Acupuncture for Neurological Disorders Associated with the Liver

Acupuncture for Neurological Disorders Associated with the Liver It matters not whether medicine is new or old, it only matters that it is applied for the benefit of the patient.

Neurologic Assessment • Is it a neurologic disease? – Seizures – Intention tremor – CN deficits • Head tilt • Nystagmus – CP deficits – Dysmetria – Paralysis

Minimum Database • CBC • Chemistry – Bile acids – Cholinesterase • Urinalysis • Chest and abdominal radiographs • Abdominal ultrasound • Heartworm test • Fecal

Ancillary Neurologic Tests • Electrodiagnostics • Radiographs • CSF tap & analysis • Muscle Analysis – – – – EEG EMG BAER Cells & protein Pressure Cholinesterase Titers – – – – Skull & spinal films Myelography CT scan MRI Enzymes 2 M antibody Anti-ACH receptor antibody – Biopsy

When all else fails… Look at the patient!!!

Seizures in Small Animals • It is estimated that the overall incidence of seizure disorders in dogs and cats is around 1% • In pure breed dogs, this incidence may increase to 1520%, due to the presence of inherited, primary epilepsy in those breeds

Lesion Localization in Seizures • Cerebral Cortex • Diencephalon – Thalamus – Hypothalamus • Mesencephalon

Seizure Diagnoses SEIZURES Primary Epilepsy Secondary Epilepsy Inactive Reactive Epilepsy Active

Seizures- -TCM • Represent various aspects of the Liver (Wood) system • Excess (3 types) • Deficiency (3 types)

Seizure Diagnosis • Minimum Database • CT or MRI Scan • CSF tap & analysis • EEG – Abnormal in Reactive Epilepsy – Abnormal in Active Secondary Epilepsy – Abnormal in Secondary Epilepsy • All test are normal in Primary Epilepsy

Asymmetrical Seizures

Licking Seizure

Seizures and Signalment • Primary Epilepsypurebred dogs 1 -3 years of age • Secondary Epilepsyany age but especially under 6 months and over 3 years

Seizure Treatment • Acupuncture alone • Acupuncture in conjunction with drugs • Traditional Chinese herbs • Western herbal medicine – – – Valerian Root Kava Oats Hops Passionflower • Western drugs

Basic Antioxidants Dogs • Vitamin E 10 IU/lb daily • Vitamin C 5 -10 mg/lb twice a day • Selenium 2 µg/lb daily • Beta carotene 250 IU/lb daily • B Complex 2 mg/kg twice a day Cats • Vitamin E 100 -400 IU daily • Vitamin C 100 -250 mg twice a day • Selenium 50 µg daily • Vitamin A 1000 -5000 IU daily • B Complex 10 mg twice a day

Additional Considerations • Probably safe parasite control – – – Interceptor Frontline Top Spot Revolution • Should avoid – – – – Heartgard Proheart 6 Program Sentinel Frontline Spray Advantage Advantix

Additional Considerations • Diet – Low-carbohydrate food • Supplements – Ginkgo biloba • 2 -4 mg/kg q 8 -12 h • Ginkoba or Publix brand – Tofu or Lecithin • 20 mg/kg daily – Acetylcysteine • 25 mg/kg q 8 h qod

Phenobarbital • Cheap and effective • Dose 2 -4 mg/kg for a serum level 20 -40 mcg/ml • Takes 3 -5 days to reach steady state • Safe but can effect the liver in a few cases • Controls 80% of seizures

KBr (Bromide) • Compounded by pharmacist dissolved in H 2 O at 250 mg/ml • Dose at 22 mg/kg q 12 h • Blood level in 2 months between 1500 -4000 µg/ml • Use alone or in conjunction with Phenobarbital • Bypass liver • Good for cluster seizures

