Moxibustion Therapy in the Treatment of Radiation Fibrosis of the Throat

ABSTRACT

Head and neck cancers are less common than other neoplastic disease, accounting for approximately 3% of cancers in the United States.¹ The following case study demonstrates the clinical benefits of moxibustion therapy, a modality within the practice of traditional Chinese medicine (TCM), for radiation fibrosis of the throat.  This condition was caused by extensive radiation therapy in the treatment of stage II laryngeal cancer in a fifty-nine year-old male patient. The side effects of radiation therapy led to chronic swelling and hardening of the tissue affecting the trachea and vocal chords, which required a semi-permanent tracheostomy tube. Radiation oncologists estimated the tube would remain for approximately 2-4 years.

At the time of the initial visit, the tube had been in place for ten months. The patient sought Chinese medicine treatments to alleviate the physical discomfort caused by fibrosis, including localized pain, difficulty swallowing and speaking. The dispersion method of direct moxibustion therapy on specific areas of the throat provided significant improvement and results. In combination with local electro-acupuncture and pricking therapy, positive outcomes were achieved after only three treatments. A significant decrease in the fibrotic tissue of the affected area was measured at each follow-up visit indicating positive results.

This article is co-authored by Dr. Bianca Di Giulio, L.Ac. and Dr. James Munson, L.Ac.

UNDERSTANDING DIAGNOSIS AND TREATMENT FROM A WESTERN MEDICAL PERSPECTIVE: LARYNGEAL CANCER

Laryngeal cancer is a type of head and neck cancer. Malignant cells are identified in the soft tissue of the larynx, a part of the throat that resides at the base of the tongue and trachea. The anatomical structure of the larynx includes three parts. First, the supraglottis, the aspect above the vocal chords, the second is the glottis, where the vocal chords are located, and third is the subglottis that sits between the vocal chords and the trachea (windpipe). The larynx is responsible for the voice by way of the vocal chords that vibrate when air is directed at them. Squamous cells line the inside of the larynx where cancer develops.² Major risk factors for this type of cancer include excessive alcohol consumption and smoking. Acute physical symptoms of disease may begin with chronic sore throat, dysphagia and inability to swallow solid foods, ear pain, or awareness of a lump in the throat and changes in voice, like hoarseness.²

The Western medical diagnosis is achieved through various tests to determine exact stage and location of cancer. After a complete health history and physical exam, the patient may be referred for a chest x-ray or Barium swallow, also referred to as an upper gastrointestinal series.² This test requires the patient drink a liquid with barium to coat the esophagus and stomach before x-rays are taken. Abnormalities can also be discovered through laryngoscopy, in which a thin tube-like structure is inserted into the larynx to view and remove tissue samples. If this occurs the tissue is taken to pathology to screen for cancer. Other imaging may be required like computed tomography (CT scan), positron emission tomography (PET scan), and bone scan.²

The standard of care in conventional medicine for laryngeal cancer include the following: surgery, chemotherapy, and radiation therapy. The method and course of treatment is dependent on multiple factors like degree of spread, type, stage and health of the individual. External beam radiation therapy (EBRT) is a common method of treating many types of cancer, including those of the head and neck.² EBRT functions by creating small beams of electromagnetic waves (radiation) that permeate the tissue in precise locations to eradicate cellular disease. Prolonged radiation therapy can cause a host of side effects, from superficial erythema of the skin, and local sensitivity, to deeper and more progressive clinical symptoms in the fibers of muscle and soft tissue.¹

The effects of radiation can result in a condition referred to as radiation fibrosis syndrome (RFS). The tissue in the surrounding area becomes fibrotic, hardening into a firm mass, which in the case of head and neck cancers, can impact the vocal chords, esophagus, and ability to eat, speak and breathe normally.³ Once this occurs there are very limited treatment options. Physical therapy and speech rehabilitation is necessary in most cases and are methods that are familiar to and approved by radiation oncologists. Massage, heat therapy or myofascial release is cautioned due to the conventional understanding that local manipulation or heat application would lead to internal irritation and inflammation.

CASE STUDY: MOXIBUSTION THERAPY FOR RADIATION FIBROSIS SYNDROME

A fifty-nine year-old male presented with acute radiation fibrosis of the throat due to EBRT he completed nine months prior, for stage II laryngeal cancer. The patient reported that he first noticed discomfort in his throat with mild difficulty swallowing and intermittent earaches. Due to the slow progression of symptoms he postponed seeking medical treatment, expecting the discomfort to resolve. The patient has a history of alcoholism and long-term tobacco use, which lead him to ignore the symptoms and dismiss them as acute side effects of his addictions. The dysphagia ultimately worsened to an extent that he sought medical care with his primary physician. He was referred for endoscopy with barium swallow to image the throat. Under general anesthesia, tissue was removed, biopsied and stage II cancer was confirmed.

