A Clinical Study on the Management of Peenasa (Atrophic Rhinitis) with Vyaghri Haritaki Lehya

Introduction

It is fascinating that ancient texts like the Sushruta Samhita continue to offer insights into medical conditions that remain relevant today. Sushruta Samhita enumerated 31 types of nasal disorders. Peenasa is one of the nasarogas. Atrophic rhinitis indeed shares similarities with Peenasa based on the clinical features. Both conditions involve nasal obstruction (nasaavarodha), dryness (nasashosha), nasal discharge, and altered smell perception (gandhaajnana).¹

While the terminology and understanding of these conditions may have evolved over time, it is clear that the observations made by ancient medical practitioners still hold value in understanding and treating similar conditions in modern medicine. It is considered to be a vatakapha predominant disease. The causative factors responsible for Peenasa could be categorized into two - faulty food habits and following improper regimen or lifestyle. Faulty food habits such as consuming excessively cold, heavy, sweet, and dry foods, as well as improper water intake and eating before the previous meal is digested, can disturb the balance of doshas and contribute to Peenasa. Similarly, unhealthy lifestyle choices like irregular sleep patterns, excessive talking, loud speech, overexertion in exercise or sexual activity, and exposure to environmental pollutants like dust and smoke can exacerbate the condition.

Furthermore, factors like suppression of natural urges and changes in weather or seasons can also influence the onset of Peenasa. The concept of Agnimandya (decreased digestive fire) and Ama (undigested food products) contributing to the condition underscores the importance of maintaining proper digestion and eliminating toxins from the body.^2-4 The vitiated vata produces drying of the kapha of nose leading to formation of crusts and nasal obstruction. Vitiated kapha produces nasal discharge. Over time, various authors have referred to this condition as ‘Ozaena’.⁵

Atrophic catarrhal coryza, also known as Ozaena, is a condition characterized by inflammation and atrophy of the nasal mucosa, often resulting in foul-smelling nasal discharge. It is of two types - Primary atrophic rhinitis and Secondary atrophic rhinitis. The specific infections like syphilis, leprosy, rhinoscleroma may cause secondary atrophic rhinitis. The etiology of primary atrophic rhinitis is multifactorial, with various factors contributing to its development. Nutritional factors play a significant role in the etiology of atrophic rhinitis. Deficiencies in essential nutrients such as Vitamin A, Vitamin E, and Iron have been identified as causative factors for Ozaena.⁶ Vitamin A is crucial for the development and maintenance of the epithelial structures of respiratory passages. Its deficiency can lead to epithelial dysfunction, impairing the integrity of nasal mucosa. Vitamin E plays a role in preserving the vitality and integrity of mucous membranes by supporting their structure and function. Its deficiency may result in increased susceptibility to damage and inflammation of the nasal mucosa. Iron deficiency can lead to poor perfusion of the mucous membrane, affecting its ability to receive adequate oxygen and nutrients. This can contribute to the development of atrophic rhinitis by compromising the health and function of the nasal tissues. In addition to nutritional factors, other contributing factors to atrophic rhinitis include occupational exposures (such as to dust, fumes, or chemicals), habitual factors (such as smoking), traumatic factors (such as nasal trauma), constitutional factors (genetic predisposition), inflammatory factors (chronic infections or allergies), and endocrine factors (hormonal imbalances). Understanding the role of these factors in the development of atrophic rhinitis is essential for effective management and prevention of this condition. Ensuring adequate nutrition, addressing occupational and environmental exposures, and managing underlying inflammatory or hormonal conditions are important aspects of treatment and prevention strategies for Ozaena. It is a well-accepted fact that the variation in the levels of estrogen can cause atrophic rhinitis.⁷ The disease causes dryness of nasal mucous membrane characterized by crusting, nasal obstruction, nasal discharge, abnormality in perception of smell and foul odor from nose.⁸ The efficacy in work output may be greatly affected because of Peenasa. It is not a life-threatening condition, but it can interfere with day-to-day routine activities, thereby affecting the quality of life.

Atrophic rhinitis was found to affect about 0.3%-1.0% of the population and can pose a notable challenge in clinical practice.⁹ Current medical management strategies often revolve around the use of synthetically prepared Vitamin A, Vitamin E, and estrogen preparations aimed at improving the condition. However, despite these efforts, satisfactory results are often elusive with surgical interventions. The limitations of surgical management highlight the urgent need for alternative, more effective approaches to treat this condition. Developing an effective management strategy is indeed imperative to enhance outcomes and alleviate the burden on individuals affected by atrophic rhinitis. Research efforts should focus on exploring novel therapeutic modalities, potentially including targeted drug delivery systems, immunomodulatory agents, regenerative medicine techniques, or approaches.