Other Anticonvulsants With Efficacy • Diazepam – 1 mg/kg q 12 h • Primidone – 15 -22 mg/kg q 12 h • Felbamate – 15 -45 mg/kg q 8 h No Efficacy • • Valproic acid Nimodapine Chorazepate Lamotrigine • Phenytoin – 3 -5 mg/kg q 8 h • Gabapentin – 30 -60 mg/kg q 8 -12 h • Topiramate – 15 -25 mg/kg q 8 -12 h Note: TOXIC to Dogs

Seizures- -TCM • Excess – Wind-Phlegm • Tongue pale & greasy • Pulse wiry & slippery – Phlegm-Fire • Tongue red & greasy • Pulse rapid, wiry & slippery – Blood Stagnation • Tongue & Pulse like Wind-Phlegm • History of head trauma • Deficiency – Liver Blood Def. • Tongue pale & dry • Pulse weak & thready – Liver & Kidney Yin Def. • Tongue red & dry • Pulse weak & thready – Kidney Jing Def. • Tongue pale or red & dry • Pulse weak & thready • < 1 year of age

Seizures- -TCM • Excess – Wind-Phlegm • expel phlegm, extinguish the wind, open the orifice and stabilize the seizures • Ding Xian Wan – Phlegm-Fire • clear the liver, drain the heat, transform phlegm and open the orifices • Di Tang and Long Dan Xie Gan Tang – Blood Stagnation • expel phlegm, extinguish the wind, open the orifice, stabilize the seizures and invigorate blood • Ding Xian Wan and Tao Hong Si Wu San • Deficiency – Liver Blood Def. • tonify Qi and Blood and quiet the wind • Bu Xue Xi Feng San or Di Tang plus 8 Treasures – Liver & Kidney Yin Def. • nourish Yin and extinguish wind • Yang Yin Xi Feng San or Di Tang and Left Side Replenished (Zuo Gui Wan) or Tian Ma Gou Teng plus – Kidney Jing Def. • extinguish the wind astringe or nourish the kidney jing • Di Tang and Epimedium Powder

Wind Phlegm Emotional/Drug Stress Spleen Disorder or Chronic Illness Liver Qi Stagnation Accumulation of Phlegm (Tan) Liver Yang Rising Liver Wind (Feng) Obstruction of Shen/Mind Sudden Onset of Seizures

Wind Phlegm • Hz – Acute Seizures • Tongue – pale & greasy • Pulse – wiry & slippery • Rx Principle – expel phlegm, extinguish the wind, open the orifice and stabilize the seizure • AP – CV-15, ST-40, PC-5, GV -1, GV-26, HT-7, ST-6, LIV-3, An Shen, Da Feng Men • TCM Herbal – Ding Xian Wan • Horse: – 15 g twice daily as top dressing on feed • Dog/Cat: – 0. 5 g per 10 to 20 lb body weight twice daily

Ding Xian Wan Pinellia Citrus Bambusa Fritillary Arisaema Juncus Bombyx Scorpion Gastrodia Ophiopogon Polygala Salvia Poria Magnolia Licorice Zingiberis Ban Xia Chen Pi Zhu Ru Chuan Bei Mu Dan Nan Xing Deng Xin Cao Jiang Can Quan Xie Tian Ma Mai Men Dong Yuan Zhi Dan Shen Fu Ling Fu Shen Hou Po Gan Cao Gan Jiang Transform phlegm Move Qi, transform phlegm Transform phlegm Clear Heat Extinguish Wind, stop seizure Tranquilize Liver, extinguish Wind, stop seizure Nourish Yin, calm Shen Move Blood Drain Damp Calm Shen Move Qi Harmonize

Phlegm Fire Emotional/Drug Stress Wood Personality Liver Qi Stagnation Spleen Disorder or Chronic Illness Accumulation of Phlegm (Tan) Liver Yang Rising Liver Fire Obstruction of Shen/Mind Sudden Onset of Seizures

Phlegm Fire • Hz: – Acute Seizures – Wood Personality • Tongue – red & greasy • Pulse – Fast, wiry & slippery • Rx Principle – Clear the liver, drain the heat, transform phlegm and open the orifices • AP – CV-15, ST-40, PC-5, HT -7, LI-11, LIV-3, An Shen, Da Feng Men • TCM Herbal – Di Tang – Long Dan Xie Gan Tang

