MEDICAL ACUPUNCTURE

Volume 21, Number 4, 2009

ORIGINAL ARTICLE
# Mary Ann Liebert, Inc.
DOI: 10.1089=acu.2009.0684

Sinusitis With Polyposis Presenting as Refractory

Trigeminal Neuralgia Treated With Acupuncture
and Chinese Herbal Decoction

Edwin Yong Miao, MD, MB

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ABSTRACT

Background: Trigeminal neuralgia is a common neuralgia condition. Most data available relate to primary
trigeminal neuralgia, but little has been published about secondary trigeminal neuralgia treated with Chinese
medicine.
Objective: To describe a case of secondary trigeminal neuralgia treated with acupuncture and Chinese herbal
decoction.
Design and Patient: Case report of an Australian woman who presented in August 2005 with severe symptoms
of trigeminal neuralgia (diagnosed in 2002). She had undergone carbamazepine treatment for 3 years. She also
presented with sinusitis with polyposis.
Intervention: Acupuncture needles were applied with manual methods to the affected ophthalmic branch and
maxillary branch of the trigeminal nerve. Acupoints selected were ST 7 (Xiaguan), SI 19 (Tinggong), Ex-HN5
(Taiyang), GB 14 (Yangbai) (all right side), and LI 4 (Hegu) (both sides). De Qi was elicited every 3 minutes in
a 20-minute session. Acupuncture was performed once a week for 12 sessions. Also, an individually designed
Chinese herbal decoction was used as a coordinated approach for the treatment of sinusitis with polyposis.
Main Outcome Measures: Resolution of trigeminal neuralgia symptoms and improved symptoms of sinusitis.
Results: The severe trigeminal neuralgia gradually disappeared within 7 days after the first session of acupuncture
treatment. This result was maintained during a 12-session acupuncture treatment course as well as during an
herbal treatment period. Most importantly, this result has been maintained for more than 3 years. The patient’s
sinusitis was also resolved.
Conclusions: The combination of acupuncture and Chinese herbal decoction treatment led to a complete dis-
appearance of symptoms of trigeminal neuralgia (after a 3-year course of carbamazepine, which became inef-
fective 2 months prior to acupuncture). This approach may offer a new treatment and supports the necessity for
further research to evaluate Traditional Chinese Medicine in the treatment of trigeminal neuralgia and sinusitis.

Key Words: Trigeminal Neuralgia, Sinusitis, Acupuncture, Herbal Medicine

INTRODUCTION stabbing pain in the branches of the trigeminal nerve.2–4 It

usually affects individuals older than 40 years, women more
than men, and the occurrence is mostly unilateral.4
T rigeminal neuralgia is the most frequently occur-
ring cranial neuralgia: the incidence is 1 per 1 million
persons per year.1 It is a sudden, severe, brief, recurrent,
Diagnosis is by a careful record of the history,2 location,
and characteristics of the pain, and few neurological signs.4

