A COMPARATIVE CLINICAL STUDY ON THE EFFICACY OF …

MANAGEMENT OF KARNASRAVA WITH STHANIKA GUGGULU DHOOPANA AND RASNADIGUGGULU

A COMPARATIVE STUDY

By

Dr.SATHISH SHANKAR.B, B.A.M.S.

A dissertation submitted to the

Rajiv Gandhi University of Health Science, Bengaluru, for the partial fulfillment of Degree

AYURVEDA VACHASPATHI M.S. (SHALAKYA TANTRA)

Under the guidance of

Dr.SUMITRA.T.GOWDA M.D. (Ayu) Professor Department of Post Graduate Studies in Shalakya Tantra,

Government Ayurvedic Medical College, Bengaluru.

DEPARTMENT OF POST GRADUATE STUDIES IN SHALAKYA TANTRA GOVERNMENT AYURVEDIC MEDICAL COLLEGE

DHANWANTRI ROAD, BENGALURU – 560 009

2010-2011

GOVERNMENT AYURVEDIC MEDICAL COLLEGE DEPARTMENT OF POST GRADUATE STUDIES IN SHALAKYA TANTRA

Dhanwantri Road, Bengaluru – 560 009

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “Management of karnasrava

with sthanika Guggulu dhoopana and Rasnadiguggulu- A Comparative

study” submitted by Dr. Sathish Shankar. B for the degree of Ayurveda

Vachaspathi – M.S.(Shalakya Tantra) of the Rajiv Gandhi University of

Health Sciences, Bengaluru, is a record of research work done by him under

my guidance and supervision during the period of his study in our department.

This dissertation has not previously formed the basis for the award of any

degree, diploma, associate ship, fellowship or other similar titles.

I am recommending this dissertation for the above degree to the University

Assessment and approval.

Dr. SUMITRA.T.GOWDA. MD (Ayu) Professor Department of Postgraduate Studies in Shalakya Tantra, Government Ayurvedic Medical College, Bengaluru.

Date : Place : Bengaluru

GOVERNMENT AYURVEDIC MEDICAL COLLEGE DEPARTMENT OF POST GRADUATE STUDIES IN SHALAKYA TANTRA

Dhanwantri Road, Bengaluru – 560 009

ENDORSEMENT BY THE HOD & PRINCIPAL

This is to certify that the dissertation entitled “MANAGEMENT OF

KARNASRAVA WITH STHANIKA GUGGULU DHOOPANA AND

RASNADIGUGGULU-A COMPARATIVE STUDY” is a bonafide and

genuine research work done by Dr. Sathish Shankar. B. Under the guidance

of Dr.Sumitra.T.Gowda, M.D.(Ayu), Professor , Department of Post Graduate

Studies in Shalakya Tantra, Government Ayurvedic Medical college

Bengaluru.

Dr. B.N. Ramesh, M.D. (Ayu Shalakya) Professor and HOD, Department of P.G.studies, Shalakya tantra, Government Ayurvedic Medical college, Bengaluru.

Dr. Mangalgi, M.D. (Ayu) Principal Government Ayurvedic Medical College, Bengaluru.

Date : Date : Place : Bengaluru Place : Bengaluru

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE

BENGALURU, KARNATAKA

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “MANAGEMENT OF

KARNASRAVA WITH STHANIKA GUGGULU DHOOPANA AND

RASNADIGUGGULU-A COMPARATIVE STUDY” is a bonafide and

genuine research work carried out by me under the guidance of

Dr.Sumitra.T.Gowda M.D. (Ayu), Professor, Department of Post Graduate

Studies in Shalakya Tantra, Government Ayurvedic Medical College,

Bengaluru.

Dr. SATHISH SHANKAR.B B.A.M.S. Date :

Place : Bengaluru

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Science,

Bengaluru, Karnataka shall have the rights to preserve, use and disseminate

this dissertation in print or electronic format for academic or research purpose.

Dr. SATHISH SHANKAR.B, B.A.M.S.

Date

Place : Bengaluru

ACKNOWLEDGEMENT

I would like to take this opportunity to express my gratitude to all those who

have rendered help in conducting this clinical study and compiling of this dissertation.

It is with deep sense of gratitude and respect that I express my thanks to my

beloved guide Dr.Sumitra.T.Gowda M.D (Ayu) Professor, Department of Post

Graduate studies in Shalakyatantra, Government Ayurvedic Medical College,

Bengaluru, for her valuable guidance, constant encouragement, motivation and kind

co – operation without which the work would not have been completed.

I express my heartiest gratitude to Dr. B.N. Ramesh. M.D (Ayu Shalakya)

Professor and HOD, Department of PG Studies in Shalakyatantra, G.A.M.C,

Bengaluru for his valuable guidance and deep concern that helped me to pursue my

work with confidence.

I am grateful to our principal Dr. S.G. Mangalagi M.D (Ayu) for his kind help

and cooperation in completing this work.

I am greatful to Dr. Viswambhara M.D (Ayu Shalakya) and Dr. H.T Srinivas

M.D (Ayu) for there cooperation in completing this work.

I also express my sincere gratitude to Dr.Suja K.Sridhar, Dr. Vijayasarathi,

Dr. Shobharani, Dr. Mohankumari and Dr. Syed Munawar Pasha, Dr. Aravind,

Dr. Ashalata for their valuable suggestions and guidance regarding my work.

I express my sincere thanks to Mr. Joshi, Medical Statistician, BMC,

Bengaluru, for helping me in Statistical analysis of my study.

I thank my seniors Dr. Uma, Dr. Apeksha, Dr. Rumana, Dr. Praneeta,

Dr. Manjubhargavi, Dr. Suma and Dr. Rekha for their support and co – operation.

I would like to thank my colleagues with special thanks to my friends

Dr. Lokanath, Dr. Veeresh, Dr. Manasa, Dr. Nishitha, Dr. Suma, Dr. Bharathi,

Dr. Manjunath Joshi, Dr. Jayanth, Dr. Pratibha, Dr. Tejaswini, Dr. Sunita,

Dr. Ravi Kumar Patil, Dr. Sudarshan, Dr. Praveen, Dr. Pooja and Dr. Amol for all

the support they have extended.

I would also wish to extend my thanks to my juniors, Dr. Chiranjeevi,

Dr. Chandrashekar, Dr. Vivek, Dr. Santosh, Dr. Sharan, Dr. Navya and Dr. Gayatri

for their kind help and co – operation throughout the work.

I sincerely thank Dr. Sumit patil for his extensive and valuable support.

I extend heartfelt and humble gratitude to Dr. Ramesh Kavalgud,

Dr. Govindaraju, ENT surgeons from KCG hospital.

I would like to take this opportunity to thank my parents

Mr. Venkatakrishna B.S and Mrs. Seetaratna for being encouraging, loving and

supportive throughout my work.

It is with deep sense of gratitude and great respect that I thank my family

members Mr Santoshkumar, Mrs. Vaani, Mr. Sujay, Manoj, Murari,

Mr. Shivarama and my friend Dr. Yogeesh who have always been besides me for

each and every event of this study.

I wish to thank all the Physicians, Staff of the hospital and librarians of

G.A.M.C, Bengaluru, for their timely help.

I would also take this opportunity to thank Mr. Mohan Reddy, DTP centre,

Bengaluru, for his timely cooperation in printing.

Last, but not the least, I render my thanks to all my patients, without whose

cooperation the work would not happen.

Date : Signature of the Candidate. Place : Dr. Sathish Shankar. B.

CONTENTS

SL.NO. CONTENTS PAGE NO.

1. Introduction 1-2

2. Objectives of the study 3

Review of literature

Historical review,

4-6

Anatomy and physiology of karna 7-11

Anatomy and physiology of ear 12-28

Ayurvedic disease review 29-37

Modern review 38-50

Procedure review 51-52

3.

Drug review 53-58

4. Methodology 59-64

5. Observation and results 65-105

6. Discussion 106-115

7. Conclusion 116-117

8. Summary 118-119

9. References 120-126

10. Bibliography 127-131

11. Annexure 132-138

LIST OF TABLES

Table

No.

NAME OF THE TABLE Page

No.

1. Karnasrava samanya nidana 29

2. Sapeksha nidana of karna srava 34

3. Study design 61

4. Subjective and objective parameters 63

5. Age wise distribution of patients trail groups 65

6. Distribution of sex in trail groups 67

7. Distribution religion in trail groups 68

8. Distribution of occupation in trail groups 69

9. Distribution of marital status 71

10. Distribution of diet in trail groups 72

11. Distribution of socio economic status in trail groups 73

12. Distribution of laterality in trail groups 74

13. Distribution of chronicity in trail groups 75

14. Distribution of prevalence of nidanas 77

15. Distribution of prakruti in trail groups 79

16. Distribution of ear discharge 80

17. Distribution of perforation 81

18. Distribution of conductive deafness 82

19. Distribution of impaired hearing 83

20. Observation in the follow up period 85

21. Periodical changes in signs and symptoms in group A 86

22. Periodical changes in signs and symptoms in group B 90

23. Periodical changes in signs and symptoms in group C 94

24. Statistical analysis of parameters in group A 98

25. Statistical analysis of parameters in group B 99

26. Statistical analysis of parameters in group C 101

27. Overall assessment of results 103

LIST OF DIAGRAMS

SL.

No.

Title Page

No.

1. Diagram showing distribution of age 66

2. Diagram showing distribution of sex 67

3. Diagram showing distribution of religion 68

4. Diagram showing distribution of occupation 69

5. Diagram showing distribution of marital status 71

6. Diagram showing distribution of diet 72

7. Diagram showing distribution of socioeconomic status 73

8. Diagram showing distribution of laterality 74

9. Diagram showing distribution of chronicity 75

10. Diagram showing distribution of prevalence of nidanas 77

11. Diagram showing distribution Prakruthi 79

12. Diagram showing distribution of ear discharge 81

13. Diagram showing distribution of perforation 82

14. Diagram showing distribution of conductive deafness 83

15. Diagram showing distribution of impaired hearing 84

16. Diagram showing observation of follow-up period 85

17. Diagram showing relief in percentage after 15 days in group A 89

18. Diagram showing relief in percentage after 30 days in group A 89

19. Diagram showing relief in percentage after 15 days in group B 93

20. Diagram showing relief in percentage after 30 days in group B 93

21. Diagram showing relief in percentage after 15 days in group C 97

22. Diagram showing relief in percentage after 30 days in group C 97

23. Diagram showing statistical analysis of parameters in group A 99

24. Diagram showing statistical analysis of parameters in group B 100

25. Diagram showing statistical analysis of parameters in group C 102

26. Diagram showing assessment of overall results 104

LIST OF CHARTS Chart

No. Title Page No.