Di Tang Pinellia Citrus Arisaema Acorus Bambusa Uncaria Lumbricus Haliotis Poria Aurantium Ginseng Licorice Zingiberis Ban Xia Chen Pi Dan Nan Xing Shi Chang Pu Zhu Ru Gou Teng Di Long Shi Jue Ming Fu Ling Zhi Shi Ren Shen Gan Cao Gan Jiang Transform phlegm Move and transform phlegm Transform phlegm Open the orifice, eliminate Damp Transform phlegm Extinguish Internal Wind, clear Liver Heat Extinguish Internal Wind, stop seizure Clear Liver Heat Drain Damp Move Qi Tonify Qi Harmonize

Long Dan Xie Gan Tang Gentiana Gardenia Scutellaria Plantago Alisma Akebia Angelica Rehmannia Bupleurum Licorice Long Dan Cao Zhi Zi Huang Qin Che Qian Zi Ze Xie Mu Tong Dang Gui Sheng Di Huang Chai Hu Gan Cao Clear Liver Heat, Clear Damp-Heat Clear Damp-heat Drain Damp-Heat Nourish Blood Nourish Yin, clear Heat Soothe Liver Qi transporter Harmonize

Mansion of Mind Damp-Heat Encephalitis, SRME, GME Lonicera Forsynthia Isatidis Astragalus Akebia Platycodon Licorice Jin Yin Hua Lian Qiao Ban Lan Gen Huang Qi Mu Tong Jie Geng Gan Cao Clear heat, Expel wind 20 gm Clear heat, Detoxify 20 gm Clear heat, Cool blood 20 gm Move Qi (stimulate immune system) 20 gm Drain Damp-Heat 10 gm Transporter 15 gm Harmonizer 10 gm

Meningoencephalomyelitis • Infectious Diseases – Species Specific • Steroid Response ME (SRME) • Necrotizing Vasculitis (SRMA) • Necrotizing ME (NME) • Granulomatous ME (GME)

Meningoencephalomyelitis • Pain to paresis to plegia • Dx with CSF tap • Spinal radiographs normal • Myelography normal (might be contraindicated)

Meningoencephalomyelitis

CSF Tap • Collection site for seizures is at the cisterna magnum. • Allows analysis for cells, protein and pressure. • Cytology and titers for infectious organisms can be obtained.

Meningoencephalomyelitis • CSF Analysis – may be normal or show increased pressure, protein and/or cells. • CSF Titers – species specific tests – many must be paired with serum titers. CSF cytology form a dog exhibiting a mixed reaction with neutrophils, lymphocytes and macrophages.

Meningoencephalomyelitis • Infection – – – virus rickettsia protozoa fungus bacteria – – GME NME SRMA • Inflammation

GME • Can be: – – – peracute & progressive chronic • In brainstem, tends to be a multifocal inflammatory disorder • Responds temporarily to steroids. Patient with GME presenting with vertical nystagmus, long tract signs, and circling with incoordination.

GME histologically causes multifocal meningoencephalitis due to proliferation of reticulohistiocytic cells. Lesions also show multinucleated giant cells.

Treatment of ME • Depends upon whether infectious or inflammatory • Prednisolone – Find minimum daily dose and then used 2 times MDD QOD • Primor (activated sulfadimethoxine) – 15 mg/kg BID • Doxycycline – 5 -10 mg/kg QD • Herbal Support – Bromelain/Curcumin • 2. 5/5 mg/kg TID

Sugar Bear • 5 year old, female/spayed Jack Russell Terrier • Acute onset of dementia, change in behavior, seizures, progressing toward coma in 72 hours • Tongue: Red • Pulse: Fast & Wiry

Sugar Bear • CSF Analysis – Increased Cells & Protein consistent with inflammation • CT scan – Focal mass in the cerebral cortex

