Auricular Therapy Segmental Innervation Internal Organ I

' # ft-» \ .• • * V* x VH yp i i -* • f - . r •» »

Fig. 4.9 (A) Biopsy section from ear lobe in the area of crease (A); the arrow indicates elastic-fiber tears (x100) (with permission). (B) Biopsy section from area of ear lobe crease (ELC) the arrow indicates pre-arteriolar wall thickening (x240) (with permission).

There are, however, some aspects which have not been considered sufficiently and which require a careful and reliable standardization of the crease. The first is that the ELC was rarely evaluated by independent observers; the second is that differences in interpretation of the crease itself may account for at least a part of the different results in comparing subjects with and without CHD. For example, it is rarely stated if the creases are observed with the patient in the upright or the supine position; the creases are more evident in the second position. What is perhaps more important is that not all the authors have reached a consensus that ELC has to be considered present if it appears to involve the full thickness of the skin, extending entirely across the ear lobe. Only in a few articles has the crease been measured in three different degrees, as in the post-mortem study47 shown in Figure 4.10.

However, the question that remains open for us is how to explain the topography of the crease and its relationship to the cardiovascular system. Cardiologist Yoshiaki Omura,50 who was involved early in the observation of ear lobe creases, tried to explain the relationship between the ear lobe and myocardial abnormalities by a common neural supply. The main part of the lobe being innervated by the great auricular nerve (C2-C3), he surmised

Fig. 4.10 Ear lobe crease (ELC) grading in a post-mortem study: A, B and C show representative cases that scored respectively 0, 1, 2 points (with permission).

Fig. 4.10 Ear lobe crease (ELC) grading in a post-mortem study: A, B and C show representative cases that scored respectively 0, 1, 2 points (with permission).

that there could be an 'unrecognized supply of small branches of nerves coming directly or indirectly from the heart'. He supported his hypothesis with the possible observation in cardiac patients of a radiating pain involving also the neck, chin and occipital area, covered indeed by the same supply, C2 and C3.

Johan Nguyen51 instead supposed that the correlation between a sign corresponding to the representation of the face and the heart could be explained only with the theory of TCM. He quoted as an example a sentence from the classical textbook Su Wen, Chapter 9, 'The Heart is the source of life and the place of transformation of mental energy. Its energy manifests itself on the face.'

As regards my own opinion on this subject, I am far from being convinced that there is an easy approach to the question. I think two different topographical aspects have to be considered; the first is that the starting point of ELC, just below the intertragic notch, is constant for all types of creases. The second is the variable angle of the diagonal crease crossing the ear lobe and therefore encompassing a different surface of the anterior part of the lobe. The end point of a clear-cut crease can in certain cases reach the lowest point of the lobe or even trespass this limit backwards (see Plate XIIC); in other less frequent cases a double ELC can be observed (see Plate XIIB).

Concerning the starting point of the crease, Nogier's map does not report any point related to the cardiovascular system in this area but shows the representation of the pituitary gland on the anterior ridge of the intertragic notch; the Chinese standardization, on the other hand, reports a puzzling tooth area (LO1 ya) with the indication for hypotension, besides toothache and periodontitis. The indication for raising blood pressure was maintained from the ancient map of the China Academy of TCM and is actually coincident with this starting point of the crease (Fig. 4.11). The possibility that this auricular area is related to dysfunctions of the cardiovascular system may be supported by the fact that just nearby on the tragus there are further points related to the heart such as xinzangdian of the ancient map, located within the current area TG1, with the indications of atrial fibrillation and tachycardia. Further points for treating hypertension are currently located in the area TG2 and adrenal gland shenshang-xian located at the free border of the tragus between TG1 and TG2. The association of the tragus and the intertragic notch to diastolic pressure in hypertensive patients can be found in Chapter 5 (Figs 5.42, 5.43). As regards the possible association between CHD, ELC and ear-canal hair, which is supposed to be due to the long-term exposure to androgens, it is interesting from the topographic point of view that hair does not cover just the canal but also

1 =

heart point (French)

2 =

heart area (CO15 xin)

3 =

cardiac point (xinzangdian)

4 =

adrenal gland point (shenshangxian)

5 =

hypertension point (gaoxueyadian)

6 =

ACTH point (French) (on the internal side)

7 =

endocrine area (CO18 neifenmi)

8 =

hypophysis area (French)

9 =

point for raising blood pressure (shengyadian)

10 =

aggressiveness point (French)

11 =

neurasthenia point, in the anterior part of

the ear lobe (LO4 chuiqian)

12 =

fear area (French)

Fig. 4.11 Possible interpretation of ear lobe crease (ELC) by means of topographic overlapping of some auricular points according to Chinese and French arrangement of the auricle. ACTH = adrenocorticotropic hormone.

neighboring areas such as the tragus, the antitragus and the intertragic notch. All these areas appear to be involved in the regulation of neuroendocrine functions (Fig. 4.12).

In my opinion, therefore, the first hypothesis for ELC could be related to a complex disorder of the central mechanisms regulating blood pressure, with a progressively increasing resistance of the peripheral arterioles. A second hypothesis, possibly linked to the former, regards the areas of the anterior part of the ear bounded by the crease.

Fig. 4.12 Ear-canal hair and ear lobe crease (ELC) in a 71-year-old patient suffering with coronary heart disease (A); area of implantation of hair marked with ink (B). The patient had noticed a particularly intense growth of the hair throughout the previous 5 years.

These areas are clearly associated with the emotional state of the patient: Nogier identified a point for aggressiveness and an area for 'fear' on this part of the lobe; the Chinese called it anterior ear lobe (LO4 chuiqian). Besides toothache, as for LO1, the major indication for this area is 'neurosis', which was changed from 'neurasthenia', the former term used by the Chinese Academy of TCM.

