Practical Applicability of Nasya Karma (Ayurveda Therapy) in Sinusitis

Introduction

In Ayurveda, many therapies are used to maintain health and eradicate diseases. Nasya karma is an important therapy among them. In this therapy, medicine is administered through the nose in the form of ghrita, oil, powder, liquid or smoke. Even though it is particularly useful in the treatment of diseases of supraclavicular origin, it indirectly works by improving the functioning of the endocrine and nervous systems. According to all the Acharyas, nasa is the main doorway to shiras and medicine introduced through nasa occupies shrungatak marma and all channels of eye, ear, nose, throat and removes the morbid doshas.¹

Nasya means instilling the medicine through nostrils and delivering the drug to the brain, thereby acting on the whole body.^2,3 The word Nasya is derived from “Nasa” Dhatu, meaning ‘Gati’. Here the gati is towards the internal structures, mainly to head through the nose. It is also called Shirovirechana that implies removal of toxins from the head region.⁴ Ayurveda acharyas have included Nasya as a treatment modality in Panchakarma, and references of it can be found in Rigveda. Different types of nasya karma are described in Ayurveda and in different contexts. But it is interesting to note that in the current era, not all types are in practice or are either practiced with modifications.⁵

Nasya has many synonyms like shirovirechana, navana, nastakarma, shirovireka, nastapraschardana, murdhavirechana etc. and different classifications of nasya are Pradhamana nasya, Pratimarsha nasya, Swarasa or Avapida nasya, Dhooma nasya, Nasapana and Marsha nasya. On observation, it is found very effective in sirogata rogas and nasagata roga. Also equally effective in conditions where the pathology is urdhwajatrugatam, i.e above the shoulders. Nasya independently or when combined with other procedures has shown its effectiveness in neurological and psychological problems as well. The beauty of the procedure is that it can be used both as shamana as well as shodhana of doshas.⁵

All the recently published guidelines have adopted the term rhinosinusitis (RS) instead of sinusitis. RS is the inflammation of the nose and paranasal sinuses characterized by two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge and the second either facial pain/ pressure or reduction/loss of smell or both of these with objective findings on either computed tomography or nasal endoscopy.⁶ CRS is an important chronic public health problem affecting the quality of life of more than 5% of people.⁷ The overall prevalence of symptom-based CRS in the population has been found to be between 5.5% and 28%, and when symptoms were combined with endoscopy or CT scan, prevalence reduced to 3-6%.⁶ The treatment strategy of RS includes oral and nasal antibiotics, nasal sprays, antihistamines, steroids, and saline irrigation in chronic and acute conditions.^6,8

Among the four paranasal sinuses, sinusitis might affect any and can lead to different types of sinusitis called Atrophic sinusitis, Chronic sinusitis, Allerghic rhinitis, Rhinosinusitis, Frontal sinusitis etc. These can be compared to any of the nasagata rogas based on the signs and symptoms mentioned in Ayurvedic science. According to Acharya Sushrutha, there are 28 nasagata rogas and these include pratishyaya, dusta pratishyaya, pootinasa, peenasa, apeenasa etc⁹ that can be considered as sinusitis based on the type and stage of sinuses involved. Many studies have been conducted on the same to evaluate the effects of Ayurveda therapies and nasya karma is one of them. In this work, an attempt was made to study in detail the practical applications of a therapy called nasya in the management of sinusitis and its stages.

Mode of administration The procedure of nasya karma was carried out for 7 days, 14 days or 21 days based on the chronicity of the disease. This was administered under three steps as purva karma, pradhana karma and paschat karma.

Precautions to be taken before the procedure

● The whole procedure was explained to the patient

● Required investigations were obtained

● Patient was advised to complete their early morning chores by cleaning their teeth and washing face with warm water

● They were advised to take a non-spicy light diet or to be on empty stomach

● Patient was mentally prepared by giving assurance and informed consent was obtained

Purva karma

● Procedure was conducted in ‘Nasya room’ located in Panchakarma theatre or any comfortable room that was devoid of dust, extreme breeze and sunlight.