Sugar Bear • Biopsy confirmed GME • Western Treatment – Prednisolone – Procarbazine • TCM Treatment – – Di Tang Mansion of Mind Damp-Heat

Blood Stagnation Traumatic Injury Emotional/Drug Stress Blood Stagnation Qi Stagnation Liver Qi Stagnation Fire/Heat to Cook Body Fluids Liver Yang Rising Liver Wind (Feng) Accumulation of Phlegm (Tan) Obstruction of Shen/Mind Sudden Onset of Seizures

Blood Stagnation • Hz: – Acute Seizures – Head Injury • Tongue – red & greasy • Pulse – Fast, wiry & slippery • Rx Principle – expel phlegm, extinguish the wind, open the orifice, stabilize the seizures and invigorate blood • AP – CV-15, ST-40, PC-5, HT -7, LI-11, LIV-3, An Shen, Da Feng Men • TCM Herbal – Ding Xian Wan – Tao Hong Si Wu San

Tao Hong Si Wu San Use up to 1 month Paeonia Ligusticum Angelica Rehmannia Carthamus Persica Chi Shao Yao Chuan Xiong Dang Gui Sheng Di Huang Hong Hua Tao Ren Nourish Blood, clear Heat Move Blood, resolve stagnation Move and Nourish Blood Nourish Yin and clear Heat Break Blood stasis

Stasis in Mansion of Mind Use up to 6 months with Wie Qi Booster Angelica Pinellia Ligusticum Salvia Lumbricus Ligusticum Pueraria Carthamus Bombyx Scorpion Cimicifuga Fritillary Scolopendra Bai Zhi Ban Xia Chuan Xiong Dan Shen Di Long Gao Ben Ge Gen Hong Hua Jiang Can Quan Xie Sheng Ma Zhe Bei Mu Wu Gong Warm the Channel, relieve pain Transform phlegm Move Blood Clear Wind, invigorate Channel Relieve pain Bring Qi upward Break down Blood Stasis Transform phlegm, resolve nodule Break down Blood Stasis Ascend Qi Transform phlegm, resolve nodules Detoxify, resolve nodules

CNS Neoplasia- -Dogs • Common Types – – Meningioma Astocytoma Oligodendroglioma Choroid plexus papilloma – Lymphoma – Neuroectodermal tumors – Metastatic tumor

CNS Neoplasia- -Dogs • Dog has 1 -18 months average survival time – – – 1 -3 with nothing 6 -9 with surgery 12 -18 with radiation treatment • All tumors are invasive (malignant)

CNS Neoplasia- -Cats • Most common is meningioma • Usually extra-axial and benign • Seen in aged cats • Present with depression and dementia

Elvis

Elvis • MRI revealed mass in the cerebral cortex

Elvis

Treatment • Prednisolone (0. 25 -0. 5 mg/kg q 12 h) • • – Treats secondary effects – Cover with gastroprotectants Chemotherapy Radiation therapy

Chemotherapy • Lomustine – – – 60 mg/M 2 given Monitor CBC weekly If WBC and platelets okay in 5 weeks, then give 80 mg/M 2 – Repeat every 5 -8 weeks • Procarbazine – 2 -4 mg/kg/day for 1 week, then 4 -6 mg/kg/day – Monitor CBC – Continue as long as WBC levels are > 4000/µl & platelet count is > 100, 000/µl

Chemotherapy • 5 -hydroxyurea – – Meningiomas 50 mg/M 2 given Monitor CBC weekly Repeat every 3 -4 weeks • Melatonin – Gliomas – 0. 1 -0. 2 mg/kg once a day in the evening – Reduces growth of many tumors by 50%

Cancer Recommendations 1. Low-Carbohydrate food or use Pedigree Weight Loss Formula) (home prepared is best 2. Canine basic antioxidant formula Pharmacy 1 -800 -4 WESTLA) 3. Canine arthritis formula 4. Canine cancer formula prevention dose 5. COX-2 inhibitor (Westlab)- -use at 2 times (daily- -particularly for carcinomas) 6. Melatonin at night (0. 1 -0. 2 mg/kg)

