Acupuncture was used to manage a chronic ear infection in ... Case... · the otitis externa and is helping to manage the chronic inflammation. The dog is still under treatment at

Acupuncture was used to manage a

chronic ear infection in a “Friese Stabij”

By:

Drs. Anneke Verweij

Email: [email protected]

mailto:[email protected]

2

ABSTRACT

Acupuncture therapy was used to successfully manage a chronic ear infection.

The chronic otitis externa was related to Damp-Heat in the Gallbladder meridian and

an underlying Spleen Qi deficiency. Using acupuncture points to tonify the Spleen and

expel the Damp-Heat from the Gallbladder greatly reduced the clinical symptoms of

the otitis externa and is helping to manage the chronic inflammation.

The dog is still under treatment at the moment of writing this case report.

HISTORY

Rocky, a two year old male Friese stabij was presented for acupuncture treatment for

a chronic ear infection of the left ear and alopecia of the skin behind the ear and in the

neck on the left side. The chronic otitis externa started in November 2016. Despite

different treatments the otitis stayed present, although the seriousness of the

inflammation went up and down.

CLINICAL SIGNS/DIAGNOSTICS/DIAGNOSIS WESTERN MEDICINE

Rocky first had an otitis externa (warmth, redness and pain of the pinna and outer ear

canal, too much cerumen in the ear canal and irregular lining of the skin in the outer

ear canal) of the left ear in November 2016 which was solved with treatment with ear

ointment containing Neomycine and Hydrocortisonacetate (Auribiotic®) with a dosage

of completely filling the ear once a day. The otitis externa of the left ear returned in July

2017 and treatment with the same ointment at the same dose was started again. This

time it reduced the infection but did not solve it completely. August 2018 the ear was

flushed under general anaesthesia and cytology samples were taken. Cytology

showed a high number of normal epithelial cells, yeasts and bacteria (cocci). Bacterial

culture came back negative with a moderate amount of yeast.

At this time an allergic etiology was expected. Therefore treatment was changed to an

ear ointment containing Triamcinolon and Salicylic acid (Recicort®) with a dosage of

completely filling the ear once a day. And a trial period was started with a commercial

hypo-allergenic diet (Royal Canin Anallergenic). The amount of inflammation went up

and down but it never completely resolved and he had very regular flair ups. December

2017 the cytology and bacterial culture were repeated. Bacterial culture was negative

with no signs of yeasts or a fungal infection. Cytology did show signs of a yeast

infection and therefore treatment was changed to acidic ear drops once a day. This

seemed to give improvement at first but January 2018 the inflammation increased

again and this time he started to develop alopecia behind the base of his left ear with

some little flakes but no lacerations from the skin and no crusts. Shortly after he also

developed two spots of alopecia in his neck behind his left ear. Cytology and fungal

PCR of the alopecia spots came back negative.

3

Based on these findings a western presumptive diagnosis of allergic chronic otitis

externa was made.

Referral to a specialist for a second opinion was proposed but declined by the owner.

At this time (March 2018) acupuncture was added to the treatment protocol.

CLINICAL SIGNS/DIAGNOSIS TCM

Rocky is a very smart, alert and bit fearful dog. He is careful in approaching other dogs.

He seems to be a water constitution. The owners acquired him as a puppy and apart

from the chronic otitis externa of the left ear there are no other recurrent medical

problems.

At the moment of presentation his left ear is treated one a day with an ear ointment

based on honey (Dermiel®). His current diet is a kibble based on fish and potatoes.

According to the owner this diet did improve the condition of his fur in general and

before this diet he had some general pruritus but that disappeared with this diet. He

has a normal appetite and drinks normal quantities of water. He prefers drinking cold

water over warm water. There are no changes in his energy level. There is no obvious

preference for cold or warm places to rest. Urine is always normal, he sometimes has

diarrhea and he can vomit when he eats too quickly. He also has a sensitive gastro-

intestinal tract showing in signs of diarrhea when he eats something different.