M. Modern Traditional Chinese Medical Clinic-Acupuncture, Melbourne, Victoria, Australia.

257
 258
There are few investigations that are of value in this con-
dition.2 Pharmacological management is the first line of
treatment.3,5,6 Drugs demonstrated to be efficacious in
trigeminal neuralgia include carbamazepine, phenytoin,
clonazepam, and valproic acid. Carbamazepine is usually
suggested as the drug of first choice.7,8 Surgical options in-
clude peripheral or central (intracranial) procedures, which
may be considered if medical treatment fails or cannot be tol-
erated.4,9 Other therapies such as cryotherapy10 and gamma
knife radiosurgery11 are among the common therapeutic
approaches documented.
Trigeminal neuralgia can be divided into primary and
secondary causes.4,9 The majority of articles focus on
primary trigeminal neuralgia, evidenced by nearly 6,000
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articles recorded in February 2009 in PubMed, EMBASE,
Cochrane Library, SpringLink, AcuBrief, and AMED.
In contrast, secondary trigeminal neuralgia treatment has
been rarely documented, especially in terms of acupuncture
and Traditional Chinese Medicine (TCM) treatments. Many
Chinese clinical trials demonstrate the usefulness of acu-
puncture in treating trigeminal neuralgia.12–15
CASE REPORT
The case presented herein is of secondary trigeminal
neuralgia caused by sinusitis with polyposis treated with
acupuncture and a Chinese herbal decoction.
Patient History
A 47-year-old woman presented at M. Modern Traditional
Chinese Medical Clinic in Victoria, Australia. Her main com-
plaint was severe pain around the right side of her forehead,
eye, nose, cheek, and upper lip for 2 months. The pain started
as paroxysms of stabbing, flashing, radiating, and burning
around the above-mentioned area and lasted many seconds
or a few minutes. It was characterized by a recurrence of
similar pains in the same area, which were triggered by light
pressure or touch on the right side of the nose or cheek and
sometimes by teeth brushing, face washing, or the turning of
her head.
The patient was diagnosed with trigeminal neuralgia by a
neurologist in 2002. A dentist had ruled out a dental cause.
The condition was affecting the ophthalmic branch and
maxillary branch of the trigeminal nerve. Carbamazepine
was prescribed and the patient had taken it for 3 years.
Trigeminal neuralgia occurred, coinciding with missed
doses of carbamazepine, during those 3 years. She reported
persistent but tolerable facial pain while taking the carba-
mazepine. In general, the pain was fairly well-controlled for
3 years—until 2 months prior to presenting to our clinic. At
presentation, paroxysmal episodes of the pain occurred from
once every 1–2 hours to once every few minutes, despite the
MIAO
fact that the patient was taking carbamazepine at 800 mg=d
in 2 divided doses.
During the consultation, concern about the current
symptoms and her history of sinusitis was raised. The pa-
tient had a large amount of light green sputum daily, either
discharged from the nose or running down the back of
the throat. This disappeared for about 2 weeks in June 2005
(2 months before the TCM consultation) during 2 courses of
antibiotics. The patient reported sinusitis since 2001 and had
been taking antibiotic treatment several times a year during
the last 5 years. In July 2004, a septoplasty, bilateral eth-
moidectomy, and antrostomy was performed by an otolar-
yngologic surgeon and 1 month later, on review, her nasal
obstruction had been removed and budesonide spray was
prescribed by the surgeon.
The x-ray computed tomographic (CT) scans the patient
had June 20, 2001 and March 20, 2002, fairly prominent
ethmoidal sinusitis was noted. Referring to the brain scan,
the apical areas of the petrous temporal bone with respect to
the trigeminal ganglion appeared normal.
In addition to x-ray CT scans, magnetic resonance im-
aging (MRI) was performed on August 18, 2005 (13 days
before TCM consultation), showing that mucus had filled all
the right maxillary sinus, combined with up to 4 polyps of
considerable sizes which occupied nearly 5=6 of the space
of the sinus. There was only 1 smaller polyp with a small
amount of mucus in the left maxillary sinus.
Diagnosis and TCM Assessment
Two diagnoses of this patient were established by spe-
cialists: sinusitis and trigeminal neuralgia, although a more
accurate diagnosis, rather than sinusitis, would be sinusitis
with sinus polyposis. From all the symptoms and evidence
collected, the final diagnosis was secondary trigeminal
