The Shape Of The Ear And The Problem Of The Transcription Of Points

The research work carried out by the anthropologists Ludwig and Ilse Burkhardt and reported in the previous section is enlightening for an exhaustive appreciation of the great variability in the shape and dimension of the outer ear.

This section deals with a problem which I have long felt crucial, namely the correct transcription and recording of the points mapped on the auricle. Keeping clear records of the location of points and skin alterations helps to give a complete overview of a subject's past and current health. The adoption of a reliable system of transcription is also essential in the follow-up for a better understanding of the subject's syndrome. If, for example, a certain symptom is going to improve or disappear spontaneously we will no longer find the point or the area which was previously identified. On the other hand, persisting sensitivity despite treatment indicates that the corresponding district of the body is still affected.

The various methods of transcription of the auricular points are different but have the same intrinsic limits:

1. they are based on a bi-dimensional representation of the outer ear; the auricle, however, is tri-dimensional with its ridges and depressions

2. they do not take into account the variability of shape and dimension related to sex, age and constitution of each subject as explained in the preceding sections.

These combined factors are not easy to manage, even if a computed tri-dimensional representation of the outer ear were available, as in plastic surgery, for the reconstruction of parts of the face. While waiting for future techniques of this type we must be content with bi-dimensional maps and select the one which is simpler to use and which offers the fewest errors in transcription. It is understandable that every author considers his own graphic system to be more valuable than others. I need therefore to make a short review of this topic.

Probably the easiest way to illustrate a specific point to students is to insert a needle on a rubber model of the ear, as the Chinese and other practitioners do in the West. This method is very useful for teaching small groups, but not so useful if there are more than 8-10 students in a class and if it is necessary to record data during a course of therapeutic sessions.

Among the graphic systems which have been proposed we have to remember the following:

The first one, known as 'Nogier's buffer'. This is still on the market (made by Sedatelec). It is an ink stamp easily used for reproducing the graph of the ear on the patient's record at every session. Each graph can be used to record points on the lateral and medial surface of the ear, updating the patient's situation. Its major inadequacy is its reduced dimensions (it is only 40 mm long and 24 mm wide on the lateral surface) which absolutely does not allow for a reliable transcription (Fig. 3.13). l The various grids proposed by different authors which show squares coded by one letter and one number12,13 (Fig. 3.14). This system is interesting for teaching and makes it easy to show students the coordinates of a given point or area. Its major defect is that the grid is superimposed on a model which may or may not correspond to the ear of the actual patient to be examined. Thus it is necessary to adjust the coordinates of the point to be transcribed. This system is therefore of limited interest in the case of clinical research on larger groups of patients. l Oleson's graphic system. This has the advantage of precisely classifying the hidden and depressed areas of the ear14 (Fig. 3.15). His solutions are useful for teaching and transmitting data among international acupuncturists and have undoubtedly influenced the standardization process of

Fig. 3.13 'Nogier's buffer' (courtesy of Sedatelec).

1

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1

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V

(

V

A

J.

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Fig. 3.14 Example of an auricular grid.

the Chinese school. However, even if the system adequately fits the ridges and depressions of the ear, it is possible that the clusters of points that are going to be transcribed from the patient's ear, or from a group of patients with a given syndrome, do not coincide with a particular subdivision of the ear. • Some other graphic systems which use anatomical landmarks of the outer ear and a general reference point on the root of the helix that Nogier called point 0 (zero) (see next section).

On this subject, two authors, the Russian R. A. Durinyan and myself, have developed a grid with a variable number of sectors centered on point 0.15,16 This system, which I officially presented in 1981, was recently named a 'sectogramme' (SG, Sectogram) by the French and is a satisfactory diagnostic and therapeutic tool. The SG is obtained by subdividing the auricle by three semi-axis lines,

A, B and C, going respectively through the visual intersection point of the posterior edge of the raising branch of the helix with the lower branch of the anthelix (A); through the antitragus-anthelix groove (sulcus auriculae posterior) (B); and tangent to the posterior edge of the tragus (C). The resulting main sectors, A-B, A-C and B-C, were themselves subdivided, into 16 sectors in the case of the first two and into eight sectors in the case of the third (Fig. 3.16). This arbitrary subdivision did not aim to produce sectors of equal angles (actually they vary between 8 and 11°) but was rather intended to offer to the practitioner a graphic instrument which could be suitable for auricles of different shapes and different dimensions. The SG is not therefore intended to replace existing methods such as, for example, the Chinese standardized areas; moreover, it could be probably improved in the future. (A copy of the Sectogram is provided at the end of the book for your use.)

Auricular Acupuncturist Chart
Fig. 3.15 Oleson's14 chart (with permission).

The SG does allow, however, several operations. The practitioner is able to:

1. follow the evolution of a syndrome in a patient receiving no treatment or undergoing therapies of different types (drugs, physiotherapy, surgery, body acupuncture, etc.)

2. facilitate the topographical diagnostic process, typical of the ear, for identifying the segmental origin (muscular, skeletal, visceral, etc.) of a current symptom

3. identify, in a subject or in a series of patients with the same disease, the sector/s showing a higher concentration of points. The spatial cluster analysis adopted in this book may be useful for identifying statistically significant clusters of sectors of high or low values (i.e. with a significant higher or lower concentration of points compared to the average number per sector).

I evaluated the reliability of the SG in 385 medical doctors attending theoretical-practical seminars of ear acupuncture between 2004 and 2007. After 16-18 hours of teaching they were asked to

Fig. 3.16 Romoli's Sectogram, centered on Nogier's point zero, with the three half-lines A, B and C subdividing the auricle.

participate in the following transcription exercise: two sets of points, I and II, were projected onto a screen one after the other. Each set was composed of three points located on three different parts of the pinna (helix, anthelix and ear lobe) (Fig. 3.17). The doctors were asked to transcribe the points of sets I and II in random order on the SG or on a map of the auricle without subdivision into sectors. These two modalities were compared for total average number of correct transcriptions as well as for their relative proportions on the different parts of the ear. The same procedure was adopted with the average total number of correctly identified sectors and their proportions. The results were that the total average number of correctly transcribed points was significantly higher using the SG (P<0.001) compared to an auricular map without subdivision in sectors (Table 3.4). Also the proportions of points correctly transcribed on the different parts of the ear (helix, anthelix and ear lobe) were significantly different (Table 3.5).

Fig. 3.17 The transcription exercise: set I of points on the left; set II on the right.

Fig. 3.17 The transcription exercise: set I of points on the left; set II on the right.

The regular use of the sectogram allows practitioners to transcribe the site of auricular points and areas more precisely. By recording these locations from one session to the next it is possible to identify the clusters of points in one or more sectors which are relevant in every patient for diagnostic and therapeutic purposes.17

Table 3.4 Comparison in 385 students of the total average number of correctly transcribed points

Sectogram Yes Sectogram No Z P-value

Table 3.5 Comparison in 385 students of the proportions of correctly transcribed points on three different parts of the ear (A = helix, B = anthelix, C = ear lobe)

Sectogram Yes

Sectogram No

Z

P-value

A

0.73

0.49

6.93

<0.001

B

0.64

0.53

3.16

<0.005

C

0.47

0.32

4.17

<0.001

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