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The Disease Causes, Disease Mechanisms, and Treatment of Hou Bi (Throat Impediment)

By Bob Damone, L.Ac., M.S., PCOM Faculty Member, Former Chair of the Department of Clinical Practice

The term Throat Impediment was first used in the Su Wen (Simple Questions), in the chapter entitled "Yin Yang Bie Lun (On the Differentiation of Yin and Yang)". According to Zhong Yi Er Bi Hou Ke Xue (Chinese Medical Ear, Nose, and Throat Diseases), "Impediment is blockage and lack of free flow. Various throat diseases appear with some degree of qi stagnation, blood stasis, and channel impediment-obstruction. Many of these quite different diseases appear with the clinical picture of obstruction, that is, with redness, swelling, soreness, and pain." Throat Impediment is most commonly divided into two major patterns-Wind-Heat Throat Impediment and Vacuity Fire Throat Impediment. What follows is a partial translation and adaptation of the Throat Impediment chapter of Zhong Yi Er Bi Hou Ke Xue (Chinese Medical Ear, Nose, and Throat Diseases) followed by my commentary.

Wind-Heat Throat Impediment

Wind-heat evil toxin resulting in Throat Impediment is called Wind-Heat Throat Impediment. Its main characteristics are redness, swelling and pain of the throat accompanied by routine signs and symptoms of external contraction of wind-heat. It is also known as Wind-Heat Throat and Red Throat. At the base of the throat there may be small round projections, but swelling and distention of the tonsils is mild. There are also systemic heat signs and symptoms, which are more prominent when there is lung and stomach channel heat. Upon inspection, the throat appears red, swollen, and distended, and is painful to touch. There is often regional lymph node swelling and pain.

Disease Causes and Disease Explanation

Wind-Heat Throat Impediment usually occurs when one fails to take lifestyle precautions during sudden climatic changes (by dressing appropriately, by keeping warm, by limiting stress, by eating well, etc.). As a result, lung defense loses its security and wind-heat evil toxin takes advantage of vacuity and invades the exterior. Wind and heat directly invade the throat via the mouth and nose; they then internally damage the lung, contend, and remain. This causes the throat swelling and pain and becomes Throat Impediment. When the evil is located at the defensive exterior, the disease is relatively mild. With inappropriate treatment or when there is a lack of treatment, congested and exuberant evil heat may pass internally into the lung and stomach and present with the pattern of exuberant lung and stomach channel heat. This is a relatively serious condition.

Differentiating Wind-Heat Throat Impediment and Wind-Heat Baby Moth (ru e)

Throat redness, swelling, and pain are signs and symptoms of both Wind-Heat Throat Impediment and Wind-Heat Baby Moth. The pathological changes associated with Wind-Heat Throat Impediment occur mainly in the throat without obvious tonsillar swelling and distention, while the pathological changes associated with Wind-Heat Throat Moth occur mainly in the tonsils with tonsillar redness, swelling, and yellowish-white pus spots. Wind-Heat Throat Impediment frequently accompanies Wind-Heat Baby Moth, but Wind-Heat Baby Moth does not always accompany Wind-Heat Throat Impediment.

Representative Medicinals and Formulas for Wind-Heat Impediment

1) Heat at the Defensive Exterior: Shu Feng Qing Re Tang (Wind-Coursing Heat-Clearing Decoction). It contains jing jie (Hb. Schizonepetae), fiang feng (Rx. Ledebourelliae), nui bang zi (Fr. Arcti), gan cao (Rx. Glycyrrhizae), jin yin hua (Fr. Forsythia), lian qiao (Fr. Lonicera), xuan shen (Rx. Scrophulariae), sang bai pi (Cx. Mori Alba), chi shao (Rx. Paoniae Rubra), jie geng (Rx. Platycodi), huang qin (Rx. Scutellariae), tian hua fen (Fr. Trichosanthis), and zhe bei mu (Bulbus Fritillariae Thunbergi).

2) Exuberant Lung and Stomach Channel Heat: Qing Yan Li Ge Tang (Throat-Clearing Diaphragm-Disinhibiting Decoction). It contains jin yin hua (Fr. Forsythia), zhi zi (Fr. Gardeniae), huang qin (Rx. Scutellarie), bo he (Hb. Menthae), niu bang zi (Fr. Arcti), fang feng (Rx. Ledobourelliae), jing jie (Hb. Schizonepetae), xuan ming fen (Mirabilitum Depuratum), xuan shen (Rx. Scrophulariae), jin yin hua (Fr. Forshythia), and da huang (Rx. et Rz. Rhei).

Note: Zhu Dan-Xi, in chapter 4 of Dan-Xi Xin Fa (Dan-Xi's Experiential Methods), stated that "most cases of throat impediment [involve] phlegm-heat". This is borne out in clinical practice; therefore, one should add medicinals that clear and eliminate phlegm-heat, open binds, and disinhibit the throat. To meet these treatment principles, consider gua lou (Fr. Trichosanthis), qian hu (Rx. Peucedani), bai bu (Rx. Stemonae), zhu ru (Cauli Bambusae), she gan (Rz. Belamcandae), jie geng (Rx. Platycodi), and xing ren (Sm. Pruni Armeniacae).