1 Showing perception of sound 11

2 Showing blood supply of labyrinth 26

3 Showing samprapthi of karnasrava 31

LIST OF ABBREVIATIONS USED

A.H – Astanga Hrudaya

A.K - Amarakosha

A.S – Astanga Sangraha

BT – Before Treatment

B.P – Bhava Prakasha

Ca – Charaka

Cd - Chakradatta

Ch. – Chapter

Chi – Chikitsa Sthana

K.S – Kashyapa Samhita

M.N – Madhava Nidana

Ni – Nidana sthana

pp. – Printed pages

S.S – Sushruta samhita

Sl. – Sloka

su. – Sutra sthana

S- Sushruta

Sh – Shareera sthanas

S.y - Sahasrayoga

SJIIM – Sri Jayachamarajendra Institute of Indian Medicine

Ut – Uttara sthana

Utt – Uttara tantra

Sam-Samhita

‘t’ - Students test

ABSTRACT “Managament of karnasrava with sthanika Guggulu dhoopana and Rasnadiguggulu – A comparative study” Karnasrava can be compared to chronic suppurative otitis media. In both these, ear

discharge is the presenting complaint.

In the present study the efficacy of karnadhoopana is compared with internal

administration of Rasnadi guggulu in the management of karnasrava. It was a single

blind open random trail wherein 45 patients were selected and divided into three

Groups namely, Group A, Group B, and Group C each consisting of 15 patients .

Group A was treated with Shuddha guggulu dhoopana. Group B was treated with

Rasnadi guggulu internal administration. Group C was treated with both guggulu

dhoopana and Rasnadi guggulu internally. Two sittings of treatment procedure for

seven days each was followed, with an interval of 15 days in between. Whereas

Rasnadi guggulu was given for 30 days 1gm bid dose. Follow up was done for three

months.

Impaired hearing was the subjective parameter. Objective parameters were, ear

discharge and perforation by otoscopic examination, assessment of conductive

deafness by pure tone audiometry. These were suitably graded to asses the results

based on the clinical observations. Statistical tests were applied to analyse the results.

It was observed in the present study that Group c showed better results compared to

Group A and Group B. But Group A showed better results than Group B. The details

of clinical observations and results will be discussed further in the complete work

presented here forth.

Keywords: Karnadhoopana, Rasnadi guggulu, Perforation, Ear discharge, Pure tone

audiometry.

A Study on Karnasrava

Department of PG Studies in Shalakyatantra, GAMC, Bengaluru 1

INTRODUCTION

The treasure of ancient wisdom is depicted in the texts of Ayurveda.

Ayurveda is the science of life and it is the traditional treatment method of India. It

has eight branches. Shalakya Tantra is one of the specializations mentioned in these

eight branches, which deals with Urdhwanga chikitsa. It includes indriyas - Karna,

Chakshu, Nasa, Jihwa and Shiras. It is also known as Uttamanga.

Karna is considered as one of the Navadwaras and it is one among the

Panchendriyas. In Ayurveda, there are many treatment modalities explained for the

prevention and management of ear disorders such as karnapoorana, karna

avachurnana, karnaprakshalana, karnadhoopana etc. But this knowledge has to reach

the common man especially in developing countries where less expensive but

effective health care system is yet to be developed.

Karnasrava is one among the 28 karna rogas described by Acharya Sushruta.

Vagbhata has not mentioned karnasrava as a separate disease. But has explained

about karnasrava chikitsa. According to Charaka there are 4 types of karna srava.

Classical features of karnasrava can be compared to Chronic suppurative

otitis media. Chronic suppurative otitis media is fairly common infection affecting

the mucosa of the middle ear cleft. In the recent study the prevalence rate is 46



and16 persons per thousand in rural and urban population respectively. It is also the

single most important cause of hearing impairment which can be easily preventable.

The principle treatment modalities adopted in conventional system of

medicine are long duration of antibiotics orally and surgical treatment like

tympanoplasty, mastoidectomy etc. Oral medicines, if given for long duration causes

adverse effects like gastric irritation and reduces immunity, where as the surgical

methods may lead to complications like bleeding, damage to the inner ear, facial

nerve, meninges etc. Failure of the graft is one of the main drawbacks of these

surgeries. These treatments are expensive and beyond the reach of the common man.

Hence an effective treatment approach, which is simple and economical,

needs a serious consideration. In this regard, Karna Dhoopana with Guggulu

because of its ruksha, ushna teekshna, laghu guna acts as an effective shodhaka,

keeps the ear dry, reduces pain, discharge, foul smell and thus controls the infection.

It is also useful as Aadhidaivika chikitsa to protect the patient from external attacks.

It acts against any of the visible and invisible organisms.

As karnadhoopana is a simple, cost effective procedure, which can be done

even at the OPD level, the present clinical study to compare the efficacy of guggulu

karna dhoopana and rasnadi guggulu internally in the management of karnasrava

was taken up.



OBJECTIVES OF THE STUDY

The objectives of present study are:

1. To evaluate the efficacy of Shuddha Guggulu Karnadhoopana in the

management of Karnasrava.

2. To evaluate the efficacy of Rasnadiguggulu internally in the management of

Karnasrava.

3. To compare the effects of Shuddha Guggulu Karna Dhoopana procedure and

Rasnadi Guggulu internal administration.

4. To evaluate importance of local therapeutic procedure- Karna Dhoopana.

5. To evaluate effect of Guggulu when administered locally and internally.



REVIEW OF LITERATURE

HISTORICAL REVIEW

• Karnasrava is described in many of the samhitas. The detailed description is

available in Sushruta samhita Uttaratantra 20th and 21st chapters.

• In Astanga sangraha andAstanga hrudaya, Karnasrava is not explained as a

separate disease.But chikitsa is mentioned in 22nd chapter of Astanga

sangraha uttrratantra,18th chapter of Astanga hrudaya uttaratantra.

• Charaka did not specify karnasrava, but mentioned 4 types of karnarogas –

Vataja, Pittaja, Kaphaja, and Sannipataja and there treatment in 26th chapter

of chikitsasthana.

• Karnasrava is also explained in Bhavaprakasha madyamakhanda 64th

chapter.

• Madavakara has explained about karnasrava in 57th chapter of

madyamakhanda.



• References for treatment of karnasrava is available in Sharangadara samhita

uttarakhanda 11th chapter.

• Yogaratnakara explained karnasrava in karnarogadhikara.

• In Gadanigraha also, Karnasrava and its treatment is mentioned in

karnarogadikara.

• Vangasena had mentioned about the disease and treatment in 69th chapter.

• Chakradatta explained Karnasrava in 57th chapter.

• Dalhana has given the commentary of pootikarna in Sushruta samhita

uttaratantra 20th and 21st chapter.



KARNASRAVA

Karna srava is a type of karna roga, explained by sushruta.The term Karnasrava

comprises of two words. Karna and Srava

Karna- The organ of hearing.

Srava-Discharge.

Nirukti:1

The term Karna is derived from:

Karoti Shabda grahanam.

The term Karna srava refers to:

“Karnasya karnayorva samsravaha2”

Discharge from the Ear is reffered as karnasrava

Synonym:

→Karnasamsrava3



KARNA SHAREERA

Karna Nirukti:

• Karnyathe Akarnyate anena ithi4

It means reception and conduction of sound waves.

These are the functions of external and middle ear

Paryaya of Karna:

Shabdhapatha, Srotrapatha, Sravanam, shruti,kuharam, Dwanigraham,

Sravanapayaha etc5

Nirukti of Sravanam:

• Sruyathe anena ithi sravanam6

It means perception of sound.

It can be attributed to the internal ear function.

In Charaka Samhita, karna is described as one of the Prathyangas of the body.

Acahrya Charaka explains the word Karna as the indriya adhisthana of shabdha7. He

emphasizes that all indriyas manifest during the 3rd month of gestational period.

Sushruta while describing formation of purusha from prakrithi or Avyakta, narrated

that all indriyas are developing from the vaikarika and taijasa ahankara8. He narrated

that karna is made up of two bones which is cartilaginous9 and two sandhies10 (one

in each). Type of sandhi seen in karna is sankhavartha which is present in



Srotashringataka11. There are two mamsa peshis12 and 16 siras13, He also told that a

person with Sthira indriyas enjoy long lifespan14.

Both Vagathata and Susruta considered karna as one of the bahir srotas15.

In Astanga Hridaya, Vagbhata has stated that all indriyas are atmaja. According to

him, lowered lobules, elevated helix, projected posterior portion, fleshy and adherent

ear are indications of long span of life16.

The length of ear is 4 angula17 and that of karna moola is 2 angula18. The distance

between two ears through the back of the neck is 14 angulas19.

Marmas of Ear

The two important marmas Vidhura and Shringataka20 are located in the ear.

Vidhuras are situated in the depressed portion in the back of the ear. Injury to them

causes loss of hearing21.

The predominant dosha of ear is vata, since it is an important seat of vata. The

predominant dhatus are asthi, mamsa and majja. The external and middle ears have

the predominance of asthi and mamsa. Ear has the predominance of Akasha

mahabhuta22.

In Ayurvedic classics, detailed description of ear is not available. Karna is one of the

panchagnanendriyas and is meant for hearing. Its various parts are mentioned in the

classics as follows.

Karnapali23: It is popularly known as Lobule of the ear. Daivakrita chidra is present

in it24.



Karna putrika25: Ayurvedic scholars accepted two terms in this context. They are,

Karnaputraka and Karnaputrika26. The former is considered as Tragus and the latter

as Antitragus.

Karna shashkuli27 or Karna shashkulika: Charaka has mentioned this term while

describing different pratyangas of the body. Acharya Gananatha Sen has given the

clarification for it, as Pinna or Auricle

Karna peetha28: It is mentioned first by Susruta while describing the procedure of

Karnavyadana. Dalhana has clarified that it is the region above the Kamaputrika i.e.

the region which is at the bottom of the Concha. Vagbhata has mentioned that it is

the adhobhaga of Karna29.

Karna prushtha30: It can be taken as the cranial surface of the auricle or the

mastoid region.

Karnamoola31: It can be taken as parotid region.

Karna lathika32: Lobule of the ear is mentioned as Karna lathika by Dalhana.

Karnaavatu33: This term is used by Susruta while describing the measurements of

different angapratyangas. where he has mentioned that the distance between the

Karnaavatu is 14 angula. Dalhana has commented that, it can be taken as the

distance between two ears from behind (posteriorly).

Shabdhapatha34 or Shabdhavahasrotas35 or Srotrapatha36: The whole passage

through which the sound waves pass can be taken as Shabdhavahasrotas.

Shrotra shringataka37: It can be taken as the labyrinth of the ear.

Bahya karna —> External ear



Madhya karna —> Middle ear

Antak karna —> Internal ear

Karna utpatti:

It is formed by akasha mahabhuta38.

The fundamental characteristics are as follows;

Indriya —> srotram39

Indriya adhishthana —> karna40

Indriya dravya —> akasha41

Indriyaartha —> shabdha42

Indriya buddhi —> shrotrobuddhi

Importance:

1) Both the ears are grouped under Navadwaras43.

2) Shravanendriya is one among the Panchagnanendriyas.

