Slowly developing tinnitus
M, 62 years old. A 62-year-old man with a continuous high-pitched ringing in both ears for two years, of gradual onset, worse at night and during tired spells.
The patient
- Age and sex
- 62 years · M
- Chief complaint
- A 62-year-old man with a continuous high-pitched ringing in both ears for two years, of gradual onset, worse at night and during tired spells.
- Tongue
- Pale red, somewhat dry body with scant coating and fine cracks.
- Pulse
- Thin and deep pulse, markedly weak in both Chi (尺) positions.
Symptoms
- High-pitched, continuous ringing, more audible in silence
- Worse at the end of the day and after weeks of poor rest
- Slightly improved by pressing on the ear
- Mild dizziness on standing and eyes that tire quickly
- Dull low back ache and weak knees on stairs
- Night waking to urinate and unrefreshing sleep
Warning signs to rule out
- Tinnitus in one ear only, with progressive hearing loss on that side. → ENT referral. Unilateral tinnitus with hearing loss requires ruling out nerve pathology.
- Pulsatile tinnitus, beating in time with the heart. → Medical assessment: pulsatile tinnitus has vascular causes and is investigated differently.
- Sudden hearing loss over hours or days, with or without vertigo. → Urgent ENT care: sudden deafness has a treatment window that closes within days.
Case resolution
Think through the pattern first, then expand the resolution
- Pattern
- Kidney Essence and Yin Deficiency with vacuity of the Sea of Marrow
- Meridians involved
- Kidney, San Jiao, Gallbladder
- Pathogenic factors
- Essence vacuity, Kidney Yin vacuity
The Kidney opens into the ear and Essence fills the Sea of Marrow. When that reserve wanes with age, the ear is no longer nourished and a high-pitched, continuous, slowly developing ringing appears, worse exactly when the body is emptiest: at night and in tiredness. The low back ache, weak knees and nocturia draw the same picture from other angles. This is a vacuity pattern, and that shapes the prognosis: the aim is to reduce and stabilize the ringing, not to switch it off.
Differential diagnosis
Shares: Continuous ringing that worsens in tense periods.
Sets it apart: Fire gives loud, low-pitched, sudden ringing that worsens on pressing the ear, with irritability, a bitter mouth and a wiry (Xian), rapid pulse. Here the ringing is high-pitched, gradual and improves with pressure: the treatment is the opposite.
Shares: Ringing with a blocked-ear sensation and dizziness.
Sets it apart: Phlegm-Fire gives a muddled head and blocked ear, chest oppression and a yellow greasy coating, with a slippery pulse. Here the tongue is dry with scant coating.
Shares: Tinnitus with dizziness and a sense of ear fullness.
Sets it apart: Ménière's occurs in attacks of rotatory vertigo lasting twenty minutes to hours, with nausea, aural fullness and fluctuating hearing loss in one ear. Here the dizziness is postural and mild and the tinnitus is bilateral and constant.
Treatment
Principle: Nourish Kidney Essence and Yin, fill the Sea of Marrow and open the orifice of the ear.
| Point | Role | Technique |
|---|---|---|
| KI3 | Kidney Yuan-source: the base of the treatment in every session. | Perpendicular 0.5-0.8 cun, tonifying. |
| BL23 | Kidney Back-Shu: it sustains the replenishing of the root between sessions. | Perpendicular 0.8-1 cun, tonifying. |
| TE17 | Yifeng: the reference local point for the ear. | Perpendicular 0.5-1 cun toward the tip of the nose, with gentle stimulation. |
| GB2 | Local point that opens the orifice, with the mouth slightly open. | Perpendicular 0.5-1 cun with the mouth open. |
| TE3 | Triple Burner distal point: the channel that surrounds the ear, treated from the hand. | Perpendicular 0.3-0.5 cun. |
| GV20 | Baihui: it raises the clear Qi to the head, which is where it is lacking. | Transverse backward 0.3-0.5 cun. |
Formula: Er Long Zuo Ci Wan. Nourishes Kidney Yin with an action directed at the ear, the specific formula for this tinnitus. When Essence vacuity is marked, with dizziness and tired vision, Zuo Gui Wan supports the background better.
- Frequency
- One session weekly for twelve weeks before judging the result. It is the slowest pattern in this library, and proposing less than three months leads to dropping out in the second.
Home care
- Be in bed before eleven: Essence is replenished by sleeping and no point substitutes for it.
- Gentle acupressure on KI3 and TE17 for five minutes before sleep, when it bothers most.
- Soft background sound at night instead of absolute silence, which amplifies the ringing.
- Cut alcohol, tobacco and loud-noise exposure, which accelerate the underlying hearing loss.
Progress
- Session 1 · day 0 Continuous ringing rated 7 out of 10 at night, preventing sleep onset. Three night-time voids. KI3, BL23, TE17 and TE3. The real goal and the three-month horizon are set out, and nocturnal background sound is introduced. The ringing is unchanged, but he falls asleep sooner thanks to the background sound.
- Session 5 · week 5 He sleeps better and is down to one night-time void, but the ringing is still 7 out of 10 and he is losing heart. GB2 is added and Er Long Zuo Ci Wan is started. He is shown that nocturia and sleep are the first markers to shift, and that they run ahead of the ear. The ear is still unchanged, but he stays in treatment on seeing movement elsewhere.
- Session 9 · week 9 First real change: the ringing drops to 5 out of 10 at night and there are days he does not notice it for hours. The scheme is kept untouched. In a vacuity picture that is starting to respond, changing points is the commonest error. The improvement consolidates over the following three weeks.
- Session 12 · week 12 Ringing at 4 out of 10, continuous sleep and no dizziness on standing. Sessions move to one every three weeks and the formula continues for another six months. Stable at 3 or 4 out of 10 after six months, with no progression.
- Discharge
- There is no end point in the usual sense: treatment moves to spaced maintenance once the ringing stops interfering with sleep and conversation. Framing it this way from the start avoids the sense of failure at six weeks.
- Watch for relapses
- Weeks of little sleep and heavy work periods. The ringing flares alongside nocturia and tiredness, and responds well to a short course of four sessions.
Health notice. Educational and study content. It describes concepts of Traditional Chinese Medicine and does not replace diagnosis or treatment by a healthcare professional. Needling, medicinal herbs and invasive techniques must be applied by trained professionals. Safety guide.