Wiener Dog • 3 yr old MC Dachshund – Bitten on head as puppy • Mild clonic seizure at 1. 5 years lasting 1 minute – 3 seizures so far • Tongue: red-purple • Pulse: slightly wiry Tao Hong Si Wu San + Earthworms (Di Long)

Reba • 5 year old, German Shorthair Pointer • History of seizures starting 1 month prior – Responsive to phenobarbital • Tongue: purple • Pulse: fast & wiry

Reba • Neurologic Exam – Mild dementia – CP deficits in both hind legs – Babinski’s sign on left side of the body • Localization – Cerebrum affecting both side (>right)

Reba- -1 st CT scan

Reba • Di Tang • Stasis in Mansion of Mind • Wei Qi Booster • Western herbs

Liver Blood Deficiency Chronic Anemia or Chronic Illness Blood Deficiency Fails to Nourish Jin (sinews) Internal Wind Seizures

Liver Blood Deficiency • Hz: – Chronic seizures – Weakness, cool nose/ears • Tongue – Pale & dry • Pulse – Weak & thready • Rx Principle – Tonify Qi and blood and quiet the wind • AP – BL-17, BL-18, BL-19, SP 6, SP-9, SP-10, CV-15, ST-40, ST-44, HT-7, GV 14, GB-20, LIV-3, An Shen, Da Feng Men • TCM Herbal – Bu Xue Xi Feng San – Di Tang plus 8 Treasures (4 Gentlemen + 4 Substances)

Bu Xue Xi Feng San Paeonia Angelica Rehmannia Ligusticum Condonopsis Atractylodes Typhonium Cicada Uncaria Bombyx Bai Shao Yao Dang Gui Shu Di Huan Chuan Xiong Dang Shen Bai Zhu Bai Fu Zi Chan Tui Gou Teng Jiang Can Nourish Blood, Soothe Liver Nourish Blood and Jing Move Blood, Resolve Stagnation Tonify Qi Clear Internal Wind, Transform Phlegm Clear Wind Clear Internal Wind, Cool Liver Clear Internal Wind, Transform Phlegm

Eight Treasures Four Gentlemen Condonopsis Atractylodes Astragalus Poria Dang Shen Bai Zhu Huang Qi Fu Ling Tonify Qi and strengthen Spleen Tonify Qi Drain Damp, strengthen Spleen Four Substances Paeonia Angelica Rehmannia Ligusticum Bai Shao Yao Dang Gui Shu Di Huang Chuan Xiong Nourish Blood and Jing Move Blood, resolve stagnation

Su Ling • 3 year old Shitzu • History of flybiting seizures for 6 months • Tongue: pale & dry • Pulse: deep, weak & thready Bu Xue Xi Feng San

Liver Yin Deficiency Chronic Anemia or Chronic Illness Blood Deficiency Kidney Yin Deficiency Liver Yin Deficiency Fails to Nourish Jin (sinews) Internal Wind Seizures

Liver Yin Deficiency • Hz: – Chronic Seizures – Night Seizures • Tongue – red & dry • Pulse – Fast, weak & thready • Rx Principle – nourish Yin and extinguish wind • AP – BL-18, BL-23, SP-6, SP-9, ST-40, HT-7, GB-20, LIV-3, An Shen, Da Feng Men • TCM Herbal – Yang Yin Xi Feng San – Di Tang and Tian Ma plus II

Yang Yin Xi Feng Paeonia Cornus Rehmannia Moutan Typhonium Cicada Uncaria Bombyx Bai Shao Yao Shan Zhu Yu Shu Di Huang Mu Dan Pi Bai Fu Zi Chan Tui Gou Teng Jiang Can Nourish Blood, Soothe Liver Nourish Yin Nourish Blood and Jing Cool Liver Clear Internal Wind, Transform Phlegm Clear Wind Clear Internal Wind, Cool Liver Clear Internal Wind, Transform Phlegm