He never had surgery and there are no known scars present.

Rocky is a little bit overweight. The head has a normal position and there are no

asymmetries. He has a little bit of tartar on his teeth. There is an otitis externa of the

left ear with redness of the pinna and outer ear canal, too much cerumen in the ear

canal and some swelling of the skin on the dorsal side of the pinna. The ear is not

smelly. There is alopecia at the backside of the pinna and the root of the ear and in the

middle-cranial part of the skin at the level of the GB/SI/TH meridians. The skin is not

red and there are no lacerations of the skin. The skin feels warmer at the places of

alopecia.

There were no abnormalities in symmetry, movement and temperature of the body. In

general his skin is somewhat redder than what I would like to see. There is redness

of the fourth toe of the left hind limb and the foot pads are somewhat dry.

The mucosae are pink and somewhat sticky.

His tongue is pink, a little bit swollen and it has a crack in the middle to the tip.

The pulse is strong, fast and a bit pounding. Left and right are equal. The deep and

superficial middle position on the left side seem stronger than the others.

4

There is sensitivity on the ting points of the Gallbladder and the Liver. BL 19, BL 20,

BL 21, BL 22, LIV 13 and GB 24 are sensitive. BL 19 and GB 24 are extremely

sensitive. There is no obvious sensitivity of the local ear points.

OVERVIEW OF THE SYMPTOMS

Otitis externa with redness, warmth, pain and too much cerumen: damp and heat

Alopecia: meridians in that area could be GB, SI and/or TH. But because of the

sensitivity of the Back-Shu and Mu point of the Gallbladder meridian in my opinion it is

most likely that the Gallbladder meridian is the main meridian involved in this case.

Prefers drinking cold water: heat

Sensitive gastro-intestinal tract, sometimes diarrhea, sometimes vomiting after eating,

bit overweight: Spleen Qi deficiency

General redness of the skin: heat

Redness of the fourth toe and sensitivity of the Gallbladder ting point there: excess of

the Gallbladder meridian

Tongue pink, a little bit swollen and a crack in the middle to the tip: a little bit swollen

can be related to Spleen Qi deficiency. Crack in the middle to the tip is usually related

to heart heat.

Pulse is strong and fast: heat

The deep and superficial middle positions on the left side are stronger: Liver and

Gallbladder excess

5

Sensitivity of BL 19 (Back- Shu of the Gallbladder), GB 24 (Mu point of the Gallbladder)

and GB tingpoint: something going on in either the meridian, organ or with the

emotional component. In this case in my opinion a problem of the meridian is most

likely.

Sensitivity of BL 20 and LIV 13: something going on with either the meridian, organ or

with the emotional component. In this case the sensitivity is likely related to the Spleen

Qi deficiency signs.

Overall a TCM diagnosis was made of Gallbladder Damp-Heat and Spleen Qi

deficiency.

CONVENTIONAL (WESTERN) TREATMENT

Treatment of the left ear once a day with an ear ointment based on honey (Dermiel®)

was started prior to the acupuncture treatment and continued.

TCM TREATMENT

Treatment principle: to resolve the otitis externa by removing the Damp-Heat from the

Gallbladder meridian and tonifying the Spleen.

A balanced treatment approach was chosen with dry needles and two local needles

added. Cloud and Dragon, silicon coated, 0,22 x 0,13 mm needles where used. A

sedating technique was used for the points related to the Gallbladder damp-heat and

a tonifying technique for the Spleen points for 15 minutes with a needle depth of

approximately 5mm.

Point Anatomic Description Indications/ Applications

GB 44 Zu Qiao Yin

At the lateral aspect of the nailbed of the fourth toe of the hindlimb.

Jing-Well point, metal point. Subdues liver yang, clears heat, supports the eyes, head and lateral rib region, calms the spirit.

SP 6 San Yin Jiao

In the depression 3 CUN proximal to the tip of the medial malleolus of the tibia, on the caudal border of the tibia.

