role of jati taila va rasa in the managem (safe chronic suppur

ROLE OF JATI TAILA VARTI AND KAPHA KETU

RASA IN THE MANAGEMENT OF KARNA SRAVA

(SAFE CHRONIC SUPPURATIVE OTITIS MEDIA)

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE,

DEPARTMENT OF P.G. STUDIES IN SHALAKYA

S.D.M. COLLEGE OF AYURVEDA & HOSPITAL, HASSAN





In partial fulfillment of

MASTER OF SURGERY(

AYURVEDA VACHASPATHI

Dr. ASHWINI M.J.


COLLEGE OF AYURVEDA & HOSPITAL, HASSAN




MAYANK JAIN

Dissertation submitted to the


KARNATAKA

In partial fulfillment of

MASTER OF SURGERY(


SHALAKYA TANTRA

Under the

Dr. ASHWINI M.J.

Assist. Professor &

Dept. of Shalakya Tantra






BY

MAYANK JAIN



KARNATAKA

In partial fulfillment of the requirements for the degree of

MASTER OF SURGERY(


In

SHALAKYA TANTRA

Under the Guidance of

Dr. ASHWINI M.J.

Assist. Professor &




2011




MAYANK JAIN



KARNATAKA

the requirements for the degree of

MASTER OF SURGERY(Ayu.)


SHALAKYA TANTRA

uidance of

Dr. ASHWINI M.J. M.S.(Ayu.)

Assist. Professor & H.O.D.








the requirements for the degree of

Ayu.)


M.S.(Ayu.)

DEPARTMENT OF P.G. STUDIES IN SHALAKYA TANTRA

COLLEGE OF AYURVEDA & HOSPITAL, HASSAN–





TANTRA

573 201.



DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation / thesis entitled “ROLE OF JATI TAILA

VARTI AND KAPHA KETU RASA IN THE MANAGEMENT OF KARNA

SRAVA (SAFE CHRONIC SUPPURATIVE OTITIS MEDIA)” is a bonafide and

genuine research work carried out by me under the guidance of Dr. ASHWINI M.J.

Assistant Professor, H.O.D., Department of Post Graduate Studies In Shalakya

Tantra S. D. M. College of Ayurveda and Hospital, Hassan – 573201.

Date:

Place: Hassan Signature of candidate

Mayank Jain

�

DEPARTMENT OF POST GRADUATE STUDIES IN SHALAKYA TANTRA

S. D. M. COLLEGE OF AYURVEDA & HOSPITAL, HASSAN – 573 201

CERTIFICATE BY THE GUIDE

This is to certify that the present dissertation entitled “ROLE OF JATI TAILA

VARTI AND KAPHA KETU RASA IN THE MANAGEMENT OF KARNA

SRAVA (SAFE CHRONIC SUPPURATIVE OTITIS MEDIA)” has been

undertaken by “Mayank Jain” under my close supervision and guidance in our Dept.

of P.G. Studies in Shalakya Tantra. All the facts and findings given in this thesis have

been checked by me from time to time.

We are hopeful that the present work of Dr. Mayank Jain will certainly open a new

horizon of research for future workers in this field of Shalakya Tantra. We are fully

satisfied with the work and recommend this thesis for the award of degree of

Ayurveda Vachaspati- M.S.(Ayu.) in Shalakya Tantra from R.G.U.H.S. Bangalore,

Karnataka.

Date: Guide & Supervisor:

Place: Hassan Dr. Ashwini M.J. M.S. (Ayu.)

Assist.Professor & H.O.D


DEPARTMENT OF POST GRADUATE STUDIES IN SHALAKYA TANTRA

S. D. M. COLLEGE OF AYURVEDA & HOSPITAL, HASSAN – 573 201

(Affiliated to RGUHS, Bangalore, Karnataka)

ENDORSEMENT BY THE H.O.D. AND THE HEAD OF THE INSTITUTION

This is to certify that the Dissertation entitled “ROLE OF JATI TAILA VARTI

AND KAPHA KETU RASA IN THE MANAGEMENT OF KARNA SRAVA

(SAFE CHRONIC SUPPURATIVE OTITIS MEDIA)” is the bonafide record of

research work conducted by “Mayank Jain” under the guidance of Dr. Ashwini M.J.

Assistant Professor, H.O.D. Dept. of P. G. Studies in Shalakya Tantra, S. D. M.

College of Ayurveda, Hassan.

Dr. Ashwini M.J. Dr. Prasanna N. Rao M.S.(Ayu) M.S.(Ayu.), Ph.D

Assist. Prof. & H.O.D Principal

Dept. of P.G. Studies in Shalakya Tantra S.D.M. College of Ayurveda,

S.D.M. College of Ayurveda, Hassan Hassan.

Prof. Gurudip Singh D.Ay.M., Ph.D.

Director, Post Graduate Studies

S D M College of Ayurveda, Hassan

Date:

Place: HASSAN

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall

have the rights to preserve, use and disseminate this dissertation / thesis in print or

electronic format for academic / research purpose.

Date:

Place: Hassan Signature of candidate

Mayank Jain

© Rajiv Gandhi University of Health Sciences, Karnataka

ACKNOWLEDGEMENT

The worship, most acceptable to God comes from a thankful and cheerful heart.

The divine blessings of Praneel, Lord Manjunatheshwara and Lord

Dhanwantari, this work bears love, care, attention, sacrifice, support, guidance,

succor, boost, encouragement, friendship, help, co-operation and nevertheless,

memories, so much invaluable in turning this dream into a reality. It’s so much

pleasure and contentment in my part, to hereby express my heartfelt gratitude to all

those, who have contributed to the success of this venture, directly or indirectly; this

work is dedicated to you all-

At this elated outset of, successful, completion of my dissertation, it is beyond

the reach of any language to express the pure, warm, sweet and bright flame of

gratefulness to my loving parents, Dr. Anil Prakash Jain and Smt. Sarita Jain,

whose infinite inspirations and benisons are the prime source of my progress and

success. Nothing can ever absolve me of my indebtedness to the sacrifices of my

family members.

I take this opportunity to express my deep sense of gratitude towards Poojya

Padmabhushana Dr. Virendra Heggadeji, Dharmadhikari of Dharmasthala and the

founder of this institute, for his kind blessings.

My words cannot express the zeal of happiness while depicting my deep sense

of gratitude to my beloved teacher, the proficient Principal of the institute,

Dr. Prasanna N Rao, who has been a guiding force for us and instrumental in all the

proceedings of our life.

I am extremely grateful to Guruji, Dr. Gurdip Singh, The Dean of P.G. studies

of S.D.M.C.A., Hassan, for his untiring guidance in this work.

With an overwhelming feeling of sincere gratitude and indebtness, I am proud

of acknowledging the present work has been completed under the supervision and

guidance of my guide Dr. Ashwini M.J. Assist. Professor and H.O.D., Dept .of

Shalakya Tantra. I consider it my privilege in having worked under his brilliant and

scholarly guidance.

I owe my sincere gratitude to worthy faculty members of P.G. Department of

Shalakya Tantra, Dr. Amarnath HK, Dr Gururaj Bhat, Dr. Nalini and Dr.

Abhijith, for their valuable suggestions, help and support.

I am extremely thankful to Dr. K.S. Tyagi, ENT surgeon of District hospital,

Muzzafarnagar (U.P.) for his valuable support, constant encouragement and valuable

suggestions in my research work.

My heartfelt thanks go to all my teachers of this college; worth mentioning the

names of Dr. P. Hemanth Kumar, Dr. TB Tripathi, Dr. Girish KJ, Dr. BG

Kulkarni, Dr.Suhas Kumar Shetty, Dr. Avanish Pathak, Dr. Govind Sharma, for

their constant encouragement bestowed throughout my academic carrier. I deeply

miss the guidance of those helping teachers who left me amid my PG tenure;

Dr. Shamsa Fiaz.

I can never forget the support rendered by my seniors, Dr. Naveen BS,

Dr. Gangadhar, Dr. Chaitanya, Dr. Akhil, Dr. Jyotirmoy, Dr. Goutam,

Dr. Divya, Dr. Dilbag and others.

I fail in my duty if I do not recall the support rendered by my colleagues,

Dr. Satya Prakash, Dr. Elsy, Dr. Ashwini, Dr. Amol, Dr. Rahul, Dr. Sheetal, Dr.

B.L.Patil, Dr. Rudresh, Dr. Rudramuni and all.

I am equally thankful to my juniors Dr. Manjusree, Dr. Deepti,

Dr. Hemachandra, Dr. Shiv Balaji, Dr. Aparna, Dr. Viswalaxmi, Dr. Suraj,

Dr. Vikram and others, for their affection and support.

I also exend my thanks to the staffs of college library Mr. Krishna Gowda &

Mr. Manju et al.

This work would not be finished undisturbed if not supported by the staff

members of the college and hospital. Hence, I am so thankful to the entire hospital

staff, institutional staff and the patients, who are the pillars of my research work.

Last but not the least, the patients who have beared the pain in my study,

deserve special thanks; without their co-operation, the entire study would have

stalemated.

To err is humane; my poor memory cannot recollect all those names who have

contributed directly or indirectly in this work, I beg their pardon.

Mayank Jain

ABBREVIATIONS

Ah. Ni. - Ashtanga Hridya Nidana Sthana

Ah. Sh. - Ashtanga Hridya Sharira Sthana

Ah. Su. - Ashtanga Hridya Sutra Sthana

Ah. Ut. - Ashtanga Hridya Uttara Sthana

Ah. Ch. - Ashtanga Hridya Chikitsa Sthana

As. Ni. - Ashtanga Samgraha Nidana Sthana

As. Sh. - Ashtanga Samgraha Sharira Sthana

As. Su. - Ashtanga Samgraha Sutra Sthana

As. Ut. - Ashtanga Samgraha Uttara Sthana

As. Ch. - Ashtanga Samgraha Chikitsa Sthana

Ath. - Atharveda

Rg. - Rigaveda

B.M.Kh. - Bhava Prakasha Madhyama Khanda

B.P.Kh. - Bhava Prakasha poorva Khanda

B. S. - Bhela samhita

Ch. Su. - Charaka samhita sutra sthana

Ch. Sh. - Charaka Samhita Sharira Sthana

Ch. Ch. - Charaka Samhita Chikitsa Sthana

C. D. - Chakra Dutta

G. N. - Gada Nigraha

H. S. - Harita Samhita

M. Ni. - Madhava Nidana

O. P.D. - Outdoor Patient Department

R. T. - Rasatarangini

Ref. - Reference

Sh. Pu. Kh. - Sharangdhara Poorva Khanda

Su. Su. - Sushruta Samhita Sutra Sthana

Su. Ch. - Sushruta Samhita Chikitsa Sthana

Su.Ut. - Sushruta samhita Uttara Tantra

Su.Ks. - Sushruta Samhita Kalp Sthana

V. S. - Vangasen Samhita

Y. R. - Yoga Ratnakar

M. N. - Madanpal Nighantu

K. N. - Kaidev Nighantu

R. N. - Raja Nighantu

Sh.Uk. - Sharangdhar Utterkhanda

Sh. Pk. - Sharangdhara Poorakhanda

R. S. S. - Rasendra Sara Samgraha

R. Ch. - Rasa Chikitsa

V. S. - Vangasen Samhita

B. S. - Bhel Samhitas

B. R. - Bhashajya Ratnavali

JK - Jati Taila and Kapha Ketu rasa

J - Jati Taila

Gp - Group

CONTENTS

S. N. Section Page No.

1. Introduction 1-4

2.

Conceptual Study:

Ayurvrdic Review 5-39

Modern Review 40-65

3. Drug review 66-86

4.

Clinical Study:

Materials and Methods 87-92

Observations 93-107

Results 108-117

5. Discussion 118-126

6. Summary and Conclusion 127-131

7. References 132-135

8. Bibliography 136-140

9. Annexure 141-145

LIST OF TABLES

Table No. Name of Table Page No.

1. Classification of Karna Rogas 14-15

2. Karna Srava Bheda and Lakshna 22-23

3. Clinical Features of COM 55-56

4. Pharmaco-dynamic properties of Jati Taila 84

5. Pharmaco-dynamic properties of Kapha Ketu Rasa 84

6. Number of Patients Registered for Clinical Study 93

7. Age wise Distribution of 40 Patients 94

8. Sex wise Distribution of 40 Patients 94

9. Religion wise Distribution of 40 Patients 95

10. Education wise Distribution of 40 Patients 95

11. Occupation wise Distribution of 40 Patients 96

12. Socio-Economic Status Recorded in 40 patients 96

13. Habitat wise Distribution of 40 Patients 97

14. Marital Status wise Distribution of 40 Patients 97

15. Dietary Habit Reported by 40 Patients 98

16. Prakruti Recorded in 40 Patients 98

17. Addiction wise Distribution of 40 Patients 99

18. Laterality wise Distribution of 40 Patients 99

19. Nidana wise Distribution of 40 Patients 100

20. Chronicity wise Distribution of 40 Patients 100

21. Periodicity of ear discharge reported in 40 Patients 101

22. Amount of ear discharge reported in 40 Patients 101

23. Smell of ear discharge reported in 40 Patients 101

24. Nature of ear discharge reported in 40 Patients 102

25. Colour of ear discharge reported in 40 Patients 102

26. Perforation of T.M. Reported in 40 Patients 103

27. Hearing loss Reported in 40 Patients 103

28. Karna Kandu Reported in 40 Patients 103

29. Karna Nada Reported in 40 Patients 104

30. Effect of Kapha Ketu Rasa and Jati Taila Varti on

Periodicity of ear discharge of 18 Patients

109


Amount of ear discharge of 18 Patients

109

32. Effect of Kapha Ketu Rasa and Jati Taila Varti on Smell

of ear discharge of 18 Patients

109


Perforation of T.M. of 18 Patients

110


Hearing loss of 18 Patients

110

35. Effect of Kapha Ketu Rasa and Jati Taila Varti on Karna

Nada of 18 Patients

111

36. Effect of Kapha Ketu Rasa and Jati Taila Varti on Karna

Kandu of 18 Patients

111

37. % Relief in all signs & Symptoms of Group JK 111

38. Overall Result of Kapha Ketu Rasa orally and Jati Taila

Varti locally in ear on 18 Patients

112

39. Effect of Jati Taila Varti on Periodicity of Ear Discharge

of 16 Patients

112

40. Effect of Jati Taila Varti on Amount of ear discharge of

16 Patients

113

41. Effect of Jati Taila Varti on Smell of ear discharge of 16

Patients

113

42. Effect of Jati Taila Varti on Perforation of T.M. of 16

Patients

113

43. Effect of Jati Taila Varti on Hearing loss of 16 Patients 114

44. Effect of Jati Taila Varti on Karna Nada of 16 Patients 114

45. Effect of Jati Taila Varti on Karna Kandu of 16 Patients 114

46. % Relief in all Signs & Symptoms of Group J 115

47. Overall Result of Jati Taila Varti locally in ear on 16

Patients

115

48. Percentage Relief in Signs and Symptoms of 36 Patients

of Karna Srava of Groups JK & J

116

LIST OF GRAPHS

GRAPH

NO.

Title Page

No.

1. No. of patients registered for clinical study 105

2. Age wise Distribution of 40 Patients 105

3. Sex wise Distribution of 40 Patients 105

4. Religion wise distribution of 40 patients 105

5. Education wise distribution of 40 patients 105

6. Occupation wise Distribution of 40 Patients 105

7. Socio-Economic Status Recorded in 40 patients 105

8. Habitat wise Distribution of 40 Patients 105

9. Marital Status wise Distribution of 40 Patients 106

10. Dietary Habit Reported by 40 Patients 106

11. Prakruti Recorded in 40 Patients 106

12. Addiction wise Distribution of 40 Patients 106

13. Laterality wise Distribution of 40 Patients 106

14. Nidana wise Distribution of 40 Patients 106

15. Chronicity wise Distribution of 40 Patients 106

16. Periodicity of ear discharge reported in 40 Patients 106

17. Amount of ear discharge reported in 40 Patients 106

18. Smell of ear discharge reported in 40 Patients 106

19. Nature of ear discharge reported in 40 Patients 107

20. Colour of ear discharge reported in 40 Patients 107

21. Perforation of T.M. Reported in 40 Patients 107

22. Hearing loss Reported in 40 Patients 107

23. Karna Kandu Reported in 40 Patients 107

24. % relief in all signs & symptoms of Group JK 117

25. Overall result of Kapha Ketu Rasa orally & Jati Taila Varti

locally in ear of 18 patients

117

26. % relief in all signs & symptoms of Group J 117

27. Overall result of Jati Taila Varti locally in ear of 16 Patients 117

28. % relief in signs & symptoms of 36 patients of two groups

JK & J

117

LIST OF PHOTOS

S.N. Name of Photos Page NO.

1. Normal Tympanic Membrane 54

2. Central Perforation in TM 54

3. Shunthi 86

4. Maricha 86

5. Pippali 86

6. Hijjala 86

7. Shankha Bhasma 86

8. Vatsanabha 86

9. Jati 85

10. Tila Taila 85

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ROLE OF JATI TAILA VARTI AND KAPHA KETU RASA IN THE MANAGEMENT OF KARNA

SRAVA (SAFE CHRONIC SUPPURATIVE OTITIS MEDIA) 1

INTRODUCTION

From the earliest time, mankind must have experienced injury and disease

and hence made attempts at prevention, relief or cure, under the influence of the

instinct of self preservation or of parental feelings and sympathy for others. The

lesson thus gained by experience crystallized into empirical knowledge.

Man’s progress and happiness solely depends upon his mental and physical

health and both these conditions are interdependent. The health of the individual

depends on health of society. The main cause of disease is bad habits; wrong and

unwanted way of living, mental aberrations, sometimes strong likes and dislikes

prejudices, anger and other negative mental attitudes cause ill health.

The disease “Karna Srava” is well known since ancient times. It is described

by authors of Vrihattrayi in sufficient detail. Achraya Charaka has described four

Karna Rogas and in all of them karnasrava is a major symptom. Sushruth has

described 28 karnarogas in uttar stana chapter 20 & karna Srava is described as

independent disease under the name of karna samsrava. Acharya Vagbhatta has

described karna Srava as an important symptom among all the five Karna Shoolas.

Beside, Karnapaka and Pootikarna also comprise the feature of Karna Srava,

mentioned by Acharya Sushruta and Vagbhatta.

Infections of the middle ear space and sequelae have plaqued mankind from

the beginning of time. First described by Hippocrates in 450 B C, this universally

observed process continues to present one of the most perplexing medical problems of

infancy and childhood, while being the leading cause of hearing loss in the age group.

It is estimated that 70% of children will have had one or more episodes of otitis by

their birthday. This disease process knows no age boundaries but occurs mainly in

children from the newborn period through approximately age seven, when the

incidence begins to decrease. It occurs equally in male and females.

A racial prevalence exists, with a higher incidence occurring in specific

groups such as native Americans , Alaskan and Canadian natives and Australian

aboriginal children. African-American children appear to have less disease than do

American white children, but this observation has yet to be adequately explained.

��



Incidence of CSOM (Chronic suppurative otitis media) is higher in

developing countries because of poor socio-economic standards, poor nutrition and

lack of health education. In India, the overall prevalence rate is 46 &16 per thousand

in rural & urban population respectively. It is also the single most important cause of

hearing impairment in rural population.

Chronic otitis media is less common than in pre-antibiotic days and it is usually less

severe. The main complaint of the patient is deafness and, if there is active infection,

intermittent foul smelling discharge. Pain is rarely complained of unless there is a

coexisting otitis externa. If pain is a feature as well as deafness and discharging, there

may be an underlying malignancy in the ear or an impending mastoiditis or extradural

abscess.

CSOM (safe type or tubotympanic) is characterized by ear discharge,

hearing loss, and perforation of tympanic membrane, oedematous middle ear mucosa.

Although, complications rarely occur in tubotympanic type but persistent infection

affects the anatomical structures of the ear besides causing reduced hearing. Ossicular

necrosis, middle ear polyps may develop with time. Hearing loss is initially

conductive later sensorineural component also comes into play. No doubt much is

known about the cause and mechanism of CSOM, but it needs an intensive care for its

control and cure. General line of treatment is administering antibiotics, decongestants

and anti-inflammatory drugs and the operative procedure are myringoplasty to repair

the perforation of T.M. and ossicular reconstruction for necrosed ossicles. Though

meticulously managed CSOM get cured gradually but some times because of

improper medication, resistance to medicine and lowered immunity cause persistent

infection or of and on infection and resultant otorrhoea, which affects an individual’s

quality of life to great extent. Presence of this disease in early childhood can hamper

the speech development of child after lowering the hearing level. In school children,

there will also be hinderance in the learing, because of reduced hearing. Infection of

tonsils/adenoids/sinuses, associated with CSOM may further hamper the development

and intellect of child.

So, all the above facts leave a scope to find out better remedy for the disease

Karna Srava from amongst the medicinal heritage of traditional Indian System of

��



Medicine. Moreover, in other institutes too, a very little work has been carried out on

this disease.

The following drugs were selected for the present research work.

Kapha Ketu Rasa – for oral administration.

Jati Taila Varti – For local administration in ear

As Karna Srava has local as well as systemic aetiological factors (

mentioned by Acharaya Sushruta) therefore, two types of drug administration were

selected and two trial groups were made to see the effect of these two drugs( In one

trial group both drugs, oral as well as local were administered and in one trial group

only local drug was administered).

The entire research work will be presented in the thesis work under following

headings:

1. Review of Literature:

A relevant literary review of the disease presentation in Ayurveda as well as

in modern sciences will be taken up and analysed in accordance with the updated

modern knowledge.

2. Drug review:

A review regarding the literature of drug will be presented and individual

constituents of it described in detail under this heading.

3. Clinical study:

Materials and Methods:

This part will deal with aims of present work, criteria for selection of cases

and parameters of clinical assessment. Total 40 patients will be registered and studied

under following groups:

Group JK: The oral administration of Kapha Ketu Rasa and local administration of

Jati Taila in ear.

��



Group J: The local administration of Jati taila.

The administration of drugs will be done for 30 days in each group and afterwards the

condition of patient will be assessed at every 15 days for two months.

Observation and Results:

In this part, observation and result of present research work will be mentioned.

4. Discussion:

This part will deal with the discussion on the theme of present research work with

conceptual, clinical and therapeutic observations of the study conducted.

5. Summary and Conclusion:

In this part, the overall efficacy of trial drugs in cases of Karna Srava vis-a-vis CSOM

(safe type) will be assessed.

��



AYURVEDIC REVIEW

Historical Background of Ear Diseases / Karna Srava

Vedic Period:

Vedas are the earliest documented source of infinite knowledge on this earth and

Ayurveda is a branch or “Upveda” of Atharveda.

Description pertaining to the Urdhavajatrugata (supra-clavicular) organs and diseases

are there in Vedas along with Mantras (rhymes having imperial effect) to be recited

for their treatment16, 17, 18

Karnendriya (word used is “SHRUTEE”) has been referred in Rigveda and Yajurveda

along with many other organs (Yajur.18/1). Karnashoola and Badhirya (otalgia &

deafness) were treated by Mantras in Vedic period (Athar.9/8/1, 2, 4). Further

references regarding the treatment of Narad Rishi for Badhirya by surgical procedure

done by Ashwini Kumaras is also available in Vedas (Athar.1/117/8). However, the

disease Karnasrava has not been described in Vedic literature.

Samhita Period:

Samhita period is known as the golden period in Ayurveda. During this period,

Ayurveda was at its peak and rose to great heights. The Sages like Atreya, Agnivesha,

Dhanwantari, Sushruta, Nimi etc. established Indian medicine in a scientific manner

and arranged systematically into eight branches. They described various fundamentals

of medicine in great detail.

1. Charak Samhita:

It is a medicine-oriented text, so description of diseases related with Shalya &

Shalakya is in introductory manner. Charaka has described Karna Rogas in Chikitsa

Sthana, chapter named as Trimarmiya Adhyaya55

.

Here also, the word Karna Roga has been described similar to that of Vedic period.

The Charaka has subdivided the Karna Rogas into four groups based on

predominance of Doshas. All the diseases of ear are incorporated in these four types.

��



In all these four Karna Rogas, Karna Srava is an important feature. So Karna Srava is

a predominant symptom of Karna Roga as considered by Acharya Charaka55

.

2. Sushruta Samhita:

Acharya Sushruta has described the Karna Rogas in scientific and systematic way in

Uttara-Tantra chapter 20. He has classified Karna Rogas in 28 types; and their

elaborated descriptions are given.

Acharya Sushruta has described the disease Karna Srava as Karna-Sansrava and

Pootikarna. The aetiological factors, symptomatology and treatment of Karna Rogas

have been explained in detail,

Acharya Sushruta has also described the disorders of Karna Pali, and Karna Sandhana

(Lobuloplasty) in 16th

chapter of Sutra Sthana.

3. Vagbhata:

Acharya Vagbhata has also elaborately described the aetiological factors,

Symptomatology and treatment of Karna Shoola. Under the disease Karna Shoola,

Karna Srava has been described according to the type of Dosha, though, no

independent description of Karna Srava as disease is available (Ash. Sangraha

Ut.21).In total 25 types of Karna Rogas have been explained in detail.

4. Madhava Nidana:

Acharya Madhava has described the Karna Rogas according to Sushruta. He also has

followed the view of Charaka48

.

5. Sharangdhara:

Acharya Sharangdhara has described 18 types of Karna Rogas. No independent

description of Karna Srava is available36

.

6. Bhavaprakasha:

In Bhavaprakasha madhyam Khanda, Karna Rogas are described under the

chapter of Karna Roga Adhikar and these are classified according to Sushruta. He also

mentioned Karna-srava as independently59

.

��



7. Yogaratnakar:

Yogaratnakar has also described Karna Rogas according to Sushruta. He also

mentioned Karna-srava as an independent disease58

.

8. Gadanigraha:

He has followed the view of Sushruta and Charaka. He mentioned Karna-

Srava independently47

.

9. Vangasen Samhita:

He has also followed the view of Charaka & Sushruta. He described Nidana,

Lakshna & Chikitsa of Karna-rogas under Karna-Rogadhikara. Among these, Karna-

Srava is independently mentioned60

.

10. Bhel Samhita:

Bhel Samhita has described the Karna Roga in very brief i.e. Vataja, Kaphaja,

raktaja, & Krimija61

.

