Nasagata roga

NASAGATA ROGA
Definition: Diseases of the Nose (Nasa).

Sushruta 31
Vaghbata 18
Sharangadhara 18
Yogaratnakara / Bhavaprakasha 34

[Link] Sushruta-31 Vagbhata-18 Dosha Correlation

1. Apeenasa Apeenasa V-K Atrophic/Chronic
Rhinitis
2. Putinasya Putinasa VPK Atrophic rhinitis
3. Nasapaka Nasapaka P Furunculosis of Nose
4. Nasagata Raktapitta - R-P Epistaxis
5. Puyarakta Puyarakta VPK Frontal Sinusitis/ CSF
Rhinorrhoea
6. Kshavathu Bhrushakshava V-K Vasomotor/Allergic
Rhinitis
7. Bhramshathu - K-P Chronic Rhinitis
8. Deepta Deepti P Acute Rhinitis
9. Nasanaha Nasanaha K-V Nasal obstruction/DNS
10. Nasa Parisrava Nasa srava K CSF Rhinirrhoea
11. Nasa shosha Nasika shosha K-V Rhinitis Sicca
12-15. Nasa arsha Nasa arsha (1 type) V-P-K-Tri Nasal Polyp
16-19. Nasa shopha - V-P-K-Tri Nasal oedema
20-26. Nasa arbuda Nasa arbuda (1 type) V-P-K-Tri- Rakta- Tumors of Nose
Mamsa and Meda
27-33. Pratishyaya Pratishyaya (5 types) V-P-K-R-Tri
17. Putaka Tridosha
18. Dusta pratishyaya -
 Nasagata roga

अपीनसः पू ितन ं नासापाक थैव च ।

तथा शोिणतिप ं च पू यशोिणतमेव च ।।

वथु शथुद ो नासानाहः प र वः ।

नासाशोषेण सिहता दशैका े रता गदाः ।।

च ायशािस च ारः शोफाः स ाबु दािन च ।

ित ाया ये प व े सिचिक ताः ।

एकि ं श ता े तु नासारोगाः कीितताः ।। (S U 22/5)

1) APINASA

Sushruta:

आन ते य िवधू ते च ते शु ित चािप नासा ।

न वे ि यो ग रसां ज ुजु ं व े मपीनसेन ।।

तं चािनल े भवं िवकारं ू यात् ित ायसमानिल म् । (Su. U. 22/6)

Dalhana: आन ते कफेन िप शोिषतेन आन त इव। िवधू ते धूमायत इव, िप ात्; ते आ भवित कफात्;
शु ित िप ात्। ग रसान् ग ान् रसां े थः; अ े तु ग रसा ग रसाः, रसतेग थ ात्; याथात े न ग ं
जानाती थः। व े त् जानीयात्। केिचदमुं पाठम था पठ , स चादशना िल खतः।।

Due to Vata and kapha prakopa:

 Obstruction to the nasal passage (due to kapha dried by ushnata of pitta)

 Feels like smoke is coming out of nasal passage – due to pitta
 Sometimes nasal discharge will be there (due to kapha) and sometimes it will be very dry
(shusyati – due to pitta)
 Loss of sensation of gandha and rasa
 Symptoms similar to Pratishyaya
Note: though Apeenasa is due to Vata kapha, Sushruta has added pitta in the explanation but
Vagbhata has not added pitta in his explanation.

Vagbhata:

कफः वृ ो नासायां द् ा ोतां पीनसम्।

कुया घु घुर ासं पीनसािधकवे दनम्॥

अवे रव व ा तेन नािसका।

अज ं िप लं पीतं प ं िस ाणकं घनम्॥ (A.H. U. 19/20-21)

 Nasagata roga

सवा सु रा:-कफो नासायां वृ ो द् ा ोतां पीनसं घुघुर ासयुतं पीनसािधक जं कुयात्। तेन-अपीनसेन, अ
रोिगणो मे ष े वानवरतं ा नािसका िप लािदयु ं कफं िस ाणकं वित।

 Pravruddha kapha create obstruction in Nasa and causes Apinasa

 Patient wheezes during breathing (indicates difficulty in breathing)
 More painfull than pinasa
 Nose will be wet and continuous nasal discharge will be there like sheep nose
 Nasal discharge will be picchila, peeta varnayukta and pakva.
Chikitsa:

Sushruta:

पू व ि े पू ितन ेचज ोः ेह े दौ छदनं ं सनं च ।

यु ंभ ं ती णम ं लघु ादु ं तोयं धू मपानं च काले ।। (Su. U. 23/3)

अपीनसपूितन योि िक ामाह- पूव ि े इ ािद। पूव ि े अपीनसे इ थः। छदनं वमनं, ं सनं िवरे कः।
कृतशु े र ःसंसग िनयमय ाह- यु िम ािद। तोय पानं िनयमय ाह- उ ं तोयिम ािद। काले धूमपानकाले।

Chikitsa for Apinasa and Putinasya are same.

 Snehana, svedana, vamana and virecana

 Teekshna, alpa and laghu ahara should be given
 Ushna jala sevana
 Dhoomapana at proper time (yogya kala)

िहङ् गु ोषं व का ं िशवाटी ला ा बीजं सौरभं कट् फलं च ।

उ ा कु ं ती णग ा िवड ं े ं िन ं चावपीडे कर म् ।।

एतै ैः साषपं मू यु ं तैलं धीमा हे तोः पचेत । (Su. U. 23/4)

तयोरे वावपीडमुि श ाह- िहङ्गु ोषिम ािद। ोषं ि कटु कम् । िशवाटी े तपुननवा, शेफािलके े। उ ा वचा,
ती णग ा शोभा नकः। अवपी दीयत इ ावपीडः। केिचदमु मेव पाठम था पठ , स चादशना िल खतः।।४।।

अपीनसपूितन योरे तैरेवावपीडन ैन ाथ तैलसाधनमाह- एतै ै र ािद। केिचत् "अ न् तैले यु तः स चेत
मि ां वै ोतिस णाथ, इित पठ , स चाचायरनाष कृतः।

 Avapidana nasya should be given using drugs like hingu, trikatu, indrayava, shveta
punarnava, laksha, tulasi beeja, katphala, vaca, kustha, shighru beeja, vidanga and karanja
beeja.

Vagbhata:

कफपीनसव ूितनासापीनसयोः ि या।

ला ाकर म रचवे िहङ् गुकणागु डैः॥

 Nasagata roga

अिवमू ुतैन ं कारये मने कृते।

िश ु िसंहीिनकु ानां बीजैः स ोषसै वै ः॥

सवे सुरसै ैलं नावनं परमं िहतम्। (A.H. U. 20/22)

सवा सु रा:-पूितनासापीनसयोः कफपीनसवदु प मः। ला ािदिभ र मू ु तैः कृते वमने न ं कारयेत्।

िश ्वादीनां बीजै षािदयुतै ै लं प ं पूितनासापीनसयोन ं िहतम् ।

 Chikitsa of Putinasa and Apinasa are similar to that of kaphaja pinasa.

 After vamana, nasya prayoga with drugs like laksha, karanja, marica, vidanga, hingu,
pippali, guda with avi mootra (goat’s urine).
 Nasya with taila prepared using seeds of shighru-bruhati-kumbha, trikatu, saidhava,
vidanga and tulasi.

Atropic Rhinitis
Atrophic rhinitis, is a chronic inflammation of nose characterised by atrophy of nasal mucosa,
including the glands, turbinate bones and the nerve elements supplying the nose.

It is a chronic condition characterized by progressive atrophy of nasal mucosa and underlying

bone of the turbinates.

The presence of dried thick crusts, which emits a foul odor called ozaena (a stench), is
characteristic.

Chronic atrophic rhinitis may be primary and secondary. Special forms of chronic atrophic
rhinitis are rhinitis sicca anterior and ozaena. It can also be described as empty nose syndrome.

Causes:

Causes can be remembered by the mnemonic HERNIA:

 Hereditary factors: the disease runs in families

 Endocrine imbalance: more common in females and starts during puberty
 Nasagata roga

 Racial factors: white people are more susceptible than natives of equatorial Africa
 Nutritional deficiency: vitamins A or D, or iron
 Infection: Klebsiella ozaenae, diphtheroids, Proteus vulgaris, E. coli, etc.
 Autoimmune factors: viral infection or some other unidentified insult may trigger antigenicity
of the nasal mucosa.

Pathogenesis:

 The ciliated columnar epithelium of the nasal mucosa is replaced by stratified squamous
epithelium.
 Atrophy of mucosa, turbinal bones and seromucinous glands tends to occur, due to
obliterative endarteritis and periarteritis causing decreased blood supply, hence the supplying
area atrophies.
 Arrested development of paranasal sinuses.

Symptoms:

 The nasal cavities become roomy and are filled with foul smelling crusts which are black
or dark green and dry, making expiration painful and difficult.
Microorganisms are known to multiply and produce a foul smell from the nose, though
the patients may not be aware of this, because the nerve endings (responsible for the
perception of smell) have become atrophied. This is called merciful anosmia.
 Patients complain of nasal obstruction despite the roomy nasal cavity, which can be
caused either by the obstruction produced by the discharge in the nose, or as a result of
sensory loss due to atrophy of nerves in the nose, so the patient is unaware of the air flow.
In the case of the second cause, the sensation of obstruction is subjective.
 Bleeding from the nose, also called epistaxis, may occur when the dried discharge (crusts)
are removed.
 Septal perforation and dermatitis of nasal vestibule can occur. The nose may show a
saddle-nose deformity.
 Atrophic rhinitis is also associated with similar atrophic changes in the pharynx or larynx,
producing symptoms pertaining to these structures.
 Hearing impairment can occur due to Eustachian tube blockage causing middle
ear effusion.
Permanent loss of smell and impairment of taste may also be a result of this disease, even after the
symptoms are cured.
Diagnosis:
 Nasal crusts filling the entire nasal cavity, foeter, and increased volume of the nasal cavity
due to shrinkage of turbinates.
 Anterior rhinoscopy
 Fibreoptic, using nasendoscopy.
 Nasagata roga

 CT scan-to confirm the diagnosis and review disease extent.

Treatment:
Medical treatment-
 Nasal irrigation with warm normal saline- loosens the cruts and removes thick tenacious
discharge and crusts are then removed by forceps. It can help reduce crusting in the nose
by improving tissue hydration.
 Nasal cavity is painted with 25% glucose in glycerine- Inhibits growth of proteolytic
organisms and decreases foul smell.
 Kemicetine antiozena nasal spray- eliminate secondary infection.
 Oestradiol nasal spray- increases vascularity
 Systemic Streptomycin 1g/day for 10 days- reduces crusting and bad odour.
 Oral potassium iodide- liquefies nasal secretion.
A short course of antibiotics may be added to reduce the infection.
Surgical treatment:
 In patients with persistent crusting, modified Young’s operation in which the nostrils are
partially closed with flaps raised from inside the nasal cavity, leaving a 3-mm hole for
breathing, helps in the regeneration of normal nasal mucosa.
 Narrowing of nasal cavities by:
A) Internal submucosal injection of Teflon paste
B) Insertion of fat, cartilage, bone or Teflon strips under mucoperiosteum.
C) Medical displacement of lateral nasal wall.
 Nasagata roga

2) PUTINASYA
Sushruta:
दोषैिवद ै गलतालुमूले संवािसतो य समीरण ु ।।

िनरे ित पू ितमुखनािसका ां तं पू ितनासं वद रोगम् । (Su. U. 22/7)

पूितनास ल णमाह- दोषै र ािद। र मिप दोष ेन िववि तं, तेन दोषै रित ब वचनम् । िवद ै ः मू तैः
प ु तैवा। संवािसतः िप े र ै रा िवकृितग ेन िम ीकृतः। िनरे ित िनग ित, पूितः शिटतग ो वायुः।।

The vidagdha dosha(including rakta) which are present in gala and talu moola gets stagnated there
and hence vayu carries durgandha (fetid smell of vidagha dosha) from nasa and mukha (breath
with foul smell) and this condition is called putinasya.

Vagbhata:

तालुमूले मलैदु ैमा तो मुखनािसकात्।

े ा च पू ितिनग े त् पू ितनासं वद तम्॥ (A.H. U. 19/23)

सवा सु रा:-तालु मूले दोषै दु ै मुखनािसकाद् वायुः कफ पूितिनग े त्, तं पूितनासं वद ।

Because of dushita dosha in talumoola there will be fowl smelling breath and kapha coming out
of mukha and nasika. This condition is known as putinasa.

Accordin to Videha:

MüTüÌmɨÉqÉç AxÉ×ÎaqÉ´ÉÇ xÉÎgcÉiÉÇ qÉÔÎklÉï SåÌWûlÉÉqÉç |

ÌuÉSakÉqÉÔwqÉhÉÉ aÉÉRÇû ÂeÉÉÇ M×üiuÉÉÅͤÉzÉÇZÉeÉÉqÉç ||
iÉiÉÈ mÉëxÉlSiÉå bÉëÉhÉÉiÉç mÉÔÌiÉ zÉmÉÏiÉMüqÉç |
mÉÔÌiÉlÉxrÉliÉÑ iÉÇ ÌuɱÉiÉç bÉëÉhÉMühQÕûeuÉUmÉëSqÉç ||
Sanchita kapha-pitta along with rakta gets stagnated in head region and becomes solidified due to
ushma in that region and thus causes:
 Pain in akshi and shankha pradesha (eyes and temporal region)
 Srava from Nasa wchich is pita varna(yellow colored), durgandha yukta(foul smelling)
and rakta mishrita.
 Even the breath becomes durgandha yukta
 There will itching sensation in nose and jwara associated with this condition.

Charaka:

uÉæuÉhrÉïSÉæaÉïlkrÉqÉÑmÉå¤ÉrÉÉ iÉÑ xrÉÉiÉç mÉÔÌiÉlÉxrÉÇ µÉrÉjÉÑpÉëqÉ¶É || (Cha. Chi. 26/113)

Vaivarnya, dourgandhya, shotha in nasa will be there associated with bhrama.
 Nasagata roga

Chikitsa:

A) According to Sushruta- Chikitsa for Apinasa and Puti nasya are same (As explained in
Apinasa)
B) According to Vagbhata In Puti nasa and apinasa Kapha pinasa chikitsa should be done
i.e. Vamana and then Nasya prayoga.
C) According to Yogaratnakara:
 Vyaghri taila nasya:
urÉÉbÉëÏSliÉÏuÉcÉÉÍzÉaÉëÑxÉÑUxÉÉurÉÉåwÉÍxÉlkÉÑeÉæÈ |
ÍxÉkSÇ iÉæsÉÇ lÉÍxÉ Í¤ÉmiÉÇ mÉÔÌiÉlÉÉxÉÉaÉSÉmÉWûqÉç || (Y. R)
Nasya with taila prepared by vyaghri, danti, vaca, shighru, tulasi, trikatu and saindhava
lavana will cure putinasya.

 Shighru taila nasya:

ÍzÉbÉëÑÍxÉÇWûÏÌlÉMÑüqpÉÉlÉÉÇ oÉÏeÉæÈxÉurÉÉåwÉ xÉælkÉuÉæÈ |
ÌoÉquÉmɧÉUxÉå ÍxÉkSÇ iÉæsÉÇ xrÉÉiÉç mÉÔÌiÉlÉxrÉlÉÑiÉç || (Y.R)
Nasya with taila prepared out of shighru, kantakaari, danti beeja,trikatu, saindhava
lavana, bilvapatra.

Correlation- Atrophic rhinitis

 Nasagata roga

3) NASAPAKA
Sushruta:

ाणाि तं िप म ं िष कुया न् िवकारे बलवां पाकः ।।

तं नािसकापाकिमित व ेि ेदकोथाविप य ौ। (Su. U. 22/8)

नासापाक ल णमाह- ाणाि तिम ािद। अ ं िष णान् । िव ेद आ भावः, कोथः पूितभावः, एतौ य य न्
िवकारे , ौ दशनं गतौ।।

 Prakupita pitta present in Nasa causes arumshi (ulcer/boil/wound) which undergoes

severe suppuration (balavan paka).
 Pakva arumshi specially causes kleda (discharge/dampness) and kotha (putibhava i.e.
putrified). This condition is called Nasapaka.

Vagbhata:

पचे ासापु टे िप ं ांसं दाहशूलवत्॥

स ाणपाकः (A.H. U. 19/18)

सवा सु रा:-िप ं कतृ नासापुटे ां सं सदाहशू लं पचेत् स ाणपाका ः।

Charaka:

xÉSÉWûUÉaÉÈ µÉrÉjÉÑÈ xÉmÉÉMüÈ xrÉÉSè bÉëÉhÉmÉÉMüÉåÅÌmÉ cÉ U£üÌmɨÉÉiÉç || (Cha. Chi. 26/115)

Due to prakopita rakta and pitta in Nasa there will be daha (burning sensation), raga(redness) and
swayathu(oedema), this is called ghranapaka.