Masterpoint for the caudal abdomen and urogenital tract. Crosspoint of kidney, spleen and liver meridian. Benefits the Spleen function of transformation and transportation, transforms Dampness and Damp Heat, tonifies Qi, Blood and Yin, harmonizes the Liver, tonifies the Kidneys, moves and nourishes Blood and stops pain, calms the mind.

LU 7 Lie Que

In the depression proximal to the most medial prominence of the radial styloid process.

Masterpoint for head and neck, Luo point, Opening point for the Ren Mai, couple point for the Yin Qiao Mai. Expels

6

Wind, stimulates Wei-Qi, opens nose, pores and water passages.

TH 3 Zhong Zhu

In the depression on the dorsum of the forefoot, between the 4th and 5th metacarpal bones, proximal to the metacarpophalangeal joint.

Shu-Stream, Wood, Tonification point. Clears exterior Wind-Heat and Interior Heat, removes obstructions from the channel, regulates Qi, benefits the ear and mind.

GV 20 Bai Hui

In the depression on the dorsal midline of the skull, just rostral to the saggital crest.

Meeting point for all Yang channels, benefits yang, calms the shen, eliminates excess Yang, eliminates Wind and Heat, can be used for ear problems and immunostimulation.

GB 2 Ting Hui

In the depression rostral to the intratragic notch, at the caudal border of the condyloid process of the mandible. Ventral to SI 19.

Expels Exterior Wind, benefits the ears, removes obstructions from the channel.

LIV 3 Tai Chong

In the depression on the dorsum of the rear foot between the 2nd and 3th metatarsal bones at the level of the junction of their heads and shaft.

Source, Shu-Stream and Earth point. Subdues Liver Yang and sedates the Liver in excess patterns, promotes flow of Liver Qi, calms the Mind.

GB 43 Xia Xi

Proximal to the digital fold between the 4th and 5th metatarsophalangeal joints.

Water point. Subdues Liver yang, supports the head, eyes and ears, clears damp-heat and resolves swellings.

PC 6 Nei Guan

In the depression 2 cun proximal to the transverse crease of the carpus, between the tendons of the flexor digitorum superficialis and flexor carpi radialis.

Masterpoint for the chest and cranial abdomen, Luo point, opening point for the Yin Wei Mai, couple point for the Chong Mai, calms the heart and shen, regulates Qi, suppresses pain, helps to subdue Liver Yang.

SI 19 Ting Gong

In the depression rostral to the tragus, at the caudal border of the mandible, ventral to TH 21.

Meeting place of the Small Intestine, Gall Bladder and Triple Heater channels. Benefits the ears.

First treatment session:

GB 44 – Was used to clear heat from the Gallbladder meridian and because there was

redness and sensitivity at this point

SP 6 – Was used to tonify the Spleen and to harmonize the Liver. This point also helps

to transform damp-heat and can be used for immune stimulation and allergic skin

diseases.

LU 7 – Was used because of the relationship with Spleen (Tai Yin Channel) and

because it is the masterpoint for head and neck and can therefore help with the otitis.

It also stimulates Wei-Qi which can be helpful in trying to clear an infection.

TH 3 – Was used because of the relationship with Gallbladder (Shao Yang Channel),

to clear heat and to benefit the ear.

GB 2 – Was used at the left ear as a local point to benefit the ear.

7

GV 20 – Was used to eliminate Heat and Excess Yang, for immune stimulation, to

benefit the ear and to calm the mind.

Follow up March 23 2018

The alopecia spots are less warm and there is regrowth of hairs visible. The ear is still

quite red and there seems to be more cerumen than there was at the first treatment.

An ear cleaner (Surosolve®), for once a day, was added to the treatment protocol to

try to remove some of the excess cerumen. The redness of the fourth toe was gone.

The owner reports that he sometimes looks a bit happier.