11. Harita Samhita:

Harita has also described Karna Rogas in short; he has classified Karna Rogas

in Vataja, Pittaja, Kaphaja, Sannipataja, Vranaja, Krimija62

.

Etymology of Karna

The word Karna is derived from the root “Krina Viksyapa” by the principle of ‘Na’

and with the addition of suffix ‘Unadirna’ which means to hear.

Synonyms:

Karna

Shabdagraha

Srotra

Sruti

Sravana

Srava

Bakaraguha

(Amar Kosha)

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Karna Sharira

In Ayurvedic Samhitas (texts), the description about the Karna Sharira (Anatomy &

Physiology) is in brief and found in Sharira Sthana of Sushruta Samhita and

Ashtanga Samgraha only.

Acharya Sushruta has given second most importance to Karnendriya after Chakshu.

In Ayurvedic literature, Karna is organ of Shravanendriya, the function of which is

hearing, which are situated each side of head, four Angula from Apanga Sandhi i.e.

lateral canthus of eye.

Garbha Karna Sharira:

Shrotrendriya is formed mainly by Akasha Mahabhuta. According to

Sushruta, Garbha means the combination of Atma, Prakruti, Vikara along with Shukra

and Artava. In Garbha with Atma, all the processes of division is brought out by vata,

catabolic and anabolic processes by teja, hardness and structure is brought out by

prithivi, liquidity by Jala and all the hollow structures by akasha mahabhuta. By the

combination of all these, various organs like Hasta, Pada, Jihva, Karna etc. are

formed and the whole structure attains the name of Sharira1.

During the 3rd

month of pregnancy, Pancha Pidakas (five buds like structures)

are formed. These Pancha Pidakas represent two hands, two legs and a head, which

later on grow into the form of sharira. The pratyangas such as Karna, Netra, Nasika

etc. are found in Avyakta form. During this month the various pratyangas develops

gradually and become more and more Vyakta2.

According to all Acharayas, Karna appears in the form of pratyanga in 3rd

month. So it is clear that Karna and Karnendriya form in the 3rd

month, which is

initially Alpavyakta.

Acharaya Vagabhata says all the Chhidras (pores or empty space in organs)

are originated from Akash Mahabhuta, in addition to it Shrotrendriya, Shabda Guna

and Viviktata (Prithakta) are also formed from Akasha Mahabhuta. Shrotrendriya is

formed from Atmaja Bhava63

.

KARNA SHARIRA RACHNA:

Karna (ears) are the two supra-clavicular organs, which are the seat of

specialized sense of hearing3, 4, 5

.

��



Praman:

Pramana (measurement) of Karna is 4 Angula64

.

Situation:

Each of Karna is situated at a distance of 4 Angula from Apanga i.e. lateral canthus of

eye.

(1) Karna Shashkuli:

Shashkuli is in fact a foodstuff. It is prepared by rice and jaggery added in

it.Thereafter fried in Til Taila (oil of Sesamum Indicum). It is best in Sleshma-Pittaja

Vikara. Indegenously, it is called as Shashkuli, Pharak or Gujhiya.65, 66

.

The part of the external ear i.e. pinna is almost similar to this structure and is called

as Shashkuli.

According to Chakrapani, Shashkuli is Karnagatavartaka (whirlpool shaped

part of ear), which means that in this some circular or spiral structures are found and

seem to terminate in a hollow space. It also indicates the pinna portion of the external

ear.

(2) Pali:

Acharaya Vagbhata (I) has created controversy by saying “Pali Karna Shashkuli”

which should mean that Karna Pali is a part of Shashkuli and is not synonymous8.

Vagbhata (II) clarified it by saying “pali Bahya Karnasya Adhobhaga” 9 which

means pali is the lower portion of Bahya karna, which reflects that, it is a ear lobule

and not a shashkuli. In charak samhita, the structure Karna Pali is not described.

Chakrapani while commenting on Karna Putrak (2 Pratyanga) 10

, says that “Putrakaha

Karnapalya Adhah Bhaga”. If Karna Pali is similar to ear lobule, then there is no

structure below it. Therefore, in this context, Shashkuli and the portion below it mean

Pali i.e. Putraka indicates the ear lobule.

From above explanation, it is clear that Shashkuli is similar to Pinna and the

word ‘Pali’ is used as synonym of Shashkuli but frequently it is used as ear lobule.

(3) Karna Putraka:

Acharaya Charaka has described 2 Urdhvajatrugata Pratyanga (2

supraclavicular organs) under Karna Putraka, while Hindi commentators have

correlated it with ‘tragus’, which does not seem justified. The discussion, which has

��



been made above regarding Karnapali, also give indications to resemble the two

structures i.e. Karna Putraka or ear lobule.

Acharaya Dalhana while commenting on Karna Peetha wrote that “Putriko

Paridesh” (Da.Su.16/11)15

. Karna Peetha is back portion of the karna (pinna), from

which Tvacha (skin) and Mamsa (Muscles & Fascia) is grafted for Lobuloplasty. In

short, the word ‘Putraka’ appears to be mentioned for ear lobule. Therefore Karnapali

& Karnaputraka, both are synonyms.

(4) Karna Peetha:

According to vagbhatta (I), Karna-Adhah Bhag is back and lower portion of

Karna (pinna). It is the lowermost, cartilaginous part of pinna, from which lobule is

attached. If the Karnapali gets destroyed (or perished), loose skin flap of this portion

is used for lobuloplasty.

(5) Karna Chidra, Karna Srotas or Karna Vivar12

It is that portion of Karna, where Karna Mala or Karna Kleda is found and in

which insects can get entangled.

Shabdavaha Srotas has been referred in context to Badhirya and Karna

Pranada68

. Shabdavaha Nadis are also accounted in the disorders of Karna in Nidana

Sthana by Acharaya Sushruta67

.

Shabdavaha Srotas and Nadis seem to be the external & internal auditory

meatii and cochlear nerves in present context.

The Karna (ears) are counted among nine Bahirmukhi Srotas (External

openings), which are external auditory meatii i.e. part of external ear13, 14

.

All these Bahirmukhi Srotas act as excretory passages and these inunctions are

impaired by morbid and excessive formation of excretory products. Karna Mala

(Karna Gutha) being the excrement of Karna Srotas and it will impair the hearing

function when formed in excess68

.

Karnasthi:

Sushruta has mentioned that there is a single bone in ear while counting

bones of Shira and Griva15

.

Sushruta in Sharira Sthana while explaining type of Asthi, says that tarunasthi

present in Karna21

and Ghanekar in Sharira Sthana Teeka has considered Karnasthi as

mastoid process.

��



Sandhi:

While explaining the Sandhi, Sushruta says that in Karna and Shringatak,

there is Shankhavart Sandhi22

While describing the sandhis above the clavicle, Sushruta has counted one

sandhi in each ear. Shri Gananath sen Saraswati also agreed about one sandhi in each

ear.

Peshi:

While describing the Peshi of Greeva and Shira, Sushruta has counted 2 peshi

in each ear i.e. total 4 23

.

Marma:

Acharya Sushruta says that vidhura marma is found behind the Karna, which

is a snayu marina. As Acharya Sushruta belonged to shalya sampardaya, he had

instructed to protect the

Marmas and Avedhya siras during Shalya Karma24

.

Acharya Vagbhatta has also the same view. Both of them agree that any injury to this

manna will cause Badhriya or deafness.

• Vagbhata says that it is a dhamani marma25

• Vidhura is considered under Vaikalyakar marma26, 69

• This is the nature of Vaikalyakar marma to cause one or the other type

of defect, after an injury over them69

Ghanekar has correlated

posterior auricular vein and artery as vidhura marma, because there is

every possibility of deafness due to rupture of these structures.

Sira:

Total 10 siras in both ears are found; out of which:

4 vatvahini, 2 pittavahini, 2 Raktavahini and 2 Kaphavahini siras are linked with

Karna27

.

In Sharir sthana, regarding avedhya Shiras, further description of Siras was

given. There are ten siras in Karna, among them 2 Shabdvahini siras70

should be

protected while performing surgical procedure.

2 Shabdavahini siras out of 16 Siras present in both Karna, confined to

shankha pradesh (temple region) are not to be punctured for blood letting71

.

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Dhamni:

In Karna, there are two dhamani, which help in perception of sound29

.

Features of Prashast Karna:

Acharya Charaka in the Sharir Sthana, Chapter 8, while describing the

features of excellent parts of body of long-lived child, has explained the features of

well formed/ grown Karna.

He wrote that both the ears should be thick, broad, Smooth f rom back, well

matched, bended from back to forwards, in which the Karna putrika tightly adhere to

head and the Karna guha orifice should be big is called excellent ear31

.

From the above discussion, after reviewing the Ayurvedic literature and comparing it

on the grounds of modern science, Karna and its related parts refer to the

following structures.

1. Karna: The word Karna refers to the whole external ear including pinna, lobule,

and external auditory meatus.

2. Karna shashkuli: The word Shashkuli is used for pinna of ear.

3. Karna putrak & Karna Pali: Both of these are synonyms and used for ear lobule.

4. Karna peetha: Kama peetha refers to the posterior and lower surface of pinna.

5. Karna Chhidra, Karna srotas, and one of Bahirmukha srotas: All these terms

refer to the external auditory meatus.

6. Shabadavaha srotas: This refers to the external and internal auditory meatii,

7. Shabadavaha nadi/Dhamani: This most probably refers to the Cochlear nerve.

Shabdendriya Kriya Sharira (Physiology of hearing)

How Shabda Created?

According to Prashast pada, the following three constituents i.e. Sanyoga,

Vibhaga and Shabda (Attachment/union, Non attachment/separation and sound)

create the Shabda. On the basis of principal of origin of Shabda and also by virtue of

the principle of sound i.e. Vichi Taranga Nyaya, sound is created (Prashast pada).

Here, it has specifically been learnt that the sound manifested in one place of origin

traverse and spreads out in all directions. The sound, so manifested is not only by the

principle of Vichi Taranga and the principle of Kadamba mukula, but also plays a

��



vital role in the creation of Shabda, As the kadamba puspa starts blooming, then

blooms in all directions, Similarly according to vichi taranga law the chain of

reproduction of sound starts and spreads in all directions.

Shabdendriya Kriya Sharira (Concept of sound perception in

Ayurveda)

Indriya, Mana and Atma when make a contact with the object, then the exact

knowledge about that object is achieved.

To complete this process, five elements are attributed with each indriya

(specialized sense organs), then this process of perception is achieved. Indriya

Vishaya (object), Indriya Dravya (media), Indriya Adhishthan (organ of reception),

Indriya (sense), Indriya Budhi (specialized sense center) act in coordination with

subtle sense i.e. Mana to complete the process of perception by senses31

.

In case of Shabdendriya kriya or perception of sound, this phenomenon can be

presented as under:

Shabda

(sound)

Akasha

(space)

Shabdendriya Adhishthan (Karna)

Mana Shabdendriya (sense of hearing)

Shabdendriya Buddhi (Hearing centre)

Shabda Grahana by Atma

��



Shabdendriya Kriya Sharira

Classification of Karna-Roga:

Acharyas have different opinions regarding the total number of Karna

Rogas. Diseases belonging to Shabdendriya have also been included in this group of

disorders.

Table-1

Classification of Karna Rogas

Karna Rogas Ch.(4) Su.

(28+9)

Vag.

(25)

Ma.

Nid.

B.P. Shar.

(30)

Y.

R.

Gada

Nig.

V.S. Bhel

Sam.(5)

Har.

Sam.

(12)

1.Vattika + - - + + - + + + + +

2. Pattika + - - + + - + + + - +

3. Shlaishmika + - - + + - + + + - +

4. Sannipatika + - - + + - + + + - +

5. Raktaja - - - - - + - - - + -

6. Sansaragaja - - - - - - - - - - +

7. Ksataja - - - - - - - - - - +

8. Karnashula - + +(5) + + + + + + + -

9. Karnanada - + + + + + + + + - -

10. Badhirya - + + + + + + + + + -

11. Karna

Kshweda

- + - + + + + + + - -

12.Karna-

srava

- + - + + - + + + - -

13. Karna-

kandu

- + + + + + + + + - -

14. Karna-

gutha

- + + + + - + + + - -

15. Karna-

pratinaha

- + + + + + + + + - -

16. Krimi-

karna

- + + + + + + + + + +

17. Karna-

vidradhi

- + + + + + + + + - -

18. Karna-

vidrashi

- - + + + + + + + - -

19. Karnapaka - + + + + - + + + - -

20. putikarna - + + + + + + + + - -

21. Karna

shotha

- + + + + + + + + - -

��



22. Karna

arbuda

- + + + + + + + + - -

23. karna arsha - + + + + + + + + - -

24. paripota - + + + + + + + + - -

25. Utapata - + + + + + + + + - -

26. Unmathaka - + + + + + + + + - -

27. Dukh-

vardhana

- Gallira + + + + + + + - -

28. Parilehi - + + + + + + + + - -

29. Karna-

hallika

- Lehika - - - - - - - - -

30. Karna-

shaskuli

- + - - - - - - - - -

31. Kuchi-

karnaka

- + - - - - - - - - -

32.

Karnapippali

- + - - - + - - - - -

33. Vidarika - + - - - Vidari - - - - -

34. pali-shosa - + - - - + - - - - -

35. Tantrika - + - - - + - - - - -

36. Utaputak - + - - - - - - - - -

37. Shyava - + - - - - - - - - -

38. sakanduka - + - - - - - - - - -

39.

Avamanthaka

- + - - - - - - - - -

40. Granthika - + - - - - - - - -

41. Jambula - + - - - - - - - - -

42. Sravi - + - - - - - - - - -

43. dahawan - + - - - - - - - - -

Karnamulagata

Roga

44. Vataja - - - - - + - - - - -

45.Pittaja - - - - - + - - - - -

46. Kaphaja - - - - - + - - - - -

47. Sannipataja - - - - - + - - - - -

48. Raktaja - - - - - + - - - - -

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KARNASRAVA

Grammatical Derivation:

The word Karnasrava is composed of two words i.e. Karna and Srava. The

former word Karna is related to the organ (or site) and word Srava is related to the

disease condition.

The word srava is derived from the root Sri, which is prefixed by (Upsarga)

Sama, which means Sravit or discharge. Karnasrava means there is a

watery/serous/bloody/ pus discharge coming from the ear. Acharya Sushruta has

termed it as Karna sansrava. It is a symptom based disease, because this is described

as a disease in Ayurvedic texts but from modem view it’s merely a symptom of an

underlying pathology.

Classification

1. Charaka:

Acharya charaka has classified 4 types of Karna roga. All are having

Karnasrava as a major feature, so these are included under Karna srava.

1. Vataja Karna Roga. 2. Pittaja Karna Roga

3. Kaphaja Karna Roga 4. Sannipataja Karna Roga

2. Sushruta:

According to Sushruta, Karnasrava has been described as separate Karna Roga,

But Karna paka and Pooti Karna also have a Karna srava as major symptom, therefore

can be included under Karnasrava.

��



3. Vaghbhata :

Vaghbhata hasn’t classified Karnasrava as a separate Karna roga. As the

Karnasrava is typical feature in each of five types of Karna shoola. So, these can also

be included under Karna srava.

1. Vataja Karna shooola 2. Pittaja karna shoola

3. Kaphaja Karna shoola 4. Raktaja Karna shoola

5. Sannipataja Karna shoola.

General Nidana of Karna Roga/Srava:

According to the acharyas general causes for all diseases are relevant in case

of Karna Roga also. In addition to general causes, they have given certain specific

causes also. It is significant in this context to explain what are these specific causes

and how they participate in the diosease karna srava56

.

1. Avashyaya 2. Jalakrida

3.Karna Kanduyana 4. Mithyayogen Shastrasya

1. Avashyaya :

Excessive contact of humid weather is Avashyaya. It causes vitiation of

Kapha, Which as a result produses ‘Pratishyaya’.Vaghbhata, has replaced the

causative factor ‘Avashyaya’ by pratishyaya in the above shloka. So, pratishyaya

itself act as the main causative agent in Karna srava. As this pratishyaya produses

inflammation in nasopharynx, infection in sinuses, adenoids, tonsils; this further

causes inflammation in nasopharyngeal end of eustachian tube and this results in :

��



1.E.T. fails to drain the secretion 2. E.T. is unable to aerate

of middle ear. the middle ear.

Leads to absorption of air and

negative intratympanic pressure.

Exudation of serous discharge in

tympanic cavity.

Super-added infection

T.M. Perforation & discharge.

Above these factors cause middle ear infection or otitis media, which results in

clinical features like otorrhoea or Karnasrava along with other symptoms.

2. JaIa Krida:

Due to entering of water into external ear by taking bath in rivers, sea etc can

produces symptoms in the ear because of following reasons:

i) Symptomatology because ii) Infection in ear iii) Symptomatoogy

of moistening of wax. Because of entry of as a result of

micro-organisms sudden diving

into the river.

i) Moistening of wax:

Due to entering of water into external ear by taking bath in rivers, sea etc. may

cause moistening of wax. The moistened wax swells up and occludes the meatus. This

causes deafness and creating pressure on the TM causing giddiness, vomiting,

tinnitus, pain in ear etc.

��



ii) Infection in ear:

Bathing in infected water causes contact/entry of micro organisms (bacteria,

fungi etc.) into the ear that result in either Otitis extema or Otitis media, which ends in

Karnasrava.

If there is already a perforation of TM, it will cause inflammation of middle ear

mucosa and an active condition of chronic otitis media results.

iii) Sympyomatology due to sudden diving into the river/sea:

By recurrent diving into the water causes sudden increase in the air pressure

on the tympanic membrane. This increased pressure may cause rupture/perforation of

the TM. After the development of a perforation in TM, chances of infection in the

middle ear increase to a great extent. Infection in the external ear causes easy entry of

micro- organisms into the middle ear and there by causing otitis media. Karnasrava

occurs as a result, as one of the symptom of otitis media (CSOM).

3) Karna Kandu:

Because of itching, patient may insert certain external objects like stick,

grass, sharp metal objects etc. These instruments or objects can cause Kama srava in

two ways.

i) Deep penetration of the sharp ii) These objects are

objects can directly cause perforation generally unsterilized,

of T.M. This perforation makes easy their mild trauma on the

accessibility of micro-organisms into meatus may erode its

the middle ear from external ear. lining and may cause

The infection result in chronic otitis infection of ext. ear canal

media like conditions and produces while trauma on the T.M.

Karna srava is one of the symptoms. May cause Myringitis &

all these will result in Otorrhoea like

conditions. If there is a pre-existing

perforation, infection of middle ear

results & ultimately results in active

otitis media.

��



4) Mithyayogen Shastrasya (Iatrogenic causes):

If the instruments are not properly sterilized, may cause infection. Trauma on

ear by some instruments can be of two types:

i) Direct ii) Indirect

i)Direct:

Improper introduction of instruments by unskilled persons may injure the

ear or even rupture the tympanic membrane and middle ear causing middle ear

infection and results in Karna srava.

ii)Indirect:

Tympanic membrane rupture may also be produced by indirect violence

e.g. blow on the ear, heavy gun explosion or diving in water & flying in air may cause

sudden compression of air in the meatus. All these factors cause perforation in TM

and the symptoms like pain in the ear, deafness and bloody discharge from ear.

Specfflc Nidanaof Karna:

Acharya Sushruta, while describing Karna sansrava, has described certain

specific Nidana. These are as follows52

.

Above-mentioned Nidanas are:

1. Shiroabhighatat.

2. Nimajjatojale

3. Prapakata.

4. Vidradhi

1) Shiroabhighatat:

If a person sustains trauma or injury to the head and if the fracture of

temporal bone occurs, the bloody discharge starts coming out of the ear; while if

the patient gets injury to the middle cranial fossa, CSF (cerebrospinal fluid) mixed

discharge (which is watery in nature) starts coming. Gradually, the consistency of

discharge may change into purulent one because of secondary infection.

��



2) Nimajjato Jale:

This aetiological factor is already discussed under jala krida (Samanya

nidana).

3) Prapaakada:

Various inflammatory conditions of external ear can be included under

Prapakada. Paka is mainly caused by Pitta, which causes the features like burning

sensation (Daha), early suppuration (Ashu pakam) and yellowish discharge (Peeta

lasika sruti). In this context, Acharya Vagbhatta in uttar shatna chapter 17 has clearly

mentioned that this discharge causes inflammation wherever it comes in contact. If

this discharge comes out of the ear, it will cause inflammation on surrounding skin of

the ear (‘Sa lasika sprishet tatat pakam upaiti’).

The generalized symptoms are thin serous discharge, which may become

purulent, inflammation of lining of the E.A.M., discharge may get dried up to form

crusts. There may be mild to moderate pain in the ear.

4) Vidradhi:

Because of vidradhi or furunculosis in the ear, purulent discharge or pus mixed

bloody discharge comes out of the ear.

While describing the disease Karnasrava, though the specific causes are mentioned in

short in brihatrayee and laghutrayee. As the symptoms of Karnashoola mentioned by

Vagbhatta resembles Karnasrava; therefore, nidanas mentioned by Vagbhatta for

Karna shoola are also included under Karnasrava nidana.

I. Karnarsha produces Pootikarna (Pus discharge) 33

.

2. By Instilling Savisha Tail in ear, Karnasrava occurs72

.

3 , Karnasrava occurs as a symptom of Pooyarakta (Nasa Roga). Bloody/ pus

discharge comes out of the ear34

.

��



POORVAROOPA

Poorvaroopa indicates the upcoming disease, which is going to occur. Stage of

sthansansraya is termed as Poorvaroopa.

In the stage of sthansansraya, vitiated dosha get aggravated and move to

different parts and get accumulated in one of the region of the body. At that region,

Dosha- dushya sammurchhana takes place. In this stage, if measures for treatment are

taken, disease is rectified and no complications occur. In the same way, Dosha in

Urdhavajatrugat marga, move to produce Urdhava Jatrugat diseases.

In Ayurvedic texts, poorvaroopa of Karna srava are not mentioned. In this

context, Acharya Charka, in Urah-kshat chapter, has clarified that in case of non-

mentioning of poorva-roopa in any disease, un-manifested symptoms of disease may

be taken as Poorvaroopa.

According to this law, Avyaktata (mild) form of Karna shoola, Karna kandu,

and Karna gutha which occur before the actual symptoms may be taken as Purvaroopa

of Karnasrava.��

Karna Srava bheda and lakshana:

Different acharyas have mentioned following bheda and lakshana of Karna

srava which are shown in the Table-2:

Table-2

Karnasrava Bheda and Lakshana

S.N.

I.

Bheda and Laksna Ch.

Su.

A.H.

A.S.

Vataja Karna Srava Laksna + - + +

1. Karna naad + - - -

2. Karna Shoola + - + +

3. Karna mala Shosha + - - -

4. Tanusrava

(Serous discharge)

+ - + +

5. Badhirta + - + +

6. Ardhavibhedaka - - + +

7. Stambh - - + +

��



8. Shishir anabhinandan. - - + +

9. Shrotra Shoonyata - - + +

10. Chirata paka - - + +

II. Pittaja Karna Srava + - + +

1. KarnaSotha + - + +

2. Karna (Redness) + - - -

3. Karna daran + - - -

4. Karna daha + - + +

5. Peetasrava /Lasika + - + +

6. Pootisrava. + - - -

7. Santapa - - + +

8. Sheetechha. - - + +

9. Jwara - - + +

10. Ashupaak. - - + +

11. ��

��

- - + +

III. Karna Srava Kaphaj + - + +

1. Vaishrutya + - - -

2. Kandu + - + +

3. Sthira Shepha/Shopha + - + +

4. Shukla, Snigdha/Ghana-Srava + - + +

5. Alpa Ruka/Mandaruja + - + +

6. Shir,Hanu,GreevaGaurav - - + +

7. Ushnechha - - + +

IV. Raktaja/Abhighataja Srava, - - + +

1. Karna shoola - - + +

2. Rakta mishrit srava - - + +

V. Sannipataja Srava + - + +

1. Shotha + - + +

2. Jvara + - + +

3. Teevra Peeda + - + +

4. �� - - + +

5. Shrutijadya + - + +

6. Shweta/Krishna/Rakta Srava + - + +

7. Ghana Pooya Srava + - + +

VI. Karna-sansrava - + - -

1. Pooya Srava - + - -

VII. Karna-Paka - - + +

1. Kotha - + - -

2. Kleda - + - -

VIII. Pootikarna - + + +

1. Karnakapha Vilyamana /Vidagdha - + + +

2. Vedana - + + +

3. Ghana Srava - + + +

4. Pooti Srava - + + +

5. Kleda - + + +

��



ROOPA

1) Karnasrava is itself a roopa. Colour and consistency of a discharge (Srava)

indicates the underlying pathology. Ayurvedic texts have mentioned the different

types of Karnasrava according to the involvement of doshas.

I. (i) Vataj Karnasrava:

Watery discharge (Ch.)/ Lasika Srava (Ah.)

(ii) Pittaja Karnasrava:

Yellowish, (pooti) foul smelling Srava (Ch)/yellowish lasika (Ah.)

(iii) Kaphaja Karnasrava:

Whitish thickened discharge (Ch.)/Whitish Ghana Srava (Ah.)

(iv) Raktaj Karnasrava/Abhighataja:

Bloody/blood stained discharge (Ah.)

(v) Sannipataja Karnasrava:

According to the predominance of Dosha there will be mixed

discharge. (White /black/red thickened (Ghana) pus discharge) (Ah.)

II. Karna Paka:

Thickened pus discharge (Ghana Pooti Srava)

III. Pooti Karna:

Thickened, foul smelling, necrotising pus discharge (Ghana Pooti Srava).

The discharge of ear may be from external or middle ear. The external ear

discharge of Karna srava is mainly by boils and abscess. Its consistency is non-

mucoid. In diffuse otitis externa there is serous discharge. Discharge from middle ear

is generally mucoid, purulent, mucopurulent may be foul smelling; colour may be

whitish/yellowish/ greenish/reddish depend upon the type of otitis media.

��



Other symptoms associated with disease Karnasrava are given

below:

2) Karna Shoola:

Expressing pain in the ear is called ‘Karnashula’. The equivalent word of

Karnashoola in modem science is ‘otalgia’ . The main dosha involved in this is vata

.The vata, increases due to mithya ahara vihara (Asatmendriyartha Sanyoga). This

vitiated vata follows the course of satkriyakalas and it is obstructed either by pitta or

kapha or rakta and travels in reverse direction and thereby causing Shoola. If this vata

gets mixed up either with pitta or kapha or rakta the pain becomes severe and the

condition of the disease becomes acute.