neuralgia caused by sinusitis with polyposis.
Facial pain16 was the first or symptomatic TCM category
assessment. One of the main causes was the fact that Wind
pathogen invaded the facial area of meridians and blocked
Qi and Blood of the related meridians. Nose Yuan was the
second or chief TCM category assessment.17 Wind=Hot
pathogens invading Lung meridian in the nose region was
the main cause of this condition.
METHODS
The patient was advised to stop taking carbamazepine
while she began TCM treatment because of its latest inef-
fectiveness. She had not taken any medicines prior to the
consultation. The acupuncture treatments were performed
at the aforementioned clinic. Disposable single-use needles
were used: Kun Lun, classical style, 0.25 mm in diame-
ter and 30 mm in length (Kun Lun acupuncture needles,
Australian Registered Therapeutic Goods, 148643).
 TRIGEMINAL NEURALGIA
Acupoints selected were ST 7 (Xiaguan), SI 19 (Ting-
gong), Ex-HN5 (Taiyang), GB 14 (Yangbai) (all on the right
side), and LI 4 (Hegu) (both sides). After obtaining De Qi
immediately after the insertion, turning and twisting mani-
pulations were used to obtain the status of De Qi every
3 minutes in a 20-minute session. Acupuncture treatment
was performed once a week for 12 sessions.
Meanwhile, a raw Chinese herbal decoction was used as a
coordinated approach for the treatment of sinusitis (Nose
Yuan). This herbal decoction is a modified form (individual
flexibility under the documented classical TCM treatment
principle) of 1 of the commonly used herbal prescriptions
for the treatment of sinusitis.17 The details of the herbs are
described and used as daily dosages: Huang Qin 10 g
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(Scutellaria baicalensis), Pu Gong Yiong 15 g (Taraxacum
mongolicum), Jin Yin Hua 9 g (Lonicera japonica), Huo
Xiang 10 g (Pogostemon cablin), Bai Ji 10 g (Angelica
dahurica), Jie Geng 6 g (Platycodon grandifolrum), and
Gao Cao 6 g (Glycyrrhiza uralensis). (All the herbs were
obtained from Winner Trading Herbs Pty. Ltd., Victoria,
Australia. All the herbs were registered as therapeutic herbs
in the Therapeutic Goods Administration, Australia.) This
decoction was used 7 days every week during a scheduled
3- or 6-month treatment period (depending on the symptoms
of chronic sinusitis with polyposis).
RESULTS
The patient noticed less typical pain or attacks after
2 days of commencing the first acupuncture treatment. All
the symptoms of trigeminal neuralgia gradually disappeared
in 7 days, during which treatment involved only 1 session of
acupuncture treatment plus 7 days of the Chinese herbal
decoction. She had more noticeable sputum running from
the nose or running down the back of the throat after
commencing this treatment regimen.
There were no further acupuncture treatments after the
completion of 12 acupuncture sessions which focused on
both of her conditions, chronic sinusitis and symptoms of
trigeminal neuralgia. The herbal decoction was continued
for another 3 months, plus used during the first 3 months of
the acupuncture treatment period for a total of 6 months, and
stopped when no further sputum was discharged.
At the follow-up consultations at 12, 24, and 36 months
later, there were still no signs of any recurrence of trigem-
inal neuralgia.
DISCUSSION
Carbamazepine, as the first-line medicine, was used for
more than 3 years for the control of symptoms of trigeminal
neuralgia in this patient. However, it had become ineffec-
tive; this is not usual. Carbamazepine had been helpful for
259
controlling trigeminal neuralgia until 2 months before she
presented to our clinic. Carbamazepine was then stopped
16 hours before beginning TCM treatment. The half-life
through hepatic enzyme induction of carbamazepine aver-
aged 16–24 hours. By contrast, there was a gradual reduc-
tion and disappearance of the patient’s symptoms of
trigeminal neuralgia in 7 days. Therefore, the discontinua-
tion of carbamazepine was highly unlikely to be associated
with the improvement of the symptoms.
From the information obtained from an MRI only 13 days
before her initial TCM consultation, there was evidence that
the number of larger polyps occupied most of the space in
the right maxillary sinus. It is logical to conclude that these
polyps increased in size, applying pressure to the inside
walls of the sinus because of its limited space, thus being a
constant trigger point causing severe symptoms.
Two courses of antibiotics used 2 months before the TCM
consultation may have controlled the infection for a short