Sensitivity on: BL 18, BL 19, BL 20, BL 21, LIV 14 and GB 24. The points associated

with the Liver (BL 18 and LIV 14) are the most sensitive at this time. The pulse seemed

a bit wiry too. It was therefore decided to add a Liver point to the treatment protocol

and since he did not have any diarrhea or vomiting over the last period the Spleen

point was exchanged for the Liver point. Again a balanced treatment was chosen. An

even needle technique was used on all points for 15 minutes.

Points used in this treatment:

LIV 3 – Was used to sedate the Liver and to promote the smooth flow of Liver Qi.

GB 43 – Was used to support LIV 3, to help soothe the Liver. It also supports the ears,

clears damp-heat and resolves swellings. Also used because it is a water point this will

be useful with damp-heat.



PC 6 – Was used because of the relationship with Liver (Jue Yin Channel), to calm the

Shen, regulate Qi, suppress pain and help subdue Liver Yang.



GB 2 - Was used at the left ear as a local point to benefit the ear.

Follow-up April 6 2018

The owner reported that he had a reaction to the ear cleaner so she immediately

stopped using it and continued with just the honey-based ear ointment. Despite that

reaction; the ear and pinna are better than they have been for a long time. Less red,

less cerumen and less painful. The ear almost looks normal. The alopecia seems to

be slowly resolving. The redness on the fourth toe of the left hind limb returned. The

pulse is no longer wiry put still fast and strong. The deep middle position of the right

pulse seems to be the weakest (Spleen). Sensitivity was present on BL 19, BL 20.

Because the Spleen seemed the weakest at this time it was decided to return to SP 6

so we could treat the Spleen but also harmonize the Liver. Because he reacted quite

well to the treatment of GB 44 the first time, the redness of the toe disappeared after it

was used in the first session; it was added to the treatment protocol this time.

Points used:

GB 44 – Was used to clear heat from the Gallbladder meridian and because there was

redness and sensitivity at this point

8

SP 6 – Was used to tonify the Spleen and to harmonize the Liver. This point also helps

to transform damp-heat and can be used for immune stimulation and allergic skin

diseases.








Follow up April 24 2018

The ear is a bit redder than it was last time but not too bad. Pulse is fast and pounding.

Sensitivity at BL 18, BL 19, LIV 14 and GB 24. The sensitivity on BL 18 is stronger than

it was last time and this point is the most sensitive at the moment. It was therefore

decided to return to treat the Liver. Also because there is no sensitivity anymore of the

Back-Shu and Mu points of the Spleen.

Points used in this treatment:








Shen, regulate Qi, suppress pain and help subdue Liver Yang.




Follow-up May 8 2018

The ear and pinna are looking almost normal. There is only a bit of redness deep inside

the ear. The pulse is still fast but less pounding. Sensitivity at BL 18 and BL 19.

For two sessions in a row there is no sensitivity on the Spleen points and he also did

not have any diarrhea or vomiting. The ear is a lot better but not 100% right. And I want

to try to completely solve the ear problems. There is definitely a possibility of an

underlying etiology witch might be diet related and/or emotional (anger, frustration,

stress). In accordance with a colleague who has more experience with food therapy

the diet was changed to a homemade diet: fish, barley and vegetables. Herbal therapy

was also proposed but declined by the owner at this moment.

The acupuncture treatment was repeated:


9







shen, regulate Qi, suppress pain and help subdue Liver Yang.




Follow up June 21 2018

Rocky was doing very well! The owner reported that she was happy about not having

a monthly vet bill which didn’t happen for at least a year and a half. The hairs in his

neck are growing back nicely; the hairs on the back side of his ears are not yet growing

back. He hasn’t had any diarrhea or vomiting and he lost some weight. He is now on a

good body condition.

But unfortunately two weeks earlier Rocky decided to go for a swim and got water in

his ears, two days after the swimming his left ear got inflamed again. The owner

immediately started treating with the honey based ointment again but it didn’t

completely resolve the inflammation.

