A case report of acupuncture of dysphagia caused by herpes zoster virus infection

Ping Zhang,Xin-Ju Li,Zhi-Long Zhang*

1Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Tianjin 300120, China. 2Tianjin University of Traditional Chinese Medicine,Tianjin 300193,China.

Introduction

Herpes zoster (HZ) is a viral skin disease caused by varicella zoster, characterized by erythema, blisters along unilateral peripheral nerves and often accompanied by obvious neuralgia [1]. According to the literature, the annual incidence of HZ in Chinese people over 50 years old is 2.4-5.8%[2].Herpes zoster virus can cause multiple cranial neuritis, and the most vulnerable nerves are facial nerve, auditory nerve,glossopharyngeal nerve, trigeminal nerve, vagus nerve and abductor nerve in turn [3]. At present, studies on treatment of cranial neuritis caused by herpes zoster are mainly case reports[3-5].A patient with dysphagia caused by pharyngeal herpes zoster virus infection was admitted to the acupuncture and moxibustion department of our hospital on June 21, 2017. A retrospective analyses of the clinical diagnosis and treatment process is made as follows.

Medical records

Male, 77 years old, retired teacher, previously healthy.He was admitted to the hospital on June 21, 2017 due to"dysphagia with hoarseness for 20 days".On June 2,emerging pharyngeal burning pain with no obvious cause, the patient self-administered take cephalosporin(detailed drug name unknown) and symptoms didn’t alleviated. 3 days later, with symptomatic progression to dysphagia, hoarseness, the left ear pain, the patient went to the otolaryngology department of Tianjin Medical University General Hospital for hospitalization. Electronic laryngofiberscopy examination revealed that hyperemic and hypertrophic nasopharyngeal mucosa, bulging nasal pharyngeal posterior wall, irregular nodules and concave nest,scattered ulcer with white pseudo membrane in left round pillow, tongue root and the lingual surface of epiglottis, lymphatic tissue hyperplasia in tongue root,left vocal cord fixed in next middle position, anteverted left aryepiglottic fold,shallow left pyriform sinus. Laryngoscopic diagnosis:left vocal cord paralysis,left throat ulcer-herpes zoster?(Fig.1) Serum varicella zoster virus IgG antibody: (+);Brain MRI: brain atrophy; Chest CT: no obvious abnormality was found. Antiviral, neurotrophic and symptomatic treatment were performed, and nasogastric tube was given the next day to guarantee the intake amount and prevent microaspiration. After the condition was stable, the patient was admitted to our hospital for rehabilitation in the acupuncture and moxibustion department.

Symptoms:dysphagia,hoarse voice,diet injected by the stomach tube,left ear tight painful,no herpes in the ear, pressing pain on the mastoid behind ears, dry mouth, burn feeling in the gastric area after diet, light sleep,loose stools and 2-3 times a day, nocturnal enuresis, dark tongue, white and greasy fur,slippery and rapid pulses.

Physical examination: clear consciousness,dysarthria, illogical expression, decreased left pharyngeal reflex, poor left soft palate uplift, no other physical findings of nervous system. Water swallow test:grade 5; Classification of deglutition state: grade 2; Classification of language functional state:grade 2.

Electronic laryngofiberscopy examination: left vocal cord paralysis,chronic laryngitis(Fig.2).

TCM diagnosis: aphasia and paralysis (phlegmblood stasis chokes the Qiao); Western medicine diagnosis: glossopharyngeal nerve injury, vagus nerve injury,varicella-zoster virus infection.

Therapies

Using the principles of inducing the Yang inside and harmonizing with the Yin and “Tong Guan Li Qiao”, we adopted the acupuncture method of deep Yang stitch. Acupoint selection: lofty bone,ridge spring and side ridge spring. Operation:selecting 0.30mm*50-75mm Huatuo brand filiform needle; stabing towards the root of the tongue on ridge spring and side ridge spring acupoints and the depth is determined by needling response. Lofty bone acupoint adopts the method of deep Yang stitch (After the needle is inserted into the skin, the mind follows the tip of the needle and slowly moves down the needle to find the Qi. After getting the Qi, the mind leads the needle from the shallow to the deep so that the Yang part of the Qi leads to the Yin part. Push the Yang inside and ease the Yin. Then keep the needle inside deeply. "inducing the Yang inside and harmonizing with the Yin"). The needle moves towards the throat direction, and the depth is about 50mm-75mm.