The reader will allow me to make a short digression on this condition which belongs to the culture-bound syndromes of DSM IV but still survives in the Chinese Classification of Mental Disorders (CCMD-2-R).52-54 The Chinese translation for it is shenjing shuairuo where shen is emblematic of vitality and capacity of the mind to form ideas, jing originally refers to the meridians and channels carrying qi (vital energy) and xue (blood) through the body. Conceptually shen and and jing are treated by Chinese people and doctors as one term, shenjing, that means 'nerve' or 'nervous system'. Shuai means decline, degeneration, and ruo weakness.54

At the end of this digression it has to be specified that the CCMD-2-R diagnostic criteria for shenjing shuairuo are any of three out of five groups of symptoms such as fatigue, dysphoria (restlessness, malaise), excitement, nervous pain and sleep disturbances. This syndrome, very popular at the end of the 1980s, is nowadays less and less diagnosed by Chinese psychiatrists who now favor a diagnosis of depression.

Returning to the second hypothesis, it is possible that ELC could be associated with the particular emotional status or personality trait of patients which seem to be recurrent in those developing some form of CHD. In the past I have been impressed by the representation of the rhinencephalon drawn by Rene Bourdiol,55 a neurologist who was also Paul Nogier's closest collaborator. He dedicated his doctoral thesis to the interpretation of the different neural anatomical structures of the part of the CNS involved in 'reaction behavior' in humans. He described at least four neurophysiological systems:

the 'olfactory' brain, or rhinencephalon proper the 'sexual' brain, regulating aggression and certain compulsive behavioral traits the 'anamnesic' brain, enabling the retention of past experiences the 'reactional' brain, orientating the individual (Fig. 4.13).

Bourdiol's observations, even if not supported by any experimental data, urged me to measure at least one parameter, the anxiety level, in subjects bearing a mono- or bilateral diagonal crease completely crossing the ear lobe. With colleagues, I therefore carried out a survey on 258 consecutive subjects in my practice: 143 with unilateral or bilateral ELC (86 males, 57 females); a control group of 115 without ELC (57 males, 58 females).56 We measured the anxiety level with the IPAT anxiety scale questionnaire (ASQ) which proposes 40 items with the total score ranging from 0 to 80.57 The exclusion criteria for this study were the intake, even if temporary, of psycho-tropic drugs and the presence, in the clinical history of the patient, of previous myocardial infarction, angina pectoris or evidence at ECG of abnormal Q waves, or ST segment and T wave abnormalities. The anxiety scores in the group with ELC and in the control group showed a parallel tendency: higher in the females and decreasing from the fifth to seventh decade (Fig. 4.14). The mean anxiety scores of the two groups were compared by sex and decade using the t-test. The differences were all highly significant (P<0.001). The conclusions of the article were:

Fig. 4.13 The somatotopic representation of the rhinencephalon and limbic system according to Bourdiol (with permission).

Fig. 4.14 IPAT anxiety scores per decade and sex in asymptomatic subjects with ear lobe crease (ELC) (dots) compared to controls without ELC (hexagons).

Anxiety and coronary risk seem to have a common biological mechanism which is possibly responsible for the appearance of the crease in the course of years. The crease indeed is not present at birth, manifesting itself only in the fifth decade or so and shows its highest prevalence in the years following. We are not able to explain how and why the crease appears. Ear acupuncture may give us a key to interpreting this phenomenon, presuming the existence of somatotopic areas of the CNS on the ear lobe.56

When our article was published 20 years ago the relation between type A behavior, anxiety and CHD had long been recognized in the Western world. The type A personality (formulated by Friedman and Rosenman as the 'coronary-prone behavior pattern') was very popular as it included several characteristics of the 'modern' man such as aggressiveness, time urgency, excessive competition, striving for achievement, restlessness, hostility, etc.58 A little more than 20 years after our article the relationship between CHD and depression and anxiety was clearly underlined in a survey carried out in 38 US states on 129 499 adults aged 45 years and over, performed by a behavior risk factor surveillance system. Patients with a history of cardiovascular disease (including CHD and stroke) were more likely than those without to experience current depression and to have a lifetime diagnosis of depressive disorders or anxiety disorders.59

There are, however, several aspects of current research which are of interest for this subject such as the relationship of trait negative emotions to high-frequency heart rate variability (HF-HRV) which is considered a specific indicator of para-sympathetic cardiac autonomic function related to premature cardiovascular morbidity and mortality.60

Current research indicates that trait anxiety, abnormalities of sympathetic activity, endothelial dysfunctions and insulin resistance may increase the risk of atherosclerosis and cardiovascular disease.61-63


One of my first systematic studies on auricular diagnosis was presented at the 1st Czechoslovak

Congress of Acupuncture held in Brno in June

1981. This was also the first opportunity for me to introduce a preliminary version of the Sectogram.

An article was then published with the title 'A contribution to the study of new areas of the ear lobe for the diagnosis and treatment of essential head-ache'.64 I drew my inspiration from Oleson's original work on auricular somatotopic mapping of musculoskeletal pain65 and I examined the outer ears of 102 consecutive patients suffering with headache. All observable skin alterations in the areas corresponding to Oleson's representation of the head and neck were reported on the Sectogram

(sectors 7-9) (Fig. 4.15). At the time of my study I was still far from applying the first International Classification of Headache Disorders issued later in 1988. I classified headaches according to the

'chronopathological' classification of Francesco Sicuteri, a leading authority in those years. The classification subdivided headaches into acces-sional, chronic accessional, continuous and cluster headaches. In my group of 102 patients 70.5% were affected by accessional headache which nowadays could be considered as migraine with the recent classification (HIS 2004); 17.6% by chronic acces-sional headache and 0.8% by continuous headache; both the latter nowadays could be considered as chronic migraine. Only three patients out of 102 had a clear pain pattern of cluster headache.