According to Samprapti of Sushruta, Vata, traversing through (the faulty

passages of) the ear and covered by the other doshas, produce severe pain around (the

region of) the ear; such type of vitiation makes the treatment difficult73

. The

inflammation and pus formation in the external ear causes Karnashoola.

• Furunculosis or vidradhi in external ear causes severe pain and tenderness in the

ear. (Movements of pinna are painful. Jaw movements, as in chewing also cause

pain in the ear.)

• Inflammations in the meatal skin are also associated with pain, mild to moderate

in nature.

• In Acute inflammatory conditions of middle ear like ASOM there is moderate to

severe pain in the ear, while chronic inflammatory conditions may or may not be

associated with pain. Severe pain in these conditions is an ominous sign;

indicating malingnancy or extra or intra cranial spread of infection.

3. Karna nada:

Often Karnasrava is associated with some typical sound, very often this typical

sound is devoid of Karnasrava. In Karna nada, involvement of only Vata is found.

Usually, Karna nada is associated with the disease of external and middle ear. Some

times Karna nada is found associated with other diseases, too. The channels, which

carry sound, are obstructed by vitiated Vata due to that, there will be peculiar sounds

��



and this is called as Karna nada79

. In long standing cases of CSOM the cochlea suffer

damage due to absorption of toxins; the brain interprets abnormal rates or rhythms of

discharge in the cochlear nerve fibres as tinnitus.

4. Bhrama:

Experience of Bhrama (giddiness) occurs frequently. Sometimes, Bhrama is

associated with inflammations in the ear. Bhrama may be found in the early stages of

other disease such as jvara, agnimandya and pratishyaya.

The stage of bhrama or vertigo in case of Karnasrava (CSOM) can occur when

there is an involvement of bony labyrinth (usually of horizontal semicircular canal)

because of absorption of toxins. There is pyogenic invasion and resultant

inflammation of labyrinth.

5. Karna Kandu:

In ear, Vata with Kapha, produces itching in ear known as Karna kandu. This

symptom generally occurs because of inflammation of external ear. In the

inflammatory conditions of external ear because of trauma to skin of External

auditory canal, invasion by pathogenic organisms, hypersensitivity to infective

organisms or topical eardrops, there is irritation and strong desire to itch.

Karna kandu can also occur because of dryness of wax, or due to chlorinated

water.

6. Badhirya:

The Vitiated Vata, obstructs the shabadvaha srotas. Thus the proper perception i.e.

carrying of sound waves inside the shabdvaha Srotas are obstructed and sound waves

can not be perceived and this result in Badhirya.

Acharya Madhava, while explaining the Samprapti of Badhirya says that Badhirya

can be divided into two types; i) Sudha Vataj ii) Vata Kaphaja. In the Vata Kaphaja

type, Vayu is associated with Kapha and further pathogenesis is similar to that of

Sudha Vataj type as mentioned above.

��



• In the initial stage of AOM, oedema and hyperaemia of nasopharyngeal end of

Eustachian tube, blocks the tube, leading to absorptions of air and negative

intratympanic pressure. It tubal occlusion is prolonged, pyogenic organisms

invade tympanic cavity and inflammatory exudates appears in the middle ear.

This process causes feeling of blockage into the ear and the resultant reduced

hearing.

• In Chronic otitis media because of perforation, there is not proper conduction

of sound (as Tympanic membrane increases the amplitude of sound. Also in

intact TM, there is always a phase differential exists between sound reaching

the oval window and round window so that both do not cancel each other’s

effects)

• Collection of discharge in the ear also hampers the conduction of

sound.

• In long standing cases, cochlea may suffer damage due to absorption of toxins

from the oval and round windows causing sensorineural hearing loss, which

coexists with conductive hearing loss in case of CSOM.

Samprapti

Ayurveda has its own school of thoughts in the genesis of a whole disease process.

The process right from nidan sevana to the onset of disease is known as Samprapati.

The Samprapti word is derived from the word purva prapti, prefixed by the

‘sama’means samyak prapti. The samprapti is defined as the result of pathological

changes started by the causative factors and ended by manifestation of the diseases.

Presence of at least one or two causative factors is an invariable feature in all the

diseases. All these causative factors come under three main categories. They are

Asatmendriyartha Sanyoga, Pragnaparadha and Parinama. This, in turn, affects

Sharirika as well as Manasika Doshas resulting in further vitiation of Dhatus and

Malas and altogether the whole body. This is how, in general, the Samprapti or

pathogenesis takes place.

Nidana Panchaka are the prime source of diagnosis of all the diseases.

Among these, Samprapti is the 5th and it is the factor explaining the total

��



pathogenesis of a disease. While explaining the nature of Samprapti, Acharya

Vagbhatta says that due to the provocation of Doshas by means of various aetiological

factors, they move in different directions inside the body vitiating Dushayas etc. By

this, they generate disease and the process is called Samprapti. Acharya Sushruta

classified all the diseases into three categories i.e. Adhyatmika, Adhibhautika,

Adhidaivika. There are again three subtypes among Adhyatmika diseases. They are

Adibala Pravrita, Janmabala Pravrita and Doshbala Pravrita. In Adhibhautika

disorder, there is one subtype that is Sanghatabala Pravrita. In Adhidaivika disorder,

there are three subtypes. They are Kalabala, Daivabala and Svabhavabala Pravrita.

Karna-srava can be classified under Doshabala Pravrita Vyadhi as vitiation of

doshas is the main aetiological factor in manifestation of Karna srava.

Acharya Vagbhatta has mentioned Abhighata as aetiological factor of Raktaj

Karnasrava and Shiroabhighata is mentioned as one of the aetiological factor in Karna

Sansrava by Acharya Sushruta. So, the Karna Srava can also be included under

Sanghata bala Pravita��

Karnasrava Samprapti:

The samprapti of Karna-srava can be explained on the basis of Shat kriyakala as:

Nidana:

All the nidanas, which are already described in the section of nidanas, like Samanya

nidanas (Avashyay/Pratishyaya, Jala krida, or Jala nimajjan karna kandu, shastra

mithya prayoga) and specific nidanas mentioned by Sushruta in context of Karna

srava (Shiro abhighata, Jale- nimajjanat, Prapakad, Karna vidradhi etc.); Doshas

follow the steps of Shat kriyakala described:

1. Sanchaya Avastha:

In Sanchaya Avastha, Tridoshas get accumulated in there specific places,

and points some generalized body symptoms.

2. Prakopa Avastha:

If nidana sevan is continued, Prakopa of doshas occur according to the

specific nidana, in their respective places.

��



3. Prasara Avastha:

Prakupita doshas start disseminating in whole body. As the movement of

doshas occur because of Vata dosha, Vayu alone or with Pitta , Kapha dosha or with

Rakta prasara all over the body.

In body, where there is a defect in Srotas, disorder/disease occurs at that

particular region. They produce generalized symptoms according to the nature of the

doshas (Such as Pitta produces Osha, Chosha, Daha, Paka, Sada, Dhumayana; Kapha

produces Vaman, Gaurav etc.).

4. Sthana Sansraya Avastha:

Prakupita doshas arrive at different parts of body and cause different

diseases accordingly. Dosha which move in Urdhavajatrugata marga, cause diseases

of nose , eyes, ears, mouth and head. In case of Karna-srava, doshas sthana sansraya

occur in Karna. This Avastha is the stage of Poorva roopa. The Poorva roopa indicate

the forthcoming disease. In case of Karna-srava, the Laksana like blockage of ear,

heaviness in ears, reduced hearing, mild to moderate sometimes severe earache, fever

can be considered under Poorva roopa75

.

5. VyaktaAvastha:

The expressionsof the symptoms of a particular disease is Vyakta Avastha.

This is a fifth Kriyakala, for implementing the treatment. In case of Karna Srava,

when the symptoms of this disease are expressed completely, that stage is termed as

Vyakta Avastha e.g. Vata Dosha produces Vataj Karna Srava, Pitta Dosha produces

Pittaja Karna Srava or Karna Paka or Puti Srava (after causing vidagdhata of

shleshma), Kapha produces Kaphaja Karna Srava, Rakta and Sannipataja dosha

produces Raktaja and Sannipataja Karna Srava respectively.

6. Bheda Avastha:

Bheda Avastha is the stage of complication of the diseases76

. If the disease

is ignored even after the bheda Avastha, it can result in various complications. In case

of Karnasrava, extracranial and intracranial complications can be included under this

Avastha.

��



Samanya Nidana Vishishta Nidana

(Avashyaya, Pratishyaya, Jalakrida) (Shiroabhighata, Jalanimajjana)

Sanchaya of tridoshas in their respective sites

Prakopa of tridoshas

Doshas Prasara in whole body

Sthanasamshraya in Karna

Onset of Karna-Srava (according to nature of Doshas)

Vataja Pittaja Kaphaja Raktaja Sannipataj

Karna Karna Srava Karna Srava Karna Karna Srava

Srava Srava

Karna- Paka

Pooti-Srava

Samprapti for Sarvadehika Nidana-{Systemic Nidana}

� Nidana, which has been described by various Acharyas, can be categorized

into systemic nidanas & localized nidana. Systemic aetiological factors

(Pratishyaya, Avashyaya, Jalakrida) will follow the course of shatkriyakalas

and will manifest this disease. Whereas local causes will cause localized

vitiation of doshas and these vitiated doshas will produce Karnasrava.

��



Local aetiological factors

{Karna Kandu, Shastrasyamithyayogen, Jalakrida, karna Vidrdhi, Prapaka,

Shiroabhighata}

Cause localized trauma on ear

Cause vitiation of vata & Pitta vitiation of Rakta Dosha

Dosha {Raktaja Abhighata}

Pitta will cause Shotha Rakta-Srava

{Localised inflammation}

Pitta will make Kapha Vidagdha

{Suppuration occurs}

Karna-Srava {pus discharge}

Samprapti for Sthanika Nidanas {Local aetiological factors:

The general causes of ear diseases and specific causes of Karna-srava on

critical analysis with relevant counterpart knowledge of modern medicine

clearly suggests that the discharge from the ear can be from two parts of the

ear viz. external auditory canal and middle ear.

Avashyaya, pratishyaya, shiroabhighata, Jalnimajjana to some extent

can lead to srava from middle ear whereas Karna kandu, mithyayogen

Shastraya, prapaka, vidradhi and also jalanimajjan, avashyaya, shirobhighat to

some extent lead to Karna-srava from external auditory canal.

��



Chikitsa:

The word chikitsa is derived from the root, ‘Kit Rogapanayana’ and the word Roga is

derived from ‘Dhatu Vaisamyate’ with the addition or combination of ‘Raj Pratyaya’.

The chikitsa is nothing but that which eliminates the disease or abolishes and brings

relief to the sufferers.

Chikitsa, in other words,is curative aspect and this has to be done simultaneously

giving due importance to Nidana Parivarjana (prevention); hence,nidana parivarjana

is the first step in combating the disease and forms the part of the line of

treatment.The prevention or nidana parivarjana forms the first steps of

Pratisandhatmak chikitsa.

Description about Dinacharya, Ritu Sandhi has been mentioned by Charaka and

Vagbhatta, and there they have mentioned that a person should daily perform Karna

purna, which avoids occurernce of diseases of the ear. Negligence in doing

Karnapurna leads to formation and accumulation of wax, which may ultimately cause

Karna kandu, Karna shula and Badhirya etc.

Acharya Vagbhatta mentions that one should daily take up the snehana of shira,

pada & Karna. Acharya Sushruta has also mentioned that Snehana should be done in

manya, shira and Karna shula daily. Indulging daily in Karna purna can prevent vata

rogas of Karna.

Acharaya Vagbhata mentioned that when pus like discharge comes out from ear

canal after any pathology of inflammation then following treatment modalities

should be followed-

Dhumpana, Gandusha, Nasya and Nadi Sweda. Besides this, different Vrna-

nashaka treatments should be done. The pus held on wall of ear canal, should be

wiped at morning and evening with the help of cotton swab and guggul Dhup

should be given or Pichu Varti should be after dipping in the Raskriya of Qwatha

of Sursadigana77

.

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Samanya Chikitsa (General line of treatment of ear diseases):

Sushruta has mentioned that patient should be subjected to ghrita

pana,(snehan,svedan), Rasayana therapy, should avoid excessive physical exercise,

head bath, sexual behaviour and vocal work35

.

1. Snehan:

The administration of snehana is of two types. One is Bahya (external) and

the other is Abhyantra (internal). Karna Purana comes under the division of external

Snehana.

i) AbhayantaraSnehan:

Administration of Ghrita Pana comes under the heading of Abhyantara

(internal) Snehana. Snehana is mainly of four varieties. They are Ghrita, Taila, Vasa

and Majja. Ghrita has been considered as the superior among all the varieties of

Snehana and it has been indicated in ayurvedic texts that Ghrita Pana should be used

in all types of Karna rogas.

ii) Bahya Snehan:

Before implementing external snehan, Acharya Sushruta has advocated that

Nadi Svedana should be performed.

a) Nadi Sveda:

It is a type of vashapa Sveda. Exposing particular part of the body to Svedana with the

help of nozzle or tube is called Nadi Sveda.

Acharya Sushruta has described the following drugs to be used in Nadi Sveda. These

are Bilva, Eranda, Arka, Punamava, Dhattur, Shigaru, Ashwagandha, Ajagandha,

Agnimantha, Yava 78

.

Procedure:

Affected part of body is subjected to Sveda. Yava Kuta churna of above-mentioned

drugs boiled in a pot containing Kanzi. The Mouth of pot is closed and nozzle is fitted

by making a hole and pot is placed on fire. The administration of vashapa Svedana

reduces vata on the affected part. The pressure of steam has to be regulated.

��



b) Karna Purna:

The literal meaning Karna purna is filling of ear with lukewarm taila, swarsa,

medicated ghrita or Gomutra. Karna purna has been mentioned under the Samanya

chikitsa of Karna rogas.

Procedure:

The patient should be made to lie down on lateral position and lukewarm drug

should be poured into the ear. After pouring the medicine, it should be kept in that

position till 500 matras. (approx.ten minutes)79

.

Acharya Vagbhatta has mentioned that after pouring medicine into ear, one

should massage the root of the ear till the pain subsides. Even in healthy conditions,

oil can be poured into ear and can be kept for counting of 100 matras. All type of oil

eliminates vayu and at the same time do not increase Kapha80

.

Time of administration:

Svarsa etc should be administered before taking food. Administration of taila in

Karna purna is to be given after sunset81

.

After administration of Karna purana swedna is also advised.

References regarding Snehan in Various texts:

1. Vataj Karnaroga 98, 99

2. Pittaja Karnaroga 98

3. Kaphaja Karnaroga 98

2. Rasayanam:

The principle of nourishing the Saptadhatus is called Rasayanam. Deerghayu,

Smriti, Medha, Arogya, Yuva, Paramana, and also Swara, Parama deha bala, Indiriya,

Vaksiddhi and Kanti are the out come of rasayana therapy (Sh.S.8). The author of

Sharangdhar samhita has mentioned rasayana, as that which keeps away jaravastha &

vyadhi.

Haran Chandra while dealing with samanya chikitsa of karna rogas has used

rasasanam instead of rasayana. In rasasanam he has advocated mamsa rasa with food,

The other authors have accepted ghrita pana as rasayana & indicated it in all the types

of Karna rogas.

��



3. Avyayam:

Avyayam means not to work hard or over exertion should not be done in ear diseases.

� Because of excessive hard work, there is a possibility of Valsalva Meneuvre to

happen. Air pressure from the tympanic end of the eustachian tube can cause

perforation of tympanic membrane, through which there will be easy

accessibility of micro-organisms to enter in to the middle ear and there by

causing Karna Srava.

� Because of Valsalva Manoeuvre, infection in case of already infected sinuses,

adenoids, pharynx, will travel up to the ear because of opening of eustachian

tube and will cause middle ear infection (otitis media), which will result in

Karnasrava.

4. Ashirah-Snana-

It means take bath except shira. Head bath is contraindicated in ear diseases. The

explaination given under Jala krida also applies here:

� Impacted wax will swell up and produces pressure symptoms like pain in ear,

tinnitus etc.

� Infected water will cause infection in ear and may cause perforation of TM

which will further result in middle ear infection (otitis media).

� Chlorinated water will cause initation and itching ears.

5. Brahmacharya:

It means not to indulge in intercourse excessively. According to Ayurveda, because

of excessive intercourse, there will be Anuloma Kshya of all the Dhatus, which will

cause Kshya of oja,and this is responsible for the immunity of the body. As the

immunity will be weakened, like all the other diseases, there will be aggravation of

the features of Karna Roga or the disease will not be cured.

Acharya Vagbhatta has clearly mentioned in Sutra Sthana chapter Annaraksha

adhyayya that persons of Grihastha Asharam should practice intercourse in a

controlled manner or should follow certain rules.

��



6. Akathanam:

It means not to talk excessively. Because of excessive talking there will be

increased movement of Jaw at the TM joint. Movement of Jaw will cause discharges

from the ear. (Ear discharge has two sources a. Intra auricular b.Extra auricular)

Under the extra-auricular causes, pus from the Parotid /Mastoid can travel through the

sinus / Fissures of Santorini and reaches into the meatus. Because of movement of

Jaw, will enhance the process of pus drainage and ultimately drain externally.

Vishishta Chikitsa of Karna Srava:

1. Sushruta:

According to Acharya Sushruta, in Karna srava, Pootikarna,

Krimikarna, same line of treatment should be followed. This view is also

followed by acharaya Vagbhatta, Bhavaprakasha, Vangsena. Thereafter,

Vishishta yogas are advised82

.

Acharya Sushruta has mentioned following chikitsa karma for Karna srava: (Su.Ut.2

1/40)50

i) Shirovirechan

ii) Dhoopan

iii) Karna poorana��

iv) Pramarjan

v) Dhawan

vi) Avachurnan

vii) Abhyantariya yoga (for internal use)

1. Shirovirechan:

Shirovirechan is used to expel the vitiated doshas present in the Shiras. For

Shirovirechna, churna of the drugs like Apamarga seeds, Katphala churna, etc are

advised.

2. Dhoopana:

In order to purify the internal and external varnas (ulcers/wounds) and to

remove the foul smell, some specific drugs (dravyas) are burnt on fire and their fumes

is applied on the vrana. This process is called Dhoopana. Drugs used are Guggulu,

��



Agaru, Sarja etc; these generally act as Antiseptics (Jeevanu nashask).

Another references regarding Dhoopan in various texts are given below83,84 ,85

3. Poorana:

The literal meaning of poorana is to pour. To kill the microorganisms and to

prevent the Karnasrava, the svarasa, tail of Sanshamak, Lekhna, Sravahar and

antimicrobial drugs are administered in the ear.

The vishishta svarasa/oil mentioned by Sushruta was as follows:

i) Pancha-kasaya vriksha Kwath+Kapittha swarasa+ honey86

ii) Choorna of bark of sarj + swarasa of vankarpasa + Honey87

iii) Shaiwladi taila88

4. Pramarjan:

Literal meaning of pramarjan is to mop; means to mop with pichu, or cotton

etc. Secretions of Karna srava have to be mopped effecitively before administering

any drugs89

.

5. Dhawan/Prakshalan:

Dhawan means prakeshalan or to wash by Triphla kwath, Panchavalkal

kwatha, Nimbadi kwatha, Lodhradi Kwatha. Rajvrikshadigana, & Sursadigana37

.

6. Avachurnana:

Avachurnana means to sprinkle. Powder of kashaya rasa drug is sprinkled in

the ear e.g. Samudraphena, Manahshila and Lodhra. Powder of Laksha, Rasanjan, and

Sarja is sprinkled90

.

Internal use:

For internal use, the yogas like Indu Vati, Sarivadi vati, Karna Rogahar rasa,

Rasanadi guggulu and Triphia guggulu.

i. Patoladi ghrita91

ii. Charaka: Charaka says in rogas of Mukha, Karna, Akshi, according to the

dosha, kala, balaabala, chikitsa Karma of Peenasa should be followed92

.

� Acharya Charaka has advised vatanashak chikitsa in Karna shoola as in

Pratishyaya, like pouring of vatanashak tail, Nasya of vatanashak drugs either

of churna or oil.

��



� In case of Karna paka, when there is a pus discharge, then chikitsa that of

Vrana is implemented. The patient should be on pathya diet, and Vrana-ropak

(wound healing) oil should be administered in ear93

.

The formulations, which has been given in Charak Samhita:

� Kshar Tail for local application94

.

� Mayura ghrita for internal use.

Besides above, Nasya, Gandusha, Svedana are also mentioned under local treatment

of Karnasrava83, 84

.

Pathya:

The pathya of Karna rogas are mentioned by Sushruta, Acharya Vagbatta and

Yogratanakar.It is more elaborately described in Yogratnakar. According to him diets

like Godhuma, Shali Rice, Mudag, Yawa, Purana Ghrita, Patola, Shigru, Vartaka and

Sunnishnaka etc are homologus for the Karna rogas. Viharas like Svedana, Virechana,

Vamana, Nasya, Dhuma, Siravedha; Brahmacharya and Abhashnam etc are

homologus. Even he has clearly mentioned the non-vegetarian articles like Lava,

Mayura, Hirana, and Kukkuta etc; Above all, all the sorts of�Rasayanas are mentioned

as pathya for the Karna roga95, 96, 97

.

Apathya:

A person suffering from Karnasrava should avoid cold, humid weather,

exposure in air; He should not introduce stick, metallic objects etc in to the ear. He

should avoid head bath, brushing teeth with hard brush, diving into the water,

excessive talking, vyayama, excessive scratching of ear. He should also not consume

heavy food in addition to the kapha karaka dravyas.

Sadhyasadhyata:

Acharya Vagbhatta has mentioned the sadhya-asadhyata of Karna rogas in

general. In Ashtanga Hridaya, Uttar Tantra chapter 17/26; that out of 25 Karna-rogas,

20 rogas are Sadhya, Tridoshaja Shoola roga, Pippali roga, Vidari, Kuch karnak are

Asadhya and Tantrika roga is Yapya. So, Acharya Vagbhatta has considered

Tridoshaja shoola under Asadhya Roga, while the Ekdoshaj Shoola/Srava i.e.Vataj,

Pittaja, Kaphaja, Raktaja Shoola are Sadhya.

��



Acharya Charaka has not clearly explained the Sadhya- asadhyata of Karna

rogas. Though he has mentioned the chikitsa sutra for Karna rogas and also has

mentioned some specific formulations for Karna rogas. This indicates the Sadhya

nature of Karna Rogas.

Acharya Sushruta also, has not clearly mentioned the sadhya -asadhyata of

Karna Roga; but he has elaborately mentioned the treatment of Karna-Srava, which

indicates Sadhya nature of this disease.

��



MODERN REVIEW

Otitis Media is the inflammation of the mucous membrane of middle ear cleft.

Otitis media is classified in general in following ways:

1.Acute otitis media.

i) Acute catarrhal otitis media

ii) Acute middle ear effusion.

iii) Acute suppurative otitis media.

iv) Recurrent acute otitis media

v) Acute necrotising otitis media.

vi) Aero-otitis media (Otitic Barotraumas).

2. Chronic otitis Media:

A) Chronic Non-suppurative:

i) Secretory otitis media or otitis media with effusion.

ii) Healed otitis media (adhesive hearing loss)

iii) Otitic barotrauma

iv) Otosclerosis.

B) Chronic suppurative otitis media:

I. Old system based on Anatomical Consideration.

i) Tubotympanic disease- ‘Safe’ disease, Perforation is central and non- marginal.

ii) Atticoantral disease- ‘Unsafe’ disease; Perforation is marginal.

II. New System based on Pathological Considerations.

i) Healed otitis media.

ii) Inactive mucosal chronic otitis media.

iii) Active mucosal chronic otitis media.

iv) Active squamous epithelial chronic otitis media: Cholesteatoma.

v) Inactive squamous epithelial chronic otitis media: Retraction pocket.

C) Tuberculous otitis media.

��



CHRONIC SUPPURATIVE OTITIS MEDIA:

Chronic suppurative otitis media (CSOM) is a long standing infection of part or whole

of the middle ear cleft characterized by ear discharge and a permanent perforation. A

perforation becomes permanent when its edges are covered by squamous epithelium

and it does not heal spontaneonsly. A permanent perforation can be likened to an

epithelium lined fistulous track.

Prevalence:

The majority of reports of the incidence of chronic otitis media are from clinic data.

These tend to reflect the referral pattern to that clinic rather than the prevalence in

general population. The British Medical Research Council National Study of Hearing

looked at adults randomly selected from the general population.

The overall incidence of healed, inactive and active otitis media is 12, 2.6, and

1 .5% respectively; it unfortunately has not been possible to subdivide the inactive

and active ears into mucosal and squamous epithelial disease, However, in clinical

practice, up to 50% of active ears will be associated with a cholesteatoma. (smyth

1976).Interestingly, there is no obvious lessening of the incidence in recent years,

those in the 18-4O year age group being just as likely to have chronic otitis media as

the 40-60 age group.

Incidence of CSOM is higher in developing countries because of poor socio-

economic standards, poor nutrition and lack of health education.

In India, the overall prevalence rate is 46 and 16 persons per thousand in rural

and urban populations respectively. It is also the single most important cause of

hearing impairment in rural population. It affects both sexes equally.

As might be expected, those in manual occupation are likely to have chronic otitis

media.

Classification:

CSOM has been classified according to old system and new system. Old

system is based on anatomical considerations, while new system is based on

pathological considerations.

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A. Old system:

i).Tubotympanic disease ii) Attico-antral disease

i) Tubotympanic Disease:

It is also called the safe or benign type. This disease remains localized to the

mucosa, mostly to antro-inferior part of the middle ear cleft .Like any other chronic

infection, the processes of hearing and destruction go simultaneously, an either may

take advantage over the other depending on the virulence of organisms and resistance

of patient. These are no risk of serious complications.

ii) Aticoantral Disease:

It involves postero-superior part of middle ear cleft (attic, antrum and

posterior tympanum and mastoid) and is associated with cholesteatoma, which

because of its bone eroding properties, causes risk of serious complication. For this

reason, the disease is called unsafe or dangerous type.