3) Karna is the seat of vata dosha & this vata helps in the sense of perception of

hearing44.

4) Indicative of life span:- Thick, large in size having even lobes, with elongations

downwards, bent towards back to front, having compact Tragus and a big ear

passage is the indicative of long life span according to our Acharyas.



Physiological aspect of sound perception45:

According to Ayurveda, perception or pratyaksha of any sensation incuding

shabda occurs due to the intimate interaction of the karnendriya and the indriyartha –

shabdha resulting in shravana.

Chart No.-1 Showing the perception of sound

Atma

Manas

Indriya

Artha

Resulting in perception of buddhi (shabda) graham



EAR ANATOMY

The Ear is divided into:88

1. External ear

2. Middle ear

3. Internal ear or the labyrinth

The External Ear:

The external ear consists of the (i) auricle or pinna, (ii) external acoustic canal

and (iii) the tympanic membrane

The entire pinna, except its lobule, and the outer part of external acoustic canal are

made up of a framework of a single piece of yellow elastic cartilage covered with

skin. The latter is closely adherent to the perichondrium on its lateral surface while it

is slightly loose on the medial surface.

External Acoustic Canal:

It extends from the bottom of the concha to the tympanic membrane and

measures about 24 mm along its posterior wall. It is not a straight tube; its outer part

is directed upwards, backwards and medially while its inner part is directed

downwards, forwards and medially. Therefore, to see the tympanic membrane, the

pinna has to be pulled upwards, backwards and laterally so as to bring the two parts

in alignment.



The canal is divided into two parts: (a) cartilaginous and (b) bony

(a) Cartilaginous part: consists of fibro cartilage. It forms the outer 1/3rd of the

external canal. The skin of this part of the canal contains hair follicles,

sebaceous, and ceruminous glands; and wax secretion occurs in this part only

from sebaceous and ceruminous glands. Furunculosis of the external ear

occurs in this region from hair follicle and is very much painful as skin is

adherent to perichondrium.

(b) Bony part: forms the inner 2/3rd. Skin lining this part is thin and there is no

hair follicles, sebaceous or ceruminous glands.

Nerve Supply to external ear:89

Sensory nerve supply of the external ear: The auricle is supplied by fibres of the

great auricular nerve (C2 & C3) and lesser occipital nerve (C2). Auriculo-temporal

branch of the 5th cranial nerve and auricular branch of the vagus (Arnold’s nerve)

supply external canal. Facial nerve has small sensory contribution on the posterior-

inferior wall.

Tympanic Membrane or the Drumhead:90

It forms the partition between the external acoustic canal and the middle ear. It is

obliquely set and as a result, its posterosuperior part is more lateral than its antero-

inferior part. It is 9-10 mm tall, 8-9 mm wide and 0.1 mm thick. Tympanic

membrane can be divided into two parts:



(a) Pars Tensa

It forms most of tympanic membrane. Its periphery is thickened to form a

fibrocartilaginous ring called the annulus tympanicus which fits in the tympanic

sulcus. The central part of parts tensa is tented inwards at the level of the tip of

malleus and is called the umbo. A birght cone of light can be seen radiating from

the tip of malleus to the periphery in the anteroinferior quadrant.

(b). Pars Flaccida (Shrapnel’s Membrane)

This is situated above the lateral process of malleus between the notch of

Rivinus and the anterior and posterior malleal folds (earlier called the malleolar

folds). It is not so taut and may appear slightly pinkish.

Layers of Tympanic Membrane:

Tympanic membrane consists of three layers:

(i). Outer epithelial layer, which is continuous with the skin lining the meatus.

(ii). Inner mucosal layer, which is continuous with the mucosa of the middle ear.

(iii). Middle fibrous layer, which encloses the handle of malleus and has three types

of fibers the radial, circular and the parabolic.

Fibrous layer in the pars flaccida is thin and not organized into various fibres as in

pars tensa.



THE MIDDLE EAR91

The middle ear or tympanic cavity is an irregular, laterally compressed space

within the temporal bone. It is filled with air, which is conveyed to it from the nasal

part of the pharynx through the auditory tube. It contains a chain of movable bones,

which connect its lateral to its medial wall, and serve to convey the vibrations

communicated to the tympanic membrane across the cavity to the internal ear. The

tympanic cavity consists of two parts: the tympanic cavity proper, opposite the

tympanic membrane, and the attic or epitympanic recess, above the level of the

membrane; the latter contains the upper half of the malleus and the greater part of

the incus. Including the attic, the vertical and antero-posterior diameters of the

cavity are each about 15 mm. The transverse diameter measures about 6 mm. above

and 4 mm. below; opposite the center of the tympanic membrane it is only about 2

mm. The tympanic cavity is bounded laterally by the tympanic membrane; medially,

by the lateral wall of the internal ear; it communicates, behind, with the tympanic

antrum and through it with the mastoid air cells, and in front with the auditory

tube.The middle ear together with the Eustachian tube, aditus, antrum and mastoid

air cells is called the middle ear cleft. It is lined by mucous membrane and filled

with air.

The middle ear extends much beyond the limits of tympanic membrane

which forms its lateral boundary and is sometimes divided into (i) mesotympanum

(lying opposite the pars tensa), (ii) epitympanum or the attic (lying above the pars



tensa but medial to Shrapnel’s membrane and the bony lateral attic wall), (iii).

Hypotympanum (lying below the level of pars tensa). The portion of middle ear

around the tympanic orifice of the Eustachian tube is sometimes called the

protympanum.

Middle ear can be likened to a six sided box with a roof, a floor, medial,

lateral, anterior and posterior walls.

Tegmental Wall or Roof (paries tegmentalis) is formed by a thin plate of bone, the

tegmen tympani, which separates the cranial and tympanic cavities. It is situated on

the anterior surface of the petrous portion of the temporal bone close to its angle of

junction with the squama temporalis; it is prolonged backward so as to roof in the

tympanic antrum, and forward to cover in the semicanal for the Tensor tympani

muscle. Its lateral edge corresponds with the remains of the petrosquamous suture.

The Jugular Wall or Floor (paries jugularis) is narrow, and consists of a thin plate

of bone (fundus tympani) which separates the tympanic cavity from the jugular

fossa. It presents, near the labyrinthic wall, a small aperture for the passage of the

tympanic branch of the glossopharyngeal nerve.

The Membranous or Lateral Wall (paries membranacea; outer wall) is formed

mainly by the tympanic membrane, partly by the ring of bone into which this



membrane is inserted. This ring of bone is incomplete at its upper part, forming a

notch (notch of Rivinus), close to which are three small apertures: the iter chordæ

posterius, the petrotympanic fissure, and the iter chordæ anterius.

The Labyrinthic or Medial Wall (paries labyrinthica; inner wall) is vertical in

direction, and presents for examination the fenestræ vestibuli and cochleæ, the

promontory, and the prominence of the facial canal.

The fenestra vestibuli (fenestra ovalis) is a reniform opening leading from the

tympanic cavity into the vestibule of the internal ear; its long diameter is horizontal,

and its convex border is upward. In the recent state it is occupied by the base of the

stapes, the circumference of which is fixed by the annular ligament to the margin of

the foramen.

The promontory (promontorium) is a rounded hollow prominence, formed by the

projection outward of the first turn of the cochlea; it is placed between the fenestræ,

and is furrowed on its surface by small grooves, for the lodgement of branches of the

tympanic plexus. A minute spicule of bone frequently connects the promontory to

the pyramidal eminence

The prominence of the facial canal (prominentia canalis facialis; prominence of

aqueduct of Fallopius) indicates the position of the bony canal in which the facial



nerve is contained; this canal traverses the labyrinthic wall of the tympanic cavity

above the fenestra vestibuli, and behind that opening curves nearly vertically

downward along the mastoid wall.

The mastoid or posterior wall (paries mastoidea) is wider above than below, and

presents for examination the entrance to the tympanic antrum, the pyramidal

eminence, and the fossa incudis.

The Carotid or Anterior Wall (paries carotica) is wider above than below; it

corresponds with the carotid canal, from which it is separated by a thin plate of bone

perforated by the tympanic branch of the internal carotid artery, and by the deep

petrosal nerve which connects the sympathetic plexus on the internal carotid artery

with the tympanic plexus on the promontory. At the upper part of the anterior wall

are the orifice of the semicanal for the Tensor tympani muscle and the tympanic

orifice of the auditory tube, separated from each other by a thin horizontal plate of

bone, the septum canalis musculotubarii. These canals run from the tympanic

cavity forward and downward to the retiring angle between the squama and the

petrous portion of the temporal bone

The auditory tube (tuba auditiva; Eustachian tube) is the channel through which

the tympanic cavity communicates with the nasal part of the pharynx. Its length is

about 36 mm., and its direction is downward, forward, and medialy, forming an



angle of about 45 degrees with the sagittal plane and one of from 30 to 40 degrees

with the horizontal plane. It is formed partly of bone, partly of cartilage and fibrous

tissue.

The osseous portion (pars osseo tubæ auditivæ) is about 12 mm. in length. It begins

in the carotid wall of the tympanic cavity, below the septum canalis musculotubarii,

and, gradually narrowing, ends at the angle of junction of the squama and the

petrous portion of the temporal bone, its extremity presenting a jagged margin which

serves for the attachment of the cartilaginous portion.

The cartilaginous portion (pars cartilaginea tubæ auditivæ), about 24 mm. in

length, is formed of a triangular plate of elastic fibrocartilage, the apex of which is

attached to the margin of the medial end of the osseous portion of the tube, while its

base lies directly under the mucous membrane of the nasal part of the pharynx,

where it forms an elevation, the torus tubarius or cushion, behind the pharyngeal

orifice of the tube. The upper edge of the cartilage is curled upon itself, being bent

laterally so as to present on transverse section the appearance of a hook; a groove or

furrow is thus produced, which is open below and laterally, and this part of the canal

is completed by fibrous membrane. The cartilage lies in a groove between the

petrous part of the temporal and the great wing of the sphenoid; this groove ends

opposite the middle of the medial pterygoid plate. The cartilaginous and bony

portions of the tube are not in the same plane, the former inclining downward a little



more than the latter. The diameter of the tube is not uniform throughout, being

greatest at the pharyngeal orifice, least at the junction of the bony and cartilaginous

portions, and again increased toward the tympanic cavity; the narrowest part of the

tube is termed the isthmus. The position and relations of the pharyngeal orifice are

described with the nasal part of the pharynx. The mucous membrane of the tube is

continuous in front with that of the nasal part of the pharynx, and behind with that of

the tympanic cavity; it is covered with ciliated epithelium and is thin in the osseous

portion, while in the cartilaginous portion it contains many mucous glands and near

the pharyngeal orifice a considerable amount of adenoid tissue, which has been

named by Gerlach the tube tonsil.

Ossicles of the Middle Ear:

There are three ossicles in the middle ear the malleus, incus and stapes.