Auricular Acupuncture Migraine
Fig. 4.15 Distribution of skin alterations on the right and left ear in 102 consecutive patients suffering with headache (areas with higher concentration of skin alterations in red; areas with lower concentration of skin alterations in pink) (courtesy of Marco Banti).

Altogether 491 skin alterations were found, on average 4.8 per patient; the results of our study were as follows:

1. Skin alterations were distributed on the whole of the ear lobe and were not limited to the anti-tragus as was commonly believed when treating headache disorders. Actually the total number of skin alterations located on the peripheral zones of the ear lobe and on the antitragus were in a ratio of 2:1; sector 8 (a and b) held the highest concentration of skin alterations, 47.6% of the total on the right ear, and 55.3% of the total on the left ear.

2. Pigmented skin alterations were present in a higher concentration than vascular skin alterations (on average 47.8% to 38.7%). These findings were quite different from the general trend which indicates the prevalence of vascular over pigmentary skin alterations (see Fig. 4.4).

A sex- and age-matched group of patients without migraine indeed showed a lower prevalence of pigmentary skin alterations. 3. Distribution of skin alterations in the sectors (7-9) was significantly associated with the lateralization of pain during migraine attacks. Fifty-six patients with bilateral or alternating headache without prevalence of pain showed no differences in distribution of skin alterations on the right and left ear; instead 46 patients with recurrent or prevalent pain on one side showed a higher concentration of skin alterations on the same side (P<0.01).

The conclusions of this first study were that the areas to be included when diagnosing headache were more numerous than presumed and that the pigmentations of the antitragus and ear lobe could represent a sign of headache disorders (see Plate IXA).

The skin alterations were mainly distributed on the same side of the pain or bilaterally if headache did not show any prevalence of pain. I interpreted this finding as an indication for therapy since ear acupuncture could be presumed to be more effective if carried out on the same side as the pain.64


The second diagnostic study with the inspection was carried out at the department of endoscopy at the hospital of my city. I examined 175 consecutive patients with digestive complaints of different kinds before they underwent gastroscopy. Again drawing inspiration from Oleson's work on auricular somatotopic mapping of musculoskeletal pain, I tried to identify the areas on the concha related to disorders of the upper digestive tract. I was the blind observer and had to answer the following two questions: (i) could auricular inspection of the concha suggest the existence of whatever lesion? (ii) could the topography of the visible skin alterations suggest the lesion of a specific part of the upper digestive tract?

In 144 (82.3%) of the group of 175 patients I was able through inspection to confirm the positive diagnosis of the gastroscopy; for 17.7%, however, results were non-concordant: in 21 patients (12%) inspection was positive and gastroscopy negative; in 10 patients (5.7%) inspection was negative and gastroscopy positive. The first group was composed of 10 patients affected by anxiety and depression, regularly taking variable doses of ben-zodiazepines and antidepressant drugs; two had liver disease; one had gallstones; eight were apparently healthy. The second group was composed of considerably younger patients affected by recent digestive disorders. The first information I acquired from this study was that also dysfunctions or somatoform disorders could induce a change in auricular skin and that sufficient duration of symptoms was necessary for diagnosis through auricular inspection to be made possible.66

Regarding the second question on how to correlate the location of skin alterations on the ear with the site of lesions found at gastroscopy, we first excluded patients with multiple lesions, then selected 86 patients with only one type of lesion located on the following parts of the upper digestive tract:

1. lower third of the esophagus and cardia

2. lesser curvature of the stomach and antrum pyloricum

3. greater curvature of the stomach and gastric fundus

4. pyloric canal

5. anterior wall of duodenal bulb

6. posterior wall of duodenal bulb

7. duodenal bulb at the whole.

We noted at first a prevalent distribution of skin alterations on the right concha (65.6%); this prevalence was significantly associated with the first and second anatomical site (P<0.001) whereas the third showed a higher concentration of skin alterations on the left auricle (P<0.05).

As regards the duodenum we found some interesting differences concerning the site of lesions of the bulb (pars superior duodeni). Eleven patients affected by an ulcer of the anterior-superior wall of the bulb had a significantly higher number of skin alterations on the right ear whereas 10 patients with an ulcer of the posterior-inferior wall of the bulb had a higher number of skin alterations on the left ear. A control group of 11 patients with duodenitis affecting the whole duodenal bulb showed no differences of distribution. With t-test the difference was significant (P<0.005).

The second information I acquired from this study was that the outer ear reflects chronic ailments prevalently of the corresponding side of the body. In the case of a system such as the upper digestive tract, which we imagine to be located along the midline of the body, the representation of the different parts on the right and left ear can be very variable.

This diagnostic approach can be helpful with patients presenting puzzling symptoms, as in the following case.


A 65-year-old lady had been suffering for 4 months with intermittent pain of the left posterior thoracic area. The usual routine examinations, ECG and chest X-ray as well as ultrasound of the upper abdomen were negative. An X-ray of the thoracolumbar spine showed degenerative changes of the lower thoracic tract which could explain the patient's recurrent pain. The patient had no digestive complaints nor had she noticed a variation of symptoms related to the intake of food. Nevertheless the analgesic medication with NSAID prescribed by her GP had been ineffective up to the time she contacted me for trying acupuncture. I examined her ears and was surprised to find two telangiectasia of the left concha where the Chinese locate the stomach area (CO4 we/) and the French locate the duodenum (Fig. 4.16A). I examined her back which was stiff but frankly not painful on flexion, extension and lateral bending. Trying the skin-rolling test of Maigne, gently taking a fold of the skin between my thumb and forefinger, I found a thickened and hypersensitive area on the left side of her chest, corresponding to the seventh to eighth thoracic dermatomes (Fig. 4.16B). I also found a tender point very close to the observed telangiectasia on which I carried out the needle-contact test (NCT) (see Ch. 8) for a few seconds: the hypersensitive areas disappeared in the following minute. I did not treat this patient with acupuncture as I was uncertain about the diagnosis; nevertheless I prescribed ranitidine which indeed was effective in the following days. Gastroscopy evidenced a non-perforating ulcer of the posterior wall of the bulb. Therapy with ranitidine was therefore continued and the thoracic pain did not recur.