B. New System of Classification:

Based on pathological considerations

i) Healed otitis media

ii) Inactive (mucosal) chronic otitis media

iii) Active mucosal chronic otitis media.

iv) Active squamous epithelial chronic otitis media: cholesteatoma

v) Inactive Squamous epithelial chronic otitis media: retraction pocket.

i) Healed Otitis Media:

Here the pars tensa and pars flaccida are intact and in a normal position but

abnormal in appearance. This may be due to various degrees of scrarring, thickening,

chalk patches, tympano-sclerotic plaques or healed perforations. These are all signs

that at some time in the past, there was inflammation in the middle ear cleft, most

likely otitis media but also possibly surgical trauma due to a ventilation tube. Such an

ear is burnt out with regard to activity and, the disability, if any, will be a hearing

impairment due to ossicular chain fixation or disruption. In addition, there are many

ears that if looked at histologically will have evidence of old otitis media but the

tympanic membrane is normal. (de.Costa et.al. 1992)

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ii) Inactive (Mucosal) Chronic Otitis Media:

Here there is a permanent defect of the pars tensa but there is currently no

evidence of inflammation either of the middle ear mucosa or tympanic membrane.

The ossicular chain may be eroded or fixed. The natural history of such an ear is to

become active or remain inactive.

iii) Active (Mucosal) Chronic Otitis Media:

In addition to the tympanic membrane defect the middle ear mucosa is

inflamed and oedematous with the production of excess mucus or muco-pus. Such

activity may be intermittent or continuous. In some ears, granulation tissue or polyps

can develop.

iv) Active Squamous Epithelial Chronic Otitis Media : Cholesteatoma

Here in addition to active mucosal Chronic otitis media as defined above,

there is a squamous epithelially lined pocket full of squamous epithelial and

inflammatory debris, This most frequently arises in the pars flaccida but can occur

from a pars tensa retraction pocket. A cholesteatoma is the most common clinical

term used but keratoma, .cholesteoid, epidermoid cholesteatoma, epidermoidosis have

all been used, The adjective ‘acquired’ is sometimes used to distinguish such a

cholesteatoma from a congenital one.

v) Inactive Squamous Epithelial Chronic Otitis Media : Retraction pocket:

Various degrees of retraction of the pars flaccida must be considered normal

but when part of the retraction is out of vision for the otoscopist this is considered

abnormal because of it’s potential to retain squamous epithelial debris which might

lead to active squamous epithelial disease i.e. a cholesteatoma. The various stages of

pars flaccida retraction have been well described by Tos, stanger up and Lassen

(1987)

Staging of attic retraction:

Retraction of the pars tensa can also occur and again, if part is out of

vision, this could give rise to active disease i.e. a cholesteatoma, unfortunately. Some

surgeons because of suggested propensity of retraction pockets to become active

described their surgery of inactive retraction pockets as choesteatoma surgery.

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Aetiology: General

1. Environment:

As with many medical conditions, there is a close correlation between

patients with chronic otitis media and socio-economic group, the lower groups having

a higher incidence. It is not known why this is the case, but almost certainly it relates

to general health, diet and overcrowding in home. When investigating such factors it

is difficult to allow for others such as genetics, climate, method of screening and

previous management of the condition What is known is that in disadvantaged

populations such as Maori children and Innuits the incidence is higher than in Britain.

2. Genetic:

The question as to whether one race is more predisposed to chronic otitis

media remains unanswered, mainly because of the inability to control for many of the

factors mentioned above. It is, for example, suggested that American Negroes are less

likely to have the condition than white Americans but this could simply be due to

different patterns of attendance for medical treatment.

The importance of genetic factors was much debated earlier this century, in

particular whether the incidence was related to the size of the mastoid air cell system,

which was considered to be genetically determined. The mastoid air cell system is

smaller in individuals with otitis media, but it is not known whether this is a primary

or secondary event. Histologically, there is no doubt that with repeated

inflammation, the mastoid air cell system becomes progressively more sclerotic. The

degree of initial mastoid aeration may be a predisposing factor, but once the condition

has developed the cell system will decrease in size.

3. Previous Otitis Media:

It appears to be generally held that chronic otitis media is a sequela of acute

otitis media and /or otitis media with effusion, but it is not known what factors make

one ear, and not another, progress to the chronic condition. It has been suggested that

with the chronic retraction of the tympanic membrane, which is associated with otitis

media with effusion, there is a loss of the fibrous tissue layer (smyth, 1983), which

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will not heal if there is a subsequent acute perforation. Though this theory might

initially appear attractive, there is little evidence to support it and destruction of

fibrous tissue by unspecified enzymes in the middle ear fluid is pathologically

unlikely.

Unfortunately, there is little evidence ‘that surgical or medical management

of these childhood conditions make any difference to the incidence of chronic otitis

media. It could even be that surgery makes the matter worse, particularly by the

creation of tympano-sclerotic patches in the tympanic membrane.

4. Infections:

Bacteria can almost invariably be isolated from the mucopus or from the

mucosa of the middle ear in active chronic otitis media provided that the correct

culture methods are used .The proportion of the different organisms varies between

series but they are mainly Gram-negative, bowel-type flora and often several different

organisms will be cultured from the ear. Contrary to an opinion that is often

expressed, the types of flora are no different if a cholesteatoma is present.

The fact that organisms can be isolated so frequently is usually taken to

imply that bacterial infection of the mucosa is the main reason for the continued

activity. However, the role of bacteria can be questioned for several reasons; when the

tympanic membrane is intact, bacteriological cultures taken from the middle ear can,

on occasion, isolate organisms which are unlikely to be contaminants from the

external auditory meatus (Sipila et.al.1981). Another finding is that although

anaerobic organisms can be isolated from at least 40% of ears, their elimination by

metronidazole therapy does not cause the ear to become inactive (Browning et al.

1983). Thus, it could be argued that the bacteria in ears with chronic otitis media are

secondary invaders of a mucosa, which is inflamed because of other factors, rather

than that they are the primary cause of the disease. This does not mean that they do no

damage. There is considerable evidence that bacteria can produce substances that

affect ciliary function and hence would encourage stasis of secretions in the middle

ear. There is also evidence that polymicrobial colonization is more damaging than

monomicrobial (Book, 1987)

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Tuberculosis is much less common than formerly but should be considered

when active disease does not respond to medical or surgical management ,The route

of infection can be haematogenous from another focus such as the lungs or via the

eustachian tube e.g. from the ingestion of infected milk.

5. Upper Respiratory Tract Infections:

Though it has not been studied scientifically, many patients will state that

their ear starts to discharge after an upper respiratory tract infection. The postulate,

here, would be that the viral infection would also affect the mucosa of the middle ear

making it less resistant to the organisms that are normally present in the middle ear,

allowing bacterial over growth.

Tradition would also suggest that patients with chronic otitis media

frequently have chronic disease of the respiratory tract, such as sinusitis. The

frequency, with which this occurs, has not been reported, but clinical experience in

the 1980’s would suggest that it is uncommon. It remains a reasonable postulate that,

if one area of the respiratory tract mucosa is affected, there is an increased likelihood

that another part will also be affected, but it does not mean that management of one

condition is necessary before the other can be successful.

6. Autoimmunity:

It seems likely that individuals with established autoimmune disease will

have a higher incidence of chronic otitis media, but to date rheumatoid arthritis is the

only condition to have been studied and in this condition this appears the case.

7. Allergic:

Though postulated by some as an important factor, it remains to be proven

that allergic individuals have a higher incidence of chronic media than non-allergic

subjects. In some, allergy to the antibiotics in the eardrops or to the bacteria or their

toxins is an interesting but as yet unproven possibility.

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8. Eustachian tube malfunction:

In active chronic otitis media, the Eustachian tube is frequently blocked by

oedema but whether this is a primary or secondary phenomenon is unknown.

Certainly reconstructive surgery is frequently successful in such ears, which would

suggest that, in these ears at least, it was a secondary event. In inactive ears, various

methods have been used to evaluate eustachian tube function and most would suggest

that the tube is unable to return a negative pressure to normal,

Pathology: (New System Based on Pathological Consideration)

1. Inactive Chronic Otitis Media:

By definition, the tympanic membrane is abnormal in inactive otitis media

and the clinical appearance depends on the method of healing, but in all instances

there is a loss of the fibrous tissue layer of the tympanic membrane. Thus, in the

replacement, there is a membrane bridging the defect composed only of an outer layer

of squamous epithelium and an inner mucosal one.

When a perforation is present, the squamous epithelium of the outer

tympanic membrane meets the middle ear mucosa at a variable position, frequently

with in the middle ear. This has practical implications for myringoplasty. If there is

any residual drum, there may be a tympanosclerotic plaque in the fibrous layer.

Clinically what constitutes a marginal as opposed to a central perforation is

confusing, some equating a marginal perforation with one that extends to the bony

meatus. Others would equate it with disease which is primarily located in the postero-

superior quadrant and therefore more likely to be associated with a cholesteatoma.

Pathologically, the difference has not been clearly defined but some would suggest

that it depends on whether or not the annulus is destroyed.

2. Active Mucosal Disease (Including Polyps):

The extent to which the lining of the middle ear and mastoid air cells are

affected varies. In the middle ear, the usually nonsecretory mucosa is replaced by a

respiratory type, mucus-secreting mucosa with goblet cells. The mucosa is generally

hyperaemic with an underlying inflammatory reponse. Areas of granulation tissue

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may form especially in non-draining areas, such as around the ossicles. Depending on

its severity, there can be active, resorption and bone remodeling, irrespective of

whether a cholesteatoma is present, which can lead to dehiscence of the fallopian

canal. Surprisingly the mastoid mucosa seldom undergoes metaplasia to a secretory

lining, granulation tissue being more common.

For some as yet unknown reason polyps can sometimes arise from this

hyperaemic inflamed mucosa and progressively enlarge so that they block off

drainage via the external auditory meatus. Their surface can be ulcerated, covered in a

hyperaemic respiratory type mucosa or have areas of squamous metaplasia.

3. Active Chronic Otitis Media with Cholesteatoma:

A cholesteatoma has nothing what soever to do with cholesterol. It is

keratinized, squamous epithelial lined pocket containing keratinous debris which it

would be histologically more correct to call a keratoma. A cholesteatoma is

distinguished from a retraction pocket or areas of squamous metaplasia by its

retention of keratinous debris.

Histologically, there would appear to be little difference between the

squamous epithelium of a cholesteatoma and that of skin, all the recognized layers

being present. The number of langerhans cells may be increased but this is taken to be

a result of the underlying inflammation rather than a finding, which is specific to a

cholesteatoma. Almost invariably when keratinous debris is retained, their will be an

associated inflammatory response in the sub-epithelial connective tissue, but whether

the two are connected is uncertain. Granulation tissue will ofien develop in

association with a cholesteatoma and this may represent at it’s margins and even

develop into an aural polyp.

Patho1oy II: (Old System Based on Anatomical Consederation)

A). Tubo-tympanic type (CSOM)

Tubotympanic disease remains localized to the mucosa and, that too, mostly

to antero-inferior part of the middle ear cleft. Like any other chronic infection, the

processes of healing and destruction go hand in hand and either of them may take

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advantage over the other, depending on the virulence of organism and resistance of

the patient. Thus, acute exacerbations are not uncommon. The pathological changes

seen in this type of CSOM are:

1. Perforation of Pars tensa:

Tympanic membrane is perforated in its central portion. The size may vary

from less than 20% of the drum area to the entire drum and portions of the annulus.

Perforation of membrane in this disease results from acute otits media. The

perforation does not heal after the initial acute attack because there has been

persistence of the infection and, if this continues for long enough, the edges of the

perforation are covered by squamous eithelium from the outer surface joining the

mucosa of the middle ear so that the perforation is lined by epithelium. A patient with

such a perforation is liable to persisting or recurring discharge secondary to upper

respiratory tract infections, but middle ear infection may also result from bacteria

entering the middle ear through the perforation from the external meatus. The

perforation is always a central perforation that is it is surrounded by part of the pars

tensa throughout its circumference. The perforation may be anterior, posterior, kidney

shaped or subtotal, but it is always surrounded by drum remnant.

The formation of an atrophic two-layer membrane lacking in fibrous elements

may be seen. This membrane is rapidly destroyed during active periods of infection.

2. Middle ear Mucosa:

The mucosa varies during stages of the disease. In quiescent periods, it

appears normal unless the effects of infection have produced thickening or metaplasia

into transitional epithelium.

During active infection, the mucosa becomes thickened and hyperemic

producing a mucoid or mucopurulent discharge. After treatment the thickenings and

mucoid discharge may persist owing to chronic dysfunction of thee eustachian tube.

Allergic factors or environmental may be responsible for this persistence of mucosal

change.

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3. Tympanosclerosis:

During healing, the mucosa may exhibit the changes of tympanosclerosis.

These consist of the formation of amorphous hyaline plaques in the submucosa

varying in size, from thin layers to dense masses. In early stages, the mucosa assumes

a thick rubbery appearance. As healing progresses the plaques become yellowish,

with putty like consistency. In time, calcium salts may be deposited, creating bony

hard masses. The sites of predilection for this process are in the annular region of

tympanic membrane, particularly antero-superiorly and surrounding the ossicles. The

process may result in further or complete fixation of the ossicular system resulting in

severe hearing loss.

4. Polyps:

The mucosa may show the formation of granulation tissue and /or polyps.

This process is associated with long standing persistent discharge or active infection,

Polyp formation is commonly associated with the presence of squamous epithelium in

the middle ear and may protrude through a small perforation partially obstructing

drainage and causing persistence of disease.

5. Ossicular Chain:

It is usually intact and mobile but may show some degree of necrosis,

particularly of the long process of incus, commonly the long process of incus has

undergone necrosis because of thrombotic disease of the mucosal vessels supplying

the incus.

6. Fibrosis and Adhesions:

They are the result of healing process and may further impair mobility of

ossicular chain or block the Eustachian tube.

7. Mastoid:

Chronic suppurative otitis media most often has it’s onset in childhood.

Because mastoid pneumatization is most active between ages 5 and 10, this process of

pneumatization is often halted or reversed by otitis media occurring at this age or

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earlier, As the chronic infection continues, the mastoid undergoes a process of

sclerosis reducing the size of the mastoid process. The antrum becomes smaller,and

pneumatization is limited to a few air cell tracts in the immediate vicinity of the

antrum.

This concept is contrasted with the fact that the degree of pneumatization of

the mastoid varies among individuals. Individuals with limited pneumatization (either

from genetic cause or neonatal infection) are felt by some to have increased

susceptibility to chronic otitis media. Radiographs show these changes in the

cellularity of the mastoid so commonly that a radiological diagnosis of chronic

mastoiditis is synonymous with the actual finding of a dense small sclerotic mastoid.

B). Attico-Antral Type:

In this type of infection the bone of the attic, antrum or mastoid process is

involved as well as the mucosa of the middle ear left. It is therefore also referred to as

attico-antral disease. As erosion of bone may extend to adjacent vital structures there

is always a danger of serious complications. The bony involvement may give rise to

granulations or polypi. These may be true granulation tissue but are more often the

result of inflammatory swelling of the mucosa of the ear. Their presence, however is

usually evidence of bony involvement.

There are three basic pathological findings in the attico-antral type of disease:

1. Cholesteatoma.

2. Granulation tissue with osteitis

3. Cholesterol granuloma.

Clinical features:

Tubo-tympanic disease:

1) Ear discharge:

The discharge tends to be profuse, non-offensive, mucoid or mucopurulent,

constant or intermittent. Discharge is frequently mucoid rather than frankly purulent.

It is seldom malodorous. It may be precipitated by the passage of water through a

perforation or with the onset of upper respiratory tract infection.

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ii) Hearing Loss:

It is of conductive type; which may vary from trivial to moderately severe, that

is, averaging about 40 dB. More severe deafness is unusual and is due to involvement

of the ossicular chain either by adhesions or by necrosis causing a break in the line

Perforations of the tympanic membrane reduces the efficiency of the drum component

of the middle ear impedance matching transformer.

When the perforation directly exposes the round window niche, the protection, which

is normally afforded to the round window membrane by the drum, is lost and this has

an adverse effect on cochlear mechanics. The loss of the ‘round window baffle’ effect

is associated with a greater hearing loss than might otherwise be expected.

Destruction of ossicular chain leads to more severe hearing losses. Hearing losses in

cases with loss of the stapes arch are generally more severe than those in which the

arch is intact.

In addition to the conductive hearing loss in long standing cases many patients

have a degree of sensorineural hearing loss. Patients with unilateral chronic

suppurative otitis media were found to have significantly greater hearing thresholds in

the affected ear compared with the normal ear in a multicentre trial reported by

paparella et al (1984). Cochlear damage has been attributed to the diffusion of the

toxic products of inflammation through the scala tympani via the round window

membrane. Serofibrinous exudate has been observed in the scala tympani adjacent to

the round window in experimentally induced otitis media in the cat. Paparella et.al

studied 12 temporal bones from patients with CSOM and reported the presence of

inflammatory cells in the cochlea in four of them.

However, they failed to demonstrate the loss of hair cells. Walby, Barrer and

Schuknecht (1983) reported elevated bone conduction thresholds as compared to

those on the contra-lateral side in 87 patients with unilateral CSOM. In the same study

they also examined 12 temporal bones from patients with CSOM and failed to

demonstrate any abnormality of the hair cells. They postulated that the elevated bone

conduction thresholds were due to changes in the mechanichs of sound conduction, In

most cases of CSOM treated surgically, the postoperative bone conduction thresholds

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are the same as those found preoperatively. However, over closure of the air-bone gap

a phenomenon more usually associated with stapes surgery has been observed

following tympanoplasty.

iii) Perforation:

It is always central; it may lie anterior, posterior or inferior to the handle of

malleus. Perforation of the eardrum results from acute otitis media. The perforation

does not heal after the initial attack because there has been persistence of the infection

and if this continues for long enough, the edges of the perforation are covered by

squamous epithelium from the outer surface joining the mucosa of the middle ear so

that the perforation is lined by epithelium. A patient with such a perforation is liable

to persisting or recurring discharge secondary to upper respiratory tract infections but

middle ear infection may also result from bacteria entering the middle ear through the

perforation from the external meatus. The perforation is always a central perforation,

that is, it is surrounded by part of the pars tensa throughout its circumference.

The perforation may be anterior, posterior, kidney shaped or subtotal, but it is

always surrounded by drum remnant. It may be small, medium or large or extending

up to the annulus i.e. subtotal.

iv) Middle ear mucosa:

It is seen when the perforation is large. Normally it is pale pink and moist

when inflamed it looks red oedematons and swollen. With prolonged discharge a

polypus which is a swelling of the middle ear mucosa, may project through the

perforation into the external auditory meatus.

v) Ossicular Chain:

There may be fixation of ossicles by fibrosis. The ossicular chain may be

broken by absorption of bone particularly the long process of incus. These lesions of

the ossicular chain may cause more severe deafness.

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Table-3

Clinical Features of COM

S. NO Inactive Mucosal

COM

Active

Mucosal COM

Active squamous

epithelial COM:

Cholestaetoma

Inactive squamous

epithelial COM:

Retraction pocket

1.Ear

discharge

Usually the ear is

dry

*Mucoid or

mucopurulent.

*May be

constant/

intermittent.

*Purulent mixed

with

cholesteaomatous

debris.

*Persistent or

recurrent.

*foul smelling

No aural discharge

and examination of

the retraction pocket

under the

microscope reveals a

clean, dry pocket.

2. Hearing

loss

May be mild Usually

conductive

hearing loss.

Averaging

40dB

Moderate to

severe conductive

or sensorineural or

both.

May be mild to

moderate.

3. TM and

perforation

TM is abnormal in

clinical appearance

depends on the

method of healing

but in all instances

there is loss of

fibrous tissue layer.

So the membrane

which bridges the

defect composed

only of an outer

layer of sq.

epithelium and an

inner mucosal one.

If there is any

residual drum there

may be a

tympanosclerotic

plaque. Perforation

may be of marginal

or central type

Central

perforation

present.

Cholesteatoma

may be seen as a

grayish substance

projecting from or

filling an attic or a

marginal

perforation.

Marginal perforation

(posterosuperior) or

in the attic.

4. middle

ear

mucosa

Mucosa is

uninflammed and

uninfected.

Mucosa is

swollen,

odematous and

may on

occasion

produce polyps.

Polyp or

granulations may

be present; or may

protrude through

the perforations in

to the ear.

Dry.

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5.

ossicular

chain

Ossicular chain

usually not eroded.

After repeated

exacerbations

the ossicular

chain will

usually be

eroded atleast

in part, and this

may be visible

through the

perforation.

Bone destruction

is a feature of an

accuried

choleateatoma

resulting from

enzymatic activity

in the

subepithelial

layers.

Ossicular chain may

or may not be

eroded.

6.

Infection

in nose

sinus and

pharynx.

Not present. Present. Present. Not present.

7.

additional

features

In some cases,

disease causes

erosion of the

bone of the

labyrinth. The

most frequent site

for such a fistula

is the horizontal

semicircular canal

where it lies in the

floor of the

auditus. It

produces

giddiness

nystagmus,

hearing loss.

Examination:

The pinna should be inspected and it is important to look at both sides to exclude the

presence of a scar from previous surgery.

i) Otoscopic Examination:

Otoscopic examination will reveal the presence and position of any perforations and

retraction pockets. In the presence of a perforation, the condition of the middle ear

mucosa can be assessed. A polyp may be observed though if this is large it may

completely obstruct the ear canal precluding adequate assessment of the disease. It is

essential that all discharge be removal from the ear so that the TM may be completely

examined. The discharge is removed by mopping or by suction.

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ii) Examination under Microscope:

Most cases benefit from further assessment under the operating microscope and this

allows discharge or crusts to be removed.

• It provides useful information regarding presence of granulations, in

growth of squamous epithelium form the edges of perforation, status of

ossicular chain, tympanosclerosis and adhesions.

• An ear which appears day may show hidden discharge under the

microscope. Rarely, cholesteatoma may co exist with a central perforation

and can be seen under microscope.

• In some cases, a second examination after a course of medical treatment

will help to clarify the details of the pathology.

• In others, esp. in children, it is necessary to examine the ear under general

anesthesia in order to make a proper assessment.

• In all cases, the nasal cavities, nasopharynx and pharynx must be

examined because it is in the upper respiratory tract that the source of

infection will be found. The common causes of ascending infection are

infected tonsils, adenoids and sinusitis.

iii) Audiological Assessment:

Audiometric evaluation is necessary to determine the status of conductive and

cochlear function. By the use of air and bone, pure tone audiometry and speech

discrimination scores, the amount of ossicular damage present may be estimated,

and the hearing benefit to be gained by reconstructive middle ear surgery can be

judged.

A pure tone audiogram including air and bone conduction with full masking is

essential to evaluate the degree of hearing loss and to determine the air bone gap.

In cases in which an attempt to improve hearing is being considered, a speech

audiogram is valuable to check that the speech reception threshold is in line with

the mean hearing loss as assessed by pure tone audiometry, while there is

generally good agreement between the results of speech audiometry and mean

hearing losses calculated using the frequencies 500, 1000 and 2000 hz.

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Occasionally the speech discrimination proves to be so poor and therefore no

useful hearing improvement can be anticipated following surgery.

To aid in this evaluation the following observations will be of help:

• A simple perforation usually causes no more than a 15 to 20 dB

conductive hearing loss.

• Damage to the ossicular chain causes a 30 to 50 dB conductive hearing

loss if a perforation is present.

• Discontinuity of the hearing chain behind an intact drum causes a flat 55 to

65 dB conductive hearing loss.

• Marked impairment of speech discrimination, regardless of the bone

conduction, indicates severe cochlear damage.

Investigations:

i) Culture and Sensitivity of Ear Discharge:

It helps to select proper antibiotic.

ii) Radiological Assessment:

A radiographic examination of the mastoid in chronic otitis media is of limited

diagnostic value compared to the benefits of otoscopy and audiometry.

a) X-Ray

The standard views are:

i) The Schuller view:

It shows the extent of pneumatization of the mastoid from laterally and above.

This becomes of value in surgery by defining the position of the lateral sinus and

tegmen. This is particularly helpful in a sclerotic mastoid to forewarn the surgeon and

thus prevent entry into the dura or lateral sinus.

ii) The Mayer’s or Owen’s view:

This view is taken from above and anterior to the middle ear. This throws the

ossicles and attic into view and allows one to determine whether bone destruction has

involved these structures.

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iii) The Stenver’s View:

It shows the length of the petrous pyramid and is more useful in showing the

internal auditory canal vestibule and semicircular canals. It also throws the antrum

into cross section and may give evidence of enlargement from cholesteatoma.

B) CT Scanning:

The anatomy of the temporal bone can be more effectively demonstrated by CT

scanning. However, the findings are unlikely to influence decisions about the

management of most cases. It may be of some value in children, medically unfit

patients and those with only one hearing ear.

CT scanning is of vital importance in the detection of intracranial

complications.

The role of MRI scanning in otitis media is currently being evaluated.

Features Indicating Complications in CSOM:

1) Pain: Pain is uncommon in uncomplicated CSOM. Its presence is considered

serious as it may indicate extradural, perisinus or brain abscess. Sometimes, it

is due to otitis externa associated with a discharging ear.

2) Vertigo: It indicates erosion of lateral semicircular canal, which progress to

labyrinthitis or meningitis. Fistula test should be performed in all cases.

3) Persistent Headache: It is suggestive of intracranial complications.

4) Facial Weakness: Indicates erosion of facial canal.

5) A listless child refuse to take feeds and easily going to sleep ( extradural

abscess)

6) Fever Nausea and Vomiting indicates intracranial infection.

7) Irritability and Neck Rigidity (meningitis).

8) Diplopia (Grandinego’s syndrome).

9) Ataxia (Labyrinthitis or cerebellar abscess).

10) Abscess round the ear indicates mastoiditis.

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Treatment

Effective treatment in chronic otitis media must be based on definition of the

causative factors involved and the stage in which the disease is found. Thus, the

factors creating chronicity, the anatomic changes preventing good healing and proper

function and the infectious process involving the ear at the time of instituting

treatment must be evaluated. When cholesteatoma, is diagnosed surgery is indicated.

Medical Management:

The basic principles of medical management of chronic suppurative otitis

media can be summarized as follows.

1. Clean the ear adequately.

2. Instill a topical antimicrobial agent in such a way that it reaches the disease in

adequate amount.

3. Administration of systemic antibiotics.

4. Treatment of polyps /granulations.

5. Treatment of contributory causes.

6. General precautions.

1. Aural Toilet:

The local treatment consists of thorough cleaning of the ear and this is best

done by mopping under direct vision, which will require the use of a forehead mirror

or headlamp.