Vacuity Fire Throat Impdiment

When Throat Impediment is cause by viscera-bowel detriment and damage, and vacuity fire flaming upward, it is called Vacuity Fire Throat Impediment. This is commonly seen in the department of ear, nose, and throat diseases. If a proliferation of small round projections called "hanging pearls" is seen at the base of throat, the name "Hanging Pearls Throat Impediment" also applies. This condition corresponds to enduring throat infection in biomedicine. Throat Impediment due to yang vacuity, qi vacuity, or blood vacuity is seen infrequently, but may also occur.

As one would expect, the routine signs and symptoms of yin vacuity fire, which can be accessed in any major textbook, are systemic features of this condition; it is the throat-specific signs and symptoms that need to be discussed here. Patients may report any or all of the following: dry throat, scratchy throat, a need to clear the throat often, scratchy throat eliciting a dry cough, and more throat discomfort in the afternoon than in the morning. Upon inspection, the throat may appear with: a slightly dark red color, distended blood vessels and spots interspersed throughout, and dry tissue.

Disease Causes and Pathophysiology

The disease causes and explanation of this disease and Vacuity Fire Baby Moth are alike; they are both due to lung-kidney detriment and damage, insufficiency of fluid and humor, and vacuity fire flaming upward. Many of the symptoms and signs are due to vacuity fire conducted upward through the channels steaming and decocting in the throat. Sometimes this disease is caused by long-term occupational exposure to irritants such as gas and dust. Habitual and excessive intake of roasted foods, alcohol, and spicy foods can also be a causative factor in Throat Impediment. Inappropriate use of medicinals may cause enduring, unresponsive, and recurrent cases; constitutional factors may also play a role. Enduring cases may present with other types of Throat Impediment such as yang vacuity, qi vacuity, or blood vacuity, but this is relatively rare.

Differentiating Vacuity Fire Throat Impediment and Vacuity Fire Baby Moth (Ru E)

The differentiation of Vacuity Fire Throat Impediment and Vacuity Fire Baby Moth is based on the appearance of the tonsils. Although the tonsils may be dark red in Vacuity Fire Throat Impediment, they will not be swollen or enlarged, they will not have pus spots, and they will not exude pus upon pressure.

Representative Formula

Lung Yin Vacuity: Yang Yin Qing Fei Tang (Nourish Yin and Clear the Lung Decoction). It contains sheng di huang (Rx. Rehmanniae Glutinosae), mai men dong (Tuber Ophiopogonis), bai shao (Rx. Paoniae Alba), mu dan pi (Cx. Moutan Radicis), bei mu (Bulubus Fritillariae), xuan shen (Rx. Scrophulariae), bo he (Hb. Menthae), and gan cao (Rx. Glcyrrhizae).

If there are many small round spots at the bottom of the throat, add jie geng (Rx. Platycodi), xiang fu (Rz. Cyperi), yu jin (Tuber Curcumae), and he huan hua (Fl. Albizziae) in order to move qi, quicken blood, resolve depression, and disperse binds.

Kidney Yin Vacuity: Liu Wei Di Huang Wan or Zhi Bai Huang Wan. The ingredients of these formulas are readily available in standard English language texts.

If there is heart fire caused by emotional vexation and worry, use Er Yin Jian (Two Yin Decoction). It contains sheng di huang (Rx. Rehmanniae Glutinosae), mai men dong (Tuber Ophiopogonis) fu ling (Scleroitum Poria Cocos), suan zao ren (Sm. Zizyphi Spinosae), xuan shen (Rx. Scrophulariae, huang lian (Rz. Coptidis), zhu ye (Hb. Lophatheri Gracilis), mu tong (Caulis Mutong), and gan cao (Rx. Glycyrrhizae).
If there is yin and blood dual-detriment, use Si Wu Tang (Four Substance Decoction) plus he shou wu, E2 jiao, and mai men dong.

Commentary

Wiseman and Ye (1998) define impediment as "blockage". This is very significant for understanding the disease cause, disease mechanisms, and treatment of any Impediment condition, including Throat Impediment (Hou Bi). Understanding Impediment as "blockage" reminds clinicians that they must fundamentally "free" Throat Impediment; this perspective should affect one's choice of medicinals for every case of "sore throat" one sees in the clinic. It has been my experience that reframing the patient's complaint of "sore throat" as Throat Impediment (Hou Bi) and following through with accurate treatment that includes "freeing" medicinals is essential to a good clinical outcome.

As stated in chapter 24 of Za Bing Yuan Liu Xi Zhu (Incisive Light on the Source of Miscellaneous Disesae): "In throat impediment, impediment means blockage; there must be extreme swelling and blockage of the throat." At its most basic level, then, impediment (Bi) is a lack of free flow; therefore, its treatment always requires the use of "freeing" (tong) methods. Of course, the importance of freeing the flow of qi, blood, and fluids in the treatment of disease is obviously not a novel perspective in Chinese medicine, but I assert that a deeper understanding of this seminal idea will influence our clinical interventions on a daily basis. It will remind us that our job is not always to supplement, but also to ensure that maintenance of free flow in the body.