His ear is red and contains quite some watery material in it. It is not really smelly but

you can see that it is bothering Rocky as he keeps this ear a bit lower and he dislikes

it when I look inside of the ear. The local acupuncture points around the ear are not

sensitive. None of the Back-Shu and Mu points is sensitive and his pulse feels normal

in my opinion.

This time it seems more of a local problem. The Spleen Qi deficiency is no longer there

and there is no obvious sensitivity in the Gallbladder meridian.

Treatment with an ear ointment containing Neomycine and Hydrocortisonacetate

(Auribiotic®) completely filling the ear once a day is started and an acupuncture

treatment was given to support the healing of the ear:

SP 6 – Was used to help transform the dampness/damp-heat and can be used for

immune stimulation and allergic skin diseases.

GB 43 – Was used to support the ear, clears damp-heat and resolve swellings. Also

used because it is a water point, this will be useful with clearing damp-heat.








10

SI 19 - Was used to support the ear and because it is a cross point of the three

meridians around the ear: Gallbladder, Small Intestine and Triple Heater can have an

influence on all three meridians.

DISCUSSION

Rocky was presented for acupuncture treatment of a chronic otitis externa of the left

ear and alopecia behind the left ear and on the left side of the neck. At the start of the

acupuncture treatments Rocky was having ear problems for a year and a halve and

the alopecia appeared two months before. Different treatments were tried before

presentation. Some seemed to give improvement but the inflammation kept coming

back and none of the treatments resulted in a complete resolution of the otitis. Two

bacterial cultures of the left ear had been performed but were negative. Cytology and

Fungal PCR of the alopecia were also negative. A western diagnosis of allergic chronic

otitis externa was suspected. But treatment with anti-inflammatory ear ointments and

a trial with a commercial hypo-allergenic diet did not resolve the problem either.

Referral to a specialist for a second opinion was declined by the owner. In March 2018

acupuncture was added to the treatment protocol.

For Western medicine the etiology of otitis externa can be divided into primary and

secondary causes which are respectively diseases or infections that directly cause

inflammation of the ear and predisposing or perpetuating factors that contribute to the

disease.1Allergy, especially atopic dermatitis is the most common primary trigger for

otitis externa. 1,4 Other primary triggers can be adverse food reactions, ectoparasites,

neoplasia, autoimmune disease, foreign bodies, hypothyroidism and keratinization

disorders.1,7 Infections with yeast and/or bacteria are mostly secondary to a primary

cause. 1,7

In this case neoplastic changes, ectoparasites, auto-immune disease, foreign body,

hypothyroidism and keratinization disorders were excluded or deemed less likely

based on the history, clinical examination, otoscopy, cytology and culture. Therefore

for western medicine a probability diagnosis of allergy (either atopic dermatitis or

adverse food reactions) was made.

11

For eastern medicine when treating chronic problems it is essential to understand the

underlying imbalance, because unless these are corrected, the discharge returns as

soon as the ear medication stops. Eastern medicine knows that the organisms in the

ear are the result of a deeper imbalance occurring within the individual and tries to

rebalance that underlying problem.6

Dermatological disease may be caused by internal and/or external etiological factors.9

Ear infections with heat and moist are considered to be Damp-Heat problems. There

is often an underlying imbalance in the spleen and liver. 6,8 The pathogenic factor

Damp-Heat is one of the primary patterns causing atopic dermatitis, it can be

generated through invasion of external pathogenic Damp and Heat or it can result from

internal Spleen deficiency.9 A spleen deficiency creates a Damp condition. Emotional

problems lead to Liver Qi stagnation generating Heat. Internal Dampness, climatic

factors and warming foods contribute further and Damp-Heat becomes lodged in the

Gallbladder Channel around the ear.6,8

Being somewhat overweight, having a sensitive gastro-intestinal tract, sometimes

diarrhea, sometimes vomiting, a somewhat swollen tongue, sensitivity of the Back-Shu

and Mu point of the Spleen are all signs of a Spleen Qi deficiency.10,11

The otitis externa was associated with redness, warmth, pain, too much cerumen and

moisture. Redness pain, swelling of the ear and discharge from the ears is associated

with Damp-Heat in the Gall-Bladder.10,11

There was alopecia on the backside of the ear and in the lateral side of the neck in the

area of the GB, SI and TH meridian. Rocky preferred cold water. Preferring cold water

is associated with Heat patterns.10 His pulse was fast and strong. A rapid pulse always

indicates Heat. 10

There was sensitivity of the Back-Shu and Mu points of the Gallbladder meridian.