Alternatively, the ear may be cleaned, using suction under the vision of an operating

microscope. Irrigation with sterile NS can be done. Ear must be dried after irrigation.

It is not possible for the patient to attend for treatment, he should be instructed to mop

out the ear twice daily, using cotton wool on a wooden carrier with a long fluffy end

firmly attached to the ear mops. With the mop made up as described, the ear can be

cleaned right down to the tympanic membrane with no risk to the middle ear

structures.

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2. Topical Antibiotic Therapy:

It is generally considered that antibiotic or antibiotic-steroid eardrops are

effective in reducing aural discharge in CSOM. The choice of antibiotic will depend

on the bacteriology. There will be high incidence of gram- negative infections such as

B. proteus or Pseudomonas pyocyanea so that antibiotic eardrops containing

neomycin, polymyxin, Chloromycetin or gentamicin are used. It is usual to combine

the antibiotic with steroids to reduce the likelihood of skin sensitivity reactions and

have local anti- inflammatory effect. To use eardrops, patient lies down with the

diseased ear up; antibiotic drops are instilled and then intermittent pressure applied on

the tragus for antibiotic solution to reach the middle ear. This should be done three or

four times a day. Acid ph helps to eliminate Pseudomonas infection, and irrigations

with 1.5% acetic acid are useful. Alternatively various types of powder chosen on the

basis of bacterial sensitivity and solubility. An effective combination is 250 mg

polymyxin B sulfate and 3 g. of chloromycetin and insufflated two or three times a

day .The use of boric acid either in solution or as a powder is not indicted because it

forms an insoluble cake that is difficult to clean out of the ear and prevents

antimicrobial agents from reaching the mucosa. Alcohol in strengths greater than 70%

should be avoided because it is both irritating and painful. Most of the antibiotics used

in topical preparations are potentially ototoxic and have been shown to cause cochlear

damage when applied topically is guinea pigs. Proud, Mittilman and Seidden (1968)

applied chloramphenicol powder to the round window of the guinea pigs and reported

cochlear damage; despite the fact that this drug is not generally considered to be

ototoxic in normal usage. There is, however, no evidence that the use of eardrops

causes sensorineural deafness in patients with chronic otitis media. Brummett

et.al(1978) have postulated that this may be because the round window niche in

humans is relatively deep and often protected by a pseudo membrane while in the

guinea pig the round window is completely exposed . Beside, care should be taken, as

eardrops are likely to cause maceration of canal skin, local allergy, growth of fungus

or resistance to organisms.

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3. Systemic Antibiotics:

Systemic antibiotics, chosen on the basis of sensitivity tests, are indicated in

acute infections superimposed on the chronic infection. Infections of a cholesteatoma

is difficult to treat because of the inability to obtain an antibiotic level within the sac

where the infection exists, In these instances, removal of obstructing masses of debris

or crusts from the mouth of the sac by gentle suction to obtain drainage is of great

help.

4. Treatment of Polyps/Granulations:

Aural polyp or large masses of granulations, if present should be removed

before local treatment with antibiotics. It will facilitate ear toilet and permit eardrops

to be used effectively. They are removed with a biting forceps or snare and the raw

surface touched with 25 to 50% silver nitrate several times at intervals of one or two

weeks to secure healing of the mucosa.

An aural polyp should never be avulsed as it may be arising from the stapes,

facial nerve or horizontal canal and thus lead to facial paralysis or labyrinthitis.

5. Treatment of Contributory Causes:

Treatment of the infection consists of eliminating upper respiratory tract

infection.

• Eustachian Tube:

The most important function to be considered is aeration and drainage of

the middle ear by way of the eustachian tube. The causes of interference with

tubal physiology must be assessed and eliminated. Chronic infection or allergy

affecting the nose and pharynx should be diagnosed and treated. Residual

adenoids creating mechanical obstruction should be removed. Determining

the ability of the tube to pass air assesses the adequacy of eustachian tube

lumen. This may be done by having the patient auto inflate the ear by

politzerization or by special manometric study of the tube.

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• Attention should be paid to treat concomitantly infected tonsils, adenoids,

maxillary antra and nasal allergy. Provided this is done it is not usually

difficult to control the ear infection by local treatment.

6. Precautions:

• Once the ear is dry there is always the risk of ascending infection from the

upper respiratory tract or infection from the outside via the external

meatus. These patients are instructed to keep water out of the ear during

bathing, swimming and hair wash. Rubber inserts can be used.

• If the patient gets a cold, he should not blow his nose as this may cause

massive movement of nasal discharge up the eustachian tube to the middle ear.

Surgical Management:

1. Myringoplasty:

An operation in which the reconstructive procedure is limited to repair of

a tympanic perforation.

Indication:

• Recurring discharge from the ear.

• Checking re-infection from external auditory canal and eustachian tube

(nasopharyngeal infection ascends easily via eustachian tube in the presence of

perforation than otherwise).

• Checking aeroallergens reaching the exposed middle ear mucosa leading to

persistent ear discharge.

• Restoring the hearing loss.

Complications of Chronic Suppurative Otitis Media:

Complications of chronic suppurative otitis media develop if the infective

process spreads beyond the confines of the middle ear. This happens less often now

than in the past, due to better and more widely available antibiotics, a healthier

population and more effective surgical treatment. The same antibiotics, however, have

altered the classical presentations of many of the complications and this can lead to

difficulty in diagnosing potentially fatal condition.

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Infection in the middle ear commonly involves the mastoid by direct

extension, but other surrounding structures may be involved, this can occur by direct

spread through an area eroded by disease or through a congenital dehiscence or a

fracture line. The other mode of spread is by thrombophlebitis of emissary veins.

Pathways of Spread of Infection:

1) Direct bone erosion: In acute infection it is the process of hyperaemic

decalcification. In chronic infection, it may be osteitis, erosion by cholesteatoma or

granulation tissue.

2) Venous Thrombophlebitis: Veins of haversian canals are connected with dural

veins which in turn connect with dural venous sinuses and superficial veins which in

turn connect with dural venous sinuses and superficial veins of brain. Thus, infection

from the mastoid bone can cause thrombophlebitis of venous sinuses and even cortical

vein thrombosis.

3) Pre-Formed Pathways:

i. Congenital dehiscences: eg. in bony facial canal, floor of middle ear over the

jugular bulb.

ii. Patent sutures: e.g. petrosquamous suture.

iii. Previous skull fractures: The fracture sites heal only by fibrous scar, which

permits infection.

iv. Surgical defects: e.g. Stapedectomy, fenestration and mastoidectomy with

exposure of dura.

v. Oval and round windows.

vi. Infection from labyrinth can travel along internal acoustic meatus, aqueducts

of the vestibule and that of the cochlea to the meninges.

Classification:

Complications of otitis media are classified into two main groups:

I) Extracranial: (Intratemporal) within the confines of temporal

bone.

II) Intracranial

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I) Extracranial Complications:

Acute

1. Mastoiditis Masked

Chronic

2. Petrositis

Circumscribed

3. Labyrinthitis Serous

Diffuse

Purulent

4. Facial nerve paralysis:

II) Intracranial Complication of Otitis Media:

1. Extradural abscess.

2. Sub dural abscess.

3. Meningitis

Temporal lobe

4. Otogenic brain abscess

Cerebellum

5. Lateral sinus thrombophlebitis.

(Sigmoid sinus thrombosis)

6. Otitic hydrocephalus.

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DRUG REVIEW

The subject of drug is as old as disease. Illness has been men’s heritage from

the beginning of his existence. The search for remedies to combat, it is perhaps

equally old.

Drugs are the most important constituents of treatment. In Charaka Sutra

1/123 emphasis has been given about the knowledge of drug and clearly mentioned

that he who does not know about the drug, is not a Vaidya, but is a killer, because

without knowledge, drug is a poison. It is clearly stated that use of proper drug at

proper time is like necter as it relieves of disease.(Ch.Su.1/138)

In Ayurveda, Aushdhi or Dravya comes under Chikitsa Chatushpada.

The knowledge of the drug is the fundamental quality needed to be present in the

physician for the success of the treatment as it depends on the Yukti.

The word- Drug comes from the old French word "drogue", which mean

“dry”, probably because medicines used to mainly be made of dry herbs. Broadly

speaking, a drug, is any substance that, when absorbed into the body of a living

organism, alters normal bodily function.

The term- Drug is used in wide-ranging as per different streams of science. In

medicine, it refers to any substance with the potential to prevent or cure disease or

enhance physical or mental welfare, and in pharmacology to any chemical agent that

alters the biochemical physiological processes of tissues or organisms. Hence, a drug

is a substance that is, or could be, listed in a pharmacopoeia.

The administration of a medicine is a common but important clinical

procedure. It is the manner in which a medicine is administered that will determine to

some extent whether or not the patient gains any clinical benefit, and whether they

suffer any adverse effect from their medicines. Two main factors determine whether

or not a drug will reach its intended site of action in the body:

1. The bioavailability of the drug

2. How the drug is given (route of administration)

�

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Bioavailability:

Bioavailability is the proportion of an administered drug that reaches the

systemic circulation and is therefore available for distribution to the intended site of

action.

Routes of administration:

There are various routes of administration available, each of which has

associated advantages and disadvantages. All the routes of drug administration need

to be understood in terms of their implications for the effectiveness of the drug

therapy and the patient’s experience of drug treatment. The main routes of

administration are;

� Oral

� Sublingual

� Rectal

� Topical

� Parenteral – Intravenous, intramuscular, subcutaneous

� Topical administration

The topical application of medicines has obvious advantages in the

management of localised disease. The drug can be made available almost directly at

the intended site of action, and because the systemic circulation is not reached in great

concentration.

The risk of systemic side-effects is reduced. For example; the use of eye drops

containing beta blockers in the treatment of glaucoma and the application of topical

steroids in the management of dermatitis etc. Topical administration has also become

a popular way of introducing drugs into the systemic circulation through the skin.

Under the disease of karna, in the treatment of Karnasrava, Achraya Sushruta

as well as Vagbhatta have advocated primarily the local treatment i.e. Karna Purana

and Vagbhatta also advocated the usage of Varti in Karnasrava.

In present clinical study, there are two drugs named as Jati taila used as varti

in Karnaguha and Kapha-ketu rasa used as an internal medicine are used in the

treatment of Karnasrava.

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JATI TAILA

Jati Taila has not direct reference for Karnasrava in ancient texts, but it is mentioned

as Karna-purana in Putikarna in Chakra-dutta. This formulation is selected after

examining the pharmacodynamic properties and therapeutic values of Jati Dravya,

that it might be advised for Karnasrava for local application. Jati Taila is having

Sothahara, Vrna Ropaka, Vrna Shodhka etc properties due to presence of Jati Dravya.

Jati Taila is prepared by the Qwatha of Jati Patra, Kalka of Jati Patra & Murchita Tila

Taila by the taila Paka vidhi. Here Qwatha is taken 4 times of Murchita Tila Taila and

Kalka is taken 1/6th

of Murchita Tila Taila.

Ingredients of Jati Taila:

(1) Jati

(2) Tila Taila

Jati

Jati consists of fresh leaves of Jasminum officinale Linn.or Jasminum grandiflorum

(Fam. Oleaceae); a large climbing shrub with dark green twigs and pinnate leaves,

found in Kashmir at analtitude of 900 - 2700 m and cultivated throughout the country.

SYNONYMS -

Sanskrit: Malati

Assam: Yasmeen

Bengali: Chamelee

English: Jasmine

Gujrati: Chamelee

Hindi: Chamelee

Kannada: Jati Maltiga, Sanna Jati Mallige

Marathi: Chamelee

Urdu: Chameli, Yasmeen

�

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DESCRIPTION -

a) Macroscopic:

Leaf single or in groups of 2-7 leaflets, upto 7.5 cm long and upto 2.5 cm

broad; imparipinnately compound; terminal leaflet larger; ovate or lanceolate,

acuminate;lateral leaflets shorter, acute, sessile or shortly petiolate; brownish-green;

taste, bitter

b) Microscopic:

Rachis - Rachis shows more or less convex outline with two lateral wings;

epidermis single layered covered by thick cuticle; hairs mostly unicellular with

pointed apex, glandular rarely found only on the upper surface; collenchyma 2 - 5

layered; pericycle represented by slightly lignified small fibre groups; vascular

bundles three, median crescent-shaped, small accessory bundle present in each wing.

Midrib - shows similar structure as rachis; 3 - 5 layers of collenchymatous

cells towards lower surface; pericycle present in the form of non-lignified fibre

groups; vascular bundle single and crescent-shaped.

Lamina - shows dorsiventral structure, epidermis single layered on either side,

covered by a thick striated cuticle; hairs as in rachis; palisade 1- 2 layered; spongy

parenchyma 4-6 layers; stomata anomocytic only in lower surface.

Powder - Yellowish-green; shows palisade and spongy parenchyma,

unicellular hairs, fibres and vessels with spiral thickening, polygonal epidermal cells

and anomocytic stomata in surface view.

IDENTITY, PURITY AND STRENGTH -

Foreign matter not more than 2 Per cent

Total ash not more than 6 Per cent

Acid-insoluble ash not more than 0.5 Per cent

Alcohol-soluble extractive not less than 18 Per cent

Water-soluble extractive not less than 25 Per cent

CONSTITUENTS - Resin, Salicylic Acid, Alkaloid (Jasminine) and essential Oil.

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PROPERTIES AND ACTION -

Rasa: Tikta, Kasaya

Guna: Laghu, Mrudu, Snigdha

Virya: Ushna

Vipaka: Katu

Karma: Tridoshahara, Vrana-ropana40, 41, 42, 43, 44

& vrana-sodhana39, 43, 44

, Kandughna

& Kushtaghna.

Part used- Leaves, root & flowers.

IMPORTANT FORMULATIONS - Jatyadi Taila, Jatyadi Ghrita, Vasanta

Kusumakara Rasa.

THERAPEUTIC USES - Siroroga, Aksiroga, Visaroga, Kusta,Vrna,

Arsa,Mukhapaka, Karnapuya, Netraroga.

Ear conditions – leaves are boiled in oil which is then used as ear drops.

Eye conditions - leaves and flowers are tied on the eyes or their juice is used as eye

drops.

In urinary disorders- the flowers or leaves are applied locally on the hypogastric

region for relieving cystitis and retention of urine.

DOSE- 10-20 g. of powder for Decoction.

Tila taila

Tila consists of dried seeds of Sesamum indicum (Linn.) Family- Pedaliaceae, the

herb extensively cultivated throughout the plains of India up to 1200 metre for its

seeds.

SYNONYMS:

Sanskrit: Tila

Assamese: Simmasim

Bengali: Tilagachh

English: Sesame, Gingelly-oil Seeds

Gujrati: Tall

Hindi: Tila, Teel, Tili

Kannada: Accheellu, Ellu

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Marathi: Tila

Urdu: Kunjad

Description:

The plant is erect, pubescent annual up to 90 cm in height, branching from the base.

The leaves are large and thin, the lower ones are lobed, sparsely hairy, uppermost

linear and intermediate usually ovate and toothed. Flowers are white, pink or purplish

with yellow marks in racemes in the leaf axils; derives in October-December. The

fruits are quadrangular, oblong, compressed capsules, deeply 4-grooved, dehiscent

from above to half way down; arises in December-January. Seeds are many in

number, black, brown or white in colour.

Parts used: Roots, leaves, seeds, oil.

Seeeds:

(A) Macroscopic:

Seed are white, brown, grey or black, flattened ovate in shape, smooth or reticulate,

2.5 to 3 mm long and 1.5 mm broad, one side slightly concave with faint marginal

lines and an equally faint central line. The appearance of seeds is pleasant and oily.

(B) Microscopic

Testa of seed shows single layered palisade-like, thin-walled, yellowish coloured

cells, and the rest of the testa composed of collapsed cells; endosperm 3 layered,

rarely 2 layered, consisting of cellulosic polygonal cells of parenchyma containing

fixed oils and small aleurone grains; cotyledons two, externally covered with thin

cuticle; single layered epidermal cell, followed by a single row of palisade- like cells;

rest of the tissues consist of polygonal, parenchyma cells containing fixed oil and

aleurone grains.

Powder- Blackish coloured; shows palisade-like cells in surface view, parenchyma

cells, aleurone grains and oil globules.

Constituents- Glycolipids, Phospholipids, Sesamol, Sesamolin.

Properties and action:

Rasa: Madhura, Katu, Tikta, Kashaya

Guna: Vyavai, Guru, Snigdha, Sukshma

Virya: Ushna

Vipaka: Madhura

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Karma: Balya, Keshya, Rasayana, Sangrahi, Vataghna, Vranaropaka,

Vranashodhaka,Vishaghna, Snehana, Snehopaga, Kushthakara, Mutrabandhaka,

Medhavardhala, Agnivardhaka, Avasadakara, Krishnakara, Kasa Vardhaka,

Karnapalivardhaka, Kaphakopaka, Mrudurechaka, Vrana Pachaka, Vrana

Dahanashaka, Bhagna Prasadaka, Vajikara, AgnibalaVardhaka.

Therapeutic uses- Ashmari, Akshiroga, Atisara, Galaganda, Gulma, Hikka, Krimi,

Kshaya, Kasa, Pinasa, Pradara, Pravahika, Visarpa, Udavarta, Yonishula, Udara,

Aanaha, Shiroshula, Raktarsha, Nadi Vrana, Mutraghata, Vatika Mukharoga

Khalitya, Palitya ( Qwatha of Patra and root is used for washing & Oil massage over

head), Agnimandya & grahni( seeds are given to eat), Arsaroga(seeds are given to eat

with butter).

Important formulations- Narsimha Churna, Paaniya Kshara, Pathyadi Gutika,

Tilashtaka, various Taila preparations like; Dhanwantara Taila, Mahanarayana taila,

Ksheerbala taila, saindhavadi taila etc.

Dose- Seed powder 5-10 gm/day, Taila- 10-20 s

KAPHA KETU RASA

Kapha –Ketu Rasa is mentioned as a drug for Karna rogas (Karna Puya, Sotha in

Karna etc) 45, 49

. As it is indicated in Karna Rogas, that’s why it might be advised in

Karna Srava. This drug is taken to evaluate its therapeutic value, whether it is

effective in Karna-Srava. Kapha Ketu Rasa is effective due to the presence of

Vatsanabha mainly, because Vatsanabha is having properties like Brahana, Balya and

Vata-Kapha Samaka.

References:

Rasendra Sara Samgraha: Karna Roga Chikitsa

Rasa Raj Sunder: Karna Rogadhikar Yoga no.936

Rasa Chikitsa: Karna Roga Chikitsa

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Vyosha (Shunthi, Maricha, Pippali), Hijjla Bija, Shankha Bhasma & Shudha

Vatsanabha are taken in equall quantity and all dravyas are pounded with water and

then Vatis are prepared of the size of Maricha. This is Kapha Ketu Rasa.

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The pharmacological properties as well as therapeutic uses of the ingredients present

in the Kapha Ketu Rasa are as follows:

SHUNTHI

Shunthi consists of dried rhizome of Zingiber officinale Roxb. (Fam. Zinglberaceae),

widely cultivated in India, rhizomes dug in January-February, buds and roots

removed, soaked over-night-in water, decorticated, and some times treated with lime

and dried.

SYNONYMS

Sanskrit: Nagara, Mahoushadha, Vishvabheshja, Srngavera, Katu-Bhadra

Assamese: Adasuth, Aadar Shuth

Bengali: Suntha, Sunthi

English: Ginger root, Ginger

Gujrati: Sunth, Sundh, Suntha

Hindi: Sonth

Kannad: Shunthi

Marathi: Sunth

Urdu: Sonth, Zanjabeel

DESCRIPTION

(A) Macroscopic:

Rhizome, laterally compressed bearing short, flattish, ovate, oblique, branches

on upper side each having at its apex a depressed scar, pieces about 5-15 cm long,

1.5-6.5 cm wide (usually 3-4 cm) and 1-1.5 cm thick, externally buff coloured

showing longitudinal striations and occasional loose fibres, fracture short, smooth,

transverse surface exhibiting narrow cortex (about one-third of radius), a well-marked

endodermis and a wide stele showing numerous scattered fibro-vascular bundles and

yellow secreting cells, odour agreeable and aromatic, taste, agreeable and pungent.

(B) Microscopic:

Transverse section of rhizome shows cortex. of isodiametric thin-walled

parenchyma with scattered vascular strands and numerous isodiametric idioblasts,

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about 40-80 � In diameter containing a yellowish to reddish-brown oleo-resin,

endodermis slightly thick walled, free from starch immediately inside endodermis a

row of nearly 138 continuous collateral bundles usually without fibres stele of thin-

walled, parenchyma cells, arranged radially around numerous scattered, collateral

vascular bundles, each consisting of a few unlignified, reticulate or spiral vessels upto

about 70 � in diameter, a group of phloem cells, unlignified, thin-walled, septate

fibres upto about 30 � wide and 600 � long with small oblique slit, like pits, present,

numerous scattered idioblasts, similar those of cortex, and associated with vascular

bundles, also present, idioblasts about 8-20 � wide and up to 130 � long with dark

reddish-brown contents: in single or in axial rows, adjacent to vessels, present,

parenchyma of cortex and stele packed with flattened, rectangular, ovate, starch

grains, mostly 5-15 � - 30-60 � long about 25 � wide and 7 � thick, marked by five

transverse striations.

IDENTITY, PURITY AND STRENGTH

Foreign matter not more than 1 per cent

Total Ash not more than 6 per cent

Acid-insoluble ash not more than 1.5 per cent

Alcohol-soluble extractive not less than 3 per cent

Water-soluble extractive not less than 10 per cent

CONSTITUENTS - Essential oil, pungent constituents (gingerol and shogaol),

resinous matter and starch.

PROPERTIES AND ACTION

Rasa: Katu

Guna: Laghu, Snigdha

Virya: Ushna

Vipaka: Madhura

Karma: Vata-Kaphahara, Dipana, Bhedana, Sothahara, Vednasthapana,

Seetaprasamana, jwaraghna & Amapachaka.

Therapeutic uses – Agnimandya, Ajirna, Adhmana, Udarsoola, Kasa, Swasa, Hikka,

Pratisyaya, Amavata, Vatavyadhi & Kapha-Vatajanya Vikaras.

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Important formulations: Ardraka Rasayana, Soubhagya shunthi, Nagradi Kasaya,

Kottamchukkadi Tailam.

Part used: Rhizome

DOSE- 1-2 gm of the drug in powder form.

MARICA

Marica consists of fully mature dried fruit of Piper nigrum Linn. (Fam.Piperaceae); a

climber, cultivated from Konkan Southwards, especially in North Konkan Kerala, and

also in Assam; fruits ripen from December to March, depending upon climatic

conditions; fruits harvested from December to April.

SYNONYMS -

Sanskrit: Vellaja, Ushna, Krsna, Dhanvantari

Bengali: Golmorich, Kalamorich, Morich

English: Black Pepper

Gujrati: Kalimori

Hindi: Kalimirch

Kannada: Karimonaru, Menaru

Marathi: Kalamiri

Urdu: Filfil Siyah, Kalimirich

DESCRIPTION -

(A) Macroscopic:

Fruits greyish-black to black, hard, wrinkled, 0.4-0.5 cm in diameter; odour is

aromatic;

Taste ispungent.

(B) Microscopic:

Fruit consists of a thick pericarp for about one third of fruit and an inner mass

of perisperm, enclosing a small embryo; pericarp consists of epicarp, mesocarp and

endocarp; epicarp composed of single layered, slightly sinuous, tabular cells forming

epidermis, below which, are present 1 or 2 layers of radially elongated, lignified stone

cells adjacent to group of cells of parenchyma; mesocarp wide, composed of band of

tangentially elongated parenchymatous cells having a few isolated, tangentially

elongated oil cells present in outer region and a few fibro-vascular bundles, a single

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row of oil cells in the inner region of mesocarp; endocarp composed of a row of

beakershaped stone cells; testa single layered, yellow coloured, thick-walled

sclerenchymatous cells; perisperm contains parenchymatous cells having a few oil

globules and packed with abundant, oval to round, simple and compound starch grains

measuring 5.5-11.0 � in dia.; having 2-3 components and a few minute aleurone

grains.

Powder - Blackish-grey; shows debris with a characteristic, in groups, more or less

isodiametric or slightly elongated stone cells, interspersed with thin-walled, polygonal

hypodermal cells; beaker-shaped stone cells from endocarp and abundant polyhedral,

elongated cells from peri sperm, packed tightly with masses of minute compound and

single, oval to round, starch grains measuring 5.5-11.0 � in dia.; having 2-3

component and a few aleurone grains and oil globules.

IDENTITY, PURITY AND STRENGTH -

Foreign matter not more than 2 Per cent

Total ash not more than 5 Per cent

Acid-insoluble ash not more than 0.5 Per cent

Alcohol-soluble extractive not less than 6 Per cent

Water-soluble extractive not less than 6 Per cent

CONSTITUENTS- Alkaloids (Piperine, Chavicine, Piperidine, Piperetine) and

essential Oil.

PROPERTIES AND ACTION -

Rasa: Katu

Guna: Laghu, Tiksna

Virya: Ushna

Vipaka: Katu

Karma: Kapha-Vatahara, Dipana, Pramathi, Lekhana, Kaphaghna, Kapha-nissaraka,

Jvaraghna, Balya, Kustaghna.

Therapeutic uses: Agnimandya, Ajirna, Adhmana, Kasa, Swasa, Pratisyaya, Kusta,

Jwara, Srotoavrodha, Sotha, Kapha-Vatajanya vikaras.

Important Formulations: Maricyadi Taila, Agnitundi Vati, Maricadi Gutika,

Maricyadi Churna.

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Dose: 250 mg - 1 g. of the drug in powder form.

PIPPALI

Pippali is a dried fruit; of Latin name Piper longum Linn.(family Piperaceae);

Normally found in hotter parts of India, from central Himalayas to Assam.It is also

found in forests of western ghats from Konkan to Kerala. It is an aromatic slender

climber. Flowers are seen in Varsarutu and fruits seen in saratkala. Vagbhatta

indicates Pippali specifically for pliha rogas. Sushruta & Vagbhatta have deliniated

two varieties of pippali viz. Pippali (P.longum), gajapippali (P. -chaba), Bhavamishra

quoted the fruit of Chavya as Gajapippali. Raja Nighantu provides four varities of

Pippali viz. pippali; gaja Pippali; Simhali Pippali and Vana Pippali. Simhali Pippali is

larger in size (imported from srilanka, Malashiya, Indoneshiya) & vana pippali is

smaller in size grown by itself in forests.