Chikitsa:

नासापाके िप ंिवधानं काय सव बा मा रं च ।।

ार ं ीरवृ च सा ाः सेका योजनीया लेपाः । (Su. U. 23/5)

नासापाके भे षजमाह- नासापाके इ ािद। बा ं ले पा प रषे कािद, आ रं पुनराहार ेहपानिवरे चनािद। सा ाः

सघृताः।।५।।

 All bahya (lepa, abhyanga, parisheka etc.) and abhyantara (ahara, snehapana, virecana
etc.) pitta hara chikitsa should be performed.
 Raktamokshana with jalouka and then seka/prakshalana of nasa with kashaya of tvak of
khseeri vruksha (vata etc.).
 Ghruta mishrita lepa prayoga.
 Nasagata roga

Vagbhata:

पाके दी ौ च िप ं ती णं न ािद सं ु तौ॥ (A.H. U. 20/20)

सवा सु रा:-नासापाके दी ौ च िप ं िचिक तम्। सं ु तौ- ावे, ती णं न ािद िहतम् ।

In Nasapaka and Deepti, pitta nashaka chikitsa should be done. Teekshna nasya is beneficiary if
srava is present.

FURUNCULOSIS OF NOSE

Acute infection of hair follicles by staphylococcus aureus.

Etiology:

 Picking of nose.
 Plucking of hairs of nose.

Causitive organism: Staphylococcus aureus.

Clinical features:

 Very painful swelling at the tip of nose.

 A small, red and tender swelling seen in the vestibule.

Treatment:

 Warm compress
 Systemic analgesics
 Topical and systemic antibiotics
 If abscess present incision and drainage is done

Precautions: Furuncle should not be squeezed or permanently incised- as infection may spread to
cavernous sinus.
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4) NASAGATA RAKTAPITTA

Sushruta:

चतुिवधं ि भवं ि माग व ािम भूयः खलु र िप म् ।। (Su. U. 22/9)

र िप ल णमनागतावे णेन िनिदश ाह- चतुिवधिम ािद। चतुिवधं वातिप कफसि पाता कम् । ि भवं ौ भवौ
यकृ ीहानौ य तं तथा; अ े तु ि ो भे देन ि ि कारणं म े; अपरे तु
ि भवमामाशयप ाशय भवमा ः। ि मागम् अधरो रमाग यम् ।।

Chaturvidha: 4 types of nasagata raktapitta: Vata, Pitta, Kapha and Sannipataja

Dviprabhavam: 1. Yakrut and Pleeha sthita raktapitta

2. Snigdha and Ruksha

3. Amashaya and Pakvashaya

Dvimarga: Urdvaga and Adhoga raktapitta

Nirukti of Raktapitta:

xÉÇrÉÉåaÉÉiÉç SÕwÉhÉÉiÉç iɨÉÑ xÉÉqÉÉlrÉÉiÉç aÉlkÉuÉhÉïrÉÉåÈ |

U£üxrÉ ÌmɨÉqÉÉZrÉÉiÉÇ U£üÌmɨÉÇ qÉlÉÏÌwÉÍpÉÈ ||

Chikitsa:

व ा ू र िप ोपशा ं (Su. U. 23/6)

र िप ानागतावे णेन स े पाथ िचिक तमाह- व ा ू िम ािद। ऊ र िप ितषे धे। उपशा ं िचिक तं
"नासा वृ े जलमाशु दे यं सशकरं नािसकया पयो वा" इ ािदकम् ।६।

Urdwaga raktapitta: Virechana is the line of treatment.

Nasagata Raktapitta is sadhya: as virechana is the best treatment for pitta and as there is
abundance of drugs that are available.

Raktapitta chikitsa:

a) Balavan rogi:
 Initially rakta sthambana should not be done.
If done so, it leads to complications like Pandu, grahani, kusta, pleeha vruddhi,
gulma and jwara.
 Shodhana chikitsa- Virechana in urdhwaga raktapitta
 Apatarpana chikitsa by langhana
 Samshamana chikitsa: Raktasthambaka and Raktapitta hara chikitsa
 Nasagata roga

b) Balaheena rogi:
 Santarpana chikitsa
 Samshamana chikitsa- Rakta sthambaka and Raktapitta shamaka chikitsa

Abhyantara chikitsa:

 Yakrt sevana along with pitta

 Laksha, rasanjana with honey
 Vamshalochana churna sharkara and madhu

In Nasapravrutta raktapitta:

bÉëÉhÉmÉëuÉרÉå eÉsÉqÉÉzÉÑ SårÉÇ xÉzÉMïüUÇ lÉÉÍxÉMürÉÉ mÉrÉÉå uÉÉ |

SìɤÉÉUxÉÇ ¤ÉÏUbÉ×iÉÇ ÌmÉoÉå²É xÉzÉMïüUÇ cɤÉÑUxÉÇ ÌWûqÉÇ uÉÉ || (Su. U. 45/40)

 Administration of water or milk dissolved with sugar via nose (nasapana).

 Administration Draksha rasa with sharkara through nostrils.
 Ksheera ghruta (ghee that comes out by churning milk, butter) with sharkara
 Ikshurasa nasapana

Dhatri lepa: Haritaki pieces fried in ghee and lepana over shiras and over nasa- bleeding stops
within seconds (Y.R)

Nasya:

 Dadima svarasa nasya

 Durva swarasa nasya
 Amrasthi svarasa nasya
 Palandu rasa nasya
By these bleeding can be stopped.

Acc to Bhaishajya ratnavali:

UxÉÉå SÉÌQûqÉmÉÑwmÉxrÉ SÒuÉïUxÉ xÉqÉÎluÉiÉÈ |

AsÉ£üMüUxÉÉåmÉåiÉÈ mÉjrÉrÉÉ uÉÉ xÉqÉÎluÉiÉÈ ||
lÉxrÉÈ mÉërÉÉåÎeÉiÉÈ Í¤ÉmÉëÇ Ì§ÉSÉåwÉqÉÌmÉ SåÌWûlÉÉqÉç |
lÉÉxÉÉU£Çü mÉëuÉרÉliÉÑ WûlrÉÉSåuÉ lÉ xÉÇzÉrÉÈ || (B.R. Raktapitta)
Dadim pushpa rasa mixed with durvarasa, laksha or haritaki svarasa and nasya should be given.
This cures tridoshaja and nasagata raktapitta.
 Nasagata roga

Chakradatta:

EkuÉïaÉå iÉmÉïhÉÇ mÉÔuÉïÇ MüiÉïurÉÇgcÉ ÌuÉUåcÉlÉqÉç |

In urdvaga raktapitta initially apatarpana should be given so that the patient will not loose bala,
mamsa and agni. Then virechana should be given.

Santarpana yoga in urdhwaga raktapitta:

iÉmÉïhÉÇ xÉbÉ×iɤÉÉæSì-sÉÉeÉcÉÔhÉæïÈ mÉëSÉmÉrÉåiÉç |

FkuÉïaÉÇ U£üÌmɨÉÇ iÉiÉç mÉÏiÉÇ MüÉsÉå urÉmÉÉåWûÌiÉ ||

Laja choorna should be taken with ghruta and madhu for santarpana in urdhwaga raktapitta.

Santarpana jala:

 eÉsÉÇ ZÉeÉÔïUqÉײÏMüÉ qÉkÉÑMæüÈ xÉmÉÃwÉMæüÈ |

´ÉÑiÉzÉÏiÉÇ mÉërÉÉå£üurÉÇ iÉmÉïhÉÉjÉïÇ xÉzÉMïüUqÉç ||

Shruta sheeta (kashaya ------) prepared by adding kharjura, mrudvika, madhuka, parushaka to
water and boiling it and added with sugar can be given for tarpana.

 ̧ÉuÉ×iÉÉ Ì§ÉTüsÉÉ zrÉÉqÉÉ ÌmÉmmÉsÉÏ zÉMïüUÉ qÉkÉÑ |

qÉÉåSMüÈ xÉͳÉmÉÉiÉÉåkuÉïU£üÌmɨÉeuÉUÉmÉWûÉ ||

Modaka prepared by trivrt, triphala, shyama trivrt, pippali, sharkara and madhu- sannipata,
urdwaga raktapitta and jwara hara.

EPISTAXIS

Bleeding from inside the nose is called epistaxis.

It is fairly common and is seen in all age groups—children, adults and older people. Epistaxis is a
sign and not a disease per se.

Blood supply of Nose:

Internal Carotid artery Opthalmic artery 1. Anterior ethmoidal artery

2. Posterior ethmoidal artery

Externa Carotid artery a. Facial artery- Septal branch of superior labial artery

b. Maxillary artery- 1. Greater palantine artery

2. Branch of spheno palantine artrey
Venous drainage:-
Ethmoildal veins – 1. Opthalmic veins
2. Cavernous sinus
 Nasagata roga

Sphenopalatine veins- 1. Pterygoid plexus

2. Maxillary veins

LITTLE’S AREA: It is situated in the anterior inferior part of nasal septum, just above the
vestibule. Four arteries—anterior
anterior ethmoidal,
ethmoidal, septal branch of superior labial, septal branch of
sphenopalatine and the greater palatine, anastomose here to form a vascular plexus called
“Kiesselbach’s plexus.” This area is exposed to the drying effect of inspiratory current and to
finger nail trauma,
uma, and is the usual site for epistaxis in children and young adults.

Retrocolumellar vein: This vein runs vertically downwards just behind the columella, crosses the
floor of nose and joins venous plexus on the lateral nasal wall. This is a common site of venous
bleeding in young people.

WOODRUFF’S PLEXUS: It is a plexus of veins situated inferior to posterior end of inferior

turbinate. It is a site of posterior epistaxis in adults.

Causes:
They may be divided into: 1. Local, in the nose or nasopharynx.
nasopha
2. General.
3. Idiopathic.

A. Local causes:

Nose:-

1. Trauma: Finger nail trauma, injuries of nose, intranasal surgery, fractures of middle third of
face and base of skull, hard-blowing
hard of nose, violent sneeze.

2. Infections: (a) Acute: Viral rhinitis, nasal diphtheria, acute sinusitis.

 Nasagata roga

(b) Chronic: All crust-forming diseases, e.g. atrophic rhinitis, rhinitis sicca,
tuberculosis, syphilis septal perforation, granulomatous lesion of the nose, e.g.
rhinosporidiosis.
3. Foreign bodies: (a) Nonliving: Any neglected foreign body, rhinolith.
(b) Living: Maggots, leeches.
4. Neoplasms of nose and paranasal sinuses:
(a) Benign: Haemangioma, papilloma.
(b) Malignant: Carcinoma or sarcoma.
5. Atmospheric changes: High altitudes, sudden decompression (Caisson disease).
6. Deviated nasal septum.

Nasopharynx:
1. Adenoiditis.
2. Juvenile angiofibroma.
3. Malignant tumours.

B. General causes:

1. Cardiovascular system: Hypertension, arteriosclerosis, mitral stenosis, pregnancy

(hypertension and hormonal).

2. Disorders of blood and blood vessels: Aplastic anaemia, leukaemia, thrombocytopenic and
vascular purpura, haemophilia, Christmas disease, scurvy, vitamin K deficiency and hereditary
haemorrhagic telangectasia.

3. Liver disease: Hepatic cirrhosis (deficiency of factor II, VII, IX and X).

4. Kidney disease: Chronic nephritis.

5. Drugs: Excessive use of salicylates and other analgesics (as for joint pains or headaches),
anticoagulant therapy (for heart disease).

6. Mediastinal compression: Tumours of mediastinum (raised venous pressure in the nose). 7.

Acute general infection: Influenza, measles, chickenpox, whooping cough, rheumatic fever,
infectious mononucleosis, typhoid, pneumonia, malaria and dengue fever.

8. Vicarious menstruation (epistaxis occurring at the time of menstruation).

C. Idiopathic:

Many times the cause of epistaxis is not clear.

Sites of bleeding in epistaxis:

1. Little’s area.

2. Above the level of middle turbinate

3. Below the level of middle turbinate

4. Posterior part of nasal cavity.

 Nasagata roga

5. Diffuse. Both from septum and lateral nasal wall. This is often seen in general systemic
disorders and blood dyscrasias

6. Nasopharynx

Classification of Epitaxis:

2. Anterior Epistaxis: When blood flows out from the front of nose with the patient in sitting
position.
3. Posterior epistaxis: Mainly the blood flows back into the throat. Patient may swallow it and
later have a “coffee-coloured” vomitus. This may erroneously be diagnosed as
haematemesis.

Management:

1. First aid:

 Bleeding from the Little’s area and can be easily controlled by pinching the nose with thumb
and index finger for about 5 min. This compresses the vessels of the Little’s area.
 In Trotter’s method patient is made to sit, leaning a little forward over a basin to spit any
blood and breathe quietly from the mouth.
 Cold compresses should be applied to the nose to cause reflex vasoconstriction.

2. Cauterization: Useful in anterior epistaxis when bleeding point has been located. The area is
 Nasagata roga

first topically anaesthetized and the bleeding point cauterized with a bead of silver nitrate or
coagulated with electrocautery.
3. Anterior Nasal packing: If bleeding is profuse and/or the site of bleeding is difficult to
localize, anterior packing should be done. For this, use a ribbon gauze soaked with liquid
paraffin. About 1 m gauze (2.5 cm wide in adults and 12 mm in children) is required for each
nasal cavity. First, few centimetres of gauze are folded upon itself and inserted along the
floor and then the whole nasal cavity is packed tightly by layering the gauze from floor to the
roof and from before backwards. Packing can also be done in vertical layers from back to the
front. One or both cavities may need to be packed. Pack can be removed after 24 h, if
bleeding has stopped. Sometimes, it has to be kept for 2–3 days; in that case, systemic
antibiotics should be given to prevent sinus infection and toxic shock syndrome.
4. Posterior nasal packing:
It is required for patients bleeding posteriorly into the throat.
A postnasal pack is first prepared by tying three silk ties to a piece of gauze rolled into the
shape of a cone. A rubber catheter is passed through the nose and its end brought out from the
mouth. Ends of the silk threads are tied to it and catheter withdrawn from nose. Pack, which
follows the silk thread, is now guided into the nasopharynx with the index finger. Anterior
nasal cavity is now packed and silk threads tied over a dental roll.

5. Endoscopic cauterization: Using topical or general anaesthesia, bleeding point is localized

with a rigid endoscope. It is then cauterized with a malleable unipolar suction cautery or a
bipolar cautery.

6. Elevation of mucoperichondrial flap and sub mucous re-section (SMR) operation: In

case of persistent or recurrent bleeds from the septum, just elevation of mucoperichondrial
flap and then repositioning it back helps to cause fibrosis and constrict blood vessels.

7. Ligation of vessels: External carotid, Maxillary and Ethmoidal arteries.

8. Embolisation: Internal maxillary artery is localized and the embolization is performed with
absorbable gelfoam and/ or polyvinyl alcohol or coils.
 Nasagata roga

5. PUYASHONITA
Sushruta:

दोषैिवद ै रथवाऽिप ज ोललाटदे शेऽिभहत तै ु।

नासा वे त् पू यमसृ िम ं तं पू यर ं वद रोगम् ।। (Su. U. 22/10)

पूयर ं दोषाग ुिनिम ं दशय ाह- दोषै र ािद। िवद ैः िप र ािध ाि ां प रणितं ा ै ः। ललाटािभघातोऽिप
िव पाकं ा ो म ः।।१०।।

There is of two types of causative factors:

1. Nija karana- Vidagdha doshotpadaka nidana

2. Agantuja karana- Abhighata on forehead etc.
due to above mentioned nidana there will be flow of puya along with rakta from nose.

Vagbhata:

िनचयादिभघाता ा पू यासृङ्नािसका वे त्।

त ूयर् अ मा ातं िशरोदाह जाकरम्॥ (A.H. U. 19/24)

सवा सु रा:-सि पातादिभघाता ा नासा पूयासृक् वेत्। त ू यर स् अं ं िशरोदाह जाकरमा ातम् ।

 Because of vitiation of tridosha or due to abhighata there will be flow of puya along with
rakta from nose.
 There will be daha and ruja (burning sensation and pain) in shira.

Charaka:

bÉëÉlÉÉiÉç xÉëuÉå²É ´ÉuÉhÉÉlqÉÑZÉÉ²É ÌmɨÉÉ£üqÉxÉëÇ iuÉÌmÉ mÉÔrÉU£üqÉç || (Cha. Chi. 26/116)

Condition in which pitta yukta rakta (rakta mixed with pitta) flowing out of nose, ears and mouth
is called puyarakta.

Chikitsa:

नाडीव ात् पू यर े िचिक ा ।।

वा े स क् चावपीडं वद ती णं घू मं शोधनं चा न म् । (Su. U. 23/6-7)

 In Puyarakta, treatment should be like that of Nadivrana

 Vamana followed by Avapidaka nasya prayoga.