The malleus: has head, neck, handle, (manubrium), a lateral and an anterior process.

Head and neck of malleus lie in the attic. Manubrium is embedded in the fibrous

layer of the tympanic membrane. The lateral process forms a knob-like projection on

the outer surface of the tympanic membrane and gives attachment to the anterior and

posterior maleal (malleolar) folds.

The incus has a body and a short process, both of which lie in the attic, and a long

process which hangs vertically and attaches to the head of stapes.

The stapes has a head, neck, anterior and posterior crura and a footplate. The

footplate is held in the oval window by annular ligament.



The ossicles conduct sound energy from the tympanic membrane to the oval window

and then to the inner ear fluid.

Mastoid antrum:

In the posterior wall of the middle ear cavity there is an opening in the upper portion

which extends from the attic to mastoid antrum. The mastoid antrum is an air

chamber in the temporal bone that communicates anteriorly with the tympanic cavity

through the aditus. Posteriorly, it communicates with the mastoid air cells. During

the development of the mastoid process, the bone is normally filled with marrow.

Only the mastoid antrum and a few periantral cells are present at birth. With

development, the mastoid process becomes cellular in majority of cases which is

regarded as normal.

Lining of the middle ear cleft:

The mucous membrane of the middle ear cavity has a very important role in this

study. A thin delicate mucous membrane lines the whole of the middle ear cavity

and is reflected on to the ossicles and the tendons of tensor tympani and stapedius

muscles. It is continuous with the mucous membrane of the Eustachian tube and the

mastoid antrum. In general, it consists of a single non-ciliated cuboidal epithelium,

two or three cells deep, without a basement membrane, but in parts the cells may be

of simple or ciliated columnar type, especially near the Eustachian tube and in the

hypotympanum.



The mucous membrane is thrown into a series of folds by the intratympanic

structures. They are important surgically because they divide the middle ear into

compartments and carry blood vessels to the ossicular chain. The ossicular chain,

ligaments, tendons, tensor tympani and stapedius muscles, chorda tympani nerve are

described by Procter as the viscera of the tympanic cavity. The mucosal folds are

considered as its mesenteries.

Intertympanic Muscles:

There are two muscles tensor tympani and the stapedius; the former attaches to

the neck of malleus and tenses the tympanic membrane while the latter attaches to

the neck of stapes and helps to dampen very loud sounds thus preventing noise

trauma to the inner ear, Stapedius is a 2nd arch muscle and is supplied by a branch of

CN VII while tensor tympani develops from the 1st arch and is supplied by a branch

of mandibular nerve(V).

Blood Supply of Middle Ear:

Middle ear is supplied by six arteries, out of which two are the main, i.e.

I. Anterior tympanic branch of maxillary artery which supplies tympanic

membrane.

II. Stylomastoid branch of posterior auricular artery which supplies middle ear

and mastoid air cells.



Four minor vessels are:

I. Petrosal branch of middle meningeal artery (runs along greater petrosal

nerve).

II. Superior tympanic branch of middle meningeal arery traversing along the

canal for tensor tympani muscle.

Branch of artery of pterygoid canal (runs along Eustachian tube).

(iv). Tympanic branch of internal carotid

Veins drain into pterygoid venous plexus and superior petrosal sinus.

Lymphatic Drainage of Ear

Lymphatics from the middle ear drain into retropharyngeal and parotid nodes while

those of the Eustachian tube drain into retropharyngeal group.

Surgical importance:

1. The middle ear is part of contiguous organs including nose, nasopharynx,

Eustachian tube and mastoid bone lined by respiratory mucosa. Any

respiratory infection or allergy is likely to pass to the middle ear.

2. Moreover middle ear suppurative disease may spread to adjacent organs and

produce complications. E.g., labyrinthitis, meningitis, facial nerve palsy, etc.,

3. Lenticular process is vulnerable in suppurative ear disease and causes

ossicular disruption.

4. Prussac’s space is the site of primary acquired cholesteatoma.92



INNER EAR:

Inner ear has two parts93

• Bony labyrinth

• Membranous labyrinth

The bony labyrinth is lined by endosteum. Between bony labyrinth and membranous

labyrinth lies the perilymph. It has three parts.

• Vestibule

• Cochlea

• Semicircular canals.

Membranous labyrinth is filled with endolymph and it consists of

• Saccule and utricle

• Membranous Semicircular ducts within the corresponding bony canals.

• The cochlear duct

Vestibule is the central part of the internal ear. On its lateral surface is the opening

of oval window which is closed by the foot plate of stapes. Bony cochlea lies in

front of the vestibule. It has 2.75 turns coiling around a bony axis called modiolus.

Cochlea is approximately 30 mm in length. The hollow centre of the modiolous is a

spiral canal containing the fibres and ganglion cells of cochlear nerve. A thin bony

sheet, the Osseous lamina winds around the modiolus. This divides the cochlear

canal into two galleries, the Scala vestibuli above and the Scala tympani below.



Semicircular canals are three in number, superior, posterior and lateral. They are

semicircular in shape and opens into the vestibule. One of the ends of the

semicircular is enlarged and is known as ampulla.

Membranous labyrinth is situated within the bony labyrinth. It is connected to the

bony labyrinth by fibrous trabeculae and is surrounded by perilymph. Endolyrnph is

situated within the membranous labyrinth.

The Utricle lies in the upper part of the vestibule while the Saccule lies below.

Utricle and Saccule both contain a single sensory patch called Macula. Each macula

is covered by neuroepithelium. Neuroepithelium consists of sensory hair cells and

supporting cells, these cells are separated by basement membrane. Fibres from the

vestibulo cochlear nerve enter the macula and pierce the basement membrane to end

either at the base of the hair cell or cell bodies. The utricle and saccule with their

macula is refered to as otolith organs.

Membranous semicircular ducts are the membranous ducts in the corresponding

bony semicircular canals. They open into the utricle by five openings. One end of

the opening of each canal is dilated called ampulla in which the sensory organ of

each canal is located.



The cross section of Scala media resembles a right angle. Its base is formed by

basilar membrane. Upon the surface of the basilar membrane the sensory cells are

arranged. These sensory cells with their supporting cells form a complex

neuroepithelium called the basilar papilla or Organ of corti named after an Italian

Microscopist. Organ of corti has a gelatinous membrane called tectorial membrane

and they are supported by pillar of corti. The pillars of corti enclose a space called

tunnel of corti which contains fluid called cortilymph.

Chart No-2 Showing the Blood supply of Labyrinth

Blood supply of labyrinth:

Labyrinthine artery

Common cochlear Anterior vestibular artery

Vestibulocochlear artery Main cochlear artery

Cochlear branch posterior vestibular artery

PHYSIOLOGY OF HEARING:

A sound signal in the environment is collected by the pinna, passes through external

auditory canal and strikes the tympanic membrane. Vibrations of the tympanic

membrane are transmitted to stapes footplate through a chain of ossicles coupled to



the tympanic membrane. Movements of stapes foot plate cause pressure changes in

labyrinthine fluids which move the basilar membrane. This stimulates the hair cells

of the Organ of corti. It is these hair cells which act as transducers and convert

mechanical energy to electrical impulses which travel along the auditory nerve.

Thus, the mechanism of hearing can be broadly divided into:

Mechanical conduction of sound (conductive apparatus)

Transduction of mechanical energy to electrical impulses (sensory system of

cochlea)

Conduction of electrical impulses to brain (neural pathways) Conduction of

sound:

Conduction of sound:

Under the surface of water we cannot hear the sound made in air because 99.95 of

sound energy are reflected away from the surface of water because of the impedance

offered by it. A similar situation exists in the ear when air-conducted sound has to

travel to cochlear fluids. Nature has compensated for this loss of sound energy by

interposing the middle ear which converts sound of greater amplitude, but lesser

force, to that of lesser amplitude and greater force. This function of middle ear is

called impedance matching mechanism or the transformer action. It is accompanied

by:

a) Lever action of the ossicles.

Handle of malleus is 1.3 times longer than long process of incus, providing a

mechanical advantage of 1.3



b) Hydraulic action of tympanic membrane.

The area of tympanic membrane is much larger than the area of stapes foot plate, the

average ratio between the two being 21:1. As the effective vibratory area of the

tympanic membrane is only two- thirds, the effective areal ratio is reduced to 14:1,

and this is the mechanical advantage provided by the tympanic membrane.

c) Curved membrane effect.

Movements of tympanic membrane are more at the periphery than at the center

where handle of malleus is attached. This too provides some leverage.

Transduction of mechanical energy to electrical impulses:

Movements of stapes footplate, transmitted to cochlear fluids, move the basilar

membrane, setting up shearing force between the tectorial membrane and hair cells.

The distraction of hair cells gives rise to cochlear microphonics which triggers the

nerve impulse.

Neural pathways:

Hair cells get innervation from bipolar cells of spiral ganglion. Central axons of

these cells collect to form cochlear nerve which goes to ventral and dorsal cochlear

nuclei. From there, both crossed and uncrossed fibers travel to superior olivary

nucleus, lateral lemniscus, inferior colliculus, and medial geniculate body and finally

reach the auditory cortex of the temporal lobe94.



DISEASE REVIEW

NIDANA:-

The common etiological factors of Karnaroga are as follows:-46

1. Avashyaya (Excessive exposure to cold)

2. Jalakreeda (Excessive swimming)

3. Karnakandooyanam (Excessive scratching)

4. Mithyayaogena shabdasya (Perverted contact of sound)

5. Mithyayogena shastrasya (improper instrumentation)

6. Abhighata (trauma)

7. Vitiation of tridoshas.

KARNASRAVA SAMANYA NIDANA:

Table No. 1 Showing the Karnasrava samanya nidana according to various

authors.

Sl.No. Samanya Nidana SU47 AH48 AS49 YR50 MN51

1 Avashyaya + + +

2 Pratishayaya + +

3 Karnakandooyana + + + + +

4 Shabda mithyayoga + +

5 Shastra mithyayoga + + +

6 Jalakreeda + + + + +

7 Abhighata + + +



VISHESHA NIDANA OF KARNASRAVA52

• Shiroabigata

• Jala nimajjana

• Karnaprapaka

• Karna vidradhi

SAMPRAPTI:

Due to common and specific etiological factors the vitiated doshas gets

sthanasamshraya in karna and cause Karnasrava. It is the stages of samprapthi were

doshas gets lodged in srotas. And starts process of dosha dooshya sammurchana53 .

Due to shiroabhigata, jala nimmajjana, karna paka, karna vidradi, vitiates vata

dosha and karna becomes avruta by vata and results in karnasrava54.

Normal physiology of dosha, dhatus, and malas entirely depends on the normality of

srotas. Dosha dooshya sammurchana or manifestation of disease will not take place

if only vitiation of doshas takes place without deformity of srotas55.

Types of vitiation of srotas are atipravrutti sanga, vimargagamana, and siragranthi.

Here in karnasrava, Atipravrutiti, sanga and vimargagamana takes place56.