Ayurvedic literature holds a vast array of oral medications for treating such nasal disorders. The oral medication selected in this study focuses on removing undigested products, increasing digestive fire and redirecting vitiated vata and kapha. The drug Vyaghri Haritaki Lehya was selected for the present study. Vyaghri Haritaki Lehya is described in the classical texts, Bhaishajya Ratnavali and Chakradutta. The Lehya is indicated for Peenasa, Kasa, Swasa, Kshata and Rajayakshma.^10,11

Materials and Methods

The main objective of the trial was to determine the efficacy of Vyaghri Haritaki Lehya in the management of Peenasa.

Study type & Research design: Experimental, single group assignment, pre-and post-study design.

Sample size - Twenty subjects.

Source of data: Outpatient department of Shalakya Tantra at Shri Jaya Chamarajendra Institute of Indian Medicine Hospital, Bangalore.

Inclusion criteria

a) Dryness of the nose and crusting,

b) Nasal obstruction,

c) Loss of perception of smell,

d) Nasal discharge,

e) Patients in the age group of 10 to 70 years.

Exclusion criteria

a) Deviated nasal septum

b) Peenasa associated with systemic illnesses like hemophilia, hypertension, diabetes mellitus, leprosy and tuberculosis.

Drug preparation

The medicine Vyaghri Haritaki Lehya was prepared as per the classical method of Avalehya preparation. The ingredients and parts used for the preparation are summarized in Table 1.

Drug administration

The medicine was administered internally at a dose of 10 grams, twice daily after food for a period of seven continuous days.

Anupana - Ushnajala

Follow up Period: 30 days

Paired t test was employed for statistical analysis

Results

a) Age wise distribution:

35% between 31 to 40 years

20% between 21 to 30 years

15% between 11 to 20 years

10% each in 41 to 50 years, 51 to 60 years and 61 to 70 years age group

b) Gender wise distribution:

55% were females and remaining were males

c) Occupation wise distribution:

30% were housewives

25% were in service

20% were students

15% were retired persons

10% were agriculturists

d) Dietary habits: 65% consumed mixed diet and the remaining were vegetarians.

e) Clinical findings as per severity: The signs and symptoms of Peenasa were categorized into mild, moderate and severe using a self-prepared Severity Assessment Scale.

Discussion

Table 5 summarizes the subjective and objective assessment findings before and after treatment, along with the response rates. The treatment showed varying degrees of effectiveness across different parameters, with nasal discharge showing the highest response rate and abnormal perception of smell showing the lowest.

Out of twenty patients who participated in the trial, one showed a very good response, eighteen experienced moderate relief and one showed a poor response. Avalehya kalpana is one of the best media to treat Peenasa. Avalehya is the beautiful fine blend of medicaments with agnideepaka, amapachaka and doshanirharana properties.

Probable mode of action of Vyaghri Haritaki Lehya

The treatment administered here was a holistic approach, combining anti-inflammatory, bactericidal, and antioxidant properties with nutritional support. By targeting the underlying causes of disease, the medication was helpful in breaking down the pathogenesis, resolving the root issues and promoting recovery. The drug was considered to be Tridosha shamaka with dominant Kaphavatahara property. It had immense potency to digest undigested stagnant products in Koshta. Simultaneously the drug had the capacity to increase digestive fire. This yoga comprises of Tannic acid (Haritaki) which has anti-histamine and anti-tussive properties.¹²  The presence of Vitamin A in Shunti has significant implications on various aspects of health, particularly in the development and maintenance of epithelial structures within the respiratory and alimentary tracts. Vitamin A plays a crucial role in the development and maintenance of epithelial tissues, which are the protective layers covering internal and external surfaces of the body. In the respiratory and alimentary tracts, these epithelial tissues are essential for protecting against pathogens and irritants, as well as for the absorption of nutrients. Adequate levels of Vitamin A support the growth and differentiation of these tissues, ensuring their integrity and function. Vitamin A supports the health of the respiratory tract by maintaining the integrity of epithelial lining. Vitamin A contributes to the maintenance of the epithelial lining, which is crucial for proper digestion, nutrient absorption, and protection against pathogens. Vitamin A's impact on epithelial tissues can help soften areas prone to crust formation, especially in the nasal passages. The presence of Vitamin B in Shunti plays a crucial role in maintaining the integrity and vitality of mucous membranes throughout the body. Estrogen in Haritaki can indeed have a significant effect on the health of mucous membranes. Estrogen’s vasodilator effect can have several benefits including increased blood flow to the tissues which enhances the nutrient and oxygen delivery, thereby supporting tissue health and vitality.

Conclusion

Classical, clinical and statistical evidence clearly indicates that the drug Vyaghri Haritaki Lehya is highly effective in the management of Peenasa. Nasal discharge was predominantly relieved while gandhajnana showed least response. The medicine was effective in treating the disease symptomatically. Additionally, the same study can be conducted with proper Shareera shodhana therapies and classical Nasya procedures prior to administering the yoga. This may enhance the absorption of the medicine resulting in better outcomes. The study could also be conducted with a larger sample size, and extended administration periods to achieve better outcomes and greater symptom relief.

Conflicts of Interest

Nil