Therefore the diagnosis of Damp-Heat related to the Gallbladder meridian around the

ear and Spleen Qi deficiency was made.

The treatment principle was therefore to tonify the Spleen and to remove the Damp-

Heat from the Gallbladder meridian.6,8,9

A balanced treatment method was chosen. The balanced method is a series of

acupuncture systems rooted in the concept of healing the body by balancing meridians.

This method results in a rapid shift of the body into a state of equilibrium thereby

relieving pain and internal disorders.12

The combination of local and distal acupuncture points is recommended to obtain local,

segmental and suprasegemental effects.13 Therefore local points were added to the

point prescription.

GB 44 was used to clear heat from the Gallbladder meridian, SP 6 was used to tonify

the Spleen and to harmonize the Liver. This point also helps to transform damp-heat

and can be used for immune stimulation and allergic skin diseases. LU 7 was used

because of the relationship with Spleen (Tai Yin Channel) and because it is the

12

masterpoint for head and neck and can therefore help with the otitis. It also stimulates

Wei-Qi which can be helpful in trying to clear an infection. TH 3 was used because of

the relationship with Gallbladder (Shao Yang Channel), to clear heat and to benefit the

ear. GB 2 was used at the left ear as a local point to benefit the ear.

GV 20 was used as a second local point to eliminate Heat and Excess Yang, for

immune stimulation, to benefit the ear and to calm the mind.

The treatment was successful in reducing the clinical symptoms of the otitis externa.

The alopecia is slowly resolving and the spleen Qi deficiency has been resolved.

Regardless of the primary underlying cause, chronic otitis can be a complicated and

difficult disease to treat.2 Chronic ear infections can lead to chronic changes within the

ear which form perpetuating factors preventing resolution and/or relapse even if

infection and primary causes are adequately treated.1,7 In patients with chronic otitis

different combinations of primary, predisposing and perpetuating factors often coexist.2

It has been proposed that some type of neural network disturbance may occur in the

affected tissue, predisposing to infections.2 Local changes might involve some degree

of local tissue alteration, which upsets the external ear defense barrier, inducing a local

impairment of the immune system.2 Acupuncture activates central self-regulating

mechanisms, which in turn could inhibit some pathological, self-maintained, segmental

reflexes. In this manner acupuncture can relieve certain visceral or somatic

dysfunctions.2 It has been suggested that acupuncture stimulates the animal defensive

system and combining acupuncture with conventional treatment of otitis externa has

been shown to have a synergistic effect.5 Acupuncture has also been shown to be

effective for preventing relapses in cases of recurrent canine otitis.2 Another study

reported that gold-beat implantation into SI19, GB1, GB20, TH21, TH20, ShenMen and

GV20 improved resolution of some clinical signs and greatly reduced relapses in

canine chronic recurrent otitis externa affected dogs.3

Of course you can never know for sure how a case would go if acupuncture has not

been added to the treatment protocol. But I strongly believe that in this case

acupuncture has been of great benefit for both relieving clinical signs and managing

the chronic infection.

Scientifically there are many ways in which acupuncture has been shown to influence

the body. The effects of acupuncture cannot be explained by a single mechanism.

Needling activates locally a vascular regulatory response involving cutaneous

inflammation and vasodilation. Increases in blood flow to painful areas should aid

healing mechanisms, bringing in nutrients and oxygen, removing metabolites and

speeding homestasis.13 This can explain why local ear points can help in resolving an

ear inflammation.

