A 51-year-old man with a one-year history of continuous tinnitus and sleep disturbance was managed using a warming and dampness-resolving herbal strategy.

Case ID: CHC-0014

Case Summary

This case describes a 51-year-old man who presented with a one-year history of continuous tinnitus, severe fatigue, and sleep disturbances. The original report documented a Western medical diagnosis of tinnitus and a TCM assessment of Spleen and Kidney Yang deficiency complicated by internal phlegm-turbidity. The patient was managed through a customized herbal approach focusing on warming the Spleen and Kidneys while transforming phlegm and descending turbidity.

Patient Presentation

• Patient: 51-year-old male.
• Main Complaint: Continuous tinnitus (sounding like cicadas) for over one year, accompanied by poor sleep and severe fatigue.
• History: The patient experienced relentless tinnitus day and night for over a year, though his hearing remained relatively intact. The condition severely impacted his sleep and quality of life. Associated symptoms included marked fatigue, an aversion to cold, excessive sweating (especially upon exertion), a sticky sensation in the mouth, and loose stools. He reported that previous Western and Chinese medical treatments had yielded unsatisfactory results.

Examination and Diagnosis

• Conventional Diagnosis: Tinnitus.
• TCM Tongue and Pulse: The tongue was pale and enlarged with a thick, white, greasy coating. The pulse was deep and moderate (沉缓).

TCM Assessment

The original practitioner interpreted the presentation as Tinnitus driven by Spleen and Kidney Yang deficiency with internal retention of Phlegm-Turbidity (脾肾阳虚，痰浊内停).

According to the principles of Yin and Yang Chinese Medicine, normal physiological function relies on the warmth of Yang energy to process and vaporize fluids. The original report noted that the patient’s age and chronic condition had depleted his Kidney Yang. This lack of foundational heat (“fire failing to warm the earth”) weakened the Spleen’s digestive power. Consequently, unprocessed fluids accumulated into damp-turbidity. Instead of clear Yang energy ascending to nourish the sensory orifices, this heavy, turbid dampness rose to block the inner ear, causing the continuous cicada-like noise. Furthermore, the deficient Yang failed to secure the exterior, leading to his excessive sweating and aversion to cold.

Treatment Approach

The primary treatment principle was to warm and tonify the Spleen and Kidneys, ascend the clear and descend the turbid, and transform phlegm while draining dampness (温补脾肾，升清降浊，化痰利湿). The goal was to restore the metabolic fire and clear the physical blockages in the head.

Herbal Formulas and Modifications

• Core Formula (Initial Visit – April 19, 2024): The practitioner prescribed a complex formula designed to simultaneously warm the core and clear the sensory orifices.
  • Warming Yang: Hei Shun Pian (Processed Aconite, decocted first), Rou Dou Kou (Nutmeg), and Bu Gu Zhi (Psoralea) were used to strongly warm the Spleen and Kidney Yang, restoring the body’s internal metabolic drive.
  • Resolving Phlegm and Wind: Ban Xia (Pinellia) and Tian Ma (Gastrodia) were combined to dry dampness, transform phlegm, and settle internal wind, directly addressing the sensory disturbance in the head.
  • Strengthening the Spleen and Draining Dampness: Bai Zhu, Cang Zhu, Chen Pi, Fu Ling, and Ze Xie were used to fortify digestive function and safely drain the excess turbid fluids through urination.
  • Supporting Qi and Circulation: Huang Qi (Astragalus) was added to boost Qi and consolidate the exterior to stop the excessive sweating, while Gui Zhi (Cinnamon Twig) warmed the channels to facilitate fluid movement.
• Modification (Second Visit – May 25, 2024): With the tinnitus significantly reduced, the patient’s primary remaining complaint was excessive sweating. The practitioner added Duan Mu Li (Calcined Oyster Shell) and Fu Xiao Mai (Floating Wheat) to the original formula to specifically astringe sweat and further anchor the spirit.

Follow-Up

• May 25, 2024 (Second Visit): After the initial course of treatment, the source reported a substantial reduction in both the frequency and intensity of the tinnitus. The patient was able to rest normally. His fatigue improved, the aversion to cold lessened, and his stools became more formed. While occasional tinnitus and sweating persisted, the overall clinical picture had significantly stabilized.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the practitioner’s focus on the digestive and metabolic systems (the Spleen and Kidneys) to treat an ear condition. While conventional treatments often focus solely on the auditory nerve or localized circulation, the original practitioner recognized that the ear is nourished by the clear energy ascended by the Spleen.

When a patient presents with chronic tinnitus alongside systemic signs of cold and dampness (a pale, enlarged tongue with a greasy coating, loose stools, and fatigue), the root cause often lies in a metabolic breakdown. By prioritizing the restoration of Kidney and Spleen Yang, the treatment effectively “evaporated” the internal damp-turbidity that was blocking the ear. This demonstrates the diagnostic reasoning unique to the tradition, where clearing a sensory blockage requires fixing the engine that processes the body’s fluids.

---

What This Case Can — and Cannot — Tell Us

This is an individual case report, not a controlled clinical trial. It documents the reasoning, treatment, and outcome reported for one patient and should not be interpreted as evidence that the same approach will produce the same result in another person.

Source

• Original source: Beijing University of Chinese Medicine Shenzhen Hospital (Longgang) / Guangdong Provincial Administration of Traditional Chinese Medicine
• Original title: 【以案说医】王进东：脾肾阳虚耳鸣苦，温补化浊耳窍苏
• Practitioner: Professor Wang Jindong (王进东)
• Publication date: October 28, 2024
• Original language: Chinese
• Source link: View original page
• ChineseHerb.org version: English translation and editorial adaptation