The SDZ- Ⅱ electronic needle therapy instrument produced by Suzhou Medical Appliance Factory were connected with lofty bone and ridge spring acupoints, choosing dilatational wave form, pulse frequency 50Hz, pulse intensity 2v, pulse width 0.2 ms, which a current is applied for 30 minutes, once a day. Treatment continued for 21 days.

Effect evaluation

After 21 days of treatment, the patient swallowed normally and could eat independently.The gastric tube was removed.

Fig. 1 The results of electronic laryngofiberscopy examination in Tianjin Medical University General Hospital.Laryngoscopic diagnosis:left vocal cord paralysis,left throat ulcer-herpes zoster?

Fig.2 The results of electronic laryngofiberscopy examination in our hospital.Laryngoscopic diagnosis:left vocal cord paralysis,chronic laryngitis.

Physical examination: clear consciousness,fluent expression, normal pharyngeal reflex, no other physical findings of nervous system. Water swallow test:grade 1; in Classification of deglutition state: grade 4; Classification of language functional state: grade 4.The patient was followed up for 1 year with normal swallowing, independent eating, clear articulation and no recurrence.

Discussion

Clinically, herpes zoster of pharynx is commonly shown as the scattered ulcer in the corresponding innervation area. As the virus invades the nerve, the ulcer is mostly unilateral (it does not cross the midline generally), but most of the ulcer may be the primary infection of herpes virus. After primary infection,nerve of the region also became a latent object of herpes virus, like skin herpes zoster, pharyngeal mucosa has become the region susceptible to herpes zoster. When patients are in the sate of immune suppression, virus invades pharyngeal mucosa after being activated again and is likely to cause cranial neuritis of IX(glossopharyngeal nerve) and X (vagal nerve)branches. Glossopharyngeal nerve and vagus nerve, close to each other anatomically, come out the skull via jugular foramen , at the bottom of which is swollen ganglion. Varicella - zoster virus lies dormant in the ganglion of cranial nerve. Hence, the glossopharyngeal nerve is usually involved when the vagus nerve is infected. These two nerves both have pharyngeal branche participating in pharyngeal plexus,which controls the feeling of pharynx and movement of related muscles. So the symptoms of dysphagia,voice hoarse and bucking will appear when infected by herpes zoster virus in pharynx.

This disease can belong to the category of motherland medicine "aphasia and paralysis"."Wonderful Well-Tried Recipes" say "aphasia and paralysis mean that the tongue can not speech,foot can not walk ", explaining that the tongue can not phonate and it is too stiff to deliver food to pharynx,then cause dysphagia. This disease should belong to "Qiao disease".Qiao position is Yin,and should get the Yang Qi from human body to be able to exert normal function. if phlegm and blood stasis block the way of Qiao,Qi is obstructed,then tongue and larynx will lose their function. Therefore, the principle of treatmen is tinducing the Yang inside and harmonizing with the Yin and“Tong Guan Li Qiao”.

(3)Fenton氧化+Ca(OH)2預處理有助于提高納濾膜通量，改善產(chǎn)水品質(zhì)，延長納濾膜的使用壽命。

Lofty bone acupoint first appeared in “Thousand Golden Prescriptions ” with position but no name."Integration of Acupuncture and Moxibustion" was originally named this acupoint.Lofty bone,also named Taizu, is on the first high bone of the spine(Fig.3)."Plain Questions" pointed out that "Person good at using acupuncture and moxibustion can guide Yin from the Yang and guide Yang from the Yin." "induce Yang to Yin" has two meanings. Firstly, the sentence means that choosing the Yang acupoint to treat the Yin part of the disease in the acupoint selection;Secondly,another meaning is referred to the needling method: treatment can be performed from the surface of the skin to the inside position, showing that the shallow puncture position is the Yang part and deep puncture position is the Yin part."Miraculous Pivot"says that stabbing Yin should adopt the deep position and keep inside;stabbing Yang should keep the needle in the shallow position and fast movement.Pharynx and larynx is the place that Three Yin Channels of Foot go through,belong to Yin. Lofty bone acupoint is located on the highest spine bone of the neck,and also located on the route of the Du Channel which governs the Yang Qi of the whole body, so Lofty bone belongs to Yang.Therefore, we stab the lofty bone acupoint deeply to treat Yin diease of dysphagia.That is guiding Yin from the Yang and inspire Yang Qi [6]. At the same time,modern medical anatomy shows that the branches of the 6th,7th,and 8th cervical nerves is under lofty bone acupoint which also located in the innervation area of the glossopharyngeum and vagus nerve. Therefore,dysphagia caused by the injuries of the glossopharyngeum and vagus nerve could be treated.