For several years I have been fascinated by melano-cytic nevi of the outer ear. Two observations stimulated my interest: the first was that nevi were among the few skin alterations noticeable in children and young people. The second was that nevi were not randomly distributed on the auricle but concentrated on specific areas innervated prevalently by trigeminal and cervical nerves. For example if we consider the distribution of nevi on the different parts of the auricle in 711 patients we can see that the helix is in first place with 38.5%, and the upper and lower concha in last place with only 1.3% (Table 4.8). One possible reason for this striking difference is that this part of the ear, innervated mainly by the tenth cranial nerve, is not concerned with the 'emigration' of melanocytes. According to what is still accepted as a hypothesis, these cells emigrate to the epidermis and derma from the lateral ridges of the neural plate as the ridges join to form the neural tube. Congenital nevi are present within the first 6 months of life; acquired nevi appear later and peak in number during the second and third decades of life, but involute spontaneously by the seventh to ninth decades.67

I too observed this phenomenon on the auricle and have presented it in Figure 4.5.

The richness of the distribution of these nevi on the helix led me to consider the possible

Fig. 4.16 (A) Double telangiectasia of the left concha in a 65-year-old female affected by intermittent posterior thoracic pain on the left side in duodenal ulcer of the posterior wall of the bulbus. (B) Hypersensitive areas at skin-rolling test of the left thoracic area in the same patient.

Table 4.8 Distribution (%) of melanocytic nevi on the different parts of the auricle in 711 subjects

Part of the auricle

Nevi distribution



Ear lobe


Medial surface






Scaphoid groove




Upper and lower concha


Other parts




associations between this still puzzling part of the ear and some skeletal abnormalities such as scoli-osis which must be considered, as is well known, a three-dimensional deformity of the spine in which lateral deviation combines with vertebral torsion.

The Chinese auricular map does not give too much importance to the helix areas HX9 lunyi to HX12 lunsi which start from the lower border of the helix tubercle and end overlapping with the tail of the helix. The indications of these areas are coincident and concern fever, tonsillitis and infections of the upper respiratory tract. The verity of these correlations is highlighted in Figure 9.15.

Nogier's opinion about the significance of the helix had been postponed until 1977 when, after much consideration and clinical application, he thought of its possible representation of the spinal cord68 (Fig. 4.17). His hypothesis is very interesting as the helix appears to be involved in several neurological conditions such as, for example, neuropathic pain of herpes zoster (see Fig. 3.20).

Seeking an association between melanocytic nevi and scoliosis I was helped by the article of Banuls69 who found a significantly higher number of nevi on the body in a group of patients with sco-liosis compared to a control group (P<0.001). The same author also assumed that a genetic factor could influence the segmental arrangement of multiple nevi, both of congenital and acquired origin.70

Vorlagen Ausdrucken Mandala Sternzeichen
Fig. 4.17 Representation of the spinal cord on the helix according to Nogier (with permission).

The possibility that a segmental arrangement of nevi could also exist on the auricle urged me to study two groups of boys and girls; the first from the Centre for Prevention of Scoliosis of the Pro Juventute Foundation in Florence; the control group from the pupils of a state secondary school of the same city. Clinical scoliosis was ruled out applying Adam's forward bending test which is proved to be the best non-invasive clinical test for evaluating scoliosis.71

A preliminary report on the association between melanocytic nevi and skeletal malformations was presented at the 5th International Symposium of Auriculotherapy and Auriculomedicine in October 2006.72

The final unpublished data concerned 311 subjects: 190 girls (average age 12.8 years, SD 1.6, range 6-16) and 121 boys (average age 12.9 years, SD 1.7, range 8-18). All subjects were examined by an orthopedist who specialized in scoliosis:

203 of them showed skeletal abnormalities, 108 were considered normal. The skeletal disorders were classified into the following four categories:

• idiopathic scoliosis (when a structural, lateral, rotated curvature of the spine was demonstrated) in 133 subjects

• compensatory scoliosis (when the lateral curvature was associated with a pelvic obliquity on the frontal plane related to a leg length discrepancy) in 37 subjects

• combined idiopathic and compensatory scoliosis in 11 subjects

• combined scoliosis and kyphosis in 22 subjects.

All observable nevi were transcribed on the Secto-gram and a first evaluation was made on the total number of nevi in the four categories and in the control group (respectively 2.04 and 1.56 nevi). With t-test for independent samples we found a significant difference (P<0.05). If in the first two categories we weigh the sectors with a significantly higher concentration of nevi compared to the control group, we may find sectors 4, 6, 10, 18, 19 and 24 in the group with compensatory scoliosis (on the left of Fig. 4.18A) and sectors 15, 17 and 18 in the scoliosis group (on the right of Fig. 4.18A). If we assume that the sectors in the sco-liosis group correspond to the representation of the thoracic spine, for the first group we should assume that the outspread distribution of nevi may correspond to other structures, thereby confirming the different pathogenesis of these conditions. Comparing the two groups, in the first group we found a significantly higher concentration of nevi on the ear lobe in sectors 3-6 (P<0.005) and on the helix in sector 20 (P<0.001) (on the left of Fig. 4.18B).