Synonyms:

Sanskrit: Magadhi, Kana, Krisna, vaidehi, capala, Ushna.

Bengali: Pipul

English: Long pepper

Gujrati: peepal

Hindi: Peepal

Kannada: Hippali

Marathi: Pipali

Urdu: Filfil Daraz

CONSTITUENTS –

Pipperlongumine, Pipperlonguminine (stem & root); n-hexadecane, n-

heptadecane, n-octadecane, n-nonadecane, n-eicosane,n-heneicosene, �-thujene,

terpinolene, zingiberene, p-cymene, p-methoxy acetophenone, Phenylethyl alcohol

and some Essential oil (dried fruit);

Piperine, Piplartine, an identified steroids and methyl-3 4 5-trimethoxycinnamate

(roots); major alkaloid piperine and sesamine (stem & fruits).

PROPERTIES AND ACTION

Rasa: Katu

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Guna: Laghu, Snigdha, Tikshna

Veerya: Anushna Sheeta

Vipaka: Madhura

Karma: Kapha-Vata shamaka, Medhya, vatahara, Mrudurechana, raktavardhaka,

raktashodhaka, Kasahara, Swasahara, Hikkanasaka, Kustaghna, Rasayana, Balya.

Pharmacological actions: Anti bacterial, Immunostimulator, Kapha suppression,

Anti inflammatory, Hepatoprotective, CNS stimulant, Anthelmintic, Antimalarial,

Analeptic, Antinarcotic, Antitubercular, Hypoglycaemic, Antispasmoic etc.

Important Formulation: Gudapippali, Pippalyasava, Vyosadi Vati,

Chausastaprahara pippali.

Part used: Fruit and root.

Dosage: powder 0.5 to 1.0 gm

HIJJALA

A medium sized glabrous tree 10-15 m in height with pale grey slender young

branches and rough dark brown bark; leaves simple, alternate, obovate-oblong or

elliptic-cuneate, the margins minutely denticulate or crenulated, main nerves 10-13

pairs; flowers fragrant, pink coloured, in pendulous many flowered racemes; fruits

bluntly quadrangular, narrowed towards the ends, crowned by a small persistent

calyx. Charaka quoted it under Vamanopaga using its synonym Vidula. Sushruta also

called it as Vidula under Urdhavabhagahara dravyas.

This drug is commonly found throughout India, in deciduous and evergreen

forests, mostly along the banks of rivers, streams and tanks.

Latin name: Barringtonia acutangula Gaertn.

Family: Lecythidaceae

Synonyms:

Sanskrit: Nicula, Vidula, Samudraphala

Hindi: Hijala, Samudraphala

Tamil: Samutrapallam

Telugu: Kanapa, Kanigi

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Kannada: Holekavau

English: Indian oak, Small Indian oak

Constituents: Barrintonic acid, Barringtogenol in seeds, sapogenin in bark & leaves.

Properties:

Rasa: Tikta, Katu

Guna: Laghu, Ruksa

Virya: Ushna

Vipaka: Katu

Prabhava: Vamana

Karma: Kapha-pittasamsodhaka, vatasamaka, seeds are lekhana, Shirovirechana,

Vedanasthapana. Fruits are Vamaka, Rechana & Krimighna. Whole plant is mutrala,

Kapha-nissaraka, rakta-shodhaka, Kustaghna and visaghna.

Therapeutic properties: as a samsodhnartha in Kapha-pattika rogas, Samnartha in

Vatarogas, Churna is used as Nasya in Shirorogas. Seeds are used as an Anjana by

rubbing in Netra rogas. Fruit is used as vamanarth in Kaphaja rogas and Virechnarth

in Pittaja Rogas. Kandtwak is useful in Amoebic dysentery. Kusta,Visha,

Vishamjwara & Jirna Jwara.

Part used: Fruit, root, stem bark, leaf.

VATSANABHA

Vatsanabh is a dried tuberous root and it is collected in winter season. The Latin name

is Aconitum ferox Wall ex Seringe & family is Ranunculaceae. This is 3-6 feet high

herb(ksup). Root is tuberous, dark brown in colour externally but seen yellowish on

fracture. It is found in Himalaya Pradesh at an altitude of 10-14 feet. Vatsanabh is

known to Ayurvedic Pharmacopeia since very early times. The herb Visa is delineated

in Atharvaveda and Brahmana Granthas. Among the Brahttrayi, Charaka mentioned it

under “Sthavara Vishas” in C.S.Chi. 23/11. He also denoted it as visa, which is one of

the ingredients of Aindri Rasayana. Vatsanabh is described under thirteen varieties of

Kanda visas (tuberous root poisons) by Sushruta (S.S. Ka.2/5), he quoted four

varieties of Vatsanabh for the first time. These are elaborated by Yogaratnakar later

viz. Brahmana, Ksatriya, Vaisya, & Sudra. Sushruta elaborated the poisonous effects

of Vatsanabh (S.S.Ka.2/12). He included it among Kustha-Hara Yogas. Vaghbatta

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preferred the name “Visa” to denote Vatsanabh and used it in the treatment of Kustha

(A.H.Chi.19/83); Timira (A.H.Ut.13/33). Vatsnabh is of two types viz. poisonous &

non poisonous. Among the Poisonous varieties both A. ferox and A. chasmanthum

are used as Vatsanabh/Visa in India. Where as Chinese medicine & Unani medicine

believe it as A. napellus.

Synonyms:

Sanskrit: Visa, Amruta, Garalam, Nagam, Nabhi

Assamese: Mithavish, Bish

Bengali: Kathavish, Mitha visa

English: Aconite

Gujrati: Basnag, Bachnag

Hindi: Visa, Meetha Visha, Bachhnaag, Teliya Vish

Kannada: Basanalli, Vatsanabha, Vatsanabhi, Vachanaga

Marathi: Bachnaga

Tamil: Vasanasi

Telugu: Nabhi

Urdu: Bachnak, Atees

DESCRIPTION

(A) Macroscopic

Roots paired, occasionally separated due to breakage, ovoid, conical, small

portions of stem sometimes attached, tapering downwards to a point, 2-4.5 cm, rarely

5cm long, 0.4 - 1.8 cm thick, gradually decrease in thickness towards tapering end;

wrinkled longitudinally and transversely, rough due to root scars; dark brown

toblackish-brown; fracture, cartilaginous, hard and white within the cambium ring and

brownish outside cambium; odour indistinct, taste, slightly bitter followed by a strong

tingling sensation, poisonous.

(B) Microscopic

Root -Shows epidermis 1-3 layered, suberised, papillose on outside, primary

cortex

consisting of 8-10 layers of oval to tangentially elongated, thin-walled,

parenchymatous cells, without or with a few intercellular spaces, a few rectangular or

��



triangular stone cells in singles found scattered in this zone; primary cortex separated

by distinct endodermis; inner bark parenchymatous, consisting of round to oval cells,

containing a few groups of phloem strands, occupying more than half the radius;

cambium having 6 -10 angles; xylem vessels arranged almost in a ring, some

scattered, often forming 'V'shaped ring, enclosing xylem parenchyma in older

portions; bundles compact often wedge-shaped having acute apex; xylem exarch,

metaxylem vessels met in centre; starch grains simple measuring 6-18 � in dia. and

compound grains consisting of 2-5 components with hilum in centre, present in

cortical cells, phloem parenchyma and xylem parenchyma.

Powder - Light grey; shows vessels, a few aseptate fibres, and numerous simple

andcompound starch grains having hilum in the centre, single grain measuring 6-18 �

India.

IDENTITY, PURITY AND STRENGTH

Foreign matter not more than 2 per cent

Total Ash not more than 5.5 per cent

Acid-insoluble ash not more than 2 per cent

Alcohol-soluble extractive not less than 8 per cent

Water-soluble extractive not less than 24 per cent

Constituents:

Alkaloids; The roots of A. chasmenthum is 10 times and A. ferox is 2 times richer in

alkaloids than those of A. napellus. The alkaloids of A. chasmenthum are less potent

and of A. ferox are more potent than those of A. napellus.

Properties:

Rasa: Madhura

Guna: Laghu, Ruksa, Tiksna, Vyavayi, Vikasi

Virya: Ushna

Vipaka: Katu

Karma: Vata-Kapha hara, Jvarahara, Visahara, Madakari, Kustaghna,

Vedanasthapana, Sothahara, balya, Brahana.

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Therapeutic properties: Kapha-vatajanya vikaras, Agnimandya, Udaravikara, Kasa,

Swasa, Bahumutra & Shyyamutra due to Nadidaurblya, Amavata, Sandhivata.

Shodhana of Vatsanabha: Firstly Vatsanabha is cut into small pieces and then these

pieces are put into Go-Mutra for 3-4 days. Afterwords these pieces are removed and

washed with clean water and tied in pottali & put in Go-Dugdha in Dola Yantra for 1

Prahar. Swadana Karma is done. Thus Vatsanabha becomes purified.

Important formulations: Anand Bairav Rasa, Kapha Ketu rasa, Mrutunjya Rasa,

Tribhuvana Kirti rasa, Mahavishgarbha Taila.

Dosage: Normal dose is 1/8 Ratti i.e. 15 mg (approx.) root powder.

Note: It is dangerous to exceed the normal dose.

SHANKHA BHASMA

SHANKHA:

Class: Mollusca

Latin name: Turbinella Rapa

Varga: Sudha Varga

Sanskrit: Shankha

Hindi: Shankha

Kannada: Shanka

English: Conch-shell

Chemical formula: CaCo3

Synonyms: Trirekha, Samudraja, Dirghanada, Ksudra.

Distribution: Coastal regions.

Shodhan of Shankh: Firstly Shankh is broken in small pieces & tied in a pottali.

Then it is suspended in Jambiri Swarasa in Dola yantra for 4 Prahar and then Swadana

Karma is done. Afterwords this pottali is removed and washed with hot water. Thus

shankh becomes purified.

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Maran of Shankh: Shudh Shankh is burned under gajaput then White bhasm of

shankh is occupied.Then it again triturated with Kumari Swarasa & one bolous is

made and then this dried bolous is burned under gajaput. Thus white coloured Shankh

Bhasm of best quality is occupied.

Properties:

Rasa: Kasaya, Katu & Ksariya

Vipaka: Katu

Virya: Sheeta

Guna: laghu, sheeta

Karma: Tridosahara, Kapaha-Vatahara, Grahi, balya, Lekhana, Stambhana.

Dosage: 2 Ratti

Anupana: Ushna Jala

Important formulations: Kapha-Ketu rasa, Grahnikapata Rasa, Mahashankh Vati,

Shankh Bhasma, Pravala-Panchamruta Rasa.

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Table-4

Pharmacodynamic Properties of Jati Taila

Drug Rasa Guna VIrya Vipaka Sansthanika-

Karma

Dosha-karma

Jati Tikta,

Kasaya

Laghu,

Mrudu,

Snigdha

Usna Katu

Vrana-ropana,

vrana-sodhana,

Kushtaghna,

Kandughna

Tridoshahara,

Tila Madhura,

Katu,

Tikta,

Kashaya

Vyavai,

Guru,

Snigdha,

Sukshma

Ushna

Madhura

Balya,

Vranaropaka,

Vranashodhaka,

Kushthakara,

Vrana

Dahanashaka,

Vrana Pachaka

Vataghna

Table-5

Pharmacodynamic Properties of Kapha Ketu Rasa

Drug Rasa Guna VIrya Vipaka Sansthanika-

Karma

Dosha-karma

Shunthi Katu Laghu,

Snigdha

Usna

Madhura

Sothahara,

Vednasthapana,

Vata-Kaphahara

Maricha Katu

Laghu,

Tiksna

Usna

Katu

Lekhana,

Kaphaghna,

Balya,

Kustaghna

Kapha-Vatahara

Pippali Katu Laghu,

Snigdha,

Tikshna

Anushna

Sheeta

Madhura

Medhya,

vatahara,

Kustaghna,

Rasayana, Balya

Kapha-Vata

shamaka

Hijjala Tikta,

Katu

Laghu,

Ruksa

Usna Katu

Vamaka,

Rechana &

Krimighna,

Kustaghna,

Kapha-nissaraka

Kapha-

Pittasamsodhaka

Shankh

Bhasma

Kasaya,

Katu &

Ksariya

Laghu,

sheeta

Sheeta

Katu

balya, Lekhana,

Stambhana

Tridosahara,

Kapaha-

Vatahara

Vatsanabha Madhura

Laghu,

Ruksa,

Tiksna,

Vyavayi,

Vikasi

Usna

Katu

Kustaghna,

Vedanasthapana,

Sothahara,

balya, Brahana.

Vata-Kapha

hara

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MATERIALS AND METHODS

History of disease is as long as life on this planet; hence struggle for its alleviation

and sound health has started since then. Whenever man has found himself contented,

the disease erupted as calamity and disturbed his ease, resulting in the research for

competent resources to combat his distress.

Any research in Ayurveda is incomplete without the clinical study. Acarya Caraka has

mentioned that timely repeated clinical trial of the drugs by researches should be done

to advance the science by honest and sincere efforts. The chief goal of any medical

research will be clinical application; hence Ayurvedic research has also the same. The

aim of Ayurveda is “to maintain the health in the healthy and quieting of sufferings

(Ch.Su.30/26).” This supports the fact that any research taking place in the field of

Ayurveda must have its impact or role in the clinical field.

So the present study has also been undertaken to add a drop in the ocean of projects,

which has been introduced to explain the reliability and usefulness of the consecrated

principles of Ayurveda on clinical grounds.

The disease Karnasrava is well known since ancient times. Our Acharyas have

mentioned in various ways as detailed in literary review. This disease entity can be

correlated with a symptom found in various discharging disorders of external ear and

middle ear. After keenly examining the symptomatology, nature of discharge, and

otoscopic picture, one can easily differentiate whether the disease involves the

external ear or middle ear or both.

In present study, after carefull examination, external ear diseases are ruled out and

chronic middle ear infection i.e. chronic suppurative otitis media (benign type) is

selected. Medical management of CSOM is based on aural toileting, administering

antibiotics for local and systemic use, decongestents, anti-inflammatory drugs.

Surgical treatment is further developed for Atticoantral type of CSOM with

Cholesteatoma or in case of complications.

In spite of above medical management, this disease persists for life long and hampers

an individual’s quality of life to great extent; nonreponsiveness is mainly because of

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drug resistance, adverse effects of drugs, persistence of infection in throat, nose,

sinuses which further aggravate the problem from time to time.

Therefore an eminent necessity is felt for obtaining better solution for management of

Karnasrava from Ayurvedic perspective. The trial drug has been selected after

thorough review of Samhitas. The oral drug, named Kapha Ketu Rasa is described in

Classics. Jati taila is taken for local application, selected on the basis of

pharmacodynamic properties mentioned in Nighantus.

To confirm the efficacy of any drug or therapy, experimental study along with clinical

study is essential. So to confirm the efficacy of Kapha Ketu Rasa and Jati Taila in the

management of Karnasrava, this clinical study is selected.

OBJECTIVE OF THE STUDY:

The present study was based on following aims and objectives.

1. To evaluate the efficacy of Kapha Ketu Rasa orally and Jati Taila Varti in the

management of Karnasrava w.s.r. safe chronic suppurative otitis media.

2. To evaluate the efficacy of Jati Taila Varti applied locally in ear in the

management of Karnasrava w.s.r. safe chronic suppurative otitis media.

3. To compare the efficacy of Kapha Ketu Rasa and Jati Taila Varti together &

Jati Taila Varti alone in the management of Karnasrava.

SELECTION OF THE DISEASE

1. No work in this institute has been carried out on Karnasrava and this

necessitated undertaking the study.

2. Availability of patients in good number.

3. Frequent occurrence in younger age group hampering their quality of life all

life long.

4. Frequent occurrence of the disease in population, may be because of

unawareness towards proper hygiene, climatic changes, poor resistance.

5. Since this disease is confined to middle ear, the response can easily be

assessed with the help of routine otoscopic examination and symptomatology.

6. Available conservative methods of treatment, some times lead to patient

resistance, poor tolerability of drugs, recurrent infections which further leads

to psychological, financial and social set back to the patients.

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SELECTION OF THE DRUG

Kapha Ketu is indicated for the diseases of Karna45, 49

, hence it is selected for

Karnasrava and Jati Taila is selected for the management of Karnasrava due to its

pharmacodynamic properties viz. Vrnaropaka40, 41, 42, 43 , 44

, Varnashodhaka39, 43, 44

&

Kandughna40, 41, 42, 43, 44

. All contents of these drugs are easily available in their

authentic form and all are cost effective too. Hence these drugs were selected for

clinical study.

Plan of Study:

The study of present research work was planned under two headings as mentioned

below

• Literary study

• Clinical study

Literay study:

(I) All ayurvedic and modern texts has been scrutinized regarding problem of

karnasrava vis-à-vis CSOM (benign type) under trial.

(II) Detailed review of the selected drug under trial was also done.

Clinical study:

I. Patients:

A total number of 40 patients of Karnasrava were selected from OPD / IPD of

Shalakya Tantra SDM College of Ayurveda & Hospital Hassan, after obtaining their

consent. Case selection was regardless of sex, occupation, socio-economic

consideration & religion etc. out of registered forty patients, only thirty four patients

were followed-up for the total trial period, six patients left the treatment before

completion of total trial period and were excluded from the study.

II.Trial Drug�

Both drugs were prepared in Dept. of Rasa-Shastra, SDM college of Ayurveda &

Hospital, Hassan.

III. Criteria of Diagnosis:

A special proforma was prepared incorporating all signs & symptoms based on both

Ayurvedic as well as modern description. All the points in the perspective of Dosha,

Dushya, Srotas and Srotodusti on Ayurvedic line were also included in the proforma.

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The patients were diagnosed on the basis of signs and symptoms of karnasrava

(CSOM benign type). The diagnosis was confirmed on the basis of otoscopic findings.

Routine blood investigations were also done. To assess the quality of hearing loss

Tuning fork test was done.

i. Subjective criteria:

a. Ear discharge:

• Periodicity : constent/intermittent

• Amount: profuse/moderate/scanty

• Odour: Foul smell/odourless

b. Hearingloss

c. Karna Kandu

d. Karna Nada

f. Karnashoola.

ii. Objective criteria:

Otoscopic examination- for assessing perforation(central)

Tuning fork test- for assessing hearingloss (quality)

IV. Inclusion criteria:

1. Patients Suffering from Safe or Tubo-Tympanic Chronic Suppurative Otitis

Media without complications.

2. Patients aged between 5 to 50 years will be taken for study.

V. Exclusion criteria:

1. Unsafe or Attico-Antral Chronic Suppurative Otitis Media, Cholesteatoma,

Polypus, Otomycosis.

2. Safe Chronic Suppurative Otitis Media with complicated systemic disease.

VI. Method of study:

A total number of 40 patients were registered for the present Clinical study, and were

divided into two groups by random sampling method. Most of the study was done in

out door patient department.

Group JK: The patients of this group were given Kapha Ketu Rasa orally, 2 tablets

(each tablet of 100 mg) three times a day with lukewarm water and simultaneously

Jati Taila Varti was kept in the affected ear, two times a day for the duration of 30

days. At the gap of one day cleaning of ear was done.

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Group J: The patients of this group were treated with Jati Taila Varti84

only which

was kept in the affected ear, in the same manner as two times a day for the duration of

30 days. The Varti which was kept at morning, that was removed at evening and

another fresh Varti was kept in the ear. On every third day cleaning of ear was

repeated.

Follow-Up:

After completion of the one month course of the treatment, the patients were asked to

attend the OPD at the regular intervals of fifteen days for a period of two months.

During this period no other drug was given and it will be noted that whether the relief

provided by the therapy is sustained.

VII. Criteria of Assessment:

The patients treated in trial groups were assessed by presence & absence of

signs & symptoms, before & after treatment. Symptomatic relief obtained by the

treatment given was assessed periodically after every seven days of initial scoring till

the completion of treatment. Results were noted on the basis of cured/markedly

improved/mildly improved/unchanged condition of signs & symptoms.

Scoring method adopted is a follows:

1. Ear Discharge:

� Periodicity

• No discharge - 0

• Intermittent discharge -1

• Continuous discharge -2

� Amount

• Nil -0

• Scanty -1

• Moderate -2

• Profuse -3

� Odour

• No smell -0

• Slight foul smell -1

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• Un-tolerable foul smell -2

2. Hearing Loss

• No hearing loss -0

• Mild hearing loss -1

• Moderate hearing loss -2

• Severe hearing loss -3

3. Perforation (Central)

• Present -3

• Unchanged -3

• Slightly healed perforation -2

• Completely healed perforation -1

4. Karna Kandu

• Not present - 0

• Occasionaly - 1

• Intermittent - 2

• Continuous - 3

5. Karna-Nada (Tinnitus)

• Not present - 0

• Occasionaly - 1

• Intermittent - 2

• Continuous - 3

OVERALL ASSESSMENT OF THERAPY:

The overall result was adjudged In terms of relief obtained in associated

signs/symptoms.

1. Cured – 100% relief in subjective as well as objective symptoms.

2. Markedly improved – 76% - 99% relief in subjective and objective

symptoms.

3. Moderately improved - 51% -75% relief in subjective and objective

symptoms.

4. Mildly improved – 25% - 50% relief in subjective and objective symptoms.

5. Unchanged – Less than 25% relief in subjective and objective symptoms.

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OBSERVATION

The observations have been made in the present study on the basis of demographic,

onstitutional, and clinical profile of 40 patients of Karna Srava (CSOM- safe type).

The 40 patients were divided into two groups, 20 patients in each group. In group JK,

20 patients were registered for the local administration of Jati taila and oral

administration of Kapha Ketu Rasa, but out of 20 patients, 2 patients did not turn up

for follow up, hence were dropped out. So, in total 18 patients completed the trial. In

group J, 20 patients were registered for local administration of Jati Taila in ear and out

of 20 patients, 4 patients left the treatment in between the course of medication, hence

4 patients were dropped out. So in total 16 patients completed the trial. (Table-

6)(Graph-1)

Table – 6

Table showing Number of Patients Registered for Clinical Study

Groups Number

of

Patients

Number

of Patients

dropped

out

Number of

patients

completed the

course

Percentage

Completed

Group JK 20 2 18 90%

Group J 20 4 16 80%

1. Age: Age wise distribution of the patients shows that maximum number of patients

i.e. 42.5% belonged to age group of 21-30, followed by age group 31-40 with 20%,

41-50 group with 17.5%, 11-20 group with 15% and age group 5-10 with 5% (Table7)

( Graph-2).

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Table – 7

Age wise Distribution of 40 Patients of Karna Srava (CSOM-Safe Type)

Age

group in

years

Group JK Group J Total

Number of

patients

% Number of

Patients

% Number

of Patients

%

5-10 2 10% 0 0% 2 5%

11-20 4 20% 2 10% 6 15%

21-30 10 50% 7 35% 17 2.5%

31-40 2 10% 6 30% 8 20%

41-50 2 10% 5 25% 7 17.5%

Total 20 00% 20 00% 40 100%

2. Sex: Table-8 shows that out of 40 patients of Karna Srava, 70% patients were male

and 30% patients were female.(Table-8) (Graph-3)

Table-8

Sex wise Distribution of 40 Patients of Karna Srava (CSOM-Safe Type)

Sex


Number of

patients

% Number of

patients

% Number of

patients

%

Male 15 75% 13 65% 28 70%

Female 5 25% 7 35% 12 30%

3. Religion: Table-9 shows that out of 40 patients of Karna Srava, maximum number

of patients i.e. 80% patients were Hindu and 20% were Muslims. (Table-9) (Graph-4)

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Table-9

Religion wise Distribution of 40 Patients of Karna Srava (CSOM-Safe Type)

Religion Group JK Group J Total

Number of

patients

% Number of

patients

% Number of

patients

%

Hindu 17 85% 15 75% 32 80%

Muslim 3 !5% 5 25% 8 20%

4. Education: Table-10 shows that out of 40 patient, maximum number of patient i.e.

30% were educated up to S.S.L.C /metric, 22.5% patient were educated up to

graduation, 20% patient were educated up to Intermediate/P.U.C., 12.5% up to middle

standard, 7.5% up to primary standard and 7.5% patient were illiterate.(Table-10)

(Graph-5)

Table-10

Education wise Distribution of 40 Patients of Karna Srava (CSOM-Safe Type)

Education


Number

of

patients

% Number

of

patients

% Number

of

patients

%

Illeterate 1 5% 2 10% 3 7.5%

Primary 2 10% 1 5% 3 7.5%

Middle 2 10% 3 15% 5 12.5%

Matric/S.S.L.C. 7 35% 5 25% 12 30%%

Intermediate/P.U.C. 3 15% 5 25% 8 20%%

Graduate 5 25% 4 20% 9 22.5%

Total 20 100% 20 100% 40 100%

�

5. Occupation: Table-11 shows that out of 40 students, maximum number of patients

i.e. 30% were student, 22.5% were businessmen, 20% were housewives, 17.5% were

servicemen and 10% were farmers. (Table-11) (Graph-6)

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Table – 11

Occupation wise Distribution of 40 Patients of Karna Srava (CSOM-Safe Type)

Occupation Group JK Group J Total

Number

of

patients

% Number

of

patients

% Number

of

patients

%

Servicemen 5 25% 2 10% 7 17.5%

Businessmen 3 15% 6 30% 9 22.5%

Housewives 2 10% 6 30% 8 20%

Farmers 3 15% 1 5% 4 10%

Students 7 35% 5 25% 12 30%

Total 20 100% 20 100% 40 100%

6. Socio-economic Status: Table-12 shows that out of 40 patients, maximum

number of patients 67.5% belonged to lower middle class, 27.5% patients were from

middle class, 5% patients were from poor status.(Table-12) (Graph-7)

Table – 12

Socio-Economic Status Recorded in 40 patients of Karna Srava (CSOM-Safe

Type)

Socio-

economic

status

Group JK

Group J Total

Number of

patients

% Number of

patients

% Number of

patients

%

Poor 1 5% 1 5% 2 5%

Lower Middle 13 65% 14 70% 27 67.5%

Middle 6 30% 5 25% 11 27.5%

Upper Middle 0 0% 0 0% 0 0%

Rich 0 0% 0 0% 0 0%

Total 20 100% 20 100% 40 100%

�

��



7. Habitat: Table-13 shows that out of 40 patients, 62.5% patients belonged to

rural area and 37.5% patients were from urban background (Table-13) (Graph-

8).