Ye Tian Shi, the well-known Qing dynasty doctor, went so far as to state that "all diseases require freeing (methods)". According to Zhong Yi Za Zhi (The Journal of Chinese Medicine, 2/2001), he derived this view from Zhang Zhong Jing's statement, "[when the] true source [qi] of the five viscera is free and open, human beings are peaceful and harmonious". Dr. Ye felt very strongly that "freeing" methods should play a prominent role in the treatment of various diseases. This theory should also be applied to the treatment of Throat Impediment.

Consider Shu Feng Qing Re Tang (Course Wing and Clear Heat Decoction), the representative formula given above for the treatment of Wind-Heat Throat Impediment. As expected, it contains exterior-resolving and heat-clearing medicinals such as niu bang zi (Fr. Arcti) and huang qin (Rx. Scutellariae); however, it also contains chi shao (Rx. Paeoniae Rubra), a blood-quickening medicinal. While it is possible that chi shao (Rx. Paeoniae Rubra) may have been chosen solely for its heat-clearing and blood-cooling actioins, it also has a "freeing" effect on static blood; in essence, it is a dynamic and moving medicinal. What possible connection could there be between Wind-Heat Throat Impediment and blood stasis?

The connection lies in the fact that when heat becomes depressed, it scorches local tissue and decocts blood, leading to swelling and blood stasis. In the case of Wind-Heat Throat Impediment, when heat is at the defensive exterior, externally contracted heat is depressed in the lung and throat; this results in redness, swelling and pain in the throat. Choosing chi shao (Rx. Paeoniae Rubra) for this condition, which cools and quickens the blood, is therefore a sound clinical strategy. In the case of Vacuity Fire Throat Impediment, internally engendered heat is steaming and decocting healthy tissue and blood, and also causing blockage.

In my opinion, one of the biggest pitfalls in the clinical evaluation of Throat Impediment is the misdiagnosis of Vacuity Fire Throat Impediment as Wind-Heat Throat Impediment. The "knee-jerk response" of treating all cases of "sore throat" as an externally-contracted wind-heat should be avoided. One of the key points to pay attention to is the presence or absence of sign and symptoms consistent with an external contraction. In the absence of supportive evidence for external contraction, even when a patient with a relatively recent onset of sore throat is encountered, one should strongly suspect Vacuity Fire Throat Impediment. Careful inquiry may reveal recent overwork, loss of sleep, or other yin-consuming behaviors and events and/or a history consistent with a yin vacuity constitution, perhaps even repeated episodes of sore throat over a period of years. Of course it is much easier to recognize Vacuity Fire Throat Impediment in enduring cases of sore throat.

Another question that arises for the responsible clinician is how to manage suspected streptococcal throat infections. This question is of greater concern for me in acute cases, when my examination of the throat reveals very swollen and pustular tonsils. Although Chinese medicine has treatment protocols that can effectively treat streptococcal infection, and I have seen them work, the safest decision in these cases is to advise the patient to obtain a throat culture through their biomedical doctor and to support antibiotic therapy should it be prescribed. Of course, the danger is that untreated streptococcal infections may lead to cardiac, renal, and septic complications; this is both a potential medical and a medico-legal quagmire. In my opinion, Chinese medical treatment, including herbal medicine, may be used along with antibiotic therapy, as I am presently unaware of any major drug-herb interactions between major antibiotics and herbal medicine. As a safeguard, it is prudent to recommend that phar maceuticals be taken at least 4 hours away from any internally-administered herbal medicine. If any new evidence comes to light, we should adjust this practice accordingly.

External application of medicinals - that is, medicinals applied directly to the surface of the throat - is an important adjunct treatment for this condition. There are many different formulas, utilizing both Chinese and Western herbs. As for myself, I have mostly utilized this method when treating Wind-Heat Throat Impediment and have relied on a combination of tincture of Propolis (two droppers applied directly to the throat), followed by two sprays of Superior Throat Powder. This regimen can be repeated several times per day until the condition has resolved.

The enduring cases of Throat Impediment that I have seen have all been previously diagnosed by biomedical physicians and have been unsuccessfully treated with repeated and often debilitating course of antibiotics by biomedical physicians; this is another matter entirely. If I encounter a patient with enduring Throat Impediment that has not been diagnosed by a biomedical physician, I always recommend that they pursue a prompt biomedical diagnosis while undergoing treatment; however, I do not feel a need to delay treatment until a diagnosis is obtained. When Chinese medicine is the appropriate treatment, correct treatment can, over a period of months, and as part of a comprehensive plan to reduce yin-consuming, heat-engendering behaviors and eating habits, be very successful in the treatment of enduring cases of Vacuity Fire Throat Impediment. In particular, spicy foods, alcohol, and smoking should be avoided. It is very important to educate the patient about the prognosis, the anticipated length of the treatment course, and the absolute necessity of making the recommended lifestyle changes in order to achieve a good clinical outcome.