● Blood pressure and pulse were recorded prior to the Nasya Karma for observation

● Actual procedure of the therapy began with bahya snehana (external application) with the prescribed luke warm taila over the shiras (oil massage over the head), gentle oil massage over gala (chin), kapola (cheeks), lalata (forehead) and karna (ears) for 10- 15 mins.

● After snehana (oil massage), mild swedana (fomentation) was given with a clean cotton napkin dipped in a hot water bowl and the water was completely removed by squeezing both the ends of the napkin.

● The fomentation was administered over the area above the shoulders with eyes closed.

Pradhana karma

● Patient was made to lie down on a table in supine position

● The head was bent at about 450 angle from the edge of the table

● Patients were instructed to be in a relaxed posture keeping limbs apart

● Eyes were covered with a cloth folded in four layers

● Then the taila was taken in a small crucible and was kept tepid by placing in hot water.

● The head of the patient was slightly raised, nostrils widened with the index, little finger of the left hand and with the help of nasya pali (gokarnika), bindu or drops of taila were instilled in each nostril in a continuous stream. The taila was instilled slowly and in an uninterrupted stream known as “avicchinna dhara”.

● The other nostril was closed while administering nasya karma through one nostril.

● As the final step, the patient was advised to inhale the medicine administered slowly and forcefully. The same procedure was repeated in other nostril too.

Paschat karma

● As post therapy instructions, patient was advised not to make any movements with his head for 100 matra and to relax in the same position for few minutes

● Slow gentle massage of skanda (shoulders), karna (ears), hasta (palms), padatala (plantar aspect of foot) was done for 3 to 5 mins.

● Patients were advised to spit out the content of taila (oil) through mouth, were strictly instructed not to swallow taila and to carry on the act of spitting till the smell and the taste of taila disappeared from the throat.

● After this, patients were advised to do kavalagraha (gargling) with hot water.

● Also were instructed to avoid excessive intake of fluid,

● Not to succumb to the emotional disturbances, or smoke, and avoid dust and exposure to sunlight

● To avoid intake of snigdha and abhishyandhi ahara (unctuous food).

● They were also advised not to take head bath and travel for one day^10,11

Discussion

According to Ayurveda, the nose is the gateway for the head. Nasya Karma is the process which eliminates the vitiated Doshas of the Urdhvanga ensuring the smooth functioning of the brain and ultimately the whole body. To explain the pathway of Nasya Karma i.e. delivery of drug from nose to brain, the following factors can be considered - Pooling of blood from nasal veins to venous sinuses of the brain is more likely to occur in head lowering position due to gravity and thus absorption of drug into meninges and related intracranial organ is a point of consideration. Administered drug enters into the intracranial region by direct pooling and to systemic circulation by vascular path.

It may be possible that Nasyaaushadhi through neurological pathway works as perception of smell is received through olfactory pathway and thus controlling various nervous and endocrinal diseases. Lipid form of medicine facilitates drug absorption. Maximum Kalpas used in Nasya are prepared in lipid base.⁴

Nowadays, nasal gels are developed on the principles of mucoadhesive drug delivery system (MDDS) for accurate drug delivery. However, the mode of action of nasya is slightly different from these. More research needs to be done to understand the exact mode of action of nasya.