Table –13

Habitat wise Distribution of 40 Patients of Karna Srava (CSOM-Safe Type)

Habitat Group JK Group J Total

Number of

patients

% Number of

patients

% Number of

patients

%

Rural 14 70% 11 55% 25 62.5%

Urban 6 30% 9 45% 15 37.5%

Total 20 100% 20 100% 40 100%

8. Marital status: Table–14 shows that out of 40 patients, maximum number of

patients i.e. 57.5% was unmarried and 42.5% were married (table-14) (Graph-9).

Table –14

Marital Status wise Distribution of 40 Patients of Karna Srava (CSOM-Safe Type)

Marital status Group JK Group J Total

Number of

patients

Number of

patients

Number of

patients

Married 6 30% 11 55% 17 42.5%

Unmarried 14 70% 9 45% 23 57.5%

Total 20 100% 20 100% 40 100%

9. Diet: Table–15 shows that out of 40 patients, maximum number of patients

i.e.(87.5%) were having habit of mixed diet, while (12.5%) were vegetarian (table-15)

(Graph-10).

��



Table -15

Dietary Habit Reported by 40 Patients of Karna Srava (CSOM-Safe Type)

Diet Group JK Group J Total

NUMBER

of patients

% NUMBER

of patients

% NUMBER

of patients

%

Vegetarian 4 20% 1 5% 5 12.5%

Mixed 16 80% 19 95% 35 87.5%

Total 20 100% 20 100% 40 100%

10. Prakruti: All the patients belonged to Dvndaja Deha Prakruti. Table–16 shows

that out of 40 patients, maximum number of patients i.e. 47.5% were of Pitta-Kaphaja

category, 40% patients were of Vata-Kaphaja category, 12.5% patients were of Vata-

Pittaja category (Table-16) (Graph-11).

Table – 16

Prakruti Recorded in 40 Patients of Karna Srava (CSOM-Safe Type)

Prakruti Group JK Group J Total

Number of

Patients

% Number of

Patients

% Number of

Patients

%

Vata-pittaja 4 20% 1 5% 5 12.5%

Vata-kaphaja 8 40% 8 40% 16 40%

Pitta-kaphaja 8 40% 11 55% 19 47.5%

Total 20 100% 20 100% 40 100%

11. Addiction: Table – 17 shows that out of 40 patients, maximum number of

patients i.e. 27.5% patients were having no addiction and same 27.5% patients were

having the habit of smoking, 22.5% patients were having the habit of smoking as well

as tobacco chewing, 10% patients were having the habit of smoking as well as

alcohol, 7.5% patients were having the habit of Tea and coffee, 5% patients were

having the habits of smoking, alcohol and tobacco chewing.(Table-17) (Graph-12)

��



Table – 17

Addiction wise Distribution of 40 Patients of Karna Srava (CSOM-Safe Type)

Addiction Group JK Group J Total

Number

of

patients

%

Number

of

patients

% Number

of

patients

%

No addiction 7 35% 4 20% 11 27.5%

Tea/coffee 1 5% 2 10% 3 7.5%

Smoking 6 30% 5 25% 11 27.5%

Smoking/tobacco

chewing

3 15% 6 30% 9 22.5%

Smoking/Alcohol 2 10% 2 10% 4 10%

Smoking/alcohol/tobacco

chewing

1 5% 1 5% 2 5%

Total 20 100% 20 100% 40 100%

12. Laterality: In present study, among all 40 patients, all patients 100% were

suffering from Karna Srava of Unilateral side (Table-18) (Graph-13).

Table – 18

Laterality wise Distribution of 40 Patients of Karna Srava (CSOM-Safe Type)

Side of Karna

Srava


Number of

patients

% Number of

patients

% Number of

patients

%

Unilateral 20 100% 20 100% 40 100%

Bilateral 0 0% 0 0% 0 0%

Total 20 100% 20 100% 40 100%

13. Nidana: In present study, out of 40 patients, maximum number of patients i.e.

57.5% having history of Avashyaya & Pratishyaya, 17.5% patients having history of

Pratishyaya & Kasa; 12.5% Patients having history of Mithyayogen Shastrasya; 7.5%

patients having history of infection in Posterior Pharyngeal wall / Oropharynx /

tonsils; 5% patients having history of Jalanimajjana (Table-19) (Graph-14).

��



Table – 19

Nidana wise Distribution of 40 Patients of Karna Srava (CSOM-Safe Type)

Nidana Group JK Group J Total

Number

of

patients

% Number

of

patients

% Number

of

patients

%

Avashyaya & Pratisyaya 11 55% 12 60% 23 57.5%

Pratisyaya & Kasa 2 10% 5 25% 7 17.5%

Mithyayogen Shastrasya 3 15% 2 10% 5 12.5%

Infection in

Tosils/Adenoids/Oropharynx/

Post. Pharyngeal wall

3 15% 0 0% 3 7.5%

Jalakrida/Jalanimajjana 1 5& 1 5% 2 5%

Shiro-abhghata 0 0% 0 0% 0 0%

Vidradhi 0 0% 0 0% 0 0%

Total 20 100% 20 100% 40 100%

15. Chronicity: In this present study, out of 40 patients, maximum number of patients

i.e. 87.5% patients were having history of Karna Srava 6-12 months old and 12.5%

were having the history of Karna Srava 1-6 months old (Table-20) (Graph-15).

Table – 20

Chronicity wise Distribution of 40 Patients of Karna Srava (CSOM-Safe Type)

Chronicity Group JK Group J Total

Number of

patients

% Number of

patients

% Number of

patients

%

1 - 6 months 2 10% 3 15% 5 12.5%

6 – 12 months 18 90% 17 85% 35 87.5%

Total 20 100% 20 100% 40 100%

16. Periodicity of Ear Discharge: In this present study, out of 40 patients, all 100%

patients were having intermittent ear discharge (Table-21) (Graph-16).

��



Table – 21

Periodicity of ear discharge reported in 40 Patients of Karna Srava (CSOM-Safe

Type)

Periodicity of ear

discharge


No. of

patients

% No. of

patients

% No. of

patients

%

Intermittent 20 100% 20 100% 40 100%

Continuous 0 0% 0 0% 0 0%

17. Amount of Discharge: In this present study, out of 40 patients, 87.5% patients

were having profuse ear discharge and 12.5% patients were having moderate ear

discharge (Table-22) (Graph-17).

Table-22

Amount of ear discharge reported in 40 Patients of Karna Srava (CSOM-

SafeType)

Amount of ear

discharge


No. of

patients

%

No. of

patients

% No. of

patients

%

Profuse 19 95% 16 80% 35 87.5%

Moderate 1 5% 4 20% 5 12.5%

18. Smell of Ear Discharge: In this present study, out of 40 patients, all 100%

patients were having ear discharge without odour (Table-23) (Graph-18).

Table-23

Smell of ear discharge reported in 40 Patients of Karna Srava (CSOM-

SafeType)

Smell of ear

discharge


No. of

patients

%

No. of

patients

% No. of

patients

%

Odour less 20 100% 20 100% 40 100%

With odour 0 0% 0 0% 0 0%

��



19. Nature of Ear Discharge: : In this present study, out of 40 patients,80% patients

were having ear discharge of muco-purulent type and 20% were having ear discharge

of mucoid type (Table-24) (Graph-19).

Table-24

Nature of ear discharge reported in 40 Patients of Karna Srava (CSOM-

SafeType)

Nature of

discharge


No. of

patients

%

No. of

patients

% No. of

patients

%

Mucoid 6 30% 2 10% 8 20%

Mucopurulent 14 70% 18 90% 32 80%

20. Colour of Ear Discharge: In this present study, out of 40 patients, 80% patients

were having ear discharge of yellowish colour and 20% patients were having of

Whitish colour (Table-25) (Graph-20).

Table-25

Colour of ear discharge reported in 40 Patients of Karna Srava (CSOM-

SafeType)

Colour of ear

discharge


No. of

patients

%

No. of

patients

% No. of

patients

%

Whitish 6 30% 2 10% 8 20%

Yellowish 14 70% 18 90% 32 80%

21. Perforation of Tympanic membrane: : In this present study, out of 40 patients,

all 100% patients were having central perforation in Tympanic membrane (Table-26)

(Graph-21).

��



Table-26

Perforation of T.M. Reported in 40 Patients of Karna Srava (CSOM-SafeType)

Perforation of T.M. Group JK Group J Total

No. of

patien

ts

%

No. of

patien

ts

% No. of

patients

%

Central 20 100% 20 100% 40

100%

Marginal/Attic/Subtotal/Total 0 0% 0 0% 0 0%

22. Hearing loss: In this present study, out of 40 patients, 57.5% patients were

having moderate type of hearing loss and 42.5% patients were having mild type of

hearing loss (Table-27) (Graph-22).

Table-27

Hearing loss Reported in 40 Patients of Karna Srava (CSOM-SafeType)

Hearing loss Group JK Group J Total

No. of

patients

%

No. of

patients

% No. of

patients

%

Mild 6 30% 11 55% 17 42.5%

Moderate 14 70% 9 45% 23 57.5%

23. Karna Kandu: In this present study, out of 40 patients, 67.5% patients were

having Complaint of Karna Kandu and 32.5% patients were not having complaint of

Karna Kandu (Table-28) (Graph-23).

Table-28

Karna Kandu Reported in 40 Patients of Karna Srava (CSOM-SafeType)

Karna kandu Group JK Group J Total

No. of

patients

%

No. of

patients

% No. of

patients

%

Absent 9 45% 4 20% 13 32.5%

Present 11 55% 16 80% 27 67.5%

��



24. Karna Nada: In this present study, out of 40 patients, all 100% patients were not

having complaints of Karna Nada (Table-29).

Table-29

Karna Nada Reported in 40 Patients of Karna Srava (CSOM-SafeType)


No. of

patients

%

No. of

patients

% No. of

patients

%

Karna Nada 0 0% 0 0% 0 0%

��



��



EFFECT OF TREATMENT

The effect of treatment in terms of regression of signs and symptoms of disease was

assessed after administering the drug in different groups for prescribed period. 36

patients of Karna Srava were treated by randomly dividing them into two groups (JK

& J). Six Patients did not continue the whole trial period. In group JK 18 Patients

were treated and here Kapha Ketu Rasa was administered orally, Jati Tala Varti84

was

administered locally in ear two times a day by cleaning of ear once at every third for

30 days. In group J, 16 Patients were treated and here Only Jati Taila Varti was

administered in ear two times a day, after cleaning of ear once at every third day for

30 days. The effects noted in these groups are being described under the respective

headings.

Effect of Kapha Ketu Rasa and Jati Taila Varti84

on the 18 Patients of Karna

Srava (Safe Chronic Suppurative Otitis Media):

In this group JK, 2 Patients were dropped out and 18 Patients were treated. Here

Kapha Ketu Rasa was administered orally, 2 tablets three times a day with lukewarm

water and Jati Tala Varti was administered locally in ear two times a day after

cleaning of ear once at first day. At every third day, the ear was used to clean by

suctioning. The total period for trial medications was of 30 days. The Effect of these

two medications on the signs and symptoms of Karna Srava is being depicted here in

tabular form with statistical data and brief description on each finding.

Effect on Periodicity of Ear Discharge: The initial mean score of Periodicity of Ear

Discharge was 1 which was insignificantly (P>0.05) reduced to 0 after administering

of Kapha Ketu Rasa orally and Jati Taila Varti locally in ear. Thus 100% relief was

noticed (Table-30) (Graph-24).

�

��



Table-30


on Periodicity of ear discharge

of 18 Patients of Karna Srava

Periodicity

of ear

discharge

Mean

score

Relief

%

SD

(±)

SE

(±)

t P

BT AT

JK Group 1 0 100% 0 0 0 >0.05

Effect on Amount of Ear Discharge: The initial mean score of Amount of Ear

Discharge was 2.94 which was significantly (P<0.001) reduced to 0 after

administering of Kapha Ketu Rasa orally and Jati Taila Varti locally in ear. Thus

100% relief was noticed (Table-31) (Graph-24).

Table-31


on Amount of ear discharge of

18 Patients of Karna Srava

Amount

of ear

discharge

Mean

score

Relief

%

SD

(±)

SE

(±)

t P

BT AT

JK

Group

2.94 0 100% 0.236 0.055 52.99 <0.001

Effect on Smell of Ear Discharge: The initial mean score of Smell of Ear Discharge

was 0 which was insignificantly (P>0.05) unchanged to 0 after administering of

Kapha Ketu Rasa orally and Jati Taila Varti locally in ear. Thus 0% relief was noticed

(Table-32) (Graph-24).

Table-32

Effect of Kapha Ketu Rasa and Jati Taila Varti on Smell of ear discharge of 18

Patients of Karna Srava

Smell of

ear

discharge

Mean

score

Relief

%

SD

(±)

SE

(±)

t P

BT AT

JK

Group

0 0 0 0 0 0 >0.05

��



Effect on Perforation of Tympanic Membrane: The initial mean score of

Perforation of T.M. was 3 which was significantly (P<0.01) reduced to 2.55 after


14.81% relief was noticed (Table-33) (Graph-24).

Table-33

Effect of Kapha Ketu Rasa and Jati Taila Varti on Perforation of T.M. of 18

Patients of Karna Srava

Perforation

of T.M.

Mean

score

Relief

%

SD

(±)

SE

(±)

t P

BT AT

JK Group 3 2.55 14.81 0.511 0.12 3.69 <0.01

Effect on Hearing loss: The initial mean score of Hearing loss was 1.66 which was

significantly (P<0.001) reduced to 1 after administering of Kapha Ketu Rasa orally

and Jati Taila Varti locally in ear. Thus 40% relief was noticed (Table-34) (Graph-

24).

Table-34

Effect of Kapha Ketu Rasa and Jati Taila Varti on Hearing loss of 18 Patients of

Karna Srava

Hearing

loss

Mean

score

Relief

%

SD

(±)

SE

(±)

t P

BT AT

JK

Group

1.66 1 40% 0.485 0.114 5.83 <0.001

Effect on Karna Nada: The initial mean score of Karna Nada was 0 which was

insignificantly (P>0.05) unchanged to 0 after administering of Kapha Ketu Rasa

orally and Jati Taila Varti locally in ear. Thus 0% relief was noticed (Table-35)

(Graph-24).

��



Table-35

Effect of Kapha Ketu Rasa and Jati Taila Varti on Karna Nada of 18 Patients of

Karna Srava

Karna

Nada

Mean

score

Relief

%

SD

(±)

SE

(±)

t P

BT AT

JK

Group

0 0 0 0 0 0 >0.05

Effect on Karna Kandu: The initial mean score of Karna Kandu was 0.5 which was

significantly (P<0.01) reduced to 0 after administering of Kapha Ketu Rasa orally and

Jati Taila Varti locally in ear. Thus 100% relief was noticed (Table-36) (Graph-24)

Table-36

Effect of Kapha Ketu Rasa and Jati Taila Varti on Karna Kandu of 18 Patients

of Karna Srava

Karna

Kandu

Mean

score

Relief

%

SD

(±)

SE

(±)

t P

BT AT

JK

Group

0.5 0 100% 0.707 0.166 2.99 <0.01

Table-37

% Relief in all signs & Symptoms of Group JK (Graph-24)

Group Discharge Perforation

of TM

Hearing

loss

Karna

Nada

Karna

Kandu Periodicity Amount Smell

JK 100% 100% 0% 14.81% 40% 0% 100%

Overall Result of Group JK: Overall Study of Group JK reveals that 77.77% (14)

Patients were moderately improved and 22.22% (4) Patients were mildely improved.

NO patient was cured as well as markedly improved and each Patient responded to the

treatment (Table-38) (Graph-25)

��



Table-38

Overall Result of Kapha Ketu Rasa orally and Jati Taila Varti locally in ear of

18 Patients of Karna Srava

Assessment No. of Patients %

Cured 0 0%

Markedly Improved 0 0%

Moderately Improved 14 77.77%

Mildely Improved 4 22.22%

Unchanged 0 0%

Effect of Jati Taila Varti84

on the Patients of Karna Srava:

In This group J, 4 Patients were dropped out and 16 Patients were treated.

Here Only Jati Taila Varti was administered in ear two times a day, after cleaning of

ear once at first day and at every third day ear was used to clean by suctioning. The

total period for trial medication was 30 days. The Effect of these two medications on

the signs and symptoms of Karna Srava is being depicted here in tabular form with

statistical data and brief description on each finding.

Effect on Periodicity of ear Discharge: The initial mean score of Periodicity of ear

discharge was 1 which was significantly (P<0.001) reduced to 0.125 after

administering of Jati Taila Varti locally in ear. Thus 87.5% relief was noticed (Table-

39) (Graph-26).

Table-39

Effect of Jati Taila Varti on Periodicity of Ear Discharge of 16 Patients of Karna

Srava

Periodicity

of ear

discharge

Mean

score

Relief

%

SD

(±)

SE

(±)

t P

BT AT

J Group 1 0.125 87.5% 0.341 0.085 10.24 <0.001


Discharge was 2.75 which was significantly (P<0.001) reduced to 0.125 after

administering of Jati Taila Varti locally in ear. Thus 95.45% relief was noticed

(Table-40) (Graph-26).

��



Table-40

Effect of Jati Taila Varti84

on Amount of ear discharge of 16 Patients of Karna

Srava

Amount

of ear

discharge

Mean

score

Relief

%

SD

(±)

SE

(±)

T P

BT AT

Group J 2.75 0.125 95.45% 0.5 0.125 21 <0.001


was 0 which was insignificantly (P>0.05) unchanged to 0 after administering of Jati

Taila Varti locally in ear. Thus 0% relief was noticed (Table-41) (Graph-26).

Table-41

Effect of Jati Taila Varti on Smell of ear discharge of 16 Patients of Karna Srava

Smell of

ear

discharge

Mean

score

Relief

%

SD

(±)

SE

(±)

t P

BT AT

J Group 0 0 0% 0 0 0 >0.05


Perforation of T.M. was 3 which was insignificantly (P>0.05) unchanged to 3 after

administering of Jati Taila Varti locally in ear. Thus 0% relief was noticed (Table-42)

(Graph-26).

Table-42

Effect of Jati Taila Varti on Perforation of T.M. of 16 Patients of Karna Srava

Smell of

ear

discharge

Mean

score

Relief

%

SD

(±)

SE

(±)

T P

BT AT

J Group 3 3 0% 0 0 0 >0.05


insignificantly (P>0.05) reduced to 1.312 after administering of Jati Taila Varti

locally in ear. Thus 4.545% relief was noticed (Table-43) (Graph-26).

��



Table-43

Effect of Jati Taila Varti on Hearing loss of 16 Patients of Karna Srava

Hearing

loss

Mean score Relief

%

SD

(±)

SE

(±)

t

P

BT AT

J Group 1.375 1.312 4.545% 0.25 0.062 1 >0.05


insignificantly (P>0.05) unchanged to 0 after administering of Jati Taila Varti locally

in ear. Thus 0% relief was noticed (Table-44) (Graph-26).

Table-44

Effect of Jati Taila Varti on Karna Nada of 16 Patients of Karna Srava

Karna

Nada

Mean

score

Relief

%

SD

(±)

SE

(±)

t P

BT AT

J Group 0 0 0% 0 0 0 >0.05

Effect on Karna Kandu: The initial mean score of Karna Kandu was 1.437 which

was significantly (P<0.001) reduced to 0.187 after administering of Jati Taila Varti

locally in ear. Thus 86.95% relief was noticed (Table-45) (Graph-26).

Table-45

Effect of Jati Taila Varti on Karna Kandu of 16 Patients of Karna Srava

Karna

Kandu

Mean score Relief

%

SD

(±)

SE

(±)

t P

BT AT

J

Group

1.437 0.187 86.95% 0.683 0.17 7.31 <0.001

�

��



Table-46

% Relief in all Signs & Symptoms of Group J (Graph-26)

Group Discharge Perforaton

of TM

Hearing

loss

Karna

Nada

Karna

Kandu

Periodicity Amount Smell

JK 87.5% 95.45% 0% 0% 4.545% 0% 86.95%

Overall Study of Group J: Overall Study of Group J Reveales that 50% (8) Patients

were moderately Improved, 43.75% (7) patients were mildely improved and 6.25%

(1) Patient were not affected with treatment. No Patient was cured and markedly

improved (Table-47) (Graph-27)

Table-47

Overall Result of Jati Taila Varti locally in ear of 16 Patients of Karna Srava

Assessment No. of Patients %

Cured 0 0%

Markedly Improved 0 0%

Moderately Improved 8 50%

Mildely Improved 7 43.75%

Unchanged 1 6.25%

Comparative study of two Groups JK & J:

In Group Jk Jati Taila Varti was administered locally into ear and Kapha Ketu Rasa

was administered orally. In Group J only Jati Taila Varti was administered locally into

ear. Then the Comparative study of these two groups reveals that In group Jk, 100%

relief is noted in Periodicity of Ear Discharge, Amount of Ear Discharge and Karna

Kandu each. 40% relief is noted in Hearing loss and 14.81% Relief is noted in

Perforation of T.M.; In Group J 87.5% relief is noted in Periodicity of Ear Discharge,

95.45% relief is noted in Amount of Ear Discharge, 86.95% relief is noted in Karna

Kandu, 4.55% relief is noted Hearing loss and no relief in Perforation of T.M. is noted

(Table-48) (Graph-28)

��



Table-48

Percentage Relief in Signs and Symptoms of 36 Patients of Karna Srava of

Groups JK & J

Groups Periodicity

in Ear

Discharge

Amount

of Ear

Discharge

Smell of

Ear

Discharge

Perforation

of T.M.

Hearing

loss

Karna

Nada

Karna

Kandu

JK 100% 100% 0% 14.81% 40% 0% 100%

J 87.5% 95.45% 0% 0% 4.55% 0% 86.95%

��



��



DISCUSSION

The Ayurvedic System of Medicine offer wide areas for research works in different

disciplines. Our plan of study to carry out a systematized standard clinical work itself

justifies our aim and objectives. The present work based on disease karna srava has

made an attempt to compile every aspect of this scientifically and systematically.

The disease Karna Srava has a specific mention in Sushruta Samhita that Karna Srava

is caused by Paka of Karnavidradhi, Jala-nimajjana, Shiro-abhighata and Avashyaya.

Achraya Charaka and Vagbhata though did not mention the disease Karna Srava or

Karna Samsrava. Four types of Karna Rogas are told by Charaka, where Karna Srava

is a one of Symptoms. Five types of Karna Soola are told by Vagbhatta where also

Karna Srava is one of symptoms.

Whatever Literature has been mentioned in our samhitas, has been thoroughly

reviewed. Chronic Suppurative Otitis Media (Benign type), is a closely similar

clinical entity to Karna Srava has been taken for consideration from modern point of

view. General aetiological factors are sequelae of acute otitis media, ascending

infection via the Eustachian tube; Infection from tonsils, adenoids, infected sinuses

may be responsible for persistent or recurring otorrhoea. General line of treatment is

administering the Antibiotics, decongestants and Anti-inflammatory Drugs and the

operative procedure are Myringoplasy for to repair the perforation of TM and

ossicular reconstruction for necrosed ossicles. Though meticulously managed CSOM

get cured gradually, but some times because of improper medication, resistance to

medicine and lowered immunity cause persistent infection or off and on infection and

resultant otorrhoea, which effects an individual’s quality of life to great extent.

The above factors leave a scope to find out a drug, which should be free from the

untoward effect of known therapy and at the same time should be effective without

any side effecs simultaneously quite affordable to the patients.

Discussion on age: The maximum number of patients i.e. 42.5% belonged to age

group of 21-30, followed by age group 31-40 with 20%, 41-50 group with 17.5%, 11-

20 group with 15% and age group 5-10 with 5%. The Observation revealed that Karna

��



Srava is more common in young adult age but it can occurr at any age. It also verifies

the prevalence of disease from modern point of view.

According to Ayurveda, this observation reveals that Kapha is predominant in Balya-

Avastha , but due to lack of Pitta, Chances of Paka is less.while in young adults

because of Pitta and Kapha predominance this disease is commonly found. While in

old age group, because of excess of vata Dosha, there is alleviation of kapha and Pitta

Dosha, hence this disease is not common in old age after 50 years.

Discussion on Sex: In present study, out of 40 patients of Karna Srava, 70% patients

were male and 30% patients were female.Whether this disease has any correlation

with any particular sex is not established.

Discussion on Religion: In present study, out of 40 patients of Karna Srava,

maximum number of patients i.e. 80% patients were Hindu and 20% were Muslims.

This is due to predominance of Hindu community in this area. This is due to

predominance of some particular community in that particular region.

Discussion on Occupation: In this present study, out of 40 students, maximum

number of patients i.e. 30% were students, 22.5% were businessmen, 20% were

housewives, 17.5% were servicemen and 10% were farmers. As this disease is more

common in young adult age due to the infection in mucosa of

oropharynx/Nasopharynx, because they are usually dependent on outside food stuffs

or beverages and exposure to irritants/pollutants.

Discussion of Education: In present study, that out of 40 patient, maximum number

of patient 30% were educated up to S.S.L.C /metric, 22.5% patient were educated up

to graduation, 20% patient were educated up to Intermediate/P.U.C., 12.5% up to

middle standard, 7.5% up to primary standard and 7.5% patient were illiterate.

Maximum number of patients were students and prevalence of this disease is found

because of their improper dietary habits and altered life styles.

Discussion on marital status: In present study, out of 40 patients, maximum number

of patients i.e. 57.5% was unmarried and 42.5% were married. Here Unmarried

��



Patients are more affected due to having improper food habits and life style. Marital

status does not affect the prevalence of disease.

Discussion on Socio-economic status: In present study, out of 40 patients, maximum

number of patients 67.5% belonged to lower middle class, 27.5% patients were from

middle class, 5% patients were from poor status. The reason for these observations

can be explained in this way that in higher income group because of improved

hygienic and health conditions, this disease is rarely found. Poverty towards health

care, poor hygiene, negligency towards manifestation of disease makes this disease

more prevalent in lower middle class people.

Discussion on Habitat: In present study, out of 40 patients, 62.5% patients belonged

to rural area and 37.5% patients were from urban background. Reason for this

observation that SDM college of Ayurveda is located at the periphery of city and this

is almost dependent on the patients of Rural area, because this area of location is

surrounded by many villeges and Rural population is having less knowledge about

proper Hygienic measures.