 Teekshna dhoomapana and shodhana nasya prayoga should be done

पूयर िवधानमाह- नाडीविद ािद। पूयर े नाडीवत् नाडीतु ा िचिक ा, या िवसपनाडी नरोगिचिक ते
ा ाता।।६।।
 Nasagata roga

पूयर े सामा ां िचिक ामिभधाय िवशे षिचिक ामाह- वा े इ ािद। अ पूयर े ; अ े तु "अ े ित नासापाके" इित
ा ानय । केिचत् "वा े स क्" इ ािदकं वथौ ं शथौ च योजय ।

Vagbhata:

पू यर े नवे कुयाद् र पीनसवत् मम्॥

अित वृ े नाडीवत् (A.H. U. 20/23)

सवा सु रा:-पूयर े नवो े र पीनस इव िचिक तं कुयात्। अित वृ े चा ाडी णवदु प मः।

 In nava puyarakta (initial stages) – Chikitsa like that of Rakta pinasa should be done
 In pravuddha puyarakta (later stages) - Chikitsa of nadi should be performed
Charaka:

mÉÔrÉÉxÉëå U£üÌmɨÉblÉÉÈ MüwÉÉrÉÉ lÉÉuÉlÉÉÌlÉ cÉ |

In puyasra raktapitta nashaka kashaya and nasya should be given.

Yogaratnakara:

mÉÔrÉÉxÉëå U£üÌmɨÉblÉÉÈ MüwÉÉrÉÉ lÉÉuÉlÉÉÌlÉ cÉ |

mÉÉMüSÉWûÉÌS UÉåaÉåwÉÑ zÉÏiÉÉ sÉåmÉÉÌSMüÉÈ Ì¢ürÉÉÈ ||
 In puyasra raktapitta nashaka kashaya and nasya should be given.
 In case of paka and daha – sheeta lepadi kriya

CSF Rhinorrhoea

Leakage of cerebrospinal fluid from the subarachnoid space to nasal cavity.

Leakage of CSF into the nose is called CSF rhinorrhoea. It may be clear fluid or mixed with blood
as in acute head injuries
 Nasagata roga

Causes:

1. Trauma: Most of the cases follow trauma. It can be accidental or surgical. Surgical
trauma includes endoscopic sinus surgery, trans-sphenoidal hypophysectomy, nasal
polypectomy or skull base surgery. In endoscopic sinus surgery, CSF leak may be
immediate or delayed in onset.

2. Inflammations: Mucoceles of sinuses, sinunasal polyposis, fungal infection of sinuses

and osteomyelitis, can all erode the bone and dura.

3. Neoplasms: Tumours, both benign and malignant, invading the skull base.

4. Congenital lesions: Meningocele, meningoencephaloceles and gliomas can have

associated skull base defect.

5. Idiopathic: Where cause is unknown and patient has spontaneous leak.

Sites of leakage:

CSF from anterior cranial fossa reaches the nose via

(i) Cribriform plate

(ii) Roof of ethmoid air cells or
(iii) Frontal sinus.
CSF from middle cranial fossa follows injuries to sphenoid sinus. In fractures of
temporal bone, CSF reaches the middle ear and then escapes through the eustachian tube
into the nose (CSF otorhinorrhoea)

Symptoms:

 Unlateral, clear, watery fluid comes from nose

 Frequent attack of purulent meningitis with rhinorrhoea
 Headache

Diagnosis:

 Hand kerchief sign: History of clear watery discharge from the nose on bending the head
or straining. CSF does not stiffens whereas other nasal secretions stiffens it.
It may be seen on rising in the morning when patient bends his head (reservoir sign—
fluid which had collected in the sinuses, particularly sphenoid, empties into the nose). CSF
rhinorrhoea should be differentiated from nasal discharge of allergic or vasomotor rhinitis
as the former is sudden, gushes in drops when bending and cannot be sniffed back.
 Halo test: CSF rhinorrhoea after head trauma is mixed with blood and shows double
target sign when collected on a piece of filter paper. It shows central red spot (blood) and
peripheral lighter halo.
 Nasal endoscopy can help to localize CSF leak in some cases.
 Otoscopic/microscopic examination of the ear may reveal fluid in the middle ear in cases
of otorhinorrhoea.
 CT and MRI – to locate the damage
 Nasagata roga

Laboratory tests:

Beta-2 transferrin is a protein seen in CSF and not in the nasal discharge. The specimen of nasal
discharge is tested for this protein. Perilymph and aqueous humour are the only other fluids which
contain this protein.

Another protein called beta trace protein is also specific for CSF and is widely used in Europe. It
is secreted by meninges and choroid plexus

Treatment:

Early cases of post-traumatic CSF rhinorrhoea can be managed by conservative measures such as
bed rest, elevating the head of the bed, stool softeners, and avoidance of nose blowing, sneezing
and straining.

Prophylactic antibiotics can be used to prevent meningitis.

Acetazolamide decreases CSF formation. These measures can be combined with lumbar drain if
indicated.

Surgical repair can be done by the following:

1. Neurosurgical intracranial approach.

2. Extradural approaches such as external ethmoidectomy for cribriform plate and ethmoid area,
trans-septal sphenoidal approach for sphenoid and osteoplastic flap approach for frontal sinus
leak.

3. Transnasal endoscopic approach. With the advent of endoscopic surgery for nose and sinuses,
most of the leaks from the anterior cranial fossa and sphenoid sinus can be managed
endoscopically with a success rate of 90% with first attempt.

Principles of repair include:

(a) Defining the sites of bony defect. It can be (i) Cribriform plate (ii) Lateral lamina close to
anterior ethmoid artery (iii) Roof of ethmoid (iv) Frontal sinus leak (v) Sphenoid sinus

(b) Preparation of graft site.

(c) Underlay grafting of the fascia extradurally followed by placement of mucosa (as a free graft
or pedicled flap)

d) If bony defect is larger than 2 cm, it is repaired with cartilage (from nasal septum or auricular
concha) followed by placement of mucosa.

(e) Placement of surgicel and gelfoam further strengthens the area. This is followed by a high
antibiotic smeared nasal [Link] fat from the thigh or abdomen is used to plug the defect
in place of fascia graft.

(f) Lumbar drain if CSF pressure is high.

 Nasagata roga

(g) Antibiotics

CSF leak from frontal sinus often requires osteoplastic flap, operation and obliteration of the sinus
with fat.

Acute Sinusitis

Acute inflammation of sinus mucosa is called acute sinusitis. The sinus most commonly involved
is the maxillary followed in turn by ethmoid, frontal and sphenoid.

A. Exciting causes:

 Nasal infections
 Swimming and diving
 Trauma
 Dental infections

B. Predisposing causes:

 Obstruction to sinus ventilation and drainage: Any factor(s) which interfere with
ventilation of sinuses can cause sinusitis due to stasis of secretions in the sinus.
They are: (a) Nasal packing
(b) Deviated septum
(c) Hypertrophic turbinates
(d) Oedema of sinus ostia due to allergy or vasomotor rhinitis
(e) Nasal polypi
(f) Structural abnormality of ethmoidal air cells
(g) Benign or malignant neoplasm.
 Stasis of secretions in the nasal cavity. Normal secretions of nose may not drain into the
nasopharynx because of their viscosity (cystic fibrosis) or obstruction (enlarged adenoids,
choanal atresia) and get infected.
 Previous attacks of sinusitis. Local defences of sinus mucosa are already damaged.

General:

 Environment: Sinusitis is common in cold and wet climate. Atmospheric pollution,

smoke, dust and overcrowding also predispose to sinus infection.
 Poor general health: Recent attack of exanthematous fever (measles, chickenpox,
whooping cough), nutritional deficiencies and systemic disorders (diabetes, immune
deficiency syndromes).
 Nasagata roga

6. KSHAVATHU

According to Acharya Sushruta Kshavathu is of 2 types:

1. Doshaja kshavathu
2. Agantuja kshavathu

1) Doshaja kshavathu:

ाणाि ते ममिण स दु े य ािनलो नािसकया िनरे ित ।।

कफानु यातो ब शः सश ं रोगमा ः वथुं िविध ाः । (Su. U. 22/11)

वथु रिप दोषज ाग ुज , त पूव दोषजमे व िनिदश ाह- ाणे ािद। ाणाि ते ममिण ाटका े; " ाणाि ते
ममिण" इ " ाणाि ते े िण" इित केिचत् पठ ।।११।।

The shrunghataka marma present in nasa when gets affected/vitiated (dushita), the prakupita vaya
over there gets associated with kapha again and again comes out of nasa with shabda (sound).

2) Agantuja kshavathu:

ती णोपयोगादितिज तो वा भावान् कटू नकिनरी णा ा ।।

सू ािदिभवा त णा थमम ुद्घािटतेऽ ः वथुिनरे ित । (Su. U. 22/12)

आग ुजं वथु माह- ती णोपयोगािद ािद। अितिज तः आ ायतः। भावान् ािण। त णा थमम नासावंशा थमम
ाटकस म् । उद् घािटते ऊ चािलते।।१२।।

Excessive consumption of teekshna dravyas, excessing inhalation of katu dravya, excessive

staring at sun, putting thread etc. in nose frequently, the tarunasthi marama i.e, shrunghataka
marma gets stimulated and hence leads to agantuja kshavathu.

Vagbhata: (Bhrushakshava)

ती णा ाणोपयोगाकर सू तृणािदिभः।

वातकोिपिभर ैवा नािसकात णा थिन॥

िवघि तेऽिनलः ु ो ः ाटकं जेत्।

िनवृ ः कु तेऽ थ वथुं स भृश वः॥ (A.H. U 19/15)

सवा सु रा:-ती ण -मरीचादे ः, ाणात्-िसंहनात्, तथा रिवर ािदिभवातकोिपिभर ैवा नासात णा थिन िवघि ते
सित वायुः कृ ो ः ाटकं ग े त्। स िनवृ ः सन् अ ं िछ ां कु ते। स भृ श व उ ते

Teekshna dravya aghrana(inhalation), excessive exposure to sunrays, insertion of sutra(thread) or

truna(grass) etc. into nose and other Vata prakopakara nidana causes vighattana (rubbing/injury)
 Nasagata roga

of tarunasthi and prakupita vata reaches shrunghataka marma. The vata coming out of it causes
frequent sneeze and is called bhrushakshava.

Chikitsa:

Sushruta:

े ंन ं मूधवै रेचनीयैना ा चूण वथौ ंशथौ च ।।

कुयात् े दान् मूि वातामय ान् ि ान् धू मान् य द ि तं च । (Su. U. 23/7)

वथौ ं शथौ च िचिक ामाह- े िम ािद। न िमित धमनिम थः, प िवध ा । मू धवैरेचनीयैः
िशरोिवरे चन ैः। धमनेन ीणे कफे वाते च वृ े सित अिनल ान् ि ािन थः। अ िदित
िशरोब म ािदकम्।।७।।

 Same line of treatment in both kshavathu and bhrushathu

 Pradhamana nasya should be permormed using shirovirechaka dravya (like vidanga,
apamarga beeja choorna etc.)
 Swedana should be given after pradhamana (In case of ksheena kapha due to pradhamana)
 In case of vata vruddhi by pradhamana nasya, snigdha dhoomapana and other vatahara
chikitsa like shirobasti, mastishka etc. should be adapted.

Vagbhata:

वथौ पु टका े च ती णैः धमनं िहतम्।

शु ीकु कणावे ा ाक कषायवत्॥

सािधतं तैलमा ं वा न ं वपु ट णुत्। (A.H. U 20/18)

सवा सु रा:- वथौ पुटका े च रोगे ती णैः धमनं िहतम् । शु ािदक ाथवत् तैलं घृतं वा सािधतं न ं वं पुटं
चह ।


In kshavathu and Putaka same line of treatment is followed

Teekshna pradhamana nasya should be administered

Nasya with taila or ghruta prepared with kalka and kashaya of shunti, kustha, pippali,
vidanga, draksha
Yogaratnakara:

bÉëÑiÉaÉÑaaÉÑsÉÑÍqÉ´ÉxrÉ ÍxÉYjÉMüxrÉ mÉërɦÉiÉÈ |

kÉÔqÉÇ ¤ÉuÉjÉÑUÉåaÉblÉÇ pÉëÇzÉjÉÑblÉÇ cÉ ÌlÉÌuÉïzÉåiÉç ||
In kshavathu and bhrushathu, dhoomapana with mixture of ghruta, guggulu and sikta(bee wax)
shoul be performed.
zÉÑhPûÏMÑü¸MühÉÉÌoÉsuÉSìɤÉÉMüsMüMüwÉÉrÉuÉiÉç |
iÉæsÉÇ mÉYuÉqÉjÉÉÅÅerÉÇ uÉÉ lÉxrÉÉiÉç ¤ÉuÉjÉÑlÉÉzÉlÉqÉç ||
Nasya with taila or ghruta prepared with kalka and kashaya of shunti, kustha, kanaa, bilva and
draksha.
 Nasagata roga

Co-relation – Allergic/ Vasomotor rhinitis:

VASOMOTOR RHINITIS

It is a non-allergic rhinitis but clinically stimulating nasal allergy with symptoms of Nasal
obstruction, rhinorrhoea, and sneezing.

The condition usually persists throughout the year.

"Vaso" means blood vessels and "motor" refers to the nerves, which innervates nasal tissue and
the blood vessels. This is sometimes referred to as idiopathic non-allergic rhinitis.

Etiology:

Although the etiology of vasomotor rhinitis is not well understood, it is thought to be associated
with the dysregulation of sympathetic, parasympathetic, and nociceptive nerves innervating the
nasal mucosa.

The imbalance among mediators results in increased vascular permeability and mucus secretion
from the submucosal nasal glands.

Pathogenesis:

Sympathetic stimulation

Causes Vaso-constriction and shrinkage of mucosa

Dys-regulation

Parasympathetic stimulation

Causes vasodilatation and engorgement Vasomotor Rhinitis

Autonomic nervous system is under the control of hypothalamus and therefore emotions play a
great role in this disease.

Nasal mucosa is also hyper-reactive and responds to several non-specific stimuli, e.g change in
temperature, humidity, blasts of air, smoke or dust.

Symptoms:

 Paroxysmal sneezing- Bouts of sneezing starts just after getting out of the bed in the
morning.
 Excessive rhinorrhoea- Profuse and watery nasal discharge and may even wet few
handkerchiefs.
 Nasal obstruction- Alternates from side to side. Usually more marked at night.
 Post-nasal drip
 Nasagata roga

Signs:

Nasal mucosa over turbinates is generally congested and hypertrophic. In some it may be normal.

Complications:

 Nasal polypi
 Hypertrophic rhinitis
 Sinusitis

Treatment:

I. Medical:
 Avoidance of physical factors which provoke symptoms
 Antihistamines and oral nasal decongestants- to relieve nasal obstructions,
sneezing and rhinorrhoea.
 Topical steroids like beclomethasone dipropionate, used as spray or aerosol
 Systemic steroids- for a short time in very severe cases.
 Psychological factors should be removed. Tranqullizers may be required in some
patients.
II. Surgical:
 Nasal obstruction relieved to reduce the size of turbinates and associated causes
like polyli, DNS needs appropriate correction.
 Vidian neurectomy- Sectioning the parasympathetic secretomotor fibres to nose, in
case of excessive rhinorrhoea, not corrected by medical therapy.

Note: Honeymoon rhinitis: Usually follows sexual excitement leading to nasal stuffiness.
 Nasagata roga

7. BHRAMSHATHU

Vagbhata has not explained this disease.

ते नािसकयैव य सा ो िवद ो लवणः कफ ु ।।

ाक् सि तो मूधिन िप त ं ंशथुं ािधमुदाहर । (Su. U. 22/13)

ं शथोल णमाह- त इ ािद। ते अ थमधः पतित नािसकयैव, न मु खेन।।१३।।

Previously sanchita Sandra, vidagdha, lavana kapha dosha in shiras gets liquefied by taapa(heat)
of pitta and comes out of Nasa. This vyadhi is called bhrushathu.

Chikitsa:

Same as explained in kshavathu.

े ंन ं मूधवै रेचनीयैना ा चूण वथौ ंशथौ च ।।

कुयात् े दान् मूि वातामय ान् ि ान् धू मान् य द ि तं च । (Su. U. 23/7)

Co-relation- Chronic rhinitis

 Nasagata roga

8. DEEPTA

Sushruta:

ाणे भृशं दाहसम ते तु िविनःसरे द् धू म इवे ह वायुः ।।

नासा दी ेव च य ज ो ािधं तु तं दी मुदाहर । (Su. U. 22/14)

दी ल णमाह- ाणे भृ शिम ािद। िविनःसरे त् िनयाित। वायुः िन ासः। दी े व िलतेव नासा ात्।।१४।।

Condition in which there will be burning sensation in nasa, the exhaled air feels like smoke is
coming out of nose, and patient feels like his nose is burning, is called as deepta.