Sanga is the obstruction of Eustachian tube; atipravrutti is being excess secretion

and discharge from the middle ear mucosa.

Vimargagamana is the propagation of discharge through external auditory meatus.

Chart No. 3 Representing the samprapti of Karnasrava57.

Samanya and vishesha nidana

↓

Vitiates vata

↓

Avarana by kapha,pitta

↓

Vimargagamana of vata

↓

Srava from karna

SAMPRAPTI GHATAKAS:

Dosha –Predominently vata,

Dooshya – Rasa,Rakta ,Mamsa

Srotas – Shabdavaha

Srotodusti – Sanga, vimarga gamana, Atipravrutthi.

Adhistana – Karna

Rogamarga - Madyama



Poorvaroopa:

Poorvaroopa of karnasrava is not mentioned separately in any Ayurvedic

classics. In practice certain poorvaroopas are noticed. The following features can be

considered as the premonitory symptoms of karnasrava.

• Karnashoola

• Karna gurutwa (Eustachian tube blockage)

• Nasavarodha

• Prathishyaya.

• Discomfort in throat. etc.

ROOPA58:

Only puyasrava is mentioned as symptom but here puyasrava refers to different

nature of discharge like Jalasrava, rasasrava which can be considered as watery,

mucopurulent and purulent discharge.

UPASHAYA AND ANUPASHAYA:

A judicious application of Aushadhi, Ahara and Vihara, when produces relief in

the symptoms is called as Upashaya and when aggravates the symptoms is called as

Anupashaya.

There is no reference available in the classics about the Upashaya and Anupashaya

of Karnasrava.



SADHYASADHYATA:

Sadhyasadhyata gives the clear picture of prognosis of the disease. It depends on

many factors like nature of disease, severity of the disease, Vaya, prakriti, bala of

the patient etc.

Sushruta has not mentioned specifically the sadhyaasadhyata of the karnarogas.

But Vagbhata has mentioned Karnasrava as a Sadhyavyadhi59.

UPADRAVA OF KARNASRAVA:

In the classics, there is no reference available regarding the upadrava of

Karnasrava.



Table No.2 Showing the sapekshanidana of Karnasrava.

Karnasrava60 Pootikarna61 Karnavidradhi62 Sannipataja

Karnashoola63

Kaphaja

karnashoola64

Nidana

Shirobhighhata

Jalanimajjana

karnaprapaka

karnavidradhi

Tridoshakara

Kshata

Abhighata

TRidoshakara

Tridoshakara Kaphakara

Nature of

Srava Puyasrava

Ghanasrava

Puyasrava

Rakta, Peeta,

Aruna Varna

Raktasrava

Sita, Asita,

Rakta,

Ghanasrava

Shweta srava

Pooti

gandha - + - - -

Vedana +/- + +(severe) +(mild)

Other

symptoms -

Bahukleda,

Daha

Dhoomayana

Daha, Chosha

Jwara,

Srutijadyata

Kandu; shiro,

hanu, Greeva

guarava

Prognosis Sadhya Sadhya Sadhya Asadhya Sadhya

Dosha

involved Vata Tridhosha Tridosha Tridosha Kapha

SAMANYA CHIKITSA:

In all the karna rogas, the following principles are told as the general line of

treatment.

• Ghritapana, Rasayana sevana, Brahmacharya palana should be followed for

the preservation of dhatu samyata and restriction of vitiation of Vata65.

• Ativyayama, Atibhashana and Ashira snana should be avoided to protect the

shiras from the affliction of Vata and Kapha66.



Samanya chikitsa for Karnasrava, Pootikarna and krimikarna67:

In all these conditions, Shirovirechana, Dhoopana, Karnapoorana, Pramarjana,

Prakshalana (Dhavana) should be done based on the necessity.

Vishesha Chikitsa for Karnasrava:

• General treatment principles of Karnasrava described in classics is closely

related to Dustavrana chikitsa68.

• In addition to that Shirovirechana, Karna dhoopana, Karna purana, Karna

Pramarjana, Karna dhavana are also indicated69.

Following treatments are also mentioned:

• Karna prakshalana with aragwadadi gana kashaya and surasadigana

kashaya70.

• Surasadigana and argwadadigana churna for avachurnana.71

Following yogas mentioned for karnapoorana:

a. Panchakashaya with kapittha swarasa and madhu .72

b. Sarjatwak choorna with karpasiphalarasa and madhu.73

c. Laksha, rasanjana with sarjachoorna.74

d. Shaivala, Mahavriksha, jambu, amra pallava kulira, kshuodra and manduki

all are taken in equal quantity and kalka is prepared and 4 times taila is taken

and 16 parts of kwatha is added and taila paka is done75.



e. Tinduka, abhaya, lodra, samanga (manjista) kwatha of this, dravyas mixed

with madhu and kapittha rasa.76

Dhoopana yoga:

• Dhoopana with guggulu .77

• Dhoopana with the choorna of Bilvapatra, husk, haridra, palandu.78

According to vagbhata:

• Ear should be cleaned with the pichu or varthi followed by guggulu

dhoopana, karnapoorana with madhu.Followed by Avachurnana with

sukshmachoorna of surasadigana.79

Yoga rathnakar:

Mentioned following drugs for karnapoorana

• Samudra phena choorna.80

• Jambuadi taila.81

Internal medications:

• Rasnadi guggulu.82

• Triphala guggulu.83

• Sarivadi vati.84

• Gandhaka rasayana.85



PATHYAAPATHYA:86

Pathya apathya mentioned for samanya karnaroga is recommended in karnasrava

also.

PATHYA:

Aharaja: Viharaja

• Godhuma Brahmacharya

• Shala Abhashanam

• Mudga Mitabhashanam

• Yava Avyayama

• Puranagrita Upacharaja

• Lava,Harina,Tittira mamsa Vamana

• Patola ,shigru, Vartaka Virechana

• Sunishannaka Nasya,Dhoomapana

• Kathillaka Siravyada

• Vanakukkuta Kavala, Gandoosha

• And all types of rasayana

APATHYAS:87

• Guru, Kaphakara aharas

• Abhishyandakara aharas

• Dhantadavana

• Shirasnana

• Vyayama

• Karna kandooyana

• Tushara sevana



CHRONIC SUPPURATIVE OTITIS MEDIA

History:95

The existence of chronic suppurative otitis media in prehistoric times has

been clearly documented. [mekenzil and brothwell 1967]

Definition:

It is defined as a long standing chronic suppuration of the middle ear cleft

and its muco periosteal lining resulting in discharging ear and deafness.

Aetiology:

1. Environmental:

a. Socio-economic group: The lower groups having a higher incidence.

b. Unhygienic conditions: Leads to recurrent respiratory tract infections

2. Genetic:

The question as to wheather one race is more Predisposed to c.s.o.m

remains unanswered. The importance of genetic factor was deleted in

particular wheather the incidence was related to the size of the

mastoid air cell system which was considered to be genetically

determined.

Mastoid air cell system is smaller in individuals with otitis media, but

it is not known whether this is a primary or secondary event.



3. Previous otitis media

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

acute otitis media or otitis media with effusion.

4. Infective

They are mainly gram negative usually streptococci, staphylococci,

pneumococci Bacteria can almost invariably be isolated form the

mucopus or from mucosa of the middle ear in active chronic suppurative

otitis media.

5. Upper respiratory tract infections

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

resistance to the organisms that are normally in the middle ear, allowing

bacterial overgrowth.

6. Allergic:

Though postulated by some as an importance factor; it remains to be

proven that allergic individuals have a higher incidence.

7. Eustachian tube malfunction:

In active chronic suppurative otitis media the eustachian tube is

frequently blocked by oedema. Eustachian tube in infants and young

children is shorter ,wider and more horizontal. Breast or bottle feeding in



a young infant in horizontal position may force fluids through the tube

into middle ear. So keep the infant propped up with head a little higher.

Specific pathology:

Inactive chronic otitis media:

By definition, tympanic membrane is abnormal in inactive chronic otitis media and

the clinical appearance depends upon 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 within the middle ear. This has practical

implications for myringoplasty.

Active mucosal disease:

The extent to which mucosa of the middle ear and mastoid is affected varies. Areas

that usually have a non secreting lining are replaced by a respiratory type, mucus

secreting mucosa with goblet cells.

The mucosa is generally hyperemic with an underlying inflammatory response.

Areas of granulation tissue may form especially in non draining areas, such as round

the ossicles. Depending on its severity there can be active resorption and remodeling



of bone, irrespective of weather a cholesteatoma is present, which can lead to a

fistula of the semicircular canal and dehiscence of the fallopian canal.

CLASSIFICATION OF CHRONIC SUPPURATIVE OTITIS MEDIA

Chronic suppurative otitis media is traditionally classified into two main groups

1. Tubotympanic (Safe from complications)

2. Attico – Antral (risk of intracranial suppuration)

Tubotympanic:

Here the disease is mainly confined to mucosa of the Eustachian tube and anterior

and inferior part of the tympanic cavity which is lined by respiratory type of

epithelium.

Tubotympanic disease is characterized by the presence of a central perforation and

the clinical presentation varies depending on extent and severity of the disease.

Factors influences the tubotympanic type are;

• Patency of the Eustachian tube

• Presence of a nidus of infection in the upper respiratory tact.

• Natural mucosal barrier to infection which is impaired in immune

compromised patients.

• The presence of mixed aerobic and anaerobic microbes.

• Extent and degree of mucosal changes

• Secondary migration of squamous epithilium



Clinically tubotympanic disease presents as symptoms.

1. Active disease: patient reports to the clinician with a

• Discharging ear

• Deafness

2. Inactive disease:

If bilateral the only presenting feature is deafness. (Conductive) while

in unilateral disease patient may not seek medial advice.

Description of clinical signs and symptoms

1. Recurrent otorrhoea;

Discharge is watery or mucoid and sometimes mucopurulent in character.

May be profuse at times but non foetid. Ear is dry in between infection.

2. Deafness- Progressive unless disease is controlled early

• Type: Conductive

• Severity: Mild to moderate depending on site and size of perforation.

3. Pain: usually absent, but may be present due to secondary infection or

associated otitis externa.

Examination:

Includes:

• Inspection of the ear

• Otoscopic examination



• Examination of nose, pharynx and postnasal space to assess the state of the

upper respiratory tract.

1. Inspection of the ear:

Inspection with a head mirror to evaluate

• Type of discharge, colour, consistency and odour

• Secondary otitis externa may be present .

2. Otoscopic examination:

Evaluating

1. Site and size of the perforation

2. State of the remainder of the tympanic membrane

3. Nature of the middle ear mucosa

1). Site and size of the perforation

Site – Antero – superior, Antero – inferior or postero – superior or postero – inferior

quadrant is involved.

2). State of the remainder of the tympanic membrane

Note presence of any tympanosclerosis, lack of middle fibrous layer around the

central perforation.