Tian Ma Plus II Gastrodia Uncaria Cornus Rehmannia Polygonurn Pinellia Bambusa Cicada Arisaema Lumbricus Bombyx Draconis Ostrea Moutan Licorice Tian Ma Gou Teng Shan Zhu Yu Shu Di Huang He Shou Wu Ban Xia Zhu Ru Chan Tui Dan Nan Xing Di Long Jiang Can Long Gu Mu Li Mu Dan Pi Gan Cao Clear Internal Wind, Relieve Pain Clear Internal Wind, Cool Liver Nourish Yin Nourish Blood, Yin and Jing Nourish Blood and Yin Transform Phlegm Transform phlegm Clear Wind Transform phlegm Clear Internal Wind, Clear Heat Clear Internal Wind, Transform Phlegm Tranquilize Liver Yang, calm Shen, astringent Tranquilize Liver Yang, astringently consolidate Cool Liver, resolve stagnation Harmonize

Josie • 4 year FS Corgi/Mix • 1 year history of seizures at night • Tongue: red • Pulse: deep & weak Yang Yin Xi Feng

Kidney Jing Deficiency Blood Deficiency Kidney Yin Deficiency Liver Yin Deficiency Fails to Nourish Jin (sinews) Internal Wind Seizures

Kidney Jing Deficiency • Hz: – Seizures < 1 year of age – Dry nose & mouth • Tongue – Pale or red • Pulse – Weak & thready • Rx Principle • extinguish the wind astringe or nourish the kidney jing • AP – KID-3, BL-23, SP-6, GV -20, ST-36, HT-7, GB 20, An Shen, Da Feng Men • TCM Herbal – Di Tang and Epimedium Powder

Epimedium Powder Epimedium Cuscuta Cistache Paeonia Polygonum Actinolite Cynomorium Psoralea Dipsacus Lycium Condonopsis Astragalus Rehmannia Angelica Ophiopogon Scrophularia Citrus Yin Yang Huo Tu Si Zi Rou Cong Rong Bai Shao Yao He Shou Wu Yang Qi Shi Suo Yang Bu Gu Zhi Xu Duan Gou Qi Zi Dang Shen Huang Qi Shu Di Huang Dang Gui Mai Men Dong Xuan Shen Chen Pi Tonify Kid Yang/Jing, Promote Sexual Desire Tonify Kid Yang, Jing & Yin Tonify Kid Yang & Yin Nourish Liver Yin & Blood Nourish Blood & Jing, Benefit Hair Tonify Kid Yang & Strengthen Bones Tonify Kid Yang & Promote Fracture Healing Nourish Liver Yin, Benefit Eyes Tonify Qi Nourish Kid Yin & Jing Nourish Blood Moisten & Nourish Yin Cool Blood & Clear Heat Move Qi & Relieve Pain

Chance • 8 month M Lhasa apso • Seizures for 1 month • Tongue: red purple • Pulse: deep & weak Di Tang and Epimedium Powder

Epilepsy -- TCM • Internal heat leading to generation of wind • Clear wind & heat and calm the Shen • Points – Constitutional points – Clear wind & heat • GB 20, LI 4, LI 11, GV 14, LIV 3 – Calm the shen • PC 6, HT 7 – Local points • GV 17, GV 20, GV 21, Long hui, GB 9, GB 13, BL 5, GV 1, ST 40 • TCM Herbals – Di Tang (TCM phenobarbital) – Specific herbs for excesses or deficiencies present

Vestibular Disease • Cardinal Signs – Head Tilt – Nystagmus • • Horizontal Rotatory Vertical Positional – Circling (tight) – Imbalance & Incoordination

Vestibular Disease • Horizontal – Fast-Phase away from head tilt – Fast Phase toward head tilt • Peripheral V. D. • Rotatory • Vertical • Positional • Central V. D.