Vagbhata:

र े न नासा द े व बा ा ः शनासहा।

भवे द्धू मोपमो ासा सा दी दहतीव च॥ (A.H. U. 19/22)

सवा सु रा:-र े न नासा द ेव बा तोऽ रत शनं न सहते। तथा धूमोपमो ासा दहतीव च। सा दी सं ा
रोगजाितः।

 Because of rakta,
 Touch will be unbearable/painful internally and externally.
 Uchwasa (exhalation) feels like smoke is coming out of nose.
 Feeling of burning will be there in the nose.

Chikitsa:

Sushruta:

दी े रोगे पै ि कं संिवधानं कुयात् सव ादु य ीतलं च ।। (Su. U. 23/8)

दी रोग िचिक ामाह- दी े इ ािद। संिवधानं कम थः, सव बा ा रम् ।।८।।

In deepta, pittahara chikitsa should be adopted and madhura sheetala chikitsa should be carried
out both externally and internally.

Vagbhata:

पाके दी ौ च िप ं ती णं न ािद सं ु तौ॥ (A.H. U 20/20)

सवा सु रा:-नासापाके दी ौ च िप ं िचिक तम्। सं ु तौ- ावे, ती णं न ािद िहतम् ।

 In nasapaka and deepta, pittahara chikitsa should be adapted.

 If srava is present then teekshna nasya can be done.
 Nasagata roga

Yogaratnakara:

lÉxrÉÇ ÌWûiÉÇ ÌlÉqoÉUxÉÉgeÉlÉÉprÉÉÇ SÏmiÉå ÍzÉUÈxuÉåSlÉqÉsmÉzÉxiÉÑ |

lÉxrÉå M×üiÉå ¤ÉÏUeÉsÉÉuÉxÉåMüÉlÉç zÉÇxÉÎliÉ pÉÑgeÉÏiÉ cÉ qÉѪrÉÔwÉæÈ ||
 Nimba and rasanjana nasya
 Mrudu shira svedana
 After nasya seka with ksheera and jala
 Mudga yusha sevana

ACUTE RHINITIS

Acute rhinitis can be viral, bacterial or irritative type.

VIRAL RHINITIS

1. Common cold (coryza):

 Aetiology. It is caused by a virus. The infection is usually contracted through airborne
droplets. Several viruses (adenovirus, picornavirus and its subgroups such as
rhinovirus, coxsackie virus and enteric cytopathic human orphan virus) are
responsible. Incubation period is 1–4 days and illness lasts for 2–3 weeks.
 Clinical features: a. There is burning sensation at the back of nose soon followed by
nasal stuffiness, rhinorrhoea and sneezing.
b. Patient feels chilly and there is low-grade fever.
c. Initially, nasal discharge is watery and profuse but may become
mucopurulent due to secondary bacterial invasion.
d. Secondary invaders include Streptococcus haemolyticus, pneumococcus,
Staphylococcus, Haemophilus influenzae, Klebsiella pneumoniae and
Moraxella catarrhalis.
 Treatment:
 The disease is usually self-limiting and resolves spontaneously after 2–3 weeks.
Bed rest is essential to cut down the course of illness.
 Plenty of fluids are encouraged. Symptoms can be easily controlled with
antihistaminics and nasal decongestants.
 Analgesics are useful to relieve headache, fever and myalgia. Nonaspirin
containing analgesics are preferable as aspirin causes increased shedding of virus.
 Antibiotics are required when secondary infection supervenes.
 Complications. Occasionally, complications such as sinusitis, pharyngitis, tonsillitis,
bronchitis, pneumonia and otitis media may result.

2. Influenzal rhinitis: Influenza viruses A, B or C are responsible. Symptoms and signs are
similar to those of common cold.

3. Rhinitis associated with exanthemas: Measles, rubella and chickenpox are often associated
with rhinitis which precedes exanthemas by 2–3 days. Secondary infection and complications are
more frequent and severe.
 Nasagata roga

BACTERIAL RHINITIS

Nonspecific infections: It may be primary or secondary. Primary bacterial rhinitis is seen in

children and is usually the result of infection with pneumococcus, streptococcus or
staphylococcus. A greyish white tenacious membrane may form in the nose, which with
attempted removal causes bleeding.

Secondary bacterial rhinitis is the result of bacterial infection supervening acute viral rhinitis.

Diphtheritic rhinitis: Diphtheria of nose is rare these days. It may be primary or secondary to
faucial diphtheria and may occur in acute or chronic form. A greyish membrane is seen covering
the inferior turbinate and the floor of nose; membrane is tenacious and its removal causes
bleeding. Excoriation of anterior nares and upper lip may be seen. Treatment is isolation of the
patient, systemic penicillin and diphtheria antitoxin.

IRRITATIVE RHINITIS

 This form of acute rhinitis is caused by exposure to dust, smoke or irritating gases such as
ammonia, formaline, acid fumes, etc. or it may result from trauma inflicted on the nasal
mucosa during intranasal manipulation, e.g. removal of a foreign body.
 There is an immediate catarrhal reaction with sneezing, rhinorrhoea and nasal congestion.
 The symptoms may pass off rapidly with removal of the offending agent or may persist for
some days if nasal epithelium has been damaged. Recovery will depend on the amount of
epithelial damage and the infection that supervenes.
 Nasagata roga

9. NASAANAHA/ NASAPRATINAHA

Anaha means avarodha i.e. obstruction.

Obstruction to the nasal passage is called a Nasa anaha.

Sushruta:

कफावृ तो वायु दानस ो यदा माग िवगु णः थतः ात् ।।

ाणं वृ णोतीव तदा स रोगो नासा तीनाह इित िद ः । (Su. U. 22/15)

नासा तीनाहल णमाह- कफावृत इ ािद। नासा ितन ते ब त इव वातेनेित नासा तीनाहः।।१५।।

When udana vayu gets avruta by kapha, gets vitiated/looses its properties and gets stagnated in its
own passage, then it causes obstruction in nasal passage. This is called Nasapratinaha.

Vagbhata:

नासानाहे तु जायते।

न िमव नासायाः े े न वायुना॥

िनः ासो ाससंरोधात् ोतसी संवृते इव। (A.H. U. 19/17)

सवा सु रा:-नासानाहा े रोगे जाते सित ाण न ं-आपूरिमव, जायते। े णा े न वातेन

िनः ासो ाससंरोधात् ोतसी संवृते इव ाताम्।

By vata dosha which is blocked by kapha, there will be obstruction to inhalation and exhalation in
the nasal passage.

Chikitsa:

नासानाहे ेहपानं धानं ि ा धू मा मूधब िन म् ।

बलातैलं सवथैवोपयो ं वात ाधाव दु ं च य त् ।। (Su. U. 23/9)

नासानाहिचिक ामाह- नासानाहे ेहपानिम ािद। ेहपानम् उ रभ कम् । मू धब े ित चकारात्

सा णोपनाहादयो गृ े। सवथै वेित पाना ानुवासनिशरोब म ािदिभः सवरे व कारै ः। अ त्
अणुतैलािदकम् ।।९।।

 Uttarabhaktaka snehapana should be administered

 Nitya upayoga of snigdha dhooma pana, shiro basti, salvana upanaha etc.
 Bala taila can be used for all snehana purposes i.e, pana-abhyanga-anuvasana-basti-
shirobasti.
 Other treatment explained for vatavyadhi , like anutaila etc. prayoga can be carried out.
 Nasagata roga

Vagbhta:

नासानाहे ऽ यं िविधः। (A.H. U. 20/19)

सवा सु रा:-नासानाहे ऽ ेष एव िविधः-िचिक े थः।

In nasanaha, chikitsa is same as Nasashosha.

नासाशोषे बलातैलं पानादौ भोजनं रसैः॥

ि ो धू म था े दो

सवा सु रा:-नासाशोषे बलातैलं पानन ादौ िहतम् । भोजनं मां सरसैिहतम् । तथा ि ो धूमः ेद िहतः।

Yogaratnakara:

 Goghruta pana is indicated.

NASAL OBSTRUCTION

Nasal obstruction or blocked nose is one of the most commonly occurring problem.

Causes:

 Infections: Common cold, flu, and sinus infections

 Allergens: It occurs due to allergens such as pollen, dust, mites etc.
 Vasomotor rhinitis
 Structural abnormalities:
1. DNS
2. Hypertrophied turbinates
3. Nasal polyps
4. External valve collapse
5. Bent or twisted nose
6. Adenoid hypertrophy

 Foreign body in nose

 Tumors of nose
 Nose injury

DEVIATED NASAL SEPTUM

This is an important cause of nasal obstruction.

Aetiology:

 Trauma and errors of development form the two important factors in the causation of deviated
septum.
 Nasagata roga

1. Trauma: A lateral blow on the nose may cause displacement of septal cartilage from the
vomerine groove and maxillary crest, while a crushing blow from the front may cause
buckling, twisting, fractures and duplication of nasal septum with telescoping of its fragments.
Trauma may also be inflicted at birth during difficult labour when nose is pressed during its
passage through the birth canal. Birth injuries should be immediately attended to as they result
in septal deviation later in life.
2. Developmental error: Nasal septum is formed by the tectoseptal process which descends to
meet the two halves of the developing palate in the midline. During the primary and secondary
dentition, further development takes place in the palate, which descends and widens to
accommodate the teeth. Unequal growth between the palate and the base of skull may cause
buckling of the nasal septum.
In mouth breathers, as in adenoid hypertrophy, the palate is often highly arched and the septum
is deviated. Similarly, DNS may be seen in cases of cleft lip and palate and in those with dental
abnormalities.
3. Racial factors: Caucasians are affected more than black Americans.
4. Hereditary factors: Several members of the same family may have deviated nasal septum.

Types of DNS:

Deviation may involve only the cartilage, bone or both the cartilage and bone.

7. Anterior dislocation: Septal cartilage may be dislocated into one of the nasal chambers. This
is better appreciated by looking at the base of nose when patient’s head is tilted backwards.
8. C-shaped deformity: Septum is deviated in a simple curve to one side. Nasal chamber on the
concave side of the nasal septum will be wider and may show compensatory hypertrophy of
turbinates.
9. S-shaped deformity: Either in vertical or anteroposterior plane. Such a deformity may cause
bilateral nasal obstruction.
10. Spurs: A spur is a shelf-like projection often found at the junction of bone and cartilage.
A spur may press on the lateral wall and gives rise to headache. It may also predispose to
repeated epistaxis from the vessels stretched on its convex surface.
11. Thickening: It may be due to organized haematoma or overriding of dislocated septal
fragments.
 Nasagata roga

Clinical features:

DNS can involve any age and sex. Males are affected more than females.

1. Nasal obstruction. Depending on the type of septal deformity, obstruction may be

unilateral or bilateral. Respiratory currents pass through upper part of nasal cavity,
therefore, high septal deviation cause nasal obstruction more than lower ones. When
examining a case of nasal obstruction, one should ascertain the site of obstruction in the
nose. It could be : (i) vestibular (caudal septal dislocation, synechiae or stenosis),
(ii) at the nasal valve (synechiae, usually postrhinoplasty),
(iii) attic (along the upper part of nasal septum due to high
septal deviation;
(iv) turbinal (hypertrophic turbinates or concha bullosa) and
(v) choanal (choanal atresia or a choanal polyp). Unilateral choanal
atresia may be missed in infancy and childhood. Choanal polyp may be missed on the
anterior rhinoscopy unless posterior rhinoscopy or nasal endoscopy is done. Cottle test. It
is used in nasal obstruction due to abnormality of the nasal valve. In this test, cheek is
drawn laterally while the patient breathes quietly. If the nasal airway improves on the test
side, the test is positive and indicates abnormality of the vestibular component of nasal
valve
2. Headache. Deviated septum, especially a spur, may press on the lateral wall of nose
giving rise to pressure headache.
3. Sinusitis. Deviated septum may obstruct sinus ostia resulting in poor ventilation of the
sinuses. Therefore, it forms an important cause to predispose or perpetuate sinus
 Nasagata roga

infections.
4. Epistaxis. Mucosa over the deviated part of septum is exposed to the drying effects of
air currents leading to formation of crusts, which when removed causes bleeding.
Bleeding may also occur from vessels over a septal spur.
5. Anosmia. Failure of the inspired air to reach the olfactory region may result in total or
partial loss of sense of smell.
6. External deformity. Septal deformities may be associated with deviation of the
cartilaginous or both the bony and cartilaginous dorsum of nose, deformities of the nasal
tip or columella.
7. Middle ear infection. DNS also predisposes to middle ear infection.

Treatment:
Minor degrees of septal deviation with no symptoms are commonly seen in patients and require
no treatment. It is only when deviated septum produces mechanical nasal obstruction or the
symptoms given above that an operation is indicated.
(i) Submucous resection (SMR) operation: It is generally done in adults under local
anaesthesia. It consists of elevating the mucoperichondrial and mucoperiosteal flaps on either
side of the septal framework by a single incision made on one side of the septum, removing
the deflected parts of the bony and cartilaginous septum, and then repositioning the flaps (see
section on Operative Surgery for details).
(ii) Septoplasty: It is a conservative approach to septal surgery. In this operation, much of the
septal framework is retained. Only the most deviated parts are removed. Rest of the septal
framework is corrected and repositioned by plastic means. Mucoperichondrial/periosteal flap
is generally raised only on one side of the septum, retaining the attachment and blood supply
on the other. Septoplasty has now almost replaced SMR operation.
 Nasagata roga

10. NASAPARISRAVA/NASASRAVA

Sushruta:

अज म ं सिलल काशं य ािववण वतीह नासा ।।

रा ौ िवशेषेण िह तं िवकारं नासाप र ाविमित व ेत् (Su. U. 22/16)

नासाप र ावमाह- अज म िम ािद। अज म् अनवरतम् । अिववणम् अिविश वणम् । अ रोगे ावः

ाटका ोतिस िवलाियतात् कफात्। व े त् जानीयात्।।१६।।

The condition in which there is continuous nasal discharge which is watery, colourless and in
which the symptom increases during night is called nasa parisrava.

Vagbhata:

ाव ुत ं ः े स वः।

अ ो जलोपमोऽज ं िवशेषाि िश जायते॥ (A.H. U. 19/19)

सवा सु रा:- ाव ु त ं ो- ाण ावा ः। स च कफादे व केवला वित। अ ो जलस शो िन ं ावो जायते,

िवशे षेण रा ौ।

Same as explained by sushruta.

Dosha involved- Kapha

Yogaratnakara:

xÉëÉuÉqÉÉWû- bÉëÉhÉÉiÉç bÉlÉÈ mÉÏiÉÍxÉiÉxiÉlÉÑuÉÉï SÉåwÉÈ xÉëuÉåiÉç xÉëÉuÉqÉÑSÉWûUå¨ÉqÉç |

Nasa roga in which there will yellowish discharge or white colored thick or thin watery discharge
is present , is called as Srava.

Charaka:

rÉÉå qÉxiÉÑsÉÑ…¡ûÉSè bÉlÉmÉÏiÉmÉYuÉÈ MüTüÈ xÉëuÉåSåwÉ mÉËUxÉëuÉxiÉÑ || (Cha. Chi. 26/112)

The condition in which there is thick, yellowish and pakva kapha/discharge is called parisrava.
 Nasagata roga

Chikitsa:

Sushruta:

नासा ावे ाणत चूणमु ं ना ा दे यं योऽवपीड ती णः ।

ती णं धू मं दे वदावि का ां मांसं वाऽऽजं यु म ािदश ।। (Su. U 23/10)

नासा ाविचिक ामाह- नास ावे इ ािद। उ ं चूण िशरोिवरे चन कृतम्। ती णोऽवपीडो "िहङ्गु ोषं
व का ं" इ ािदना इहै वा ाये ो ः। अि कः िच कः, अजमोदाम े । आजं मां सं "भोजने" इित शे षः।।१०।।

 Pradhamana nasya with shirovirechaka dravyas using nadi

 Teekshna avapidaka nasya with dravyas like hingu, vyosha, vatsaka etc.
 Teekshna dhooma with devadaru, chitraka or ajamoda etc. drugs
 Aja mamsa or mamsarasa given for food

Vagbhata:

पाके दी ौ च िप ं ती णं न ािद सं ु तौ॥ (A.H. U. 20/20)

सवा सु रा:-नासापाके दी ौ च िप ं िचिक तम्। सं ु तौ- ावे, ती णं न ािद िहतम् ।

 If srava is present then teekshna nasya can be done.

Co-relation – ?
 Nasagata roga

11. NASASHOSHA/ NASAPARISHOSHA

Sushruta:

ाणाि ते े िण मा तेन िप ेन गाढं प रशोिषते च ।।

समु िस ू मध कृ ा नासाप रशोष उ ः। (Su. U. 22/17)

नासाशोषल णमाह- ाणाि ते इ ािद। गाढम् अितशयेन।।१७।।

Due to rukshata of prakupita vata and ushnata of pitta, the kapha in nasa gets excessively dried up
and inhalation and exhalation becomes highly difficult in such patients. This condition can be
called as Nasaparishosha.