3). Nature of middle ear mucosa:

Note weather – oedematous, slightly injected, red and velvety, presence of

tympanosclerotic plaques.

Investigations:



1. Examination under microscope:

It provides useful information regarding presence of granulations, in growth

of squamous epithelium from the edges of perforation.

Status of ossicular chain

Tympanosclerosis and adhesions

2. Audiogram:

To assess degree of hearing loss and its type. Usually it is conductive.

3. culture and sensitivity: to select proper antibiotic

4. Mastoid x-rays: Usually sclerotic, but may be pneumatised.

Treatment:96

1. Aural toilet: Remove all discharge and debris

It can be done by

I. Dry mopping

II. Suction clearance

2. Ear drops: Antibiotic ear drops containing neomycin, polymyxin, chloromycetin

or gentamicin are used.

These are combined with steroids which have local anti inflammatory effect.

1. Systemic antibiotics: in acute exacerbation of chronically infected ear.

2. Precautions; Keep water out of ear during bathing, swimming and hand wash

3. Treatment of contributory causes:

Like infected adenoids, tonsils, nasal allergy.



Surgical treatment:

Aural polyp or granulations if present should be removed before local

treatment.

Once ear is dry myringoplasty with or without ossicular reconstruction can

be done.

Purpose: 1. To close the perforated drum and avoid recurrent discharge.

2. To restore hearing

Atticoantraltype: ::

It involves postero superior part of middle ear cleft (Attic, antrum, posterior

tympanum and mastoid.) and is associated with cholesteatoma because of its bone

eroding properties, causes risk of serious complications.

Cholesteatoma:97

Normally, middle ear cleft is lined by difference types of epithelium.

1.Ciliated columnar epithelium in antero inferior part

2. Cuboidal in middle part

3. Pavement like in attic

The middle ear is no where lined by keratinized squamous epithelium. If it is present

in the middle ear or mastoid that constitutes a cholesteatoma.



Origin:

1. Presence of congenital cell rests

2. Invagination of tympanic membrane from attic or posteriosuperior part of

pars tensa. In the form of retraction pocket (wittmacks theory)

3. Basal cell hyperplasia (Ruedis theory)

4. Epithelial invasion (Habermanns theory)

From meatus or outer tympanic membrane surface.

5. Metaplasia of middle ear mucosa.[sades theory]

Pathological process

1. Cholesteatoma

2. Ostetis and granulation tissue

3. Ossicular necrosis

4. Cholesterol granuloma – mass of granulation tissue with foreign body

giant cells.

Symptoms:

1. Ear discharge: usually scanty, always foul smelling.

2. Hearing loss: mostly conductive but sensorineural element may be added.

3. Bleeding may occur from granulations or polyp, while cleaning the ear.

Signs:

1. Perforation: Attic or postero superior marginal type

2. Retraction pocket: an invagination of tympanic membrane is seen in the attic

or postero superior area of pars tensa.



3. Cholesteatoma: pearly white flakes of cholesteatoma can be sucked from the

retraction pockets.

Investigations:

1. Examination under microscope: for presence of cholesteatoma its site and

extent, evidence of bone destruction, granuloma, condition of ossicles.

2. Tuning fork tests and audiogram: to confirm degree and type of hearing loss.

3. X-Ray mastoids / CT scan temporal bone.

Indicate extent of bone destruction and degree of mastoid pneumatisation

4. Culture and sensitivity of ear discharge.

To select proper antibiotic

Treatment:

Surgical:

It is the mainstay of treatment

1. Primary aim in surgical treatment is to remove the disease and render the

ear safe.

2. To preserve or reconstruct the hearing but never at the cost of the primary

aim.

1. Modified radical mastoidectomy:

The disease is eradicated from the epitympanum and mastoid bone. Outer

attic wall and posterior meatal wall are removed. So that mastoid cell area

and attic become a common cavity.


Department of PG Studies in Shalakyatantra, GAMC, Be

ngaluru 48

2. Radial mastoidectomy: this operation is to eradicate disease of the middle ear

and mastoid in which the mastoid antrum, attic and middle ear are

exteriorized. So that they form a common cavity with the external canal.

Complications of Csom:98

• Postauricular abscess

• Facial nerve paresis

• Labyrinthitis

• Labyrinthine fistula

• Mastoiditis

• Temporal abscess

• Petrositis

• Intracranial abscess

• Meningitis

• Otitic hydrocephalus

• Sigmoid sinus thrombosis

• Encephalocele

• CSF leak

Pathophysiology:

Spread of infection from the ear and temporal bone causes intracranial complications

of otitis media. Spread of infection occurs through 3 routes, namely, direct

http://emedicine.medscape.com/article/232915-overview



extension, thrombophlebitis, and hematogenous dissemination. Extracranial

complications are usually direct sequelae of localized acute or chronic inflammation.

• The following signs or symptoms are suggestive of intracranial

complications:99

o Fever associated with a chronic perforation

o Lethargy

o Focal neurologic signs (eg, ataxia, oculomotor deficits, seizure)

o Papilledema

o Meningismus

o Altered mental status

o Severe headaches

• The following signs or symptoms are suggestive of extracranial

complications:

o Fever associated with a chronic perforation

o Postauricular edema or erythema

• Facial nerve paresis or paralysis

• Fetid otorrhea

• Retro-orbital pain on the side of the infected ear.

• Vertigo

• Spontaneous nystagmus associated with sensorineural hearing loss.

• An infected ear

• Presentation of extracranial complications includes the following:



o Labyrinthitis - Fever, nystagmus, serous or suppurative otitis media.

o Mastoiditis with subperiosteal abscess - Fever, fluctuance overlying.

the mastoid area, lateral displacement of pinna, otitis media.

o Petrositis - Retro-orbital pain, otorrhea, abducens paralysis, fever.

• Presentation of intracranial complications includes the following:

o Brain abscess - Fever, possibly seizures or focal neurologic signs,

headache

o Meningitis - Fever, meningismus

o Otitic hydrocephalus - Headache, signs of increased intracranial

pressure in setting of otitis media

o Sigmoid sinus thrombosis - Spiking fever, otitis media, edema and

tenderness over mastoid cortex, headache



PROCEDURE REVIEW

Dhoopana is administering dhuma with the help of dhupana dravya.100

There are many references regarding Dhupana in Ayurvedic classics.

In Kashyapa Samhita there are 40 types of Dhoopana advised for children.

Anesthesia (mohajanana Dhoopa) is also mentioned .For this Dhoopana, the drugs

used were herbs, hairs of animals, legs, horns, hairs of Brahman, old clothes of

Buddhist monks.101

From the references available regarding dhoopana we can understand that karna can

be protected from maggots (Krimi), bacteria (Rakshogna), lice etc. References

clearly indicate the analgesic and disinfectant effect of Dhoopana karma time and

again.

Dhoopana is mentioned for dusta vrana chikitsa. It reduces vedana, srava,

pootiganda of dustavrana. It also helps in vrana ropana. Dustavrana chikitsa is

mentioned in the treatment of karnasrava.102

Origin of Dhoopana:103

Children of the rishis were constantly harassed by the rakshasas. So the sages/rishis

approached lord agni for shelter. Agni in turn gave them Dhoopana dravya and

asked the sages to use the Dhoopana for protection against rakshasas, bhutas,

pishachas.



Classification of Dhoopana:104

1. It is classified into Dhupa, Anudhupa and Pratidhupa.

2. On the basis of origin,It is classified into Jangama and Sthavara

Selection of guggulu for Dhoopana

1. Sayana introduced guggulu as a well known Dhoopana dravya.105

2. It is Best vatahara.106

3. It is Krimigna107.

4. As it contains oleoresin.108

5. In Astanga hrudaya Guggulu Dhoopana mentioned for Puya karna.109

Karna Dhoopana Indications:110

1. Karna srava.

2. Putikarna.

3. Krimikarna.

4. Vataja Karnashula .

5. Pakwa Puyavaha karna .111

Contraindications;

There is no mention of any contraindication of karna dhoopana in our classics



DRUG REVIEW

In this chapter attempt has been made to review the drugs used in the present study.

Shuddha guggulu was taken for Karna dhoopana in Group A and Rasnadi guggulu

was administered internally in Group B. In Group C both Guggulu karna dhoopana

and Rasnadi guggulu internally was administered.

Historical review of Guggulu:112

Guggulu has a long history of use in Ayurveda. Atharvaveda, one of the well-

known scripture (Vedas) of the Hindus, is the earliest reference to the medicinal and

therapeutic properties of Guggulu. Detailed description regarding the actions, uses,

and indications as well as the variety of Guggulu has been described in the

Ayurvedic classics by Charaka, Sushruta and Vagbhata. In addition, various

Nigantus (Medical lexicons) were written between 12th and 14th centuries A.D was

based on the Ayurvedic literature also describes Guggulu.

The explanation of word Guggulu is that Gunjo vyadhegurdti rakshati which means

to give relief against different diseases.

Guggulu is the best medicine, because it develops through the rays of hot sun on

specific circumstances. Guggulu has an aromatic odour.



1. GUGGULU:113

Latin name : Commiphora mukul

Family : Burseraceae

Rasa : Tikta, Katu

Guna : Laghu, Ruksha, Visada, sukshma, sara

Veerya : Usna

Vipaka : Katu

Action : Rasayana, Lekhana

Dosha karma : Tridoshahara

Chemical composition:

Oleoresin – Z- Guggulsterone, E – Guggulsterone

Gum – guggulignans I and II; gugguluTetrols, mukulol allylcembrol, c-27

guggulusterol I, II and III, Z and E – guggulusterol

Volatile oils- Phenol, euginol, cuminic aldehyde-2 pinine Limonene and

Sesquiterpines

Parts used: Gum oleoresin.

Guggulu lipid stimulates the activity of white blood cells in the body contributing to

the build up of the immune system. Guggulu lipid also helps to eliminate and expel

dead tissues, wastes, and toxins from the body.

Guggulu purity test:114

1. A yellowish brown emulsion is obtained when Guggulu is triturated with water.



2. An ethereal solution of the drug attains reddish colour when treated with br2

vapours and purple colour, when moistened with nitric acid.

In the present study Group B was treated with Rasnadi guggulu. The ingredients are

Rasna, Guduchi, Erandamula, devadaru, shunti.

Method of preparation of Rasnadi guggulu:115

One part each of Churna of Rasna, Guduchi, Erandamoola, Devadarau and shunti

were taken, to this 5 parts of shuddha guggulu is added and vati is prepared by

adding adequate quantity of gruta

2. RASNA:116

Latin name : Alpinia officinarum

Family : Zingiberaceae

Rasa : Tikta

Guna : Guru

Virya : usna

Vipak a : Katu

Dosha karma : Kapha– vatahara

Action : Vayastapana

Chemical composition: Galangin, kaemferide, diaryl heptanoid

3. GUDUCHI:

Latin name : Tinospora cordifolia

Family : Menispermaceae



Rasa : Tikta kashaya

Guna : guru, snigda

Virya : ushnaDahapra

Vipaka : Madhura

Dosha karma : Tridosha shamaka

Action : Rasayana, medya, deepaniya, grahi, medohara,

Kandugna, Jwarahara, shamana

Chemical composition: Tinosporin, Tinosporid and cordifolide

Pharmacological action:

C.N.S depressant antibacterial, antimicrobial, antipyretic, anti-inflammatory, anti-

arthritic, anti-allergic, hepatoprotective, analgesic, immunostimulant,

immunosuppressive, anti-neoplastic, anti-stress, anti-diabetic, anti-tumor,

adaptogenic, antioxidant , hypotensive, diuretic.