This stage and pathology indicates a tumor that has not grown outside of the throat. There is no lymph involvement, nor spread to distant sites. Since the tumor size and lack of spread did not require surgery or chemotherapy, standard protocol was six weeks of daily radiation therapy. Within two weeks of completing the course of treatment, he reported difficulty breathing and experienced acute respiratory distress. He was rushed to the emergency room where a tracheostomy was performed. This is a surgical procedure wherein a hole is made from a specific point on the neck into the trachea to allow oxygen-rich air to reach the lungs.

In this particular case, the tracheostomy became a permanent outcome due to excessive radiation therapy causing fibrosis of the throat. The hardening of the tissue impacts the open passageway of the trachea, becoming immobile, firm, and compromising the simple act of respiration. Not only does this affect the ability to breathe, but eating and swallowing with RFS is also compromised. Consequently, the patient remained in the hospital for three weeks with a feeding tube and underwent rehabilitative therapy with vocal cord specialists, speech therapists, dietitians, and physical therapy.

This patient was referred to our Chinese medicine clinic approximately eleven months after the Western medical procedures. A thorough intake indicated the RFS impacted activities of daily living and overall wellbeing. Three-month follow-ups with his oncologist confirmed he was cancer free. Despite being cleared of malignancy, the patient expressed immense frustration with the tracheostomy tube. According to the patient, “the doctors and therapists have nothing else to offer. They say I just have to wait it out and hope the fibrosis decreases.”

With ease, he used his tracheostomy tube to describe his symptoms. Stating that internally his throat felt extremely dense. He was acutely aware of an immobile mass that never decreased in size. He gestured to his throat and pressed firmly along the sides of the throat, across the scalenes, bilaterally. As he pushed, he said it was “hard as a rock.” There was no report of pain, but he explained that he could feel tenderness and swelling inside the throat locally. The extensive swollen area extended from just above the laryngeal prominence, to the jugular notch and approximately four inches lateral in both directions.

Palpation by both practitioners exhibited hardened, fibrotic tissue, warm to the touch, swollen, and visibly red. Applying pressure did not elicit pain. He explained there was a constant need to clear his throat, with a mild, chronic cough because of phlegm and sputum that would not flush naturally through his throat. He wore an ascot around his neck, which, at the time of the initial treatment, was adjusted to its largest circumference.

He continued to explain that the previous year had clearly affected his physical and emotional health. His energy and stamina was reported as very low, he required sleep medications to fall and stay asleep, and maintained a long history of insomnia. His body tended toward hot, with desire for cold drinks, and a constant dry mouth. Prior to his cancer diagnosis, he was treated for asthma, which required the use of inhalers during activity. His blood pressure was elevated requiring prescriptions. He experienced occasional headaches and reported digestion as normal. Prescription medication included Vicodin (as needed), Prozac, Lisinopril, and Xanax.

CHINESE MEDICINE DIAGNOSIS

The current academic literature for Chinese medicine practitioners seeking guidance for cancer patients is limited. Due to the very nature of cancer being a resiliently complex disease, the available material is not exhaustive of every cancer, stage, diagnosis and treatment. Therefore, clinicians must diligently research and hone their clinical skills to treat patients with lesser-known or more rare tumors. Nasopharyngeal cancers exist within that category. Fortunately, TCM physicians can rely upon pattern differentiation, including the eight-principles, interior-exterior, and excess-deficiency to properly diagnose and effectively treat.

Examination of the patient’s tongue and pulse demonstrated a mixed syndrome. This is often true with individuals diagnosed with cancer and complex disease patterns. The tongue body was red with deep cracks in the middle and upper jiaos, and a greasy-yellow coat in the rear. The pulse furthered this pattern, the Liver was wiry-full, Spleen slippery, Kidneys deep, thin, and the overall rate was rapid.

TCM diagnosis:

Upper jiao phlegm with toxic heat, qi-blood stagnation, Kidney-Liver yin deficient heat

TCM treatment principle:

Dissolve phlegm, clear toxic heat, clear deficient heat, nourish yin and calm spirit.

Effective Application of Moxibustion Therapy for Radiation Fibrosis Syndrome:

Moxibustion therapy was instrumental in the patient’s reduction of symptoms as a result of RFS. Therefore, we have outlined its application as a singular, useful modality for practitioners. Theoretically, moxibustion may seem counterintuitive in this case given that heat therapy is generally considered a contraindication with signs of heat, like redness or swelling. There is a concern its effects will inflame or worsen the condition. This is especially true with respect to philosophy and clinical application in Western medical paradigms. However, TCM relies upon the treatment philosophy of “like treats like,” proven in this case study with proper technique of moxibustion therapy.