Vagbhata:

शोषय ािसका ोतः कफं च कु तेऽिनलः।

शूकपू णाभनासा ं कृ ादु सनं ततः॥

ृतोऽसौ नािसकाशोषो (A.H. U. 19/16)

सवा सु रा:-शोषय ािसका ोतः कफं च वायुः शू कपूणाभनासा ं कु ते। ततः कृ ादु सनं ात्। असौ
नािसकाशोषः ृतः।

The prakupita vata dries up(solididies) the kapha which is present in nasa and thus nose feels like
filled with shuka (awn of barley etc. cereals/bristles) and makes it difficult to breathe. This is
called nasa shosha.

Charaka:

M×ükSÈ xÉ xÉÇzÉÉåwrÉ MüTÇü iÉÑ lÉÉxÉÉ´ÉÑ…¡ûÉiÉMü bÉëÉhÉÌuÉzÉÉåwÉhÉÇ cÉ || (Cha. Chi. 26/111)

The prakupita vata dries up(solididies) the kapha which is present in nasa and shrungataka and
causes nasashosha.

Chikitsa:

Sushruta:

नासाशोषे ीरसिपः धानं िस ं तैलं चाणुक ेन न म् ।

सिपःपानं भोजनं जा लै ेहः े दः ैिहक ािप धू मः ।। (Su. U. 23/11)

नासाशोषे िचिक ामाह- नासाशोषे ीरसिप र ािद। ीरसिपः आिदत उ म् । धानं े म् । न ेन िवषये।
अणुक ेन अणुतैलिवधानेन वात ा ु े न। सिपःपानम् अ भ कम् । जा लै ः एणािदमां सैः, ेहः ेद इ थः।
ैिहको धूमो मधू ािदिभः।।११।।

 Ksheerasarpi pana. (The sarpi that comes when the milk is churned)
 Nasagata roga

 Anutaila nasya
 Jangala mamsa rasa bhojana
 Snehana, swedana and snaihika dhoomapana should be administered.

Vagbhata:

नासाशोषे बलातैलं पानादौ भोजनं रसैः॥ (A.H. U. 20/19)

ि ो धू म था े दो

सवा सु रा:-नासाशोषे बलातैलं पानन ादौ िहतम् । भोजनं मां सरसैिहतम् । तथा ि ो धूमः ेद िहतः।

 Chikitsa is same in Nasashosha and Nasanaha

 Bala taila should be used for pana(internal administration), nasya etc. purposes
 Mamsa rasa should be given in bhojana
 Snigdha dhooma and swedana should be done.

Yogaratnakara:

lÉÉxÉzÉÉåwÉå ¤ÉÏUmÉÉlÉÇ xÉÍxÉiÉÇ cÉ mÉëzÉxrÉiÉå ||

Milk mixed with sugar is indicated.

RHINITIS SICCA

Sicca – the word is derieved from latin word siccus which means dry.

It is also a crust-forming disease seen in patients who work in hot, dry and dusty surroundings,
e.g. bakers, iron- and goldsmiths. Condition is confined to the anterior third of nose particularly of
the nasal septum.

Here, the ciliated columnar epithelium undergoes squamous metaplasia with atrophy of
seromucinous glands. Crusts form on the anterior part of septum and their removal causes
ulceration and epistaxis, and may lead to septal perforation.

Clinical features:

 Nasal obstruction due to presence of crusts in anterior third of nose esp. septum.
 Epistaxis- on removing the crusts
 Septal perforation
 Nasagata roga

Treatment:

 Correction of the occupational surroundings

 Use of masks and filters
 Application of bland ointment or one with an antibiotic and steroid to the affected part.
 Nose pricking and forcible removal of crusts should be avoided.
 Nasal saline douche- nasal irrigation and removal of crusts
 Nasagata roga

12-15. NASAARSHA

Nasarsha is not explained by acharya Charaka.

Sushruta:

दोषै िभ ैः पृ थगे कश ू या थाऽशािस तथैव शोफान् ।।

शाला िस ा मवे चािप सवा कं स ममबु दं तु । (Su. Ni. 2/19)

इदानीमु ानामशआदीनां सामा े न ल णमाह- दोषै र ािद। पृथ ोषै ः ी शािस, सि पातेनैकं, एवं च ायशािस।
तथै व शोफािनित शोफा अिप च ार इ थः। शाला िस ा मवे ेित "वातेन िप े न कफेन चािप" इ ािदना
िनदान थाने षडबुदािन िनिद ािन, स मं सवा कं शाला त े ।।१८।।

Prakupita vatadi dosha which gets sthana samshraya in urdhwa jatru causes arsha in karna, netra,
nasa and mukha.

Symptoms in Nasarsha are:

 Pratishyaya
 Kshavathu
 Difficulty in breathing due to obstruction
 Putinasya
 Pain in shiras
Nasa arsha is of 4 types:

1. Vataja
2. Pittaja
3. Kaphaja
4. Sannipataja

Vagbhata:

अश बु दािन िवभजे ोषिल ै यथायथम्।

सवा सु रा:-अशा बुदािन च दोषिल ै यथा ं जानीयत्।

In arsha and arbuda dosha involved should be understood according to the symptoms.

सवषु कृ ो सनं पीनसः ततं ुितः॥

सानु नािसकवािद ं पू ितनासः िशरो था। (A.H. U. 19/26)

सवा सु रा:-सवषु -अशः बुदे षु च, कृ ादु सनम् । तथा पीनसोऽनवरतं वः, तथा सानुनािसकभािषतं, तथा
पूितनासः िशरो थे ित ु ः।

In all types of arsha and arbuda, the symptoms are:

 Difficulty in breathing
 Nasagata roga

 Pinasa
 Frequent/continuous sneezing
 Nasal voice
 Putinasa-
 Shirovedana- pain in head

Chikitsa:

Sushruta:

शेषान् रोगान् ाणजान् सि य े दु ं तेषां य था संिवधानम् ।। (Su. U. 20/25)

अशः भृ तीनां िचिक ामाह- शे षािन ािद। शे षान् रोगानशःशोफादीन्, सि य े त् िचिक े त्। उ ं संिवधानं े े
िचिक ते।।१२।।

Chikitsa for rest of the diseases i.e. Arbuda, arsha, shopha etc. are explained in their respective
chapters.

Vagbhata:

द े श बु दे षु च।

िनकु कु िस ू मनो ालकणाि कैः॥

क तैघृतम ां ाणे वित वे शयेत्।

िश ् वािद नावनं चा पू ितनासोिदतं भजेत्॥ (A.H. U. 20/25)

सवा सु रा:-अश बुदे षु च द ेषु िनकु ािदिभः क तैघृतम ां ाणे वित वेशयेत्। िश ्वािदकं च न ं
पूितनासो ं भजे िदित।

In Nasarsha and Nasa arbuda:

 Agni karma should be performed

 Kalka of danti, nishotha, saindhava, haratala, pippali, chitraka added with madhu and
ghruta should be made into varti and kept/placed in nasa.
 Shighrusimhadi nasya explained in putinasa.

Yogaratnakara:

1. Gruhadhoomadi taila/ shikhari taila: (chakra data)

aÉ×WûkÉÔqÉMühÉÉSɤÉÉUlÉ£üÉlWûxÉælkÉuÉæÈ |

ÍxÉ®Ç ÍzÉZÉUÏoÉÏeÉæ¶É iÉæsÉÇ lÉÉxÉÉzÉïxÉå ÌWûiÉqÉç ||

Taila prepared by gruhadhooma, pippali, daruharidra, yavakshaara, karanja, saindhava,

apamarga beeja is used for nasya.
 Nasagata roga

2. Raktakaraveera pushpa taila:

U£üMüUuÉÏUmÉÑwmÉÇ eÉÉirÉÇ uÉÉ iÉjÉÉ qÉÎssÉMüÉrÉÉÈ |

LiÉæÈ xÉqÉÇ ÌiÉsÉiÉæsÉÇ lÉÉxÉÉzÉÉåïlÉÉzÉMÇü mÉUqÉç|| (Y.R)

Taila prepared by using rakta karaveera pushpa, jati pushpa and mallika pushpa with equal
quantity of tila taila can be used for Nasya in Nasa arsha.

3. Samanya chikitsa:

¤ÉÉUÉåÅoÉÑïSåÅzÉïqÉÉÇxÉå cÉ Ì¢ürÉÉ || (Y.R)

 Kshara prayoga can be done in Nasa arsha and arbuda

 Patient should be placed in vatarahita sthana (there should not be direct air currents in the
room of patient), covered wih thick bedsheets, Gandusha, langhana, nasya, dhooma,
vamana and siravyadha can be performed (according to requirement).
 Chitrakadi taila and godhooma siddha taila which are explained by chakradatta are used.

NASAL POLYP

Nasal polypi are non-neoplastic masses of oedematous nasal or sinus [Link] are divided
into two main varieties:

1. Bilateral ethmoidal polypi- arises from ethmoidal sinuses

2. Antrochoanal polyp- arises from maxillary sinuses

 Nasagata roga

1. Bilateral ethmoidal polyp:

Aetiology:

Aetiology of nasal polypi is very complex and not wellunderstood. They may arise in
inflammatory conditions of nasal mucosa (rhinosinusitis), disorders of ciliary motility or
abnormal composition of nasal mucus (cystic fibrosis).

Various diseases associated with the formation of nasal polypi are:

1. Chronic rhinosinusitis: Polypi are seen in chronic rhinosinusitis of both allergic and
nonallergic origin. Nonallergic rhinitis with eosinophilia syndrome (NARES) is a form of chronic
rhinitis associated with polypi.

2. Asthma: Seven per cent of the patients with asthma of atopic or nonatopic origin show nasal
polypi.

3. Aspirin intolerance: Thirty-six per cent of the patients with aspirin intolerance may show
polypi. Samter’s triad consists of nasal polypi, asthma and aspirin intolerance.

4. Cystic fibrosis: Twenty per cent of patients with cystic fibrosis form polypi. It is due to
abnormal mucus.

5. Allergic fungal sinusitis: Almost all cases of fungal sinusitis form nasal polypi.

6. Kartagener syndrome: This consists of bronchiectasis sinusitis, situs inversus and ciliary
dyskinesis.

7. Young syndrome: It consists of sinopulmonary disease and azoospermia.

8. Churg–Strauss syndrome: Consists of asthma, fever, eosinophilia, vasculitis and granuloma.

9. Nasal mastocytosis: It is a form of chronic rhinitis in which nasal mucosa is infiltrated with
mast cells but few eosinophils. Skin tests for allergy and IgE levels are normal.

Pathogenesis:

Nasal mucosa, particularly in the region of middle meatus and turbinate, becomes oedematous
due to collection of extracellular fluid causing polypoidal change.

Polypi which are sessile in the beginning become pedunculated due to gravity and excessive
sneezing.

Pathology:

In early stages, surface of nasal polypi is covered by ciliated columnar epithelium like that of
normal nasal mucosa but later it undergoes a metaplastic change to transitional and squamous
type on exposure to atmospheric irritation. Submucosa shows large intercellular spaces filled with
serous fluid. There is also infiltration with eosinophils and round cells.
 Nasagata roga

Site of origin:

 Multiple nasal polypi always arise from the lateral wall of nose, usually from the middle
meatus.

 Common sites are uncinate process, bulla ethmoidalis, ostia of sinuses, medial surface and
edge of middle turbinate. Allergic nasal polypi almost never arise from the septum or the
floor of nose.

Symptoms:

1. Multiple polypi can occur at any age but are mostly seen in adults.
2. Nasal stuffiness leading to total nasal obstruction may be the presenting symptom.
3. Partial or total loss of sense of smell.
4. Headache due to associated sinusitis.
5. Sneezing and watery nasal discharge due to associated allergy.
6. Mass protruding from the nostril.

Signs:
 On anterior rhinoscopy, polypi appear as smooth, glistening, grape-like masses often pale in
colour. They may be sessile or pedunculated, insensitive to probing and do not bleed on touch.
Often they are multiple and bilateral.
 Long-standing cases present with broadening of nose and increased intercanthal distance.
 A polyp may protrude from the nostril and appear pink and vascular simulating neoplasm.
 Nasal cavity may show purulent discharge due to associated sinusitis. Probing of a solitary
ethmoidal polyp may be necessary to differentiate it from hypertrophy of the turbinate or
cystic middle turbinate.

Diagnosis:

 On clinical examination.
 Computed tomography (CT) scan of paranasal sinuses is essential to exclude the bony
erosion and expansion suggestive of neoplasia. Simple nasal polypi may sometimes be
associated with malignancy underneath, especially in people above 40 years and this must
be excluded by histological examination of the suspected tissue.
CT scan also helps to plan surgery.
 Nasagata roga

Treatment:

Conservative: 1. Early polypoidal changes with oedematous mucosa may revert to normal with
antihistaminics and control of allergy.

2. A short course of steroids may prove useful in case of people who cannot tolerate
antihistaminics and/or in those with asthma and polypoidal nasal mucosa. They may also
be used to prevent recurrence after surgery.
Note: Contraindications to use of steroids, e.g. hypertension, peptic ulcer, diabetes,
pregnancy and tuberculosis should be excluded.

Surgical:

1. Polypectomy- One or two polyps which are pedunculated can be removed with snare. Multiple
and sessile polypi require special forceps.

2. Intranasal ethmoidectomy- When polypi are multiple and sessile, they require uncapping of the
ethmoidal air cells by intranasal route, a procedure called intranasal ethmoidectomy.

3. Extranasal ethmoidectomy. This is indicated when polypi recur after intranasal procedures and
surgical landmarks are ill-defined due to previous surgery. Approach is through the medial wall of
the orbit by an external incision, medial to medial canthus.

4. Transantral ethmoidectomy. This is indicated when infection and polypoidal changes are also
seen in the maxillary antrum. In this case, antrum is opened by Caldwell–Luc approach and the
ethmoid air cell approached through the medial wall of the antrum. This procedure is also
superceded by endoscopic sinus surgery.

5. Endoscopic sinus surgery. These days, ethmoidal polypi are removed by endoscopic sinus
surgery more popularly called functional endoscopic sinus surgery (FESS). It is done with various
endoscopes of 0°, 30° and 70° angulation. Polypi can be removed more accurately when ethmoid
cells are removed, and drainage and ventilation provided to the other involved sinuses such as
maxillary, sphenoidal or frontal.

2. Antrochoanal polyp (SYN. KILLIAN’S POLYP)

This polyp arises from the mucosa of maxillary antrum near its accessory ostium, comes out of it
and grows in the choana and nasal cavity.

Thus it has three parts. 1. Antral, which is a thin stalk.

2. Choanal, which is round and globular.

3. Nasal, which is flat from side to side.

Aetiology: Exact cause is unknown. Nasal allergy coupled with sinus infection is incriminated.
Antrochoanal polypi are seen in children and young adults. Usually they are single and unilateral.
 Nasagata roga

Symptoms:

 Unilateral nasal obstruction is the presenting symptom. Obstruction may become bilateral
when polyp grows into the nasopharynx and starts obstructing the opposite choana.
 Voice may become thick and dull due to hyponasality.
 Nasal discharge, mostly mucoid, may be seen on one or both sides.

Signs:

 As the antrochoanal polyp grows posteriorly, it may be missed on anterior rhinoscopy. When
large, a smooth greyish mass covered with nasal discharge may be seen. It is soft and can be
moved up and down with a probe.
 A large polyp may protrude from the nostril and show a pink congested look on its exposed
part.
 Posterior rhinoscopy may reveal a globular mass filling the choana or the nasopharynx. A large
polyp may hang down behind the soft palate and present in the oropharynx. Examination of the
nose with an endoscope may reveal a choanal or antrochoanal polyp hidden posteriorly in the
nasal cavity.

Differential diagnosis:

1. A blob of mucus often looks like a polypus but it would disappear on blowing the nose.

2. Hypertrophied middle turbinate is differentiated by its pink appearance and hard feel of bone
on probe testing.

3. Angiofibroma has history of profuse recurrent epistaxis. It is firm in consistency and easily
bleeds on probing.

4. Other neoplasms may be differentiated by their fleshy pink appearance, friable nature and their
tendency to bleed.

X-rays of paranasal sinuses may show opacity of the involved antrum. X-ray (lateral view), soft
tissue nasopharynx, reveals a globular swelling in the postnasal space. It is differentiated from
angiofibroma by the presence of a column of air behind the polyp.

Treatment:

 An antrochoanal polyp is easily removed by avulsion either through the nasal or oral route.
Recurrence is uncommon after complete removal.
 In cases which do recur, Caldwell– Luc operation may be required to remove the polyp
completely from the site of its origin and to deal with coexistent maxillary sinusitis.
 These days, endoscopic sinus surgery has superceded other modes of polyp removal. Caldwell–
Luc operation is avoided.
Nasagata roga
 Nasagata roga

16-19. NASASHOPHA

Vagbhata has not explained Nasashosha.