4. ERANDA:

Boranical name : Ricinus communis

Family : Euphorbiaceae

Rasa : Madhura, Katu kashaya

Guna : Snigda, Tikshna, Sukshma

Virya : Ushna

Vipaka : Madhura



Doshakarma : Kapha – vatahara

Action : Rechana, vrishya


Seeds and leaves - Ricinine

Seed coat - Lupeol, lipids, phosphatides

Seed oil - Arachidic, ricinoluc, palmitic

Pharmacological activities:

Anti-inflammatory, spasmogenic, Hepatoprotective, antifertility, purgative,

immunizing, C.N.S depressant.

5. DEVADARU:

Botnaical name : Cedrus deodara

Family : Pinaceae

Rasa : Tikta katu, kashaya

Guna : Laghu, ruksha

Virya : Usna

Vipaka : katu

Dosha – karma : kaphavatahara, dipana, kasahara

Action : Dipana, kasahara


Stem bark: deodarin, toxifolin

Pharmacological activities:



Antibacterial, Atherosclerotic, Antihistaminic, Anti- arthritic, Antiviral, Anti-

inflammatory, Anti- rheumatic, hypocholestremic, hypolipedemic, Anti-fertility,

increases high density serum cholesterol. Fibrinolytic activity.

It is useful in worm infestation. It is used as lotion for wounds and as gargle in

dental carries, weak and spongy gums.

Karma: Shoolahara. Vedanastapana, Vranshodana, Vranaropana

6. SHUNTI:

Botanical name : Zingiber officinale

Family : Scitaminae

Rasa : Katu

Guna : Guru, ruksa, tikshana

Veerya : Usna

Vipaka : Madhura

Dosha karma : vata kaphahara

Action : Deepana, bhedana


Alpha and Beta zingiberenes, zingiberol, Zingerone, gingerols.



MATERIALS AND METHODS

Aim of the study:

To evaluate the effect of Shuddha Guggulu Karnadhoopana and Rasnadi guggulu

internally in the management of Karnasrava.

The objectives of present study are:

1. To evaluate the efficacy of Shuddha Guggulu Karnadhoopana in the

management of Karnasrava.

2. To evaluate the efficacy of Rasnadiguggulu internally in the management of

Karnasrava.

3. To compare the effects of Shuddha Guggulu Karna Dhoopana procedure and

Rasnadi Guggulu internal administration.

Source of data:

Patients with classical features of Karnasrava selected from the OPD and IPD of

Shalakya tantra SJIIM Hospital Bengaluru.

Sampling method:

The patients diagnosed as Karnasrava were selected randomly irrespective of

their sex, caste, and socio economic status. The patients were examined in detail as

per the specially prepared case sheet proforma which includes both Ayurvedic and

Modern methods of examination.



Criteria for selection of patients:

Inclusion criteria:

1. Patients in the age group of 5 yrs to 65 yrs.

2. Chronicity of Karnasrava of more than 3 months.

3. Karnasrava associated with conductive deafness.

4. Karnasrava without any systemic complications.

5. Central perforations of tympanic membrane – pin hole, small, subtotal.

Exclusion criteria:

1. Patients below 5 yrs and above 65 yrs.

2. Karnasrava of less than 3 months chronicity.

3. Attic, marginal, total perforation of tympanic membrane.

4. Blood stained and fetid ear discharge.

5. Karnasrava associated with Sensori-neural and mixed deafness.

6. Karnasrava associated with other systemic disorders.

Investigations:

• Pure tone Audiometry

• Blood for hemoglobin percentage

• Total count

• Differential count

• Erythrocyte sedimentation rate



Research design:

Patients were randomly divided into 3 groups group A, Group B and Group C.

Table No.3 Showing the Study design:

Groups Chikitsta Prayoga Prayogaavadhi Nireekshana

A Karnadhoopana

with guggulu For 7 days

2 sittings of 7 days

each with an interval

of 2 weeks i.e30 days

3 months

B

Rasnadigugglu

interal

administration

Two tables (each

500mg) twice a

day for 30 days

30 days 3 months

C

Karnadhoopana

withguggulu

along with

rasnadiguggulu

internal

administration

Dhoopana 7 days

rasnadigugglu

two tables twice a

day

30 days of 2 sittings

of 7 days each with a

gap of 2 weeks

Rasnadi gugglu 3o

days

3 months

Method of Karnadhoopana

Poorva karma:

The patient is asked to sit comfortably on a chair, in a place having sufficient light

and devoid of dust. The effected ear is cleaned thoroughly with cotton swab.

Pradhanakarma:

The patient is asked to relax completely on the chair, and fumes are passed to the ear

with dhoopana yantra.



Dhoopana yantra has two ends one which is funnel shaped kept covering the ear for

the passage of dhuma into the ear canal and the other end in which shudda guggulu

is sprinkled over a ignited charcoal to produce fumes. This dhoopana was given for

5 minutes.

Paschat karma:

After this procedure, the patient is advised to avoid cold and refrigerated food and

drinks, cold water bath, cold wind, fog, and prevent water from entering the ear.

Follow-up study:

After the completion of treatment all the patients are advised to attend the OPD once

in 30 days, upto a period of 3 months for the follow up study.

The drug formulations taken up for the study are;

1. Shuddha Guggulu

2. Rasnadi Guggulu

Collection of drugs:

All the raw materials and Shuddha Guggulu were procured and purchased from

reliable Ayurvedic raw material vender.

Preparation of Rasnadi guggulu:

Was done in Bhaishajya Department of G.A.M.C., Bangalore.

Method of preparation of Rasnadi guggulu:

One part each of Churna of Rasna, Guduchi, Erandamoola, Devadarau and Shunti

were taken. To this 5 parts of Shuddha guggulu is added and vati is prepared by

adding adequate quantity of Gruta.



Criteria for assessment of effects of the treatment:

1. Impaired hearing

2. Otoscopic examination

A.Ear discharge

B.Perforation

3. Pure tone Audiometry

Table No.4, Showing the Subjective and objective Parameters

SUBJECTVE PARAMETERS

Impaired hearing 0 – Absent

1 – Unable to hear whispering voice

2 – Unable to hear normal voice

3 - Unable to hear loud voice

OBJECTIVE PARAMETERS

Otoscopic examination

1. Ear discharge 0 – Absent

1 – Mild - scanty secretion near Tympanic membrane

2 – Moderate - Secretion irrigating in the ear canal

3 - Severe - secretions coming out of ear canal

2. Perforation 0 – No perforation of tympanic membrane

1 – Mild - pin hole, small central perforation

2 – Moderate - large central perforation

3 - Severe – sub total perforation

Pure tone audiometry 0 – upto 25 dB

1 – 26 to 45dB

2 – 45 to 65dB

3 - more than 65dB



Statistical analysis of the result:

The result having P value less than <0.05 is considered as statistically significant in

this study.

Criteria for assessment of overall effects:

Overall effect of the therapy was assessed in terms of complete remission, marked

improvement, moderate improvement, and mild improvement and unchanged is

observed by adopting the following criteria.

• Complete remission: 100% relief in Chief complaints and no recurrence

during follow up study were considered as complete remission.

• Marked improvement: 75-100% improvement in chief complaints is

recorded as marked improvement.

• Moderate improvement: 50-75% improvement in chief complaints is

recorded as moderate improvement.

• Mild improvement: 25-50% improvement in chief complaints is considered

as mild improvement.

• Unchanged: Less than 25% improvement in chief complaints or recurrence

of the symptoms to the similar extent of severity is noted as recurrence.

Follow up study:

After the completion of treatment, all the patients were advised to attend the O.P.D

for three months at regular interval of thirty days for the follow up study.



CLINICAL OBSERVATIONS

DEMOGRAPHIC DATA

Table-5

Age wise distribution of patients:

Group A Group B Group C Total Age

Total No. Total No. Total No. Total No. %

5-14 2 1 1 4 8.88

15.24 6 4 5 15 33.34

25-34 1 1 4 6 13.34

35.44 3 3 4 10 22.23

45-54 13 4 1 8 17.77

55-65 0 2 0 2 4.44

Total 15 15 15 45 100

Out of 45 patients selected 4 (8.88%) were in the age group of 5-14 yrs. 15 (33.34%)

were in the age group of 15-24 yrs. 6(13.34%) were in the age group of 25-34 yrs.

10 (22.23%) were in the age group of 35-44yrs. 8 (17.77%) were in the age group

of 45-54 yrs. 2 (4.44%) were in the age group of 55-65yrs.

In group A, 2 (13.33%) were in the age group of 5-14yrs. 6(40%) were in the age

group of 15-24yrs. 1 was (6.67%) in the age group of 35-44yrs. 3 (20%) were in

the age group of 45-54yrs.

In group B, 1 (6.67%) was in the age group of 5-14yrs. 4 (26.66%) were in the age

group of 15-24yrs. 1 (6.67%) was in the age group of 25-34yrs. 3(20%) were in the



age group of 35-44yrs. 4(26.66%) patients were in the age group of 45-54yrs. 2

(13.34%) patients were in the age group of 55-65yrs.

In group C, 1 (6.67%) was in the age group of 5-14yrs. 5 patients (33.34%) were in

the age group of 15-24yrs. 4 (26.66%) were in the age group of 25-34 yrs. 4

(26.66%) were in the age group of 35-44yrs. 1 (6.67%) patient was in the age group

of 45-54yrs.

Diagram-1 showing age wise distribution

Age wise distribution

15

6

10

8

5 to 14 15-24 25-34 35-44 45-54 55-64



Table-6

Distribution of sex in trial group

Total Sex Group A Group B Group C

No.s Percentage

Male 08 07 10 25 55.55%

Female 07 08 058 20 44.45%

Total 15 15 15 45 100%

Diagram – 2 showing distribution of Sex in trial group

Among 45 patients selected, 25(55.55%) were males and 20(35.56%) were females.

In group A, out of 15 patients 8(53.33%) were males and 7(46.67%) were females.

In group B, out of 15 patients 7(46.67%) were males and 8 (53.33%) were females.