The first information we obtained from this evaluation was that a reduced number of nevi (<2), in boys and girls aged 10-14, may indicate a low risk

Fig. 4.18 (A) Sectors with a significantly higher concentration of nevi compared to control group in 170 girls and boys (average age 12.8 years): 37 subjects with compensatory scoliosis (on the left); 133 subjects with idiopathic scoliosis (on the right).


Fig. 4.18 (A) Sectors with a significantly higher concentration of nevi compared to control group in 170 girls and boys (average age 12.8 years): 37 subjects with compensatory scoliosis (on the left); 133 subjects with idiopathic scoliosis (on the right).


16 15 14

13 12






Fig. 4.18, cont'd (B) Sectors with a significantly higher concentration of nevi in the same subjects with compensatory scoliosis compared to idiopathic scoliosis (on the left); sector 4 has a significantly higher number of nevi in boys and girls who have worn fixed or mobile bite-plates compared to control (on the right).

of skeletal abnormalities; a higher average number of nevi (>2), however, may be associated more frequently with a skeletal abnormality of the spine.

The second information we obtained was that a deformity of the spine is not only associated with a distribution of nevi on the helix and the anthelix, parts which we commonly presume to be related to the spinal cord and the vertebral column, but it also reflects an evident extension on portions of the ear lobe which are presumed to be the representation of the cranial bones and the central nervous system.

We formed a hypothesis about the particularly striking differences between the groups with idio-pathic and compensatory scoliosis, and carried out a further analysis on the whole group of 311 boys and girls, at first as regards the wearing of fixed or mobile bite-plates for orthodontic-esthetic purposes. A large percentage of these young subjects (54.5%) had worn these plates for a longer or shorter time and we compared the total number of nevi in this group with a group of boys and girls who had never worn this kind of appliance. We did not find a significant difference (the average number of nevi was respectively 1.98 and 2.03), but we found that sector 4 had a significantly higher concentration of nevi in the first group (P<0.001) (on the right of Fig. 4.18B).

Our hypothesis was that the nevi located on the ear lobe (sectors 3-6) may be the representation of asymmetries of the central nervous system and the cranial bones, often related to craniomandibu-lar disorders (see Plates XC and XD). As the compensatory scoliosis group was characterized by a short-leg syndrome we made an analysis regarding also this issue.

We had the opportunity, for a second study involving the same group of subjects, to measure both lower limbs with various techniques (visual and instrumental) with the aim of ascertaining the intra- and inter-rater reliability of each method. The visual inspection of pelvic obliquity and the correction of it using lift blocks under the short leg in the standing position and the visual appreciation of tibial and femoral shortening following the classical orthopedic examination73 proved to be the best diagnostic tools. The examination was performed by two independent observers and gave some unexpected results as 181 of 311 girls and boys showed various short-leg patterns. A right or left short tibia or femur was found in 51.9% in this group, followed by the combination of short tibia and short femur on the same side in 32.6%. In a minority of cases a further combination was found of short tibia and femur on the opposite side: 21 subjects showed a right short tibia and a left short femur; 7 showed a left short tibia and a right short femur (in total 15.5%). These cases were excluded from the analysis and in the remaining group of 153 girls and boys we compared first the total number of nevi with the rest of the subjects showing a symmetrical length of the lower limbs. The difference was significant since the average number of nevi was respectively 2.1 and 1.6 (P<0.05).

Applying paired samples t-test to the distribution of nevi on the right and left ear, we obtained a significantly higher number of nevi on the right ear in case of right short tibia (P<0.05) and in all categories comprehending a short tibia or femur of the right lower limb (P<0.02). The left short tibia and the short femur, however, did not show any difference (Table 4.9A).

The hypothesis that an incomplete growth of the bones of the lower limb could be associated with an asymmetrical distribution of nevi on the auricle was subsequently verified in a group of adults in my practice, in whom skeletal growth was complete.

I examined 127 consecutive adults (average age 35.8 years, range 18-69, SD 12.8) bearing at least one nevus on their ears, in both standing and lying positions. In the latter position I measured the distance twice between the anterior inferior iliac spine (AIIS) and the medial malleolus with a tape-measure. I calculated the average of two measurements, which appears to have acceptable validity and reliability when used as a screening tool.74

I found 79 subjects with a shorter leg (42 on the right and 37 on the left) with an average number of 4.6 nevi, and 48 subjects with equal length of the lower limbs with an average of 3.1 nevi; the difference was significant (P<0.001). Considering the distribution of nevi on the auricle according to the various short-leg patterns, we obtained a significantly higher number of nevi on the right ear for the right short leg and in a similar way a higher number of nevi on the left ear for the left short leg (P<0.001). Only 10 subjects with short right femur did not show any difference (Table 4.9B). If we report the location of all nevi corresponding to the short side (left side of Fig. 4.19), whether right or left, we may visually better appreciate their greater number compared to the contralateral side

Table 4.9A Short-leg patterns and distribution of nevi on an average age of 12.9 years

the right and left ear

in 153 girls and boys with

Number of subjects

Average number of nevi on the right ear

Average number of nevi on the left ear


Right short tibia





Left short tibia





Right short femur





Left short femur





Right short tibia and right short femur





Left short tibia and left short femur





All categories (right short tibia or right short femur)





All categories (left short tibia or left short femur)





Table 4.9B Short-leg patterns and distribution of nevi age of 34.7 years

on the right and left ear

in 79 adults with an


Number of subjects

Average number of nevi on the right ear

Average number of nevi on the left ear


Right short tibia





Left short tibia





Right short femur





Left short femur





Right short tibia and right short femur





Left short tibia and left short femur





All categories (right short tibia or right short femur)





All categories (left short tibia or left short femur)





Adam Auricular Acupuncturist Chart
number of nevi in case of short femur or short tibia are colored. Dots = lateral surface; circles = medial surface.