Ridge spring acupoint first appeared in“Miraculous Pivot”. “Ridge” means edge with the extended meaning of pure.“Spring”is the position where water comes out. This acupoints, such as the adam's apple of the edge, are the way of body fluid which is like the clean spring, so it’s named ridge spring with the alias of “the pool”and“tongue base”. Ridge spring is located between tongue and throat, belonging to Ren Channel, and is the intersection acupoint of Ren Channel and Yin Link Channel. Needling this acupoint can clear the throat and unchoke the tongue meridians(Fig.4).

Side ridge spring acupoint, beside the ridge spring acupoint, means assistant. Using acupuncture on the there acupoints of ridge spring,left and right side ridge spring at the same time,compared with a single acupuncture on ridge spring or side ridge spring, the stimulation scope is lager. The selection of acupuncture direction and depth on the there acupoints also exactly go through the area where the nerves converge,especially the hypoglossal nerve branches and mylohyoid muscle nerve, which can more effectively improve the normal function of pharyngeal muscle tongue[7].

The waveform of electroacupuncture is selected as the dilatational wave, frequency 50 Hz,stimulating time for 30 minutes, that is a kind of low-frequency, percutaneous and intramuscular electrical stimulation. The mechanism of electroacupuncture may be promoting the communication between nerve center and swallowing organs through the early sensory input and the later muscle contraction, and then achieving the goal of improving swallowing function. The treatment principle of dissipating phlegm, removing blood-stasis, and “Tong Guan Li Qiao”all used on the above mentioned there acupoints, so as to make Qi and blood unobstructed and nourish the Qiao way,recovering the swallowing function ultimately.

Fig.3 The position of lofty bone acupoint

Fig.4 The position of ridge spring and side ridge spring acupoints

Clinically, the diseases which can cause dysphagia are complicated, such as esophageal tumor, cerebrovascular disease, craniocerebral trauma and brain tumor. The main reasons of dysphagia are space-occupying lesions in oropharynx and esophagus occupying, and nerve injury. The dysphagia caused by nerve injury is relatively difficult to alleviate.Yang Ge [8] found that electroacupuncturing Ridge spring and Fengfu had certain excitatory regulation effects on brainstem swallowing reflex physiologically.Zhang Yi [9] performed a meta-analysis of randomized controlled trials of electroacupuncture treatment for dysphagia caused by stroke before May 2016, and found that electrotherapy has significant clinical efficacy for dysphagia after stroke. Dysphagia after stroke mainly caused by nerve injury which can be recovered by stimulating nerve conduction pathway through electroacupuncture to promote the recovery of swallowing function. In this case, the reason of dysphagia is also attributed to mainly due to nerve injury caused by herpes zoster infection.Therefore, on the basis of the treatment of deep Yang stitch method,the electroacupuncture was used as an adjuvant therapy to achieve the better clinical effect.

This case is rare in clinical practice, and provides a new research field for acupuncture treatment of dysphagia.Other dysphagia caused by nerve injury can also use this treatment method which is worth further promotion. However, this case still has the following problems:1.The clinical cases of dysphagia caused by herpes zoster virus infection are relatively rare, so it is difficult to carry out further clinical research and raise the level of evidence; 2. At present, there the is no standardized operation procedure about deep Yang stitch method. So, it is difficult to ensure the accuracy of the technique in the clinical practice and promotion process, resulting in influencing the acupuncture efficacy.

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