It has been observed that the rheological properties of mucous were found out with incubation of dry powders into the nasal passage.¹² This hyper osmolarity increases the mucociliary clearance which is in conjunction with the concept of shodhana in Ayurveda. Oil based medicines may have better mucoadhesive properties thereby increasing the bioavailability of the active principles and may also act as smoothening agents. This notion supports the shamana concept of Ayurveda where mainly the doshas are pacified with the help of certain drugs. The aqueous formulations used in nasya are humidifying in nature and may increase the mucociliary activity of the nasal passage. Standardization is another issue faced by Ayurveda and this dilemma starts right from the concept of bindu. In one study, it was reported that one bindu is approximately 0.44 mL.¹³

Chronic Sinusitis (Dushta Pratishyaya) A clinical trial was performed in which 31 chronic sinusitis patients were randomly classified into three groups: A, B, and C. Trayodashanga Kwatha with Madhu was orally administered in group A; Pradhamana Nasya with Trikatu & Triphala Churna was administered in group B; and Pradhamana Nasya was initially administered in group C (combined group), followed by oral Trayodashanga Kwatha with Madhu. Total relief was seen in group A in 10 percent of patients, marked progress was seen in group B in 81.82 percent of patients, and significant relief was observed in group C in 60 percent of patients. Group C showed percentage- wise better outcomes for most of the symptoms compared to the other groups (Group A and Group B).¹⁴

Allergic Rhinitis (Anurjata Janita Pratishyaya)

A clinical research was performed on 69 allergic rhinitis patients. Patients were chosen and divided randomly into three groups. For 14 days, Group A received Shunthi Taila Nasya with oral drug Shuddha Haridra 2 gms TDS for 21 days, Group B received Pradhamana Nasya with Katphal churna till Samayaka Shuddhi Lakshana was obtained, followed by oral drug Shuddha Haridra 2 gms TDS for 21 days, and Group C received oral drug Shuddha Haridra 2 gms TDS for 21 days. The two trial drugs used for Nasya Karma were found to provide better results compared to the oral drug group.¹⁵ Another study was performed on 32 allergic rhinitis patients divided randomly into two groups. Haridra Khanda in group A and Pippalyadi Taila Nasya in group B were administered for two months with the oral drug Haridra Khanda. It was concluded that patients in group B showed marked improvement in allergic rhinitis signs and symptoms.¹⁶

Peenasa

A clinical research on 100 diagnosed cases of Peenasa Roga was performed. Selected patients were divided randomly into two classes. In group A, patients were treated with Sneha, Swedana and Nasya Karma with Nirgundi Taila (4 drops in each nostril) and in group B, patients were treated with Sneha and Swedana; the period for both groups was seven days. Group A was found to display substantially improved results in Peenasa Roga signs and symptoms.¹⁷

Apeenasa

In a randomized controlled study, thirty patients were divided into three groups, with 10 patients in each group. In Group A, Nasya karma was given once a day for 7 days and in Group B, Vyoshadi vati was given twice a day for 7 days and in Group C, Nasya karma and Vyoshadi vati in combination was given for 7 days. Statistically significant results were seen in reduction of shirashoola and shwasagurguratha and improvement in gandhagnananasha of patients with apeenasa with p<0.001. Group C (Nasya karma with vyoshadi vati) showed statistically significant results compared to Group A (nasya karma) and Group C (Vyoshadi vati) in reduction of shirashoola and shwasagurguratha and improvement in gandhagnananasha of patients suffering from apeenasa.¹⁸

The taila or the powder or any other material used for the purpose of nasya karma enhances the efficacy of the therapy and thereby helps in relieving the symptoms of the patient. In case of sinusitis or rhinosinusitis, nasya karma aims at pacifying nasal block in order to relieve the cascade of succeeding symptoms and helps to prevent the problem progressing and makes patients free from the suffering.

Conclusion

Apart from the indications of nasya karma as opined by our Ayurveda Acharyas, if administered systematicaly, nasya karma definitely provides benefits. This has been shown in different studies involving different diseases with significant results. Application of nasya karma practically with the right taila or the choorna after the proper diagnosis and assessment of the disease can bestow multiple benefits. Nasya karma has shown significant results in sinusitis in relieving the symptoms of patients effectively. More clinical studies with larger sample size needs to be carried.

Conflicts of Interest

None.