(right side of Fig. 4.19). What is interesting is the distribution of the nevi on the auricle: in the first rank is the helix with 31.6%, followed by the ear lobe with 24.9% and the medial surface with 18.6%. If, however, we sum all nevi belonging to the helix, whether located on its lateral or its medial side, we obtain 43.6% of the total. The full importance of the helix has yet to be revealed and meanwhile we must be satisfied with collecting further fragments of the mosaic. I could not understand, for example, why sectors 12 and 13, which consistently belong to the topographic representation of the neck, should carry a significantly higher number of nevi in case of short tibia and femur. On the other side it is perhaps easier to interpret the higher number of nevi on sector 20 for the short tibia (P<0.05) and on sector 21 for the short femur (P<0.005). Both sectors may indeed be related to the representation of the lower limb according to Nogier's map and the Chinese standardization (left side of Fig. 4.19).

In the case of Plate XB, the 43-year-old lady pictured showed at least four nevi on the left ear and only one on the right. The pelvic obliquity in a standing position, the visual appreciation of a short left tibia and the measurement of the distance between the AIIS and the medial malleolus were consistent with the finding of a ~13 mm shorter left leg.

From this second series of analyses some further elements emerged relating to the possible role of auricular nevi indicating, on the same side of the body, developmental or growth defects of the skeletal system as in the case of short-leg syndrome. However, follow-up observation should be carried out on the same subjects over time, starting from infancy, to distinguish the congenital nevi from those acquired and to understand if their appearance can be associated with musculoskeletal disorders manifesting themselves at puberty or in adulthood.


The crus cymbae has been described in Chapter 3 as a possibly dominant morphological trait consisting of a more or less raised and extended ridge in the upper concha.

Nogier wrote on this subject in 1956 describing the case of a young lady whom he had been treating since she was 16 years old because she was suffering from hypertension of unknown origin. He said:

one day on inspection of the ears I saw an anomaly of the kidney area (in the upper part of the concha) shaped like a vertical cartilaginous ridge. As the patient was a young girl suffering with hypertension and slight albuminuria I concluded that she probably had a congenital anomaly of the kidney manifesting itself on the corresponding auricular area.75

Nguyen76 tried to verify this possibility examining 45 consecutive subjects bearing crus cymbae and 80 (40 male and 40 female) patients of a control group without this sign.

For each patient he recorded the following data: previous surgery of the urinary tract; previous syndromes/symptoms of the urinary tract such as kidney diseases, calculi, prostate diseases and hematuria; previous recurrent urinary infections needing further diagnosis with imaging techniques. He found 13 patients (28.9%) in the first group compared to 6 (7.5%) in the control group who had undergone surgery for prostate adenoma (8 cases), renal cystic disease (2 cases), bladder pap-illoma (2 cases) and cystocele (1 case). The other patients bearing crus cymbae had various symptoms such as recurrent bladder infection, hematuria, suspected renal colic with or without calculi, etc. What is perhaps interesting in Nguyen's observational study is the surprisingly high number of anomalies of the genitourinary tract. Indeed two females aged 35 and 63 years, had, respectively, a ureteropelvic duplication and a non better defined congenital anomaly of the uterus. Furthermore a male subject aged 54 suffering with recurrent urinary infection had a son with a ureteral duplication.

Unfortunately I did not come across as many cases as Nguyen, therefore my experience on this subject is not of much value. In a couple of cases, however, I could demonstrate a nephroptosis with a downward displacement of the kidney and in some other cases recurrent urinary infection with calculi, without any demonstration of congenital anomalies, as in the case in Figure 4.20.

What is interesting in Nogier's case report is the further confirmation that the first representation of the kidney area was indeed on the upper concha where the Chinese still locate the kidney (CO10 shen). It is still not clear why, in the contemporary French map, the kidney and the ureter (but not the bladder) have been shifted to the ascending part of the helix.

Fig. 4.20 Crus cymbae in a 43-year-old female affected by recurrent urinary infections and calculi.


There are some articles in the literature about this odd and apparently out of place aspect of diagno sis. Given the enormous diagnostic possibilities offered today by the various imaging techniques it would appear to be completely unnecessary to rely also on the inspection of the outer ear in cases of tumor. Nevertheless it is still feasible that a tumor could be hidden and diagnosis made too late. This may, and in fact does, occur often in the following cases: the subject is asymptomatic and does not consider it necessary to consult a physician; the subject has no time or is not willing to participate in prevention campaigns, for example for breast, colon or prostate cancer; the subject presents unclear symptoms for which he has not yet completed all the tests focused on excluding such a possibility. In any case the chance of an acupuncturist being approached by a patient with a hidden tumor, asking to be treated for example for pain presenting due to a primary neuromuscular disorder, is not so remote. As the information needed for preventing cancer is vast and involves several aspects of a person's life, it is perhaps possible to obtain some clues also from an auricular inspection.

In Western countries only Nguyen and I have published case reports of patients with tumors: Nguyen found, in the case of adenoma of the prostate gland, a nodule of the French area of representation of the ureter, and a sebaceous cyst in the fossa ovalis corresponding to the Chinese representation of the uterus.77

In my first article dedicated to the topic of inspection (with Vettori) I published two case reports of lung cancer. A circumscribed atrophic area with desquamation in the first case and an atrophic depressed area in the second case were visible in the middle of the lower concha on the same side as the lesion.78

The China Academy of TCM and several authors such as Zhu Dan79 have published numerous articles on this topic and identified two main specific tumor areas, n. I and II, on the ear lobe and the helix. These areas, according to different authors, have a variable extension: the former corresponds to sectors 4-9, the latter to sectors 15-19 of my Sectogram.