Positional Nystagmus • Only present in certain positions especially when patient is placed on back

Vestibular Disease 8 th Nerve only Idiopathic V. D. 8 th Nerve, 7 th Nerve & Horner’s Syndrome Inner Ear Disease Brainstem Anything Else Central V. D. Cerebellum

Pathology of Liver Heat Liver Blood & Yin Deficiency Child Heat & Damp KID/BL LIV Shen Disturbance Liver Heat Parent Grandchild Organ Grandparent LU/LI Channel Feet Eyes GB Ears SP/ST

Idiopathic Vestibular Disease • Acute Onset of Vestibular Signs – Head tilt – Horizontal or Rotatory nystagmus with fastphase away from head tilt – Nothing else • Can Be Very Severe • Acute, regressive disease

Idiopathic V. D. • Minimum Data Base • Physical Examination • Neurologic Examination – Only 8 th nerve signs • Odoscopic Examination

Idiopathic V. D. • Re-check in one week • Thought to be secondary to an – Ought to be better immune act on the • Re-check in one month 8 th nerve – Should still be improving • Re-check again if any signs persist – Head tilt may be permanent – Remember each cranial nerve is antigenically distinct • Can re-occur

Idiopathic Vestibular Disease -- TCM • Wind (heat) invasion • Clear wind & heat and calm the Shen • Points – Constitutional points – Clear wind & heat • GB 20, LI 4, LI 11, GV 14 – Calm Shen • PC 6, HT 7, GV 17, GV 20, GV 21 – Local points • TH 17, TH 18, TH 21, SI 19, GB 2, Er jian, An shen

Inner Ear Disease • 8 th Nerve Signs • 7 th Nerve Signs – ear & lip droop – lack of palpebral reflex – nose turn – nostril flaring • Horner’s Syndrome

Horner’s Syndrome • Small Animals – – – Ptosis Myosis Enophthalmos • Large Animals – Facial sweating (horse) – Lack of muzzle sweating (cow)

Inner Ear Disease • Most cases are secondary to bacterial infection (otitis media & interna) – extension from otitis externa – pharyngitis with extension up the Eustachian tube – hematogenous spread

Inner Ear Infection • Treat with bacteriocidal drugs which penetrate bone and blood-tissue barriers – Combination therapy • cephalosporins • sulfa drugs – Enrofloxacin • Must treat 6 -8 weeks

Ear Polyps in Cats • Benign growth in the external ear canal which causes signs by extension. • Can also be pharyngeal mass which grows into middle ear via the Eustachian tube.

Ear Polyps in Cats • Treatment is surgical removal. • Damage can be permanent, if pressure necrosis has destroyed the inner ear structure.

Bilateral Vestibular • Lacks classical signs • Wide head excursions • No physiologic nystagmus

Inner Ear Disease • Treat with • Recheck at 6 antibiotics and months recheck in 2 weeks – re-examine any – if better, continue – if worse, reassess • Recheck in 1 month abnormalities (such as abnormal bulla radio-graphs) • If problems worsens – if normal, stop or persists without antibiotics change for 4 weeks, – if still residual problems, continue 2 consider referral. more weeks

Inner Ear Disease -- TCM • Invasion of external pathogen leading to wind, heat, damp. • Heat boils the fluids leading to the accumulation of phlegm. • Quiet the wind, reduce heat, disperse damp and activate the blood to dissolve stagnation.

Inner Ear Disease -- TCM • Points – Constitutional points – Clear wind & heat • GB 20, LI 4, LI 11, GV 14 – Calm the shen • PC 6, HT 7, GV 17, GV 20, GV 21 – Eliminate damp • SP 9 – Activate Qi & blood • ST 36, ST 40, Xin shu – Local points • TH 17, TH 18, TH 21, SI 19, GB 2, Er jian, An shen

Ear Damp-Heat Artemisia Bupleurum Scutellaria Moutan Prunulla Lophatherum Tribulus Luffa Melia Qing Hao Chai Hu Huang Qin Mu Dan Pi Xia Ku Cao Dan Zhu Ye Bai Ji Li Si Gua Teng Chuan Lian Zi Clear Damp-Heat Soothe Liver Qi Clear Damp-Heat Cool Blood Clear Heat Transform Phlegm, Resolve Stagnation Move Qi