Safe method and application of moxibustion for this case is highlighted below:

• Type: coarse, green, low-grade moxibustion was utilized to create an intense, strong dispersing heat
• Size: moxa was shaped into very tight, firm cones in order to create a slow, intense heat (approximately the size of a Hershey’s Kiss)
• Quantity: 4-6 cones were placed directly on the patient’s throat at specific areas with most fibrotic, tight, dense tissue
• Method: Using an incense stick, each cone was lit and watched carefully as it burned toward the skin. The cone was removed when the patient reported a sensation of heat directly under the cone, or the practitioner estimated that enough heat had accumulated locally
• Technique: The cone was removed with forceps and placed in a cup of water. The point was not covered by the finger to retain heat, but rather to allow the heat to disperse internally
• Duration: This technique was repeated on each point until there were palpatory and/or visual changes, or the practitioner deemed it adequate for treatment

The larger, tightly packed moxibustion cone causes a longer burn time, which allows more heat to develop and facilitate the scattering of the heat toxin as well as to encourage wei qi (defensive qi) to the surface and aid in the dispersion. In TCM theory, not immediately covering the point upon removing the cone, allows the heat/evil pathogen to exit. However, it is crucial that the practitioner quickly place the next cone in the same location, if necessary, to keep the heat at a steady, high level.

In this case, palpation and close visual examination was integral to deciding how many cones were applied to each point.  When the tissue softened and there was less density with pressure, this indicated positive change and heat reduction. In addition, with close examination,g the area became less swollen and red. It is important to state that this type of technique needs to be done with the full understanding and consent of the patient, and by those practitioners who are experienced and confident with moxibustion. In a case of RFS, the integrity of the skin, sensory function, and normal sensation has been greatly compromised due to radiation therapy. By and large, Western-trained doctors believe heat is contraindicated with signs of swelling and redness, and as a result, caution patients to receive any kind of physical or manual therapy because of the higher level of sensitivity. Thus, the practitioner needs to judge appropriate strength of treatment through their own skill and observation without relying on the patient’s feedback as they may not feel the heat acutely.

Constitutional Support: Acupuncture Therapy

Moxibustion was an integral component to alleviate discomfort and hasten healing of the fibrotic tissue. Given that Chinese medicine is a synergistic system that incorporates multiple modalities for healing, constitutional acupuncture was also employed. The following acupuncture point combinations were included as part of this patient’s sessions. In total, he received only three treatments, but substantial changes were evident following each visit reported by the patient and observed by the practitioners through palpation.

Treatment #1

Tongue: Red, deep cracks, sticky yellow coat

Pulse: wiry, chi positions deep, Lung/Heart excess, slippery,
slightly rapid

Acupuncture:

Seirin needles used for all acupuncture

• Open Ren: LU 7, K 6

– Pathway of the Ren channel courses through the throat
– Combination of extraordinary meridians nourishes yin

• Open Chong: SP 4, PC 6
• Ren 6, Ren 12, Ren 14, Ren 22

– Palpation along the Ren meridian exhibited skin changes in tone, texture, and temperature  on the above noted points, which were then needled in dispersing method

• LV 14

– Spread Liver qi

• ST 40

– Clear Phlegm

• SP 9

– Clear Damp

Local: 2 ashi points on each side of the throat, approximately on Large Intestine channel

Moxibustion:

Dispersing technique, direct cones placed in 4 positions on throat and each applied three times. Please see above section for discussion and technique.

Results

Immediately following this treatment, palpation on the throat and neck demonstrated soft, more malleable tissue that shifted slightly with pressure. When the patient was asked to swallow, he reported that the mass of rigid, fibrotic tissue that enveloped his throat had lessened, allowing more movement when he swallowed. The yellow coat on the tongue dispersed, his pulses slowed to a normal rate, and visually, the systemic redness and inflammation that was present on his cheeks, forehead, and overall skin tone, lessened.

Treatment #2

The patient returned two weeks later and reported he was able to decrease the length of his ascot size down to a smaller clasp. He was very encouraged by this quick response. Palpation indicated smaller mass circumference and the edges of the fibrotic area were less rigid. He noted improvement in his ability to swallow solid food and a decrease in the tendency to clear his throat from rattling phlegm. He reported that he did not need to take Vicodin during this two-week period for throat pain. However, the patient disclosed a long history of alcoholism and stated he was beginning to attend sobriety meetings. Given that alcohol is a primary risk factor to laryngeal cancer, the cellular pathology is rooted in this condition, but also illustrates deeper emotional roots and complex patterns that correlate to his overall well-being and health.