Li-Chun Huang80 wrote about area n. II, describing 'a dark grey color, dark brown color or a color of fly droppings which will fade if pressed; and small nodule(s) in specific area II indicate a tumor in the body'. The China Academy of TCM named the areas zhongliuteyiqu I and II respectively, but a further area (III) was also proposed on the back of the helix precisely overlapping n. II (Fig. 4.21). Another three points shortly named tumor (zhongliu 1, 2 and 3)

Tumor specific region II (lateral surface)

Tumor specific region II (lateral surface)

Fig. 4.21 Representation of tumor-specific areas I-III and tumor points 1-3 according to the China Academy of TCM.

Tumor 1

Tumor 2

Tumor 3 (medial surface)

Tumor specific region III (medial surface)

Tumor specific -region I (lateral surface)

Fig. 4.21 Representation of tumor-specific areas I-III and tumor points 1-3 according to the China Academy of TCM.

were located by the China Academy, the first on the tragus, the remaining two on sector 10: number 2 on the lateral surface of the helix, number 3 on the medial surface, about 2 mm below the former. Other areas have been proposed by Zhu Dan for an early diagnosis of tumor, such as the representation of the internal ear, subcortex, endocrine, adrenal cortex and gluteus muscles. The standardization process has almost completely abandoned these representations and retained only one zone, Lower Tragus (TG2 xiaping).

We designed a project to verify if the assertions of the Chinese authors made before standardization had been of some significance or not. Two pupils, Miriam Manetti and Gianfranco Matera, independently examined a series of consecutive patients in the departments of oncology at their hospitals. For each patient, age, sex, histology and stage of the tumor were recorded and each visible skin alteration was then photographed and recorded on the Sectogram. A preliminary communication on this research was presented as a poster at the European Traditional Medicine (ETM) International Congress held on 4-6 October 2007 in Vinci.81

The number and the type of skin alterations of 165 patients with various types of cancer were compared with those of a sex- and age-matched group of patients of mine without any current or past history of tumor. As regards the distribution of skin alterations in the two groups we found no significant differences for tumor area I (sectors 15-19) and tumor areas II and III (sectors 4-9). We therefore could not confirm the specificity of these areas in the diagnosis of tumor. Nevertheless our research was not useless as we found some striking differences for some particular skin alterations such as angioma.

It has to be remembered that angioma is itself an extremely common benign tumor, made up of newly formed blood vessels, and resulting from the malformation of angioblastic tissue during fetal life. The angioma usually seen on the auricle are tiny and have a diameter of 1-5 mm; when pressed with the fingertip they characteristically disappear and reappear. My impression, in singular cases, that this sign could be associated with some kind of tumor was confirmed by this larger observational study. The number of these vascular skin alterations was 1.54 in the cancer group vs. 0.44 in the control patients (P<0.001). Not all types of tumor showed the same tendency to manifest angioma on the auricle; especially tumors of the breast, lung, colon, stomach and the genitourinary system seemed to show a higher concentration on the helix, anthelix and ear lobe. The confounding aspect of these observations is that frequently angi-oma tend to develop on parts of the ear which apparently are not the representation of the corresponding site of the tumor. Only in some cases of breast, lung and stomach tumor did we find this kind of correspondence.

Despite the small numbers of patients ranked according to different types of cancer, which are a limiting factor for any further analysis, we can nevertheless notice that the sectors where angioma are located may still have a relation to the corresponding somatotopic areas according to Nogier's alignment principle. If we consider, for example, the distribution of angioma in two groups of 11 patients with cancer of the lung and colon we can see that, despite their apparent similarity, in the first group (on the left of Fig. 4.22) there is a higher number of angioma on the lower concha and the antitragus whereas in the second group they tend to spread toward the superior part of the helix (on the right of Fig. 4.22). An advisable strategy, in case the reader were to dedicate himself to this type of observation, could be not to rely too much on single sectors but to take account of larger parts of the ear. For example, in the case of breast cancer, 20 patients out of a total of 32 (62.5%) showed particularly tiny angioma especially on the lower half of the anthelix and helix (on the left of Fig. 4.23), some of them coinciding with Nogier's and the Chinese representation of the chest (see Plate VIIID). Moreover, if we consider patients with benign adenomas of the thyroid gland we can see that there is a basic overlapping in the distribution of angioma (on the right of Fig. 4.23).

This study is continuing with the aim of identifying a possible specificity of angioma for particular types of cancer. Some provisional conclusions can be reported:

1. The specific tumor areas proposed by the Chinese do not show a different concentration of skin alterations in cancer and control patients. The sectors thought to be specific when presuming the presence of a hidden tumor probably have per se a higher concentration of skin alterations as shown in Figure 4.7.

2. Cancer patients have a higher number of angioma compared to the control group, but

Segmentale Innervation Organe
Fig. 4.22 Location of angioma in 11 patients with lung cancer (on the left) and in 11 patients with cancer of the colon (on the right). Dots = lateral surface; circles = medial surface.
Fig. 4.23 Location of angioma in 20 patients with breast cancer (on the left) and 10 patients with adenomas of the thyroid gland (on the right). The cross on the upper helix (on the left) indicates an angioma of the internal (hidden) border.

probably only specific types of tumor show a higher rate of this skin alteration.

3. Also patients declaring benign tumors such as adenomas of the thyroid and prostate (see Plate VIIIA), adenomas and papillomas of the breast (see Plate VIIIB, C) and uterine myomas in their case history may show a larger number of angi-oma compared to control patients.

4. Angioma tend, however, to be concentrated on areas which do not coincide with the presumed representation of the affected organ. Sometimes there is a segmental representation on the helix which roughly follows a subdivision of the abdominal and thoracic organs. Therefore cancer of abdominal organs such as the colon, kidney or prostate perhaps could be represented more in the upper part of the ear, while cancer of the thoracic organs such as the lung instead could be represented more on the lower part of the ear.