while; nevertheless, it did not assist in relieving the symp-
toms of trigeminal neuralgia. This is understandable because
sinus polyps respond to systemic oral steroids or intrapolyp
steroid injection,18 not antibiotics. Sinus polyps are caused
by inflammatory tissue, which is allergy-type inflammation,
and other pathogenic mechanisms remain unclear.19,20 Thus,
steroids have become widely used in medical practice in the
treatment of sinus polyps.18 If applied, steroids would create
further complications in addition to frequent sinus infections
or perhaps chronic infections in this case. Indisputably, the
use of antibiotics was necessary for the control of the sinus
infections. However, it did not assist in the relief of symp-
toms of trigeminal neuralgia. For the rational design of
treatment, it was practical to find a medicine with anti-
inflammatory effects, including effects on allergy type of
inflammation and with an anti-infection effect at the same
time, and which could also be used long-term without risky
or serious side effects. This herbal decoction was fitting for
these treatment principles.
Acupuncture treatment may assist in the treatment of
sinusitis due to allergy.21 Thus, the rational design of
12 acupuncture sessions would be beneficial for the treat-
ment of chronic sinusitis; more importantly, minimiz-
ing the chance of recurrence of trigeminal neuralgia due to
its refractory and chronic status. In addition, the reduction of
the degree of the inflammatory status of polyps may have
taken some time in this treatment regimen (herbal decoc-
tion), as sinus polyps were the likely cause of the trigeminal
neuralgia. The disappearance of symptoms of trigeminal
neuralgia may not have lasted if the acupuncture treatment
had stopped after only a few sessions; therefore, a longer-
term acupuncture course over 3 months improved the
chance of cure for trigeminal neuralgia.
We know that acupuncture treatments can relieve the
symptoms of trigeminal neuralgia. The manipulation of the
above-mentioned acupoints, especially GB 14 (Yangbai)
and LI 4 (Hegu) every 3 minutes, could provide relatively
 260
stronger pain relief. However, the speed of this patient’s
response to pain relief was surprising. Thus, it is perhaps
reasonable to deduce that the Chinese herbal decoction may
have played an important role in relieving the pressure
caused by sinus polyps. Reviewing the function of this
herbal decoction may provide some information: it con-
tained natural antibiotic agents and it reduced inflammation
and relieved pain, assisting acupuncture treatment.22 This
herbal decoction is very complex in terms of its organic
chemical compounds. For instance, for 1 of the key ingre-
dients, Huang Qin (S baicalensis), the active chemical
structures are as follows: baicalin (4–5.2%) and baicalein,
wogonoside and wogonin, and skullcapflavone I, II.23
Huang Qin has antibacterial as well as anti-inflammatory
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effects.23 Other herbs with similar effects reinforce the ef-
fects of Huang Qin. Generally speaking, a combination of
herbs has better therapeutic effectiveness compared
with a single herb22 and therefore creates a more complex
combination. The decoction’s assistance in the reduction of
inflammation may have acted in a key role in relieving
the degree of inflammation of the polyps. Consequently,
less pressure was applied to trigger points in the maxillary
area that were associated with trigeminal neuralgia. Most
importantly, acupuncture and herbal decoction treatment
effect was maintained for up to 3 years after the total of
6 months of treatment in this case.
CONCLUSIONS
The combination of acupuncture and Chinese herbal de-
coction treatment successfully led to a complete disap-
pearance of symptoms of trigeminal neuralgia due to
sinusitis and polyposis, and this outcome was maintained for
up to 3 years. Little information exists regarding the out-
come of medical management in secondary trigeminal
neuralgia, especially in relation to sinusitis and polyposis.
This case report is unable to establish causality as to whe-
ther acupuncture alone may have resulted in a cure, or the
herbal treatment alone, or both. However, it emphasizes the
direction that the approach described provides—a new way
of treatment—and warrants further research, evaluation, and
clarification in this area.
DISCLOSURE STATEMENT
No competing financial interests exist.
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 TRIGEMINAL NEURALGIA 261

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