Monika et al. also found in her study that 84.62% patients belonged to rural area and

15.38% belonged toUrban area.

Discussion on Dietary habit: In present study, out of 40 patients, maximum numbers

of patients i.e. (87.5%) were having habit of mixed diet, while (12.5%) were

vegetarian. According to Ayurveda Mamsahara is grouped under Tamas and

Abhishyandi Ahara. It increases Kapha and lowers the body immunity. The spices

mixed in this type of food cause soreness of mucosa of oropharynx very frequently,

which is one of precipitating facter for URTI, thereby spreading the infection to ear.

Discussion on Addiction: In present study, out of 40 patients, maximum number of

patients i.e. 27.5% patients were having no addiction and same 27.5% patients were

having the habit of smoking, 22.5% patients were having the habit of smoking as well

as tobacco chewing, 10% patients were having the habit of smoking as well as

alcohol, 7.5% patients were having the habit of Tea and coffee, 5% patients were

having the habits of smoking, alcohol and tobacco chewing. The Patients who are not

having any addiction, may had chronic infection in nasal mucosa due to cold climate,

��



which is very common in this area or infection of oropharyngeal mucosa. The patients

were having addiction of smoking, alcohol, tobacco chewing and tea or coffee are

more susceptible to oropharyngeal infection or Pitta Prokopa according to Ayurveda.

The infection may travel to middle ear via Eustachian tube from oropharyngeal

mucosa.

Discussion on Prakruti: In present study, out of 40 patients, maximum number of

patients i.e. 47.5% were of Pitta-Kaphaja category, 40% patients were of Vata-

Kaphaja category, 12.5% patients were of Vata-Pittaja category. The random

selection of patients for this study presented the Prakruti observation as mentioned

above.

Discussion on Laterality: In present study, among all 40 patients, all patients 100%

were suffering from Karna Srava of Unilateral side.

Monika et al. found in her study that 92.3% patients were suffering from Karna Srava

of unilateral side and 7.7% suffered from Karna Srava of bilateral side. So this reveals

that most of the time this disease occurs in unilateral side and rarely in bilateral side.

Discussion on Chronicity: In present study, out of 40 patients, maximum number of

patients i.e. 87.5% patients were having history of Karna Srava 6-12 months old and

12.5% were having the history of Karna Srava 1-6 months old. As CSOM presents the

Chronocity for its manifestation, that’s why maximum number of patients presented

history of 6-12 months.

Discussion on Nidana: In present study, out of 40 patients, maximum number of

patients i.e. 57.5% havingt history of Avashyaya & Pratishyaya, 17.5% patients

having history of Pratishyaya & Kasa; 12.5% Patients having history of Mithyayogen

Shastrasya; 7.5% patients having history of infection in Posterior Pharyngeal wall/

Oropharynx/tonsils; 5% patients having history of Jalanimajjana. Here most of

patients were having the history of Chronic Rhinitis. It is due to cold climate of this

area and this infection might migrate to middle ear via Eustachian tube. Whatever

causes are mentioned in literature regarding the occurance of disease were

encountered in our study too.

��



Discussion on Signs and Symptoms: out of 40 patients, all 100% patients were

having intermittent ear discharge, 87.5% patients were having profuse ear discharge

and 12.5% patients were having moderate ear discharge, 100% patients were having

ear discharge without odour, 80% patients were having ear discharge of muco-

purulent type and 20% were having ear discharge of mucoid type, 80% patients were

having ear discharge of yellowish colour and 20% patients were having of Whitish

colour, 100% patients were having central perforation in Tympanic membrane, 57.5%

patients were having moderate type of hearing loss and 42.5% patients were having

mild type of hearing loss, 67.5% patients were having Complaint of Karna Kandu and

32.5% patients were not having complaint of Karna Kandu, Karna Nada though

included under criteria of assessment was not found in any of patients of both groups.

Here all symptoms, which were observed in two groups are mentioned in Modern as

well as Ancient literature. Thus ear discharge is a cardinal feature of Karna Srava

(safe type of CSOM) and others are are associated features of this disease.

Discussion on effect of therapy:

Effect of Jati Taila varti locally in ear and Kapha Ketu Rasa orally:

Effect on Periodicity of Ear Discharge: The initial mean score of Periodicity of Ear

Discharge was 1 which was insignificantly (P>0.05) reduced to 0 after administering

of Kapha Ketu Rasa orally and Jati Taila Varti locally in ear. Thus 100% relief was

noticed.


Discharge was 2.94 which was significantly (P<0.001) reduced to 0 after


100% relief was noticed.


was 0 which was insignificantly (P>0.05) unchanged to 0 after administering of

Kapha Ketu Rasa orally and Jati Taila Varti locally in ear. Thus 0% relief was

noticed.

��




Perforation of T.M. was 3 which was significantly (P<0.01) reduced to 2.55 after


14.81% relief was noticed.


significantly (P<0.001) reduced to 1 after administering of Kapha Ketu Rasa orally

and Jati Taila Varti locally in ear. Thus 40% relief was noticed.


insignificantly (P>0.05) unchanged to 0 after administering of Kapha Ketu Rasa

orally and Jati Taila Varti locally in ear. Thus 0% relief was noticed.

Effect on Karna Kandu: The initial mean score of Karna Kandu was 0.5 which was

significantly (P<0.01) reduced to 0 after administering of Kapha Ketu Rasa orally and

Jati Taila Varti locally in ear. Thus 100% relief was noticed.

Overall Result of Group JK: Overall Study of Group JK reveals that 77.77%

Patients were Moderately Improved and 22.22% Patients were Mildely Improved. NO

patient was cured as well as Markedly Improved and each Patient responded to the

treatment.

Effect of Jati Taila Varti locally in ear:

Effect on Periodicity of ear Discharge: The initial mean score of Periodicity of ear

discharge was 1 which was significantly (P<0.001) reduced to 0.125 after

administering of Jati Taila Varti locally in ear. Thus 87.5% relief was noticed.


Discharge was 2.75 which was significantly (P<0.001) reduced to 0.125 after

administering of Jati Taila Varti locally in ear. Thus 95.45% relief was noticed.


was 0 which was insignificantly (P>0.05) unchanged to 0 after administering of Jati

Taila Varti locally in ear. Thus 0% relief was noticed.

��




Perforation of T.M. was 3 which was insignificantly (P>0.05) unchanged to 3 after

administering of Jati Taila Varti locally in ear. Thus 0% relief was noticed.


insignificantly (P>0.05) reduced to 1.312 after administering of Jati Taila Varti

locally in ear. Thus 4.545% relief was noticed.


insignificantly (P>0.05) unchanged to 0 after administering of Jati Taila Varti locally

in ear. Thus 0% relief was noticed.

Effect on Karna Kandu: The initial mean score of Karna Kandu was 1.437 which

was significantly (P<0.001) reduced to 0.187 after administering of Jati Taila Varti

locally in ear. Thus 86.95% relief was noticed.

Overall Study of Group J: Overall Study of Group J Reveales that 50% Patients

were moderately improved, 43.75% patients were mildely Improved and 6.25%

Patient were not affected with treatment. No Patient was cured and markedly

improved.

Comparative study of two Groups JK & J:

In Group JK:

Jati Taila Varti was administered locally into ear and Kapha Ketu Rasa was

administered orally. In group JK, 100% relief is noted in Periodicity of Ear Discharge,

Amount of Ear Discharge and Karna Kandu each. 40% relief is noted in Hearing loss

and 14.81% Relief is noted in Perforation of T.M.

In Group J:

In Group J only Jati Taila Varti was administered locally into ear. 87.5%

relief is noted in Periodicity of Ear Discharge, 95.45% relief is noted in Amount of

Ear Discharge, 86.95% relief is noted in Karna Kandu, 4.55% relief is noted Hearing

loss and no relief in Perforation of T.M. is noted.

��



The comparative study of these two groups reveals that better improvement is

there in group JK as compared to group J regarding Periodicity and Amount of ear

discharge & Karna Kandu. But regarding Hearing loss some improve is there in group

JK and very less improvement is there in group J. Regarding Perforation of TM less

improvement is there in group JK, but there is no improvement in group J.

Probable mode of Action of Trial Drugs:

In this clinical study Jati Tala is used locally in the form of Varti in ear and

Kapha Ketu Rasa is used orally in the form of tablet.

Jati Taila is having Jati and Tila taila. According to Sushruta and other Nighantus Jati

is used as a Vrna-Shodhaka.

Acharaya Sushruta mentioned the Jati in Laksadi Gana. Laksadi Gana dravya

is Kasaya, Tikta and Madhura predominant which alleviates Kapha & pitta and acts as

a Vrna Shodhaka. It is having Kandughna property as well. Research claims that Jati

is having antibacterial properties.

Tila Taila is Kapha Shamaka due to having properties like Katu, Tikta and

Kasaya and also Vata Shamaka due to its Ushna Virya.

Vrna Shodhaka property of Jati and Kapha-Vata Shamaka property of

TilaTaila heals up the inflammation and infection of ear and improves the local

immunity of ear thus controls the pathology.

Kapha Ketu Rasa is indicated in Karna Rogas. This is having following drugs-Vyosha

(Shunthi, Maricha, Pippali), Hijjala, Vatsnabha and Shankha Bhasma.

Sushruta mentioned the Vyosha or Triushna or Trikatu in Pippalyadi gana.

This Pippalyadi Gana is Kaphahara and Vatasamaka and research has proved that

Pippallyadhi gana is anti-inflammatory as well. Shunthi is Vata & Kapha shamaka dut

to having of UshnaVirya. It is having Sothahara properties also. Maricha is

Vatashamaka due to having UshnaVirya; and Kaphashamaka due to having of

properties like Katu, Ruksa and Tiksna. It is having Antibacterial activity also. Its

pramati property proves that it is best Sroto-Shodhaka. Hence it helps in removing

��



Kapha from ear. Pippali is Kaphahara due to being Katu and Vatashamaka due to

being Snigdha. It is a best Antibacterial drug. It also acts as a Rasayana & Balya.

Hence it helps in healing of perforation and removes the infection from middle ear

mucosa. Its kaphahara property relieves kandu significantly.

Hijjala is Kapha-Pitta Samshodaka and Vatahara. Hence it is effective in Karna

Srava.It acts as a Lekhya, thus removing the Kapha from ear canal and it is

Kandughna also. It also acts as a Antibacterial.

Vatsanabha is a Kaphahara due to having properties like Ruksa, Tiksna and Laghu

and Vatahara due to having UshnaVirya. It is having the property of Sothahara and it

enhances the immunity of body. Thus helps in treating the Karna Srava and healing of

perforation. It is having Kandughna property, so helps to treat Kandu.

Thus due to all above Drugs, these two Medications are effective in Karna Srava.

��



SUMMARY & CONCLUSION

Summary provides a whole theme of the study and anything in Research needs to be

summarized and put in a nutshell, so that a further progress in the subject or any part

of the matter can be considered in future for the benefit of the similar patients.

The present study entitled “Role Of Jati Taila Varti and Kapha Ketu Rasa in the

management of Karna Srava (Safe Chronic Suppurative Otitis Media)” solely aims to

observe the role of Jati Taila & Kapha Ketu Rasa and Jati Taila alone in the

management of Karna Srava. This subject has been presented in six sections viz.

1. Introduction

2. Conceptual Study

3. Drug review

4. Clinical Study

5. Discussion

6. Summary and Conclusion.

1. INTRODUCTION:-

This section describes the details of the dissertation, selection of the problem,

selection of the drugs, review of the previous work and plan of study.

2. CONCEPTUAL STUDY:-

The second section i.e. Conceptual Study consist two subsections are Ayurvedic

review and Modern review.

Ayurvedic review section contains the historical background of Karna and Karna

Srava; aetiopathogenesis, clinical features and treatment of Karna srava on the ground

of Ayurveda.

Modern review entails the literature on CSOM & relevant points. It comprises the

description of disease, aetiology and pathology of disease, clinical features and

management of disease on the ground of modern science.

3. DRUG REVIEW:-

The third section Drug review deals with the detailed description of trial drugs viz.

Synonyms, morphology, their pharmacodynamic properties, parts which are useful in

medication and dosage.

��



4. CLINICAL STUDY:-

The fourth section Clinical Study deals with the need and plan of study in detail, aims

and objects, materials and methods, inclusion and exclusion criteria, sampling

method, treatment schedule, assessment criteria, observations in tabular and graphic

form along with the statistical analysis of results obtained etc.

5. DISCUSSION:-

This section has an account of interpretations based on the observations included in

cinical study, effect of therapy and probable mode of action of trial drugs.

6. SUMMARY & CONCLUSION:-

The sixth and last section that is the section is devoted to summary as well as

conclusion drawn here as under:

Observations:

• Maximum number of patients i.e. 42.5% belonged to age group of 21-30,

followed by age group 31-40 with 20%, 41-50 group with 17.5%, 11-20 group

with 15%.

• Maximum number of Patients i.e. 70% patients were male and 30% patients

were female.

• Maximum number of patients i.e. 80% patients were Hindu and 20% were

Muslims.

• Maximum number of patientsi.e. 30% were educated up to S.S.L.C /metric,

22.5% patient were educated up to graduation, 20% patient were educated up

to Intermediate/P.U.C.

• Maximum number of patients i.e. 30% were student,

• Maximum number of patients 67.5% belonged to lower middle class, 27.5%

patients were from middle class, 5% patients were from poor status.

• Maximum number of patients i.e. 62.5% patients belonged to rural area and

37.5% patients were from urban background.

• Maximum numbers of patients i.e. 57.5% were unmarried and 42.5% were

married.

• Maximum numbers of patients i.e. (87.5%) were having habit of mixed diet.

��



• Maximum numbers of patients i.e. 47.5% were of Pitta-Kaphaja category,

40% patients were of Vata-Kaphaja category.

• Maximum number of patients i.e. 27.5% patients were having no addiction

and same 27.5% patients were having the habit of smoking, 22.5% patients

were having the habit of smoking as well as tobacco chewing.

• All patients 100% were suffering from Karna Srava of Unilateral side.

• Maximum number of patients i.e. 57.5% having history of Avashyaya &

Pratishyaya.

• Maximum number of patients i.e. 87.5% patients were having history of Karna

Srava 6-12 months old.

• All 100% patients were having intermittent ear discharge.

• Maximum number of patients i.e. 87.5% patients were having profuse ear

discharge.

• All 100% patients were having ear discharge without odour.

• Maximum number of patients i.e. 80% patients were having ear discharge of

muco-purulent type and 20% patients were having ear discharge of mucoid

type.

• Maximum number of patients i.e. 80% patients were having ear discharge of

yellowish colour and 20% patients were having of Whitish colour.

• All 100% patients were having central perforation in Tympanic membrane.

• Maximum number of patients i.e. 57.5% patients were having moderate type

of hearing loss and 42.5% patients were having mild type of hearing loss.

• Maximum numbers of patients i.e. 67.5% patients were having Complaint of

Karna Kandu and 32.5% patients were not having complaint of Karna Kandu.

• All 100% patients were not having complaints of Karna Nada.

Effect of Therapy:

• In group JK, where patients were treated with Kapha Ketu Rasa orally 2

teblets tid and Jati Taila Varti locally in ear two times a day for 30 days, it was

found that there was a statistically significant (p<0.001) relief in amount of ear

discharge, insignificant (p>0.05) relief in periodicity of ear discharge,

insignifant (p>0.05) unchange in smell of ear discharge, significant (p<0.01)

��



relief in perforation of TM, significant (p<0.001) relief in hearing loss,

insignificant (p>0.05) unchanged of Karna Nada and significant (p<0.01)

relief in Karna Kandu. Here % relief is found in clinical features like

periodicity of ear discharge (100%), amount of ear discharge(100%),

perforation of TM(14.81%), hearing loss(40%) and Karna Kandu(100%).

Smell of ear discharge and Karna Nada features were absent and there was no

change in these.

• In group J, only Jati Taila Varti was administered locally in ear two times a

day for 30 days. It was found that there was a statistically significant

(p<0.001) relief in periodicity and amount of ear discharge & Karna Kandu.

Insignificant (p>0.05) unchange in smell of ear discharge and Karna Nada;

insignificant (p>0.05) unchange in perforation of TM; and insignificant relief

in hearing loss. Here % relief in these clinical features was periodicity (87.5%)

and smell (95.45%) of ear discharge & Karna Kandu (86.95%), hearing loss

(4.545%) and perforation (0%). Because there was no improvement in the

condition of perforation of T.M. Smell of ear discharge and Karna Nada

symptoms were not found.

OVERALL EFFECT OF THERAPIES:-

• The overall Study of Group JK reveals that 77.77% (14) Patients were

moderately improved and 22.22% (4) Patients were Mildely improved. NO

patient was cured as well as markedly improved and each Patient responded to

the treatment.

• The Overall Study of Group J Reveales that 50% (8) Patients were moderately

Improved, 43.75% (7) patients were mildely improved and 6.25% (1) Patient

was not affected with treatment. No Patient was cured and markedly

improved.

Conclusion:

From the result and observations which were obtained from this study, it can be

concluded that:

� Combined therapy ( Jati Taila Varti & Kapha Ketu Rasa) was providing good

results as compared to single therapy ( only Jati Taila Varti).

��



� The patients who were treated with Jati Taila Varti (local administration in

ear) & Kapha Ketu Rasa (oral tablet) getting more improvement in clinical

features like periodicity & amount of ear discharge, perforation of TM,

hearing loss and Karna Kandu as compared to Jati Taila.

� The effectiveness of these drugs might be studied in other perforations of TM

in the future trials, if conducted.

� The disease is more common in young adult age, lower middle class, rural

area, in persons having Deha Prakruti Pitta-Kaphaja followed by Vata-

Kaphaja.

� By improving the educational and economic status of society such diseases

can be prevented.

� Larger sample should be studied to verify the results.

� Duration of treatment should be increased to have more sharper and accurate

result.

� No toxic or side effects of trial drugs were observed.

��



��

1. Su.Sh. 5/3

2. Su.Sh.3/15

3. Ch. Sh. 7/7

4. Ch.Su.8/10

5. Su.Su.35/12

6. Su.Su.16/3

7. Ch.Sh.7/11

8. As.Ut.1/38

9. Ah.Su.29/49

10. Ch.Sh.8/51

11. Ch.Sh.7/11

12. Su.Ut.21/58

13. Su.Sh.5/10

14. Ch.Su.7/42-43

15. Su.Sh.5/21

16. Rg. 10/162/1

17. Ath. 2/33/1

18. Ath.10/ 2/31

19. Ath. 9/8/1

20. Ath. 9/8/4

21. Su.Sh.5/22

22. Su.Sh.5/32

23. Su.Sh.5/48

24. Su.Sh.6/28

25. Ah.Sh.4/42

26. Su.Sh.6/12

��



27. Su.Sh.7/8

28. Su.Sh.8/25

29. Su.Sh.9/5

30. Ch.Sh.8/51

31. Ch.Su.8/3

32. Su.Ut.20/10

33. Su.Ni.2/19

34. Ch.Ch.26/116

35. Su.Ut.21/3

36. Sh. Pk. 7/142-143

37. Su.Ut.21/41

38. Ah.Ut.18/19

39. Su.Ch.19/14

40. R.N. Karviradi Varga, Sloka-74-76

41. K.N. Page no.272-273, Sloka no.1473-1474

42. M.N. Karpuradi Varga, Sloka-85

43. B.P.Kh. Puspa Varga,Sloka no.28

44. B.M.Kh. Vranasothadhikar, Sloka no.88-95

45. R.S.S. Karna Roga Chikitsa,Sloka-1

46. G.N. Kaya Chikitsa Khanda, Karna Rogadhikar, Sloka-5

47. M.Ni. Karna Roga Nidanam, Sloka-5

48. Y.R. Karna Rogadhikar, Page no.-310, Sloka-6

49. R.Ch. Karna Roga Chikisa, page no.321

50. Su.Su.38/22

51. Su.Su.20/1-2

52. Su.Su.20/10

53. Su.Su.20/11

54. Ch.Ch. chapter-26/127-128

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55. B.R. Karna Rogadhikar 62/45

56. Y.R. Karna Rogadhikar, Page no.309, Sloka-1

57. Y.R. Karna Rogadhikar, Page no.310, Sloka-6

58. B.M.Kh. 64/10

59. V.S. Karna-Rogadhikar/5

60. Bhel.Sam. Chi. 21/51, 63, 64

61. H.S. 44/6

62. Ah. Sh.3/4-5

63. Ch.Vi.8/117

64. Ch.Su.25/40

65. Su.Su.46/40

66. Su.Ni.1/83

67. Su.Ut.20/7,8

68. Ch.Su.28/4,5

69. Ah.Sh.4/57

70. Su. Sh. Page-62

71. Ah.Sh.3/31

72. As.Su. 8/50

73. Su.Ut. 20/6

74. Ah.Ut. 17/9

75. Su.Su.21/33

76. Su. Su, 21/35

77. Ah.Ut.18/17,18,19

78. Su.Ut.21/6,7

79. Sha.Ut. 1/127-28

80. As.Su 31/21

81. Sh.Ut. 11/131

82. Su.Ut.21/39

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83. Ah.Ut.18/11

84. Ah.Ut.18/18

85. As.Ut.22/11

86. Su. Ut. 21/42

87. Su.Ut.21/43

88. Su. Ut.21/45

89. As.Ut.22/6,7

90. Su. Ut. 21/44

91. Su Ut.39/227-229

92. Ch. Chi. 26/230

93. Ch Chi. 26/ 221

94. Ch. Chi,26/227,229

95. Su.Ut. 21/3

96. Ah. Ut 18/6

97. Y. R 1/3

98. Ah.Ut. 18/5

99. As.Ut.22/2

��



��

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PREVIOUS REASERCH WORK

Role of Jati Taila and Sarivadi Vati in the management of Karna Srava done

by Patel GM in 1987 in Jamnagar.

Management of Karna Srava with Karna Praksalana with Vidanga Qwatha

done by Narayana Rao in 1990 in Hydrabad.

A clinical study on the management of Karna Srava w.s.r. to Otomycosis done

one by Anant Gyandev Javela in 2005 in Jamnagar.

Role of Ayurvedic Drugs in the management of Karna Srava w.s.r. to Chronic

Suppurative Otitis Media (Benign type) done by Monika in 2005 in Paprola.

Effect of Arka Taila in the management of Karna Srava w.s.r. to Otomycosis

done by Anupama Patra in 2007 in Jamnagar.

Further study on the Role of Arka Taila in the management of Karna Srava

w.s.r. Otomycosis done by Komal Palmar in 2010 in Jamnagar.

��!��



DEPARTMENT OF POSTGRADUATE STUDIES IN SHALAKYA TANTRA,

S.D.M. COLLEGE OF AYURVEDA & HOSPITAL, HASSAN-573201,RAJIV

GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

CASE SHEET PROFORMA

Role of Jati Taila Varti & Kapha Ketu Rasa in the management of

Karnasrava (safe chronic suppurative otitis media)

Date …………

Patient’s name: D.O.A:

Age: D.O.D:

Sex: Address:

Religion:

Occupation:

Education:

Habitat: Urban/ Rural

Marital Status: Married/ Unmarried

Socio-economic status: Poor/Lower middle/Middle/Upper

Middle /Rich

Chief complaints with duration:

Ear Discharge: Present/ Absent

Deafness: Present/ Absent

Tinnitus: Present/Absent

Earache: Present/Absent

��!��



H/o Present illness :

Past history :

General body illness:

Allergic disorders:

Any other disease history: Tuberculosis/Dibetesmellitus/Hypertension/

Trauma/Ear surgery/Head injury

Family history:

Personal history:

Agni: Manda/ Tiksna/ Vishama/ Sama

Mutravega: Normal/ polyuria/ scanty micturition/

Bsurning micturition

Malavega: Regular/ irregular/ constipated/ loose stools

Prakruti:

Diet: Veg./ Nonveg./ Mixed

Sleep: Sound/ Disturbed

Addiction: Tea/ coffee/ smoking/ tobacco chewing/

Alcohol/ opium

Samprapti Ghatak:

Dosha:

Dushya:

Srotas:

Srotodusti:

Vyadhi Swabhava: Aashukaree/Chirakaree

Treatment history:

Local examination:

External Ear:

Pinna:

��!��



External auditary meatus:

Foreign body/ Wax/ Furuncle/ inflammation/ Fungal

Infection/ All are absent

Discharge:

Colour: Whitish/ yellow/yellowish

Nature: Mucoid/Mucopurulent/ Purulent

Amount: Profuse/ Moderate/ Scanty

Periodicity: Continuous/ intermittent

Smell: Odourless/Foul smelling

Tymapanic membrane:

Colour: Normal/ Congested

Perforation:

Location: Central/Posterosuperior/ Attic

Size & shape: Small size/Medium size/subtotal/Total

Cone of light: Present/ absent/ interrupted

PHARYNX:

Nasopharynx: Normal/ Congested

Oropharynx: Normal/ Congested

Eustachian tube: Normal/ Blocked

NASAL CAVITY: (anterior Rhinoscopy)

Mucosa: Normal/ congested

Deviated septum: Yes/No

Hypertrophic turbinates: Yes/No

Furunculosis: Yes/No

Discharge: Watery/ thick/Absent

��!��



Functional examination of ear:

(Qualitative test for hearing by tuning fork)

Test Right

BT AT

Left

BT AT

Rinne’s Test

Weber’s Test

Laboratory Investigation:

Investigation BT AT

HB%

T.L.C.

D.L.C.

E.S.R.

Swab test for sensitivity

(if necessary)

��!��



Examination criteria with grades:

Sign&symptoms

BT

DT (day)

AT (day)

8th

15th

22nd

30th

Ear discharge (Karna-

Srava) :

1. Periodicity

2.Amount

3. Smell

4. Perforation of T.M.

5. Hearing loss

6. (Karna nada) Tinitus

7. Karna kandu

Treatment group:

Group JK: Local application of Jati Taila Varti & oral intake of

Kapha Ketu Rasa. ( )

Group J: Local application of Jati Taila Varti. ( )

Follow-up:

S.N. F.U.(1) F.U.(2) F.U.(3) F.U.(4)

1. Cured

2. Markedly

improved

3.

Moderately

improved

4. Mildly improved

5. Unchanged

Signature of Guide:

Signature of H.O.D.:

Signature of Scholar

role of jati taila va rasa in the managem (safe chronic suppur

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