5. However, no information can be given as regards the issue of laterality in the distribution of angi-oma. Seemingly, in the case of lesion of one of two coupled organs and/or in the case of metastases of one side of the body, a higher distribution of angioma can be foreseen on the auricle located on the same side. Nevertheless a much larger sample of patients is needed to clarify this issue.

The reader will allow me to add a last consideration on this subject about the interesting association of stasis of Blood and tumors in TCM. According to Maciocia:82

abdominal masses are always characterized by either stagnation of qi or stasis of Blood, the former being non-substantial and the latter substantial masses. In addition to stagnation, there may also be Phlegm. However, in all cases of abdominal masses there is always an underlying deficiency of qi. Deficient qi fails to transport and transform and, leading to stagnation of qi and Blood, it allows masses to form.

As reported in the validation of auricular diagnosis in Chapter 9, the inspection of the outer ear seems to give better results than the other two methods commonly used, namely the pain pressure test (PPT) and the electrical skin resistance test (ESRT). This section reports unpublished data on the possibilities offered by inspection for diagnosing different syndromes, with the aim of giving practitioners a simple tool for integrating diagnostic procedures with their patients. The following paragraphs are based on the observation of 325 patients, evaluated between 2004 and 2007, examined blindly with the three methods mentioned above. For the methodology applied the reader is invited to consult Chapter 9.

I have always felt the urge to find one or more clues to cast light on the issue of whether acupuncture is of value in treating mental disorders. In my opinion this is a promising field for research but different reasons have hampered its growth. One of the reasons may be the reduced and incomplete terminology adopted by textbooks of acupuncture. In an article published in 2005 with the title 'Why is clinical research on acupuncture in psychiatric disorders so lacking?'83 I reported, with colleagues, the results of a survey among 67 GPs and 42 psychiatrists; 50.7% of the first group and 26.2% of the second had regularly practiced acupuncture for at least 3 years. The colleagues were invited to rate all symptoms, listed in two Chinese textbooks published approximately 20 years apart (1975 and 199785), among the therapeutic indications for every acupuncture point, as primarily psychological/ psychiatric, psychosomatic or somatic. The symptoms were considered prevalently somatic by the majority of colleagues. A consistent interpretation of a psychological/psychiatric term was reached in the first textbook for the following 11 conditions: hysteria, schizophrenia, mental disorder, mania, anorexia, anxiety, neurasthenia, neurosis, insomnia, dream-disturbed sleep, poor memory; only six terms reached an agreement in the second text: mania, depression, anorexia, irritability, insomnia, globus hystericus.

The conclusions of my survey were that:

even in recent years Chinese acupuncture books report a reduced and incomplete list of psychological/psychiatric terms compared to medical literature. This may be one of the reasons for the apparent lack of interest in the West for controlled clinical trials evaluating acupuncture's effect on psychiatric disorders. Potential researchers in this field should include patients according to the internationally accepted classifications of


mental disorders and choose an adequate acupuncture treatment according to the syndromes of TCM.

As regards ear acupuncture the situation was no better than that of acupuncture until a few years ago. Recently, however, in the West, several trials have been published applying different types of auricular stimulation such as acupuncture, acupressure, press needles and Vaccaria seeds, mainly for anxiety and insomnia, and to a lesser extent for phobias and depression.86-97


As a general practitioner and an acupuncturist, in my observation of the outer ears of hundreds of people a year I took the following signs into consideration because I felt they were of special clinical value:

1. depressed areas and incisures of the upper part of the ear lobe

2. incisures and drills of the antitragus and the scapha

3. nevi of the anterior part of the ear lobe

4. comedones of the lower concha

5. telangiectasia of the upper and lower concha.

These signs were compared in two groups of patients: the first group bore the specific sign; the other did not and was considered a control group. The groups were always compared, when possible, for t-test for independent samples.

1. Depressed areas and incisures of the upper part of the ear lobe

These are quite similar to those reported in Chapter 3 (Fig. 3.10) as descriptive non-hereditary characters referred to in the literature by anatomists and anthropologists. Depressions and incisures in this area may be more or less evidenced; in two out of three cases they are tender to PPT (Fig. 4.24, numbers 1 and 2) (see Plates XIIC and XIID). My clinical intuition has always been that this area could be associated with mood disorders. In effect 75.8% of patients bearing one of these signs, compared to the control group (43.5%), declared or confirmed depression or symptoms consistent with this diagnosis. The difference was highly significant

drills, incisures, creases depressed areas

Fig. 4.24 Depressed areas, grooves and incisures of the upper and posterior parts of the ear lobe. For their possible clinical significance see the text.

using Student's t-test (P<0.001). Insomnia, which is one of the important symptoms accompanying mood disorders, was also represented more in the first group (51.5%) compared to the control group (34.9%) but did not reach a significant level. It has to be noticed that this area coincides with Nogier's representation of the hypothalamus and partially with the Chinese temple area (AT2 nie), both of which also report partially consistent indications such as headache, insomnia and dizziness. Anxiety and related disorders such as panic attacks and phobias on the other hand showed no significant differences. In conclusion, this area appears to be important for the diagnosis of mood disorders. In all probability it should be included in any treatment for regulating mood (see also Chapters 5 and 7).

2. Deepening of the anthelix-antitragus notch and/or deepening of the final part of the scaphoid groove

These have been considered together because they are both aligned on sectors 8 and 9 and are supposed to have similar significance (Fig. 4.24, numbers 4 and 6). Out of 78 patients, 49 showed the first pattern and 11 the second, and 18 showed both patterns. My intuition that they were associated with sleep disorders proved to be exact: in effect 61.5% of subjects bearing one or both of these signs were bad sleepers compared to 28.7% of the control group (P<0.001). Depression was also represented more in the first group (64.1%) than in the control group (41.3%); but the difference did not reach a significant level. In this area, at

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