A Comprehensive Text, 1981 Eastland Press, Seattle, WA.Iwasaki K, et al., Traditional Chinese medicine Banxia Houpu Tang improves swallowing reflex, Phytomedicine 6(2): 102-106.Hsu HY, Chinese herb therapy for abnormal sensations of the throat, Bulletin of the Oriental Healing Arts Institute 1984; 9(2): 63-66.Hou Jinglun, Traditional Chinese Treatment for Otolaryngologic Diseases, 1997 Academy Press, Beijing.Xie Qiang and Yang Shurong,Clinical observation on combination therapy of acupuncture and Chinese herbal medicine in treating vocal cord nodule, Chinese Journal of Integrated Traditional and Western Medicine 2000; 6(1): 56-57.Jiang Youguang, Clinical applications of point futu, Journal of Traditional Chinese Medicine 1986; 6(1): 6-8.Gu Lide and Fan Liandi,Effect of traditional massage on closure insufficiency of glottis in singers, Journal of Traditional Chinese Medicine 1981; 1 (1): 67-68.

March 2002

APPENDIX: STEAM AND DECOCTION FOR VOCAL CORD NODULES

In the article on treating vocal nodules with acupuncture and Chinese herbs (12), the following herb recipes were given:

Herbal Steam FormulaLicorice6 gMentha6 gCarthamus6 gCitrus fiber6 gMume6 gGreen tea3 g

This recipe is decocted, and while still hot, the patient would inhale the steam through his mouth for 10 minutes each time, twice daily. Alternatively, it can be administered via a nebulizer or other aerosol. After that, the patient would drink a similar medicinal tea:

Herbal Tea FormulaLicorice3 gMentha3 gCarthamus6 gRose flower3 gCitrus fiber3 gOroxylum3 gGinseng2 gMume3 gGreen tea3 g

The tea is to be consumed slowly once every two hours, 100 ml (about three fluid ounces) each time, six times daily for 20 consecutive days.

In these formulas, mume serves a function similar to that of terminalia. The difference between the steamed herbs and the tea that is drunk is the addition of ginseng, oroxylum, and rose flower to the latter. Ginseng is a tonic herb that is used to bolster the qi; oroxylum is one of the specific throat benefiting herbs in the phlegm-resolving and antitussive category, while rose flower is used to regulate qi circulation. The steam and decoction are administered for 20 days consecutively, as part of the complete treatment that includes acupuncture therapy.

Figure 1: Approximate locations of major points for treating throat disorders. The basic illustration, withrenying (ST-9) and futu (LI-18) indicated is from A Manual of Acupuncture by Deadman and Mazin (1998).Kaiyin yihao xue is 0.5 cunlateral to renying, while theyansixue points are 0.5 cunabove and below that point and are approximately the same as qiangyin (extra point HN-25) and zhengyin(HN-26).

Figure 2: Various throat massage techniques.