The subsequent treatment plan included moxibustion, auricular acupuncture to support alcohol withdrawal, and an eight extraordinary meridian (EEM) protocol utilizing the Dai meridian to dredge and open the Liver and Gallbladder, clear heat, detoxify the system, and move and regulate qi. The Dai treatment is indicated for emotional release and letting go – also therapeutically relevant for this patient.

Tongue: red, deep cracks, sticky yellow coat

Pulse: wiry, Kidney deep-thin, Lung/Heart slippery, slightly rapid

Acupuncture:

• Auricular (bilateral): Shen Men, Liver, Lung 1, Sympathetic, Kidney
• Local (ashi throat, bilateral): needle angled medially toward the mass, inserted approximately ½ cun

– Electrical stimulation (e-stim)   leads were placed on four of the   throat needles, 10 hz, increased slowly to a level where the patient reported a noticeable, continuous frequency

– Needles retained for twenty minutes

• Open Dai: GB 41 (left first), LV 13, GB 26, GB 28, Ren 15

Topical:

Zhen Gu Shui was applied topically at the end of the session to the throat

Moxibustion:

Indirect heat applied with smoky moxa over areas of significant hardness using the dispersing method. The moxa stick is held over the identified point, with the practitioner’s hand placed between the heat and the skin to moderate temperature. The moxa is held until the heat escalates and then the stick is pulled away for a moment, before returning to the same position. The point is not covered with the supporting hand in order to disperse the heat.

Treatment #3

The patient returned to the clinic one week following the second session. The circumference of the mass had decreased in size significantly, which was confirmed by the patient noting the ascot size was now at its tightest possible placement. He reported that internally his throat felt less inflamed, large, and swollen and had “opened up.” There was also an evident shift in his emotional state, observable from both the practitioner’s perspective, but also shared by the patient, and independently confirmed by his daughter. He was making decisions to return to rehab for his alcoholism, and expressed more optimism about his health and the future.

Tongue: Red, deep cracks, thin- yellow coat

Pulse: wiry, rapid; Lung/Heart thin-slippery

Acupuncture:

• LI 4, LV 3

– Classic “4 Gates” point combina   tion to circulate qi-blood, move   the Liver, tonify qi

• ST 40, SP 9

– Resolve Damp and Phlegm Accu   mulation

• Ren 17, Ren 22

– Open the chest and throat, descend rebellious qi

• ST 25, Ren 12, Ren 6

– Classic “4 Doors” point combination to regulate digestion, by nourishing Spleen-Stomach qi, tonify and raise qi

• Local (ashi points, bilateral): approximately six acupoints along the lateral aspect of the mass, according to palpation

– Electro stimulation attached on all six point locations, beginning with 10 Hz

• Pricking therapy (bilaterally): ST 45, in-out needling method to clear heat

– The Stomach channel descends from the orbital region, through the throat, culminating on the 3rd toe at ST 45

Moxibustion:

Indirect, dispersion technique along the throat combined with four rounds of direct cones on two local areas where thicker fibrotic tissue remained.

Results

After the third treatment the patient called to report positive changes in the mass and associated symptoms, but decided to return to a rehabilitation center to address his alcoholism. Although the course of treatment was quite short and not the preferred duration to properly address his concerns, both practitioners were optimistic that with ongoing treatments the fibrotic tissue would slowly continue to soften and symptoms would improve as a result.

CONCLUSION

This case study illustrates the range of traditional Chinese medicine techniques in the treatment of cancer-related conditions, like RFS. The side effect of radiation therapy can extend from the superficial erythema, to deeper levels of soft tissue changes requiring specific and refined approaches. Although the practitioners were only afforded three treatments to address a well-established condition, the clinical outcome was evident. It is also important to note that with just a few moxibustion cones and needles, immediate results were attained. This speaks to the synergistic aspect of TCM modalities and how treatments need not be overly involved, especially when appropriate modalities are used together as they were intended in classical Chinese medicine.

REFERENCES

1) American Society of Clinical Oncology: Head and Neck Cancer Statistics 2017. Alexandria, Va. https://www.cancer.net/cancer-types/head-and-neck-cancer/statistics. Accessed March 27, 2018.

2) National Institute of Health- National Cancer Society. Laryngeal Cancer Treatment (Adult). https://www.cancer.gov/types/head-and-neck/hp/adult/laryngeal-treatment-pdq. Accessed March 15, 2018.

3) Hojan, K., & Milecki, P. (2014). Opportunities for rehabilitation of patients with radiation fibrosis syndrome. Reports of Practical Oncology and Radiotherapy, 19(1), 1–6. http://doi.org/10.1016/j.rpor.2013.07.007.

This article is co-authored by Dr. Bianca Di Giulio, L.Ac. and Dr. James Munson, L.Ac.