दोषै िभ ैः पृ थगे कश ू या थाऽशािस तथैव शोफान् ।। (Su. U. 22/18)

इदानीमु ानामशआदीनां सामा े न ल णमाह- दोषै र ािद। पृ थ ोषैः ी शािस, सि पातेनैकं, एवं
च ायशािस। तथैव शोफािनित शोफा अिप च ार इ थः।

Nasa shopha is of 4 types : Vataja, Pittaja, Kaphaja and Sannipataja

Lakshana, chikitsa of Nasa shopha is similar to general shopha and its chikitsa.

bÉëÉhÉÉÍ´ÉiÉÉxÉ×YmÉëpÉ×iÉÏlÉç mÉëSÕwrÉ MÑüuÉïÎliÉ lÉÉxÉɵÉrÉjÉÑÇ qÉsÉÉ¶É || (Cha. Chi. 26/115)

Prakupita dosha in nasa vitiates rakta etc. dhatu and causes nasa shopha.

Co-relation: Oedema of Nose

 Nasagata roga

20-26. NASA ARBUDA

शाला िस ा मवे चािप सवा कं स ममबु दं तु । (Su. U. 22/19)

शाला िस ा मवे ेित "वातेन िप ेन कफेन चािप" इ ािदना िनदान थाने षडबुदािन िनिद ािन, स मं
सवा कं शाला त े ।।१८।।

Nasa arbuda is of 7 types:

1. Vataja
2. Pittaja
3. Kaphaja
4. Tridoshaja
5. Raktaja
6. Mamsaja
7. Medaja

ोतःपथे यि पु लं कोशव ाबु दं भवे त् ।। (Su. U. 22/20)

Hair like growth which is large that is present in the nasal passage is called as Nasa arbuda.

Vagbhata:

अश बु दािन िवभजे ोषिल ै यथायथम्।

सवषु कृ ो सनं पीनसः ततं ुितः॥२६॥

सानु नािसकवािद ं पू ितनासः िशरो था। (A.H. U. 19/26)

सवा सु रा:-सवषु -अशः बुदे षु च, कृ ादु सनम् । तथा पीनसोऽनवरतं वः, तथा सानुनािसकभािषतं, तथा
पूितनासः िशरो थे ित ु ः।

In nasa arbuda, vitiateddosha should be identified by the lakshanas.

In all types of arsha and arbuda, the symptoms are:

 Difficulty in breathing
 Pinasa
 Frequent/continuous sneezing
 Nasal voice
 Putinasa- Halitosis
 Shirovedana- pain in head

bÉëÉhÉå iÉjÉÉåcduÉÉxÉaÉÌiÉÇ ÌlÉÃkrÉ qÉÉÇxÉÉxÉëSÉåwÉÉSÌmÉ cÉÉoÉÑïSÉÌlÉ | (Cha. Chi. 26/116)

 Nasagata roga

Chikitsa:

Sushruta:

Chikitsa for Nasarbuda is similar to that of samanya arbuda.

Vagbhata:

द े श बु दे षु च।

िनकु कु िस ू मनो ालकणाि कैः॥

क तैघृतम ां ाणे वित वे शयेत्।

िश ् वािद नावनं चा पू ितनासोिदतं भजेत्॥ (A.H. U. 20/25)

सवा सु रा:-अश बुदे षु च द ेषु िनकु ािदिभः क तैघृतम ां ाणे वित वेशयेत्। िश ्वािदकं च न ं
पूितनासो ं भजे िदित।

In Nasarsha and Nasa arbuda:

 Agni karma should be performed

 Kalka of danti, nishotha, saindhava, haratala, pippali, chitraka added with madhu and
ghruta should be made into varti and kept/placed in nasa.
 Shighrusimhadi nasya explained in putinasa.

Yogaratnakara:

Chikitsa is similar in Nasa arsha and Nasa arbuda.

¤ÉÉUÉåÅoÉÑïSåÅzÉïqÉÉÇxÉå cÉ Ì¢ürÉÉzÉåwÉåÅmrÉuÉå¤rÉ cÉ |
ÎxjÉÌiÉÌlÉïuÉÉiÉÌlÉsÉrÉå mÉëaÉÉRûÉåwhÉÏwÉkÉÉUhÉqÉç |
aÉhQÕûwÉÉå sÉÇbÉlÉÇ lÉxrÉÇ kÉÔqÉzNûÌSïÈ ÍzÉUÉurÉkÉÈ ||
 Kshara prayoga can be done in Nasa arsha and arbuda
 Patient should be placed in vatarahita sthana (there should not be direct air currents in the
room of patient), covered wih thick bedsheets, Gandusha, langhana, nasya, dhooma,
vamana and siravyadha can be performed (according to requirement).
 Chitrakadi taila and godhooma siddha taila which are explained by chakradatta are used.
 Nasagata roga

TUMORS OF NOSE

A. External nose:

1. Congenital tumour:
 Dermoid cyst- Simple dermoid: It occurs as a midline swelling under the
skin but in front of the nasal bones. It does not have any external opening.
Dermoid with a sinus: It is seen in infants and children and is represented by a pit
or a sinus in the midline of the dorsum of nose. Hair may be seen protruding
through the sinus opening. In these cases, the sinus track may lead to a dermoid
cyst lying under the nasal bone in front of upper part of nasal septum or may have
an intracranial dural connection. In those with intracranial extension, sinus tract
passes through the cribriform plate or foramen caecum and is attached to dura or
has other intracranial connection. Meningitis occurs if infection travels along this
path. Treatment of such cysts may necessitate splitting of the nasal bones to
remove any extension in the upper part of the nasal septum. A combined
neurosurgical–otolaryngologic approach is required in those extending
intracranially so as to close simultaneously any bony defect through which the
fistulous tract passed

 Meningoencephalocele- herniation of brain tissue through a congential bony

defects. An extranasal meningoencephalocele presents as a subcutaneous pulsatile
swelling in the midline at the root of nose (nasofrontal variety), side of nose
(nasoethmoid variety) or on the anteromedial aspect of the orbit (naso-orbital
variety). Swellings show cough impulse and may be reducible. Treatment is
neurosurgical; severing the tumour stalk from the brain and repairing the bony defect
through which herniation has taken place.
 Nasagata roga

 Glioma: It is a nipped off portion of encephalocele during embryonic development.

Most of them (60%) are extranasal and present as firm subcutaneous swellings on the
bridge, side of nose or near the inner canthus. Some of them are purely intranasal (30%),
while 10% are both intra- and extranasal. Extranasal gliomas are encapsulated and can be
easily removed by external nasal approach.

2. Benign tumors:
 Rhinophyma: or potato tumour is a slow-growing benign tumour due to
hypertrophy of the sebaceous glands of the tip of nose often seen in cases of long-
standing acne rosacea.
It presents as a pink, lobulated mass over the nose with superficial vascular dilation;
mostly affects men past middle age. Patient seeks advice because of the unsightly
appearance of the tumour, or obstruction to breathing and vision due to large size of the
tumour.
Treatment consists of paring down the bulk of tumour with sharp knife or carbon dioxide
laser and the area allowed to re-epithelialize. Sometimes, tumour is completely excised
and the raw area skin grafted.
 Nasagata roga

 Papilloma (Skin wart): The exact etiology is unknown, but human papillomavirus
infection, smoking, and chronic sinusitis are predisposing factors for the development of
nasal papillomas.
Patients often present with unilateral nasal obstruction, anosmia, and
intermittent epistaxis. On examination, nasal papillomas appear dull gray/pink and are
friable. CT or MRI delineate the extent of the papilloma; diagnosis is established
on biopsy. All nasal papillomas should be completely excised.

 Haemangioma:
 Seborrhoeic keratosis:
 Neurofibroma:

3. Malignant tumours:
 Basal Cell carcinoma (Rodent ulcer): This is the most common malignant tumour
involving skin of nose (87%), equally affecting males and females in the age group of
40–60 years.
Common sites on the nose are the tip and the ala. It may present as a cyst or papulo-
pearly nodule or an ulcer with rolled edges. It is very slow growing and remains
confined to the skin for a long time. Underlying cartilage or bone may get invaded.
Nodal metastases are extremely rare. Early lesion can be cured by cryosurgery,
irradiation or surgical excision with 3–5 mm of healthy skin around the palpable
borders of the tumour. Lesions which are recurrent, extensive or with involvement of
cartilage or bone are excised and the surgical defect closed by local or distant flaps or a
prosthesis.
 Nasagata roga

 Squamous cell carcinoma: This is the second most common malignant tumour (11%),
equally affecting both sexes in 40–60 age group. It occurs as an infiltrating nodule or an
ulcer with rolled out edges affecting side of nose or columella. Nodal metastases are
seen in 20% of cases.
Early lesions respond to radiotherapy; more advanced lesions or those with exposure of
bone or cartilage require wide surgical excision and plastic repair of the defect.
Enlarged regional lymph nodes will require block dissection.

 Melanoma: This is the least common variety. Clinically, it is superficially spreading

type (slow growing) or nodular invasive type. Treatment is surgical excision.

B. Nasal cavity:

1. Benign neoplasms:
 Squamous papilloma: Verrucous lesions similar to skin warts can arise from the
nasal vestibule or lower part of nasal septum. They may be single or multiple,
pedunculated or sessile. Treatment is local excision with cauterization of the base to
prevent recurrence. They can also be treated by cryosurgery or laser.

 Inverted papilloma: It is a tumour of the nonolfactory mucosa of nose (Schneiderian

membrane) and paranasal sinuses. Most common site of origin is lateral wall of nose
in the middle meatus; less commonly it arises from the maxillary, frontal or sphenoid
sinus. It is so named because hyperplastic papillomatous tissue grows into the stroma
rather than in exophytic manner. Human papilloma virus is thought to be responsible
 Nasagata roga

for its aetiology. It is almost always unilateral and presents with nasal obstruction,
nasal discharge and epistaxis. It can invade sinuses or orbit. Orbital involvement
causes proptosis, diplopia and lacrimation. On examination of nose or endoscopy, it
presents as a pale polypoidal mass resembling a simple nasal polypus or polypi.
Computed tomography (CT) and magnetic resonance imaging (MRI) show the
location and extent of the lesion. MRI also helps to differentiate associated
secretions in sinus from the actual tumour mass. Biopsy is essential for diagnosis.
Care should be taken as simple nasal polypi may be associated with it or even
the patient might have been operated for their removal. Treatment. Medial
maxillectomy is the treatment of choice. It can be performed by lateral rhinotomy or
sublabial degloving approach. These days endoscopic approach is preferred. In 10–
15% of cases, it is associated with malignancy. Wider external surgical approaches
may be required for tumour extending to the frontal sinus or orbit. Recurrence can
occur. Radiotherapy is not advised as it may induce malignancy.

 Pleomorphic adenoma: Rare tumour, usually arises from the nasal septum.
Treatment is wide surgical excision.

 Schwannoma: Schwannoma is an uncommon benign tumour arising from the nose

or paranasal sinuses. The latter include ethmoid, maxillary and sphenoid sinuses.
It arises from the Schwann cells of nerve sheath.
Clinically it presents a rounded mass, firm in consistency, yellowish in colour and
may show blood vessels running on its surface. It can cause pressure necrosis of the
surrounding bones.

Imaging techniques, CT and MRI, are useful to show the extent. Diagnosis is
made on biopsy.
Treatment is surgical excision. They can be removed by endoscopic surgery or by
external approaches.
 Meningioma: It is an uncommon tumour found intranasally. Treatment is surgical
excision by lateral rhinotomy.
 Haemangioma: It may be:
(a) Capillary haemangioma (bleeding polypus of the septum). It is a soft, dark
red, pedunculated or sessile tumour arising from the anterior part of nasal
septum. Usually it is smooth but may become ulcerated and present with
recurrent epistaxis and nasal obstruction. Treatment is local excision with a
cuff of surrounding mucoperichondrium.
(b) Cavernous haemangioma. It arises from the turbinates on the lateral wall of
nose. It is treated by surgical excision with preliminary cryotherapy. Extensive
lesions may require radiotherapy and surgical excision.
 Chondroma: It can arise from the ethmoid, nasal cavity or nasal septum. Pure
chondromas are smooth, firm and lobulated. Others may be mixed type fibro-, osteo-
or angiochondromas.
Treatment is surgical excision. For recurrent or large tumours, wide excision
should be done because of their tendency to malignant transformation after
repeated interference.
 Angiofibroma: It is included in nasal tumours because its primary site of origin is
 Nasagata roga

supposed to be posterior part of nasal cavity near the sphenopalatine foramen.

2. Malignant neoplasms:

 Squamous cell carcinoma: Squamous cell carcinoma. It may arise from the
vestibule, anterior part of nasal septum or the lateral wall of nasal cavity. Most of
them are seen in men past 50 years of age.

(i) Vestibular: It arises from the lateral wall of nasal vestibule and may extend into
the columella, nasal floor and upper lip with metastases to parotid nodes.

(ii) Septal: Mostly arises from mucocutaneous junction and causes burning and
soreness in the nose. It has often been termed “nose-picker’s cancer.” Usually,
it is of low-grade malignancy.

(iii) Lateral wall: This is the site most commonly involved. Easily extends into
ethmoid or maxillary sinuses. Grossly, it presents as a polypoid mass in the
lateral wall of nose. Metastases are rare. Treatment is combination of
radiotherapy and surgery.

 Adenocarcinoma: They arise from the glands of mucous membrane or minor

salivary glands and mostly involve upper part of the lateral wall of nasal cavity.

 Malignant melanomas: Usually seen in persons about 50 years of age. Both sexes
are equally affected. Grossly, it presents as a slaty-grey or bluish-black polypoid
mass. Within the nasal cavity, most frequent site is anterior part of nasal septum
followed by middle and inferior turbinate. Amelanotic varieties are nonpigmented.
Tumour spreads by lymphatics and blood stream. Cervical nodal metastases may be
present at the time of initial examination. Treatment is wide surgical excision.
Immunological defences of the patient play a great role in the control of this disease.
Radiotherapy and chemotherapy suppress the immune processes and are avoided. A
5-year survival rate of 30% can be expected after wide surgical excision.
 Lymphomas: Rarely a non-Hodgkin lymphoma presents on the septum.
 Sarcomas:

C. Paranasal Sinuses:

1. Benign neoplasms:
 Osteomas: They are most commonly seen in the frontal sinus followed in turn
by those of ethmoid and maxillary. They may remain asymptomatic, being
discovered incidentally on X-rays. Treatment is indicated when they become
symptomatic, causing obstruction to the sinus ostium, formation of mucocele,
pressure symptoms due to their growth in the orbit, nose or cranium.
 Nasagata roga

 Fibrous dysplasia: In this condition, bone is replaced by fibrous tissue; mostly

involves maxillary but sometimes the ethmoid and frontal sinuses. Patient
seeks advice for disfigurement of the face, nasal obstruction and displacement
of the eye. Treatment is surgical resculpturing of the involved bone to achieve
a good cosmetic and functional result.
 Ossifying fibroma: Seen in young adults. The tumour can be shelled out
easily.
 Ameloblastoma: It is a locally aggressive tumour that arises from the
odontogenic tissue and invades the maxillary sinus. Treatment is surgical
excision.
2. Malignant neoplasms:

Carcinoma of sinus:

Aetiology: Cause of sinus malignancy is largely unknown. People working in

hardwood furniture industry, nickel refining, leather work and manufacture of mustard
gas have shown higher incidence of sinunasal cancer.

Cancer of the maxillary sinus is common in Bantus of South Africa where locally
made snuff is used, which is found rich in nickel and chromium.

Workers of furniture industry develop adenocarcinoma of the ethmoids and upper

nasal cavity, while those engaged in nickel refining get squamous cell and anaplastic
carcinoma.

Ca of maxillary Sinus:

It arises from the sinus lining and may remain silent for a long time giving only vague
symptoms of “sinusitis.” It then spreads to destroy the bony confines of the maxillary
sinus and invades the surrounding structures.

Clinical features: Disease is common in 40–60 age group with preponderance in

males.
1. Early features of maxillary sinus malignancy are nasal stuffiness, blood-stained
nasal discharge, facial paraesthesias or pain and epiphora. These symptoms may be
missed or simply treated as sinusitis.
2. Late features will depend on the direction of spread and extent of growth.
3. Medial spread to nasal cavity gives rise to nasal obstruction, discharge and
epistaxis. It may also spread into anterior and posterior ethmoid sinuses and that is
why most antral malignancies are antroethmoidal in nature.
4. Anterior spread causes swelling of the cheek and later invasion of the facial skin.
5. Inferior spread causes expansion of alveolus with dental pain, loosening of teeth,
poor fitting of dentures, ulceration of gingiva and swelling in the hard palate.
6. Superior spread invades the orbit causing proptosis, diplopia, ocular pain and
epiphora.
7. Posterior spread is into pterygomaxillary fossa, pterygoid plates and the muscles
 Nasagata roga

causing trismus. Growth may also spread to the nasopharynx, sphenoid sinus and base
of skull.
8. Intracranial spread can occur through ethmoids, cribriform plate or foramen
lacerum.
9. Lymphatic spread. Nodal metastases are uncommon and occur only in the late
stages of disease. Submandibular and upper jugular nodes are enlarged. Maxillary and
ethmoid sinuses drain primarily into retropharyngeal nodes, but these nodes are
inaccessible to palpation.
10. Systemic metastases are rare. May be seen in the lungs (most commonly) and
occasionally in bone.