Micro-trauma of the acupuncture needle stimulates the nervous system locally and

systemically. Depending on the acupuncture point selected and the method of

stimulation there will be sequential and simultaneous activation of local, segmental and

13

super-segmental neural pathways. These changes ultimately lead to altered blood flow,

altered humoral responses and affects within the immune system. 13

Acupuncture points stimulate the central nervous system to release biochemical into

muscles, the spinal cord and the brain. These biochemical can affect, for example, the

experience of pain and/or release of other biochemical, such as hormones, that

influence the body’s self-regulating systems. 13 Acupuncture affects immunological

function in two directions: either strengthening the weak responses; or in cases of over-

expressive responses regulating or inhibiting the over activities. 13 Acupuncture also

increases blood flow to organs. 13 Several experimental research studies demonstrated

the positive influence of acupuncture on chronic inflammation. 13 All these effects, and

probably many more, contributed to the reduction in clinical symptoms in this case.

In Summery acupuncture greatly helped to manage the chronic otitis externa of Rocky.

Rocky’s chronic otitis externa was related to Damp-Heat in the Gallbladder meridian

and an underlying Spleen Qi deficiency. Using acupuncture points to tonify the Spleen

and expel the Damp-Heat from the Gallbladder greatly reduced the clinical symptoms

of the otitis externa and is helping to manage the chronic inflammation. The alopecia

is slowly resolving and the Spleen Qi deficiency has been resolved by the combination

of Acupuncture and food therapy. At the moment of writing this case report Rocky is

still under treatment with the goal of completely resolving his chronic ear infection.

REFERENCES

1. Paterson, S. Discovering the causes of otitis externa. In practice Volume 38 Issue

Suppl 2. (May 2016): 7-11

2. Sanchez-Araujo, Max and Puchi, Alfredo. Acupuncture prevents relapses of

recurrent otitis in dogs: a 1-year follow-up of a randomized controlled trial.

Acupuncture Med 29 (2011): 21-26

3. Sumano, Hector, Tapia-Perez, Graciela, Gutierrez, Lilia. Gold beads implants for

the treatment of canine chronic recurrent otitis externa. J Vet Clin 30-2 (2013): 0-6

4. Saridomichelakis, MN. Et al. Aetiology of canine otitis externa: a retrospective

study of 100 cases. Vet Dermatology 18-5 (2007): 341-347

5. Sanchez-Araujo, M. and Puchi, A. Acupunture enhances the efficacy of antibiotics

treatment for canine otitis crisis. Acupunct Electrother Res 22-3 (1997): 191-206

6. Schwartz, C. Four paws five directions. Berkely: Celestial Arts, 1996.

7. Bacon, N.J. Veterinary Surgery Small Animal, Chapter 22 Pinna and external ear

canal. Canada: Elsevier Saunders, 2012

14

8. Xie, H., Wedemeyer, L. and Chrisman, C.L. Practical guide to traditional Chinese

veterinary medicine Emergencies and five element syndromes. Tianjin, China: Chi

institute press, 2014

9. Xie, H., Wedemeyer, L., Chrisman, C.L. and Trevisanello, L. Practical guide to

traditional Chinese veterinary medicine Small animal practice. Tianjin, China: Chi


10. Maciocia, Giovanni. Diagnosis in Chinese Medicine. Missouri: Elsevier Limited,

2018

11. Xie, H. and Preast, V. Traditional Chinese veterinary medicine. Tianjin, China: Chi


12. Snijders,A. Balanced method in acupuncture. BEVAS Course notes: Module 5

(2017-2018): extra document

13. Skoien, J. Neurophysical acupuncture mechanisms. IVAS Course Notes: Chapter

14 (2016): 23-41

Documents

Acupuncture was used to manage a chronic ear infection in ... Case... · the otitis externa and is helping to manage the chronic inflammation. The dog is still under treatment at