TCM Ear Drops Coptis Huang Lian Clear Heat, Detoxify Alum Bai Fan Borneol Bing Pian Dry Damp, Transform Phlegm, Stop Bleeding, Relieve Itching Clear Heat, Relieve Pain, Open Orifices, Dissipate Swelling Glycerol Gan You Carrier

Western Ear Drops • • • – – – – – Detergent Solution: 1 drop of “free” dishwasher soap 8 ounces of water Vinegar Solution: 1 ounce apple cider vinegar 3 ounces of water Vitamin E/garlic oil: crush one clove of garlic (use press) into 1 ounce of extra virgin olive oil let sit overnight at room temperature pour oil into dropper container add content of a 1000 IU vitamin E capsule use 2 -3 drops in the ear canals, plus 1 -2 on the pinnae

Central Vestibular Disease • Postural Changes – CP Deficit – Dysmetria • Reflex Changes – hyperactive reflexes – crossed-extensor reflexes – Babinski’s sign Conscious proprioceptive deficit may be on the same or opposite side of the lesion.

Central Vestibular Disease • CSF Analysis – may be normal or show increased pressure, protein and/or cells. • CSF Titers – species specific tests – many must be paired with serum titers. CSF cytology form a dog exhibiting a mixed reaction with neutrophils, lymphocytes and macrophages

Central Vestibular Disease • Inflammatory or Infectious Diseases – canine distemper – toxoplasmosis and neosporiosis – fungal – rickettsial – GME – SRME

Central Vestibular Disease • Trauma or Vascular – remember dogs don’t get atherosclerosis ! • Neoplasia – meningiomas – choroid plexus papillomas – oligodendrogliomas – astrocytomas – metastatic neoplasia

Central Vestibular Disease • Infectious Diseases – – FIP Fe. LV toxoplasmosis cryptococcosis • Trauma • Metabolic – thiamine deficiency • Toxicity – organophosphates • Neoplasia – meningiomas

Central Vestibular Disease MRI of Cerebellar Meningioma

Cerebellar Disease • Signs include head tilt – paradoxical (head tilt is away from the lesion) • If horizontal nystagmus exists, the fast-phase is toward the head tilt • Also signs of dysmetria and whole body tremors (including head)

Cerebellar Disease The output of the cerebellum is through the activation of the Purkenjie cells. This output is inhibitory. When the cerebel-lum is damaged, the result is disinhibition of brainstem nuclei. Asymmetrical damage cause increased in motor tone on the side of the lesion, leading to the head tilting away from the damage.

Central Vestibular Disease • Corticosteroids – prednisolone @ 1 mg/kg/day in 3 divided doses for 3 -7 days • Misoprostol – 3 -4 µg/kg twice a day – may stop when at alternate-day steroids – reduce prednisolone dose • Doxycycline to 1/3 mg/kg twice a day – 5 -10 mg/kg once a day for 2 weeks – find minimum daily dose and go to alternate-day • Sulfadimethoxine therapy (over weeks) – 15 mg/kg twice a day

Central Vestibular Disease -- TCM • Can be wind, heatdamp or wind cold based upon the causative factor involved. • Points – – – Constitutional 8 Principle Zang-Fu

Jerry • 10 year old, Mx • Progressive loss of coordination and head tilt • Personality change • Tongue: purple • Pulse: fast & wiry

Jerry • Neurologic Exam – Left head tilt – Positional, vertical nystagmus – Mild CP deficits in rear L>R – Xextensor R -> L in rear • Localization – L Cerebellar pontine angle with cerebral signs

Jerry • TCM Dx: – Liver Blood Stagnation • TCM Rx: – Stasis in Mansion of Mind – Wie Chi Booster

Jerry- -MRI scan

Conclusion • Many conditions can be helped with TCM herbal medications, acupuncture and Western treatments • TCM herbs offer a choice between them and Western drugs