Diagnosis: Radiography, CT, Biopsy

Classification and treatment:

 Early cases with Stage I and II squamous cell carcinomas are treated with surgery or radiation
with equal results.
 T3 and T4 lesions are treated by combined modalities of radiation and surgery. Radiation in
 Nasagata roga

such cases may be given preoperatively or postoperatively.

 Chemoradiation, i.e. chemotherapy and radiation concomitantly has also been used for large
and inoperable tumours by different workers with 5 year survival of more than 60%. Intra-
arterial infusion of 5-Fu or cisplatin and 5-Fu with concomitant radiation has also been used
with good results in preference to deformities created by extensive surgery associated with
advanced malignancy.

Ethmoid Sinus Malignancy:

Ethmoid sinuses are often involved from extension of the primary growth of the maxillary sinus.
Primary growth of ethmoid sinuses per se is not common.

Clinical features:

1. Early features include nasal obstruction, blood-stained nasal discharge and retro-orbital pain.

2. Late features are broadening of the nasal root, lateral displacement of eyeball and diplopia.
Extension through cribriform plate may cause meningitis.

3. Nodal involvement is not common. Upper nodes may be involved.

Treatment: CT scan is essential to know the extent of disease and intracranial spread. In early
cases, treatment is preoperative radiation, followed by lateral rhinotomy and total ethmoidectomy.
If cribriform plate is involved, anterior cranial fossa is exposed by a neurosurgeon and total
exenteration of the growth in one piece is accomplished by what is called craniofacial resection.

Frontal Sinus malignancy:

Clinical features:

Pain and swelling of the frontal region are the presenting features. Growths may erode through
the floor of frontal sinus and present as a swelling above the medial canthus. Growths of frontal
sinus may extend through the ethmoids into the orbit. Dura of anterior cranial fossa may be
involved if growth penetrates the posterior wall of the sinus.

Treatment: Frontal sinus malignancy is treated by preoperative radiation followed by surgery.

Surgery includes frontal sinusotomy with ethmoid and orbital exenteration. Neurosurgical
approach may be required to resect the dura of anterior cranial fossa, if involved.

Sphenoid Sinus malignancy:

Primary malignancy of the sinus is rare. It has to be differentiated from the inflammatory lesions
in this area. Plain X-rays, CT scan and biopsy through sphenoidotomy are essential to know the
nature and extent of disease. Radiotherapy is the mainstay of treatment.
 Nasagata roga

PUTAKA
Explained only by Vagbhata.

िप े ाव ोऽ नासायां शोषये त् ।

कफं स शु : पु टतां ा ोित पु टकं तु तम् ।। (A.H. U. 19/25)

Vayu which is obstructed by pitta and shleshma dries up the kapha present within nose.

The dried kapha becomes thick like skin (puta) and hence the condition is called Putaka.

Chikitsa:

 Treatment is same as kshavathu.

 Pradhamana nasya with teekshna dravyas.
 Nasya by taila or ghruta prepared with shunti, kustha, kana, vidanga, draksha.
 Nasagata roga

Prathishyaya
ETYMOLOGY (urÉÑimĘ́É)

mÉëÌiɤÉhÉÇ zrÉÉrÉiÉå CÌiÉ |

mÉëÌiÉ + zrÉæ + zrÉɲkÉÉxÉÑxÉÇqÉuÉëiÉÏËUÌiÉ |

The word Pratishyaya is derived from zrÉæ and zrÉÉSÒuÉkÉÉ mÉëirÉrÉ, which means the continuous outflow of
Doshas.
Dictionary meaning

mÉëÌiÉzrÉÉrÉ - A cold, catarrh.

DEFINITION (ÌlÉÂÌ£ü)

uÉÉiÉÇ mÉëÌiÉ AÍpÉqÉÑZÉÇ xrÉÉrÉÉå aÉqÉlÉÇ MüTüÉÌSlÉÉÇ rÉ§É xÉ mÉëÌiÉzrÉÉrÉÈ |

The Vata dosha attains pratiloma gati and moves upwards to mastishka pradesha. There it
vitiates the Kaphadi dosha and causes the disease Pratishyaya.

bÉëÉhÉqÉÔsÉå ÎxjÉiÉÈ zsÉåwqÉÉ ÂÍkÉUÇ ÌmɨÉqÉåuÉ uÉÉ |

qÉÉÂiÉÉkqÉÉiÉÇ ÍzÉUxÉÉå qÉÉÂiÉÇ zrÉÉrÉiÉå mÉëÌiÉ |
mÉëÌiÉzrÉÉrÉxiÉiÉÉå bÉÉåUÉå eÉÉrÉiÉå SåWûMüzÉïhÉÈ |

In the patient whose head is filled up with vitiated vata, kapha, rudhira or pitta
located in the upper portion (mula = lit. root) of the nasal passage, moves towards the vayu
(located in the head) as a result of which is of serious nature and which causes emaciation
of the body is manifested.
 Nasagata roga

CLASSIFICATION OF THE DISEASE PRATISHYAYA

Table No. 1 Showing the Classification of the disease Pratishyaya, according to

various authors.

Authors Vataja Pittaja Kaphaja Raktaja Sannipataja

Charaka + + + - +

Sushruta + + + + +

Vagbhata + + + + +

Kashyapa + + + - +

Madhava + + + + +

Bhava Prakasha + + + + +

Sharangadhara + + + + +

Yogaratnakara + + + + +

Gada Nigraha + + + + +

AMA AND PAKWA PRATISHYAYA LAKSHANA

MåüÍcɲخxÉÑzÉ×iÉÉå£Çü, - AÂÍcÉÌuÉïUxÉÇ uÉY§ÉÇ lÉÉxÉÉxÉëÉuÉÉå ÂeÉÉ AUÌiÉÈ | ÍxÉUÉåaÉÑÂiuÉÇ ¤ÉuÉjÉÑeuÉïU¶ÉÉqÉxrÉ sɤÉhqÉç |

iÉlÉÑiuÉqÉÉqÉÍsÉXûÉlÉÉÇ ÍzÉUÉålÉÉxÉÉxrÉsÉÉbÉuÉqÉç | bÉlÉmÉÏiÉMüTüiuÉÇ cÉ mÉYuÉmÉÏlÉxÉsɤÉhÉqÉç | CÌiÉ mÉëÌiÉzrÉÉrÉÉlÉÉqÉÉqÉmÉYuÉsɤÉhÉÇ

mÉPûÎliÉ |

Aruchi, virasavakrata, nasa srava, ruja, arati, shirogurutva, kshavathu, jwara are the
lakshanas of Ama Pratishyaya.

Tanutva amalinga, Shiro nasa laghuta, Ghana pita kaphatva are the lakshanas of
Pakwa Pratishyaya.
 Nasagata roga

Types

1. Vataja
2. Pittaja
3. kaphaja
4. rakthaja
5. sannipataja

Vataja pratishyaya
आन धा प हता नासा तनु ाव व तनी ।
गलता वो ठशोष च न तोदः श खयो तथा ।।
वरोपघात च भवेत ् त यायेऽ नला मके । (S U 24/6)
Dalhana commentary: वातज त याय य ल णमाह- आन धा प हते या द। आन धा आ माता
पू रतेव। प हता रजःशूकपूणव।।
 Anaddha- आ माता पू रतेव- Nasal blockage as if air is filled/ obstructed.
 Pihita- रजःशूकपूणव- As if dust particles present in the nose
 tanu srava- watery discharge
 Gala talu oshta shosha- dryness in throat, palate and lips.
 pain in shanka pradesha
 swaropaghata- hoarseness of voice

त वाता त याये मुखशोषो भश

ृ ं वः॥
ाणोपरोध न तोदद तश ख शरो यथाः।
क टका इव सप तीम यते प रतो व
ु ौ॥
वरसादि चरा पाकः श शरा छकफ ु तः। (AH U 19/4)
 Mukhashosha- dryness in mouth
 brisham kshava- excessive/recurrent sneezing
 ghranoparodha- nasal block
 Nisthoda- pain in nose
 vyatha- pain in teeth, shanka pradesha, shiras
 the person feels as if the ants are crawing around the eye brows
 swarasada- weakness of voice.
 chirath paka- delay in production of fluid
 Discharge of cold and clear fluid
 Nasagata roga

Charaka

ाणा ततोदौ वथज

ु लाभः ावोऽ नलात ् स वरमध
ू रोगः ।। ( Cha Chi 26/105)

 Ghran arthi- pain in nose

 thoda- aching pain
 kshwathu- sneezing
 jalabha srava- watery discharge
 swarabheda- hoarseness of voice
 moordha roga- head disorders

Chikitsa

वा तके तु त याये पबेत ् स पयथा मम ् ।

प च भलवणैः स धं थमेन गणेन च ।।
न या दषु व धं कृ नमवे ेता दते रतम ् । (S U 24/6)
Commentary: वा तक त याय य च क सामाह- वा तक इ या द। यथा मं नेहपान मेणे यथः।
थमो गणो वदा रग धा दः। कृ नं सम तम ्। अ दते रतं अ दत च कि सतो तम ्।।

 Ghrita pana a) Pancha lavana sidda ghrita

b) Vidaryadhi gana sidda ghrita
 Nasya
 ardita chikitsa (Su Chi 5/22)

पबे वात त याये स पवात नसा धतम ्॥

पटुप चक स धं वा वदाया दगणेन वा।
वेदन या दकां कुयात ् च क साम दतो दताम ्॥ (AH U 20/10)
Vatanashaka dravya sidda ghrita
pancha lavana or Vidaryadhi gana sidda ghrita
Sweda-nasya etc chikitsa as explained in Ardita chikita.

Charaka
ि न ध या थापनैद षं नहरे वातपीनसे । (च. च. २६/१४१)

 intake of Go ghrita+ yava kshara

 intake of warm mamsa rasa
 intake of war milk
 snaihika dhoomapana
Yoga
1. shatahwadi dhoomavarti
2. Anutaila
 Astaoana basti prayoga(Cha chi 26/141)
 Pathya
 Nasagata roga

1. snigdha ushna amla laghu bhojana

2. Gramya mamsa rasa sevana
3. hot water bath and for drinking
4. staying in nivatha and ushna griha
 Apathya
1. chinta
2. vyayama
3. vaak cheshta
4. vyavaya

Allergic Rhinitis
DEFINITION

It is an IgE – mediated immunologic response of nasal mucosa to air – borne allergens

and is characterized by watery nasal discharge, nasal obstruction, sneezing and itching in
the nose. This may also be associated with symptoms of itching in the eyes, palate and
pharynx. Two clinical types have been recognized.
1. Seasonal: Symptoms appear in or around a particular season when the pollens of particular
plant, to which the patient is sensitive, are present in the air.
2. Perennial: Symptoms are present throughout the year.

AETIOLOGY

1. Age: Usually it affects children, young adults from the age of 15 years onwards, and tends
to recede after the age of 40 to 50 years.
2. Sex: Both sexes are affected.

3. Predisposing Factors:

i. Heredity: It may run in families. If both parents are allergic, there is a high incidence
of the disease occurring in children.
ii. Hormonal: Since the disease often begins at puberty and increases during
pregnancy, a hormonal basis is possible.
iii. Climate: Change in humidity, and atmospheric pollution may make the nose more
susceptible to allergy.
iv. Emotional: Psychological factors may affect the nose.

4. Precipitating Factors (Allergens)

The allergens are exogenous or endogenous:

a) EXOGENOUS (External agents)

i. Inhalants (The commonest allergens): Dust, pollens, animal odour, feathers,

moulds, housedust and mites.
 Nasagata roga

ii. Ingestants: Foods like eggs, fish, milk, citrus fruits and cocoa.
iii. Contactants like cosmetics and powders.
iv. Irritants like fumes and smoke.
v. Drugs: Aspirin, hypotensive drugs, iodides.
vi. Infection: Bacteria, fungi and products of inflammation may cause allergy, or they
may be secondary invaders.

b) ENDOGENOUS (within the body)

Intestinal helminths, tissue proteins in transudates and exudates.

MECHANISM OF ALLERGY

The following three factors are necessary for the development of allergy in the human
subject.
a. Predisposition
b. The initial conduct of the antigen and the body, followed by a latent period of allergization,
during which antibodies appear in the tissues and the blood stream, and the altered
reactivity develops.
c. The subsequent re-application of the antigen with resulting antigen – antibody reaction,
and the allergy reactions of hypersensitive reaction which follows the conjugation of
allergen and antibody in the cell consists in the following :
 Edema
 Contraction of the smooth muscle fibers.
 Dilatation of arterioles and capillaries.
 Infiltration with eosinophil cells.
 In mucous membranes, increased glandular activity.

CLINICAL FEATURES

 There is no age or sex predilection. It may start in infants as young as 6 months or

older people. Usually the onset is at 12 – 16 years of age.
 The cardinal symptoms of seasonal nasal allergy include
1. paroxysmal sneezing, 10 – 20 sneezes at a time, nasal obstruction, watery
nasal discharge and itching in the nose.
2. Itching may also involve eyes, palate or pharynx. Some may get
bronchospasm. The duration and severity of symptoms may vary with the
season.
 Symptoms of perennial allergy are not as severe as that of the seasonal type. They
include
1. frequent colds,
2. persistently stuffy nose, and
3. loss of sense of smell due to mucosal edema,
4. postnasal drip,
 Nasagata roga

5. chronic cough and

6. hearing impairment due to Eustachian tube blockage or fluid in the middle
ear.

Signs of allergy may be seen in the nose, eyes, ears, pharynx or larynx.

Nasal signs include

1. transverse nasal crease – a black line across the middle of dorsum of nose
due to constant upward rubbing of nose simulating a salute (allergic salute),
2. pale and oedematous nasal mucosa which may appear bluish.
3. Turbinates are swollen.
4. Thin, watery or mucoid discharge is usually present.

Ocular signs include

1. oedema of lids,
2. congestion and
3. cobble – stone appearance of the conjunctiva, dark circles under the eyes
(allergic shiners).

Otologic signs include

1. retracted tympanic membrane or
2. serous otitis media as a result of eustachian tube blockage.

Pharyngeal signs include

1. granular pharyngitis due to hyperplasia of submucosal lymphoid tissue.

Laryngeal signs include

1. hoarseness of voice and edema of the vocal cords.

A child with perennial allergic rhinitis may show all the features of prolonged mouth
breathing as seen in adenoid hyperplasia.
 Nasagata roga

PATHOGENESIS

Specific allergic stimulus (IgE – mediated) Non specific stimuli

1. Weather changes
2. Emotinal stimuli
3. Salicylates
4. Viral infections
5. Air pollution

Mast cell or blood basophil

Drop in cAMP/cGMP ratio

Release of preformed and newly – formed

mediators

Increased Change in Hyperactivity of

smooth glands
vascular
permeability and

Increased
Tissue oedema
secretion

Bronchospasm Rhinorrhoea
Nasal blockage
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DIAGNOSIS

A detailed history and physical examination is helpful, and also gives clues to the
possible allergen. Other causes of nasal stuffiness should be excluded.

INVESTIGATIONS

1. Total and differential count. Peripheral eosinophilia may be seen but is an inconsistent
finding.

2. Nasal smear shows large number of eosinophils in allergic rhinitis. Nasal smear should be
taken at the time of clinically active disease or after nasal challenge test. Nasal eosinophilia
is also seen in certain non-allergic rhinitis.
e.g NARES (non-allergic rhinitis with eosinophilia syndrome.)

3. Skin tests help to identify specific allergen. They are prick, scratch and intradermal tests.

4. Radioallergosorbent test (RAST) is an in vitro test and measures specific IgE antibody
concentration in the patient’s serum.

5. Nasal provocation test: A crude method is to challenge the nasal mucosa with a small
amount of allergen placed at the end of a toothpick and asking the patient to sniff into each
nostril and to observe if allergic symptoms are reproduced. More sophisticated techniques
are available now.

COMPLICATIONS
Nasal allergy may cause:

1. Recurrent sinusitis because of obstruction to the sinus ostia.

2. Nasal polypi.
3. Serous otitis media.
4. Orthodontic problems and other ill – effects of prolonged mouth breathing especially in
children.
5. Bronchial asthma: Patients of nasal allergy have four times more risk of developing
bronchial asthma.

TREATMENT
Treatment can be divided into:

1. Avoidance of allergen.

2. Treatment with drugs.

3. Immunotherapy.
 Nasagata roga

1. Avoidance of allergen: This is most successful if antigen involved is single.

Removal of a pet from the house, encasing the pillow or mattress with plastic sheet, change
of place of work or sometimes change of job may be required. A particular food article to
which the patient is found allergic can be eliminated from the diet.
2. Treatment with drugs :

a. Antihistaminics: They control rhinorrhoea, sneezing and pruritis. All anti histamines have
the side effect like drowsiness and othes.
b. Sympathomimetic drugs (oral or topical). Alpha – adrenergic drugs constrict blood vessels
and reduce nasal congestion and oedema. They also cause CNS stimulation and are often
given in combination with antihistamines to counteract drowsiness, Pseudoephedrine and
phenylpropanolamine are often combined with antihistaminics for oral administration.
Topical use of sympathomimetic drugs causes nasal decongestion. Phenylephrine,
oxymetazoline and xylometazoline are often used to relieve nasal obstruction, but are
notorious to cause severe rebound congestion.

c. Corticosteroids: Oral corticosteroids are very effective in controlling the symptoms of

allergic rhinitis but their use should be limited to acute episodes which have not been
controlled by other measures.
Topical steroids such as beclomethasone dipropionate, budesonide, flunisolide acetate
fluticasone and mometasone inhibit recruitment of inflammatory cells into the nasal
mucosa and superior late phase allergic reaction, are used as aerosols and are very effective
in the control of symptoms. It is wise to break their use for 1 – 2 weeks every 2 – 3 months.
They may promote growth of fungus.

d. Sodium Cromoglycate: It stabilizes the mast cells and prevents them from degranulation
despite the formation of IgE- antigen complex. It is used as 2% solution for nasal drops or
spray or as an aerosol powder. It is useful both in seasonal and perennial allergic rhinitis.

3. Immunotherapy: Immunotherapy or hyposensitisation is used when treatment fails to

control symptoms or produces intolerable side effects. Allergen is given in gradually
increasing doses till the maintenance dose is reached.
Immunotherapy suppresses the formation of IgE. It also raises the titer of specific
IgG antibody.
Immunotherapy has to be given for a year or so before significant improvement of
symptoms can be noticed. It is discontinued if uninterrupted treatment for 3 years shows no
clinical improvement.28
 Nasagata roga

GENERAL: Vitamin C and calcium are often recommended, but are of doubtful
value.
LOCAL TREATMENT:

a. Hydrocortisone injections in the inferior turbinates give relief for about a year in 70%
of cases. 0.5 cc of hydrocortisone is injected on either side of the nose once a week on
4 – 5 occasions.
b. Zinc ionization, cryosurgery and laser are not very helpful. They reduce nasal
obstruction, but sneezing and rhinorrhoea persist.
c. Auto haemo injections in the inferior turbinates once a week on 4 to 5 occasions may
give long term relief.
d. 15% silver nitrate topical applications to inferior turbinates have been recommended
for long term relief. It is applied once a week on 4 to 5 occasions after anaesthetizing
the nose topically. Recurrence can be treated by repeating the application of silver
nitrate.

SURGERY

Surgery does not treat allergy, but it reduces nasal obstruction and infection
a. Nasal obstruction: Treatment of nasal obstruction like polyps, deviated nasal septum
and hypertrophic turbinates does not reduce allergy, but relieves nasal obstruction.
b. Septic foci: Removal of sources of infection like tonsils, adenoids and sinusitis are of
doubtful value.
Inadvertent tonsillectomy may aggravate allergy.

c. Vidian neurectomy: The nerve of the pterygoid canal is severed or cauterized to

obstruct the sympathetic and parasympathetic nerve supply.
Recurrence is quite common and sneezing may not be relieved. This procedure is
likely to be useful in cases having vasomotor rhinitis.

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Pittaja Pratishyaya
उ णः सपीतकः ावो ाणात ् व त पै के ।।७।।
कृशोऽ तपा डुः स त तो भव ृ णा न( भ)पी डतः ।
सधम
ू ं सहसा वि नं वमतीव च मानवः ।। (S U 24/6)
Commentary: सपीतक ईष पीत इ यथः। सधम
ू म त सधम
ू मव वि नं नासया वमती यथः। सहसा
अक मात ्।
 Nasal discharge- Ushna and peetha(yellow)
 patient- Krisha, panduvarna, jwara, trishna
 Spontaneous feeling of smoke and fire coming out of the nose.

प ा ृ णा वर ाण प टकास भव माः॥
नासा पाको ो णता पीतकफ ु तः। (AH U 19/5)
 Trishna
 jwara
 pitika in nasa
 bhrama
 nasagra paka( vestibulitis)
 nasal discharge- ruksha, ushna, tamra, peeta varna.

Charaka (Cha chi 26/106)

नासा पाका वरव शोषत ृ णो णपीत वणा न प ात ्। (च. च. २६/ १०६)
 Nasagra paka
 jwara
 Mukhashosha
 trishna
 Nasal discharge- ushna peeta varna

Chikitsa

प र तो थयोः पेयं स पमधरु कैः शत

ृ म ् ।।
प रषेकान ् दे हां च कुयाद प च शीतलान ् । (S U 24/26)
 Madhurakadi( Kakolyadi gana) oushadi sidda ghrita pana
 sheetala oushadi pariseka and pradeha(pralepa)

ीसजरसप ग य गुमधश
ु कराः ।।
ा ामधू लकागोजी ीपण मधक
ु ै तथा ।

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यु य ते कवला चा वरे को मधरु ै र प ।। (S U 24/27)

 Sriveshtaka, sarjarasa, raktha chandana, priyangu, madhu, sharkara, drakshna,
guduchi, gojihwa, gambhari siddha GRHITA PANA and KASHAYA KAVALA
 Virechana with Yashtimadu etc
 Dhavadi taila nasya

Ashtanga Hridaya opines same as sushruta

Charaka

पैते स पः पबेत ् स धं ृ गवेरं त

ु ं पयः ।
पाचनाथ पबेत ् प वे काय मूध वरे चनम ् ।।( च. च. २६/ १४४)

Ghrita or ksheerapaka prepared using Shringavera(shunti) for dosha pachanartha

Shirovirechana

Paatadi taila nasya- Pakwa peenasa

Pathya

 Ghrita
 ksheera
 yava
 shaali
 godhooma
 jangala mamsa rasa
 sheeta-amla tikta shaka(vegetables)
 Mudga yusha

Correlation- Acute Viral Rhinitis.

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 Nasagata roga

Kaphaja Pratishyaya
कफः कफकृते ाणा छु लः शीतः वे मुहुः ।
शु लावभासः शन
ू ा ो भवे गु शरोमख
ु ः ।।
शरोगलौ ठतालूनां क डूयनमतीव च । (S U 24/6)
 Nasal discharge- swetha and sheeta srava
 patient- shuklaavabhasa
 netra shopha
 shiro gurutha(heaviness in head)
 mukha gurutha (heaviness in mouth)
 kandu in shira, gala, oshta, talu.

कफा कासोऽ चः वासो वमथग

ु ा गौरवम ्॥
माधय
ु वदने क डूः ि न धशु लकफ ु तः। (AH U 19/6)
 kasa
 aruchi
 shwasa
 vamana
 gatra gowrava
 mukha madhurya
 kandu
 nasal discharge- snigdha and shukla

Charaka
कासा च ावघना सेकाः कफा गु ः ोत स चा प क डूः । (च. च. २६/ १०६)

 Nasal discharge- Ghana srava

 Kasa
 aruchi
 nasa kandu
 praseka

Chikitsa

कफजे स पषा ि न धं तलमाष वप वया ।।

यवा वा वामये वा तः कफ नं ममाचरे त ् । (S U 24/30)
Step 1- Ghrita pana
Step 2- vamana with (tila+masha) yavagu
Step 3- Kapha nashaka anna samsarjana krama

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उभे बले बह
ृ यौ च वड गं स क टकम ् ।।
वेतामल
ू ं सदाभ ां वषाभंू चा संहरे त ् ।
तैलमे भ वप वं तु न यम योपक पयेत ् ।।
सरला क णह दा नकु भे गु द भः कृताः ।
वतय चोपयो याः युधमपाने
ू यथा व ध ।। (S U 24/33)
Baladi taila nasya

Dhoomapana
कफजे ल घनं लेपः शरसो गौरसषपैः।
स ारं वा घत
ृ ं पी वा वमेत ्, प टै तु नावनम ्॥
ब ता बुना पटु योषवे लव सकजीरकैः। (AH U 20/13)
 Langhana
 gowra sarshapa shiro lepa
 Vamana using Yava kshara+ghrita
 nasya prayoga using- Saindava, trikatu, vidanga, vatsaka, jeeraka+ aja mutra

Charaka
गौरवारॊचके वादौ ल घनं कफपीनसे ।
वेदाः सेका च पाकाथ ल ते शर स स पषा ।। (च. च. २६/ १४९)
 If case of shiro gurutva and Aruchi- Langhana in the beginning
 Ghrita lepa on shiras( note: though it is kaphaja, charaka has explained ghrita lepa on
shiras)
 Sweda and pariseka
 kapha nashaka vamana
 dhoomapana
 avapeedana nasya
 Manasheeladi nasya
 Bargyadi taila nasya
Pathya

 Varthaka
 kulaka
 trikatu
 kulattha
 mudga yusha
 ushna jala
 kapha nashaka ahara

correlation- Rhinitis Caseosa

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Tridoshaja Prathisyaya
भू वा भू वा त यायो योऽक मा व नवतते ।।
स प वो वाऽ यप वो वा स सव भवः मत
ृ ः।
ल गा न चैव सवषां पीनसानां च सवजे ।।(S U 24/11)
 pratishyaya lakshana appearing now and again and also spontaneously ceasation of
pratishyaya lakshana.
 pakwa or apakwa pratishyaya( *see the explanation below)
 lakshana of all types of pratishyaya

*AMA AND PAKWA PRATISHYAYA LAKSHANA

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Aruchi, virasavakrata, nasa srava, ruja, arati, shirogurutva, kshavathu, jwara are
the lakshanas of Ama Pratishyaya.

Tanutva amalinga, Shiro nasa laghuta, Ghana pita kaphatva are the lakshanas
of Pakwa Pratishyaya.

सवजो ल णैः सवरक मा व ृ धशाि तमान ्॥ (AH U 19/7)

Same as sushruta.

Charaka
सवा ण पा ण तु सि नपतात ् युः पीनसे ती जेऽ त दःु खे ।( च. च. २६/ १०६)

 lakshana of all types of pratishyaya

 tivra vedana(severe pain)
 diseases which causes atyanyta dukha(excessive suffering).

Chikitsa
सप ष कटु त ता न ती णधम
ू ाः कटू न च ।
भेषजा युपयु ता न ह युः सव कोपजम ् ।। (S U 24/34)
 ghritapana with ghrita prepred using Katu or tikta dravya
 tikshna dhoomapana
 katu dravya oushada prayoga

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 Rasanjana taila nasya

रसा जने सा त वषे मु तायां भ दा ण ।
तैलं वप वं न याथ वद या चा बु धमान ् ।। (S U 24/34)
 dasha ksheera ghrita/taila
 Mustadi kashaya kavala dharana

कटुती णैघतै
ृ न यैः कवलैः सवजं जयेत ्॥ (AH U 20/14)
katu, Theekshna dravya sidda ghrita- Nasya and kavala dharana.

Correlation- Infective Rhinitis

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Rakthaja Prathisyaya
र तजे तु त याये र ता ावः वतते ।
ता ा च भवे ज तु रोघात पी डतः ।।
दग
ु धो वासवदन तथा ग धा न वे च।
मू छि त चा कृमयः वेताः ि न धा तथाऽणवः ।।
कृ ममूध वकारे ण समानं चा य ल णम ् । (S U 24/13)
 Nasal bleeding
 netra becomes tamra varna
 patient presents Uroghaata lakshana
 Durgandha uchhwasa and vadana(foul smell in breath and Halitosis)
 Anosmia
 krimi utthaptti- shweta, snigdha, sukshma krimi.
 Krimija shiroroga samaana lakshana.

द ु टं नासा सराः ा य त यायं करो यसक

ृ ्।
उरसः सु तता ता ने वं वासपू तता॥८॥
क डूः ो ा नासासु प ो तं चा ल णम ्। (AH U 19/8)
 Dhooshita raktha takes sthana samshraya in nasagata sira and causes pratishyaya.
 uras suptata
 Tamra netra
 shwasa poothita
 Kandu in karna akshi nasa
 Pittaja pratishyaya samana lakshana

Chikitsa

 Pittaja pratishyaya samana chikitsa

समू प ा चो द टाः याः कृ मषु योजयेत ् ।

यापनाथ कृ म ना न भेषजा न च बु धमान ् ।। (S U 24/42)

in case of Krimi- krimighna dravya like vidanga etc are dravya+ go mutra/ go pitta
Nasya karma.
Note:

Krimi uthpatti( sushruta)- Rakthaja pratishyaya

Krimi uthpatthi( Vagbhata)- Dushta pratishyaya

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Dushta pratishyaya
Sushruta has not considered dushta pratishyaya as a type of pratishyaya but mentioned in the
prathisyaya chapter after explaining 5 types of pratishyaya.

Vagbhata has considered dushta pratishyaya as atype of Pratishyaya.

ि ल य त पन
ु नासा पन
ु च प रशु य त ।।
मुहुरान यते चा प मुहु व यते तथा ।
नः वासो वासदौग यं तथा ग धा न वे च ।।
एवं द ु ट त यायं जानीयात ् कृ साधनम ् । (S U 24/42)
 Nose gets moistened and again dries up.
 it gets blocked and again opened
 foul smell in breath
 anosmia
 it is difficult to cure

Pratishyaya Upadrava
सव एव त याया नर या तका रणः ।।
कालेन रोगजनना जाय ते द ु टपीनसाः ।
बा धयमा यम ाणं घोरां च नयनामयान ् ।
कासाि नसादशोफां च व ृ धाः कुवि त पीनसाः ।। (S U 24/17)
any type of pratishyaya if not treated properly end up in causing multiple disease and leads to
dushta pratishyaya.
multiple diseases such as

1 Badirya
2 andatha
3 ghrana shakthi nasha
4 bayankara netra roga
5 kasa
6 agni mandhya
7 shopha

सव एव त याया द ु टतां या युपे ताः॥

यथो तोप वा ध या स सवि यतापनः।
साि नसाद वर वासकासोरःपा ववेदनः॥
कु य यक मा बहुशो मुखदौग यशोफकृत ्।
ना सका लेदसंशोषशु धरोधकरो मुहुः॥

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पूयोपमा सतार त थत ले मसं ु तः।

मू छि त चा कृमयो द घि न ध सताणवः॥ (AH U 19/12)
Any pratishyaya neglected leads to dushta pratishyaya.
causes multiple disease such as
1 indriya peeda
2 agnimandya
3 jwara
4 shwasa
5 kasa
6 ura vedana
7 parshwa vedana
8 mukha dowrgandhya
9 kleda and shushkata in nasa
10 on and off nasa avrodha
11 puya samana Krishna, raktha, grathita kapha srava
12 KRIMI- deerga, snigdha, shweta, anu uthpatthi.

Charaka
सव ऽ तव ृ धोऽ हतभोजना ु द ु ट त याय उपे तः यात ् । (च. च. २६/ १०७)

Prathishyay rogi

Ahitakara ahara sevana

neglecting the disease

Dushta pratishyaya
causes multiple disease such as
1 kshwathu
2 nasashosha
3 pratinaha
4 nasa parisrava
5 poothinasa
6 apeenasa
7 nasapaka
8 shotha
9 arbuda
10 puyaraktha
11 arunshi
12 shira, karna netra roga
13 khalitya
14 hari lomata
15 trishna
16 shwasa
17 kasa
18 jwara

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19 rakthapitta
20 swarabheda
21 shosha
रोध भघात वशोषपाकै ाणं युतं य च वे ग धम ्।
दग
ु ि ध चा यं बहुशः को ष द ु ट त यायमुदाहरे त ् तम ् ।। ( च. च. २६/ ११०)
1 Nasa avarodha
2. Nasa abhighata
3. nasa srava or shushka
4. nasa paka
5. gandha jnana nasha
6. mukha dowrgandha
7. dosha prakopa occurs often.
Chikitsa
Upadrava yuktha pratishyaya- Chardi, anga sada, jwara, gowrava, aruchi, arathi. atisara

Step 1- LANGANA
Step 2- Pachana
Step 3- Deepana
Vata-Kapha upsrishta vayastha(taruna) rogi- Vamana after giving large quantity of water.

Ashtanga Hridaya
 Yakshma chikitsa
 krimi chikitsa
 Nasa and Mukha dhoomapana

Note:

1 Raktha pratishyaya
Sushruta- दग
ु धो वासवदन तथा ग धा न वे च।
मू छि त चा कृमयः
Vagbhata- वासपू तता

8. Dushta pratishyaya
Sushruta- नः वासो वासदौग यं तथा ग धा न वे च ।।
Vagbhata- मख
ु दौग यशोफकृत ्। मू छि त चा कृमयो

Charaka- न वे ग धम ्। दग
ु ि ध चा यं
Correlation- Rhino-sinusitis

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