In group C, out of 15 patients 10(66.67%) were males and 5 (33.33%) were females



Table-7

Distribution of religion in trial group

Total Religion Group A Group B Group C

No.s Percentage

Hindu 11 14 12 37 82.22%

Christian 01 01 00 02 4.45%

Muslim 03 00 03 06 13.33%

Others 00 00 00 00 0.0%

Total 15 15 15 45 100%

Diagram – 3 showing distribution of Religion in trial group

Among 45 patients selected 37(82.22%) were Hindus, 2 (4.45%) were Christians,

6(13.33%) were Muslims.

In group A, out of 15 patients, 11(73.33%) were Hindus, 1(6.67%) was

Christian,3(20%) were Muslims.

In group B, out of 15 patients, 14(93.33%) were Hindus, 1(6.67%) was Christian.

In group C, out of 15 patients, 12(80%) were Hindus, 3(20%) were Muslims.



Table-8

Distribution of Occupation in trial group

Total Occupation Group A Group B Group C

No.s Percentage

Executive 04 04 01 09 20.0%

House wife 02 02 03 07 15.55%

Manual workers 07 05 07 19 42.22%

Student 02 04 04 10 22.22%

Total 15 15 15 45 100%

Diagram – 4 showing distribution of Occupation in trial group



Among 45 patients selected 9(20.0%) were Executives, 7(15.55%) were

Housewives, 19(42.22%) were manual workers, and 10(22.30%) were students.

In group A, out of 15 patients 4(26.67%) were executives, 2(13.33%) were

Housewives, 7(46.67%) were manual workers, 2(13.33%) were students.

In group B, out of 15 patients 4(26.67%) were executives, 2(13.33%) were

Housewives, 5(33.33%) were manual workers, 4 (26.67%) were students.

In group C, out of 15 patients 1(26.67%) was a Executive. 3 (20%) were

Housewives, 7(46.67%) were manual workers, and 4 (26.67%) were students



Table-9

Distribution of Martial status in trial group

Total Martial status Group A Group B Group C

No.s Percentage

Married 09 10 08 27 60%

Unmarried 06 05 07 18 40%

Total 15 15 15 45 100%

Diagram – 5 showing distribution of Martial Status in trial group

Among 45 patients selected 27(60%) were married and 18(40%) were unmarried.

In group A, out of 15 patients 9(60%) were married and 6(40%) were unmarried.

In groupB, out of 15 patients 10(66.67%) were married and 5(33.33%) were

unmarried.

In group C, out of 15 patients 8(53.33% ) were married and 7(46.66%) were

unmarried.



Table -10

Distribution of diet in trial group

Total Diet Group A Group B Group C

No.s Percentage

Vegetarian 04 06 07 17 37.78%

Mixed 11 09 08 28 62.28%

Total 15 15 15 45 100%

Diagram – 6 showing distribution of diet in trial group

Among 45 patients selected, 17(37.78%) were vegetarians and 28(62.22%) were of

mixed diet.

In group A, out of 15 patients, 4(26.67%) were vegetarians and 11(73.33%) were of

mixed diet.

In group B, out of 15 patients, 6(40%) were vegetarians and 9(60%) were of mixed

diet.

In group C, out o 15 patients, 7(46.67%) were vegetarians and 8(53.33%) were of

mixed diet.



Table-11

Distribution of socio-economic status in trial group

Total socio-economic

status Group A Group B Group C

No.s Percentage

Upper class 03 02 03 08 17.78%

Middle Class 05 05 07 17 37.77%

Lower Class 07 08 05 20 44.44%

Total 15 15 15 45 100%

Diagram – 7 showing distribution of socio-economic status in trial group

Among 45 patients selected, 8(17.71%) were from upper class, 17(37.77%) were

from middle class, 20(44.44%) were from lower class.

In group A, out of 15 patients 3(20%) were from upper class, 5(33.33%) were from

middle class, and 7(46.67%) were from lower class.

In group B, out of 15 patients, 2(13.34%) were from upper class, 5(33.33%) were

from middle class and 8(53.33%) were from lower class.

In group C, out of 15 patients, 3(20%) were from upper class, 7(46.67%) were from

middle class, 5(33.33%) were from lower class.



Table-12

Distribution of laterality in trial group

Total Laterality

Group

A

Group

B

Group

C No.s Percentage

Unilateral 9 8 9 26 57.78

Bilateral 6 7 6 19 42.221

Total 15 15 15 45 100%

Diagram – 8 showing distribution of Laterality in trial group

Among 45 patients selected, 26(57.78%) had Unilateral involvement and

19(42.22%) had bilateral involvement.

In group A, among 15 patients 9(60%) had Unilateral involvement and 6 (40%) had

bilateral involvement.

In group B, among 15 patients 8 (53.33%) had Unilateral involvement and

7(46.67%) had bilateral involvement.

In group C, among 15 patients 9(60%) had Unilateral involvement and 6(40%) had

bilateral involvement.



Table -13

Distribution of chronicity in trial group

Total Duration of illness in

years Group A Group B Group C

No.s Percentage

Below 1 year 1 1 2 4 8.88%

1-2 7 6 8 21 46.66%

2-3 5 2 2 6 13.33%

Above 3 2 6 3 14 31.11%

Total 15 15 15 45 100%

Diagram – 9 Showing distribution of chronicity in trail group

Out of 45 patients selected, in 4(8.88%) the duration of illness was below 1

year, in 21(46.66%) duration was between 1-2years, in 6(13.33%) duration was 2-3

years and in 14(31.11%) duration was above 3 years.



In group A, out of 15 patients in 1(6.66%) the duration was below 1 year, in

7(46.66%) duration was between 1-2 years, in 2(13.33%) duration was 2-3 years

and in 5(33.33%) duration was more than 3 years.

In group B, out of 15 patient’s in 1 (6.66%) duration was below 1 year, In 6(40%)

the duration was 1-2 years. In 2(13.33%) the duration was 2-3 years and in 6(40%)

the duration was above 3 years.

In group C, out of 15 patients, in 2(13.33%) the duration was below 1 year, In

8(53.33%) the duration was 1-2 years and in 2(13.33%) the duration was 2 -3 years

and in 3(20%) the duration was above 3 years.



Table-14

Distribution of Prevalence of Nidanas in trial group

Total Prevalence of

Ndianas

Group

A

Group

B

Group

C No.s Percentage

Jala Nimajjana 5 06 08 19 42.22%

Prapakat vidradhi - - - - ---

Shiroabhigata 2 1 1 4 08.88%

Avashyaya 06 06 5 17 37.77%

Pratishyaya 15 15 15 45 100%

Karnakandooyana 02 03 02 07 15.55%

Total

Diagram – 10 showing distribution of Prevalence of Nidanas in trial group

Among 45 patients selected, 19(42.22%) had Jala Nimajjana, 4(8.88%) had

Shiroab

Prevalence of Nidanas

19

04

1745

7

Jalanimajjanat Prapakat vidradhi ShirobhighataAvashyaya Pratishyaya Karnakanduyana

igata, 7(15.55%) had Karna Kandooyana as Nidana along with pratishyaya.



In group A, out of 15 patients 5(33.33%) had Jala Nimajjana as Nidana, 2(13.33%)

had Shiroabigata as Nidana, 6(40%) had Pratishyaya as Nidana, 2(13.33%) had

Karna Kandooyana as Nidana.

In a group B, 6(40%) had Jala Nimajjana as Nidana, 1(6.66%) had Shiroabigata as

Nidana, 6(40%) had Avashyaya as Nidana, 8(53.33%) had Pratishyaya as Nidana,

2(13.33%) had Karna Kandooyana as Nidana.

In group C, 8(53.33%) had Jala Nimajjana as Nidana, 1(6.66%) had Shiroabigata as

Nidana, 5(33.33%) had Avashyaya as Nidana, 7(46.66%) had Pratishyaya as

Nidana, 2(13.33%) had Karna Kandooyana as Nidana.



Table-15 Prakruti wise distribution of patients

Group A Group B Group C Total Prakruti Total

No. %

Total No.

% Total No.

% Total No.

%

Vatakaphaja 8 53.33 7 46.66 10 66.66 25 55.55

Kaphavataja 5 33.34 6 40 2 13.34 13 28.89

Vatapittaja 2 13.34 2 13.34 3 20 07 15.56

Total 15 100 15 100 15 100 45 100

Out of 45 patients selected 25 (55.55%) were of vatakaphaja prakruti, 13 (28.87%)

were of Kaphavataja prakaruti, 7 (15.56%) were of vatapitiaja prakruti.

In Group A, 8(53.33%) were of vatakphaja prakarut,i 5 were of (33.34%)

Kaphavataja prakruti, 2 (13.34%) were of vatapittaja prakurti.

In Group B, 7 (46.66%) were of vatakaphaja prakruti, 6 (40%) were of kaphavataja

prakurt, 2(13.34%) were of vatapittajaprakruti.

In Group C, 10 (66.66%) were of vatakaphaja prakruti, 2( 13.34%) were of

Kaphavataja prakruti, 3(20% ) were of vatapittaja prakruti.

Diagram-11 Showing Prakrutiwise Distribution

Prakruti wise

2513

7

VK KV VP



Table-16 Showing distribution of ear discharge in trail group

Group A Group B Group C Total Percentage Ear

Discharge Rt Left Rt Left Rt left Rt left Rt left

Nil 5 4 3 5 4 5 12 14 26.67% 31.2%

Mild 0 0 1 2 1 2 2 4 4.45% 8.89%

Moderate 6 5 4 3 4 3 14 11 31.12% 24.45%

Severe 4 6 7 5 6 5 17 16 37.78% 35.56%

Total 15 15 15 15 15 15 45 45 100% 100%

Out of 45 patients selected, 19 had (42.23%) bilateral ear discharge, 12(26.67%) had

unilateral discharge only in left ear, 14 had (31.13%) only right ear discharge. In total 31

(68.88%) had left ear discharge. And 33(73.33%) had right ear discharge.

Out of 45 patients 1(6.67%) each in Group B and Group C had mild right ear discharge.

2each (13.34%) in Group B and Group C had mild left ear discharge.

6 (40%) in Group A, 4(26.67%) each in Group B and Group C had moderate Right

ear discharge.

5 (33.34%) group A, 3 (20%) each in group B and Group C had moderate left ear

discharge.

4(26.67%) in group A, 7(46.67%) in group B, 6 (40%) in group C had severe right

ear discharge.

6 (40%) in group A, 5(33.34%) each in group B and Group C had severe left ear

discharge.



1214

2 4

1411

1716

05

101520

Nil Mild Moderate Severe

Ear discharge incidence

Right Left

Diagram-12 showing distribution of Ear discharge in percentage

Table-17 Showing distribution of perforation in trail Group

Group A Group B Group C Total Percentage Perforation

Rt Left Rt Left Rt left Rt Left Rt Left

Nil 5 4 3 5 4 5 12 14 26.64% 31.12%

Mild 6 6 6 7 6 7 18 20 40.00% 44.45%

Moderate 3 4 4 2 3 2 10 8 22.23% 17.78%

Severe 1 1 2 1 2 1 5 3 11.12% 6.68%

Total 15 15 15 15 15 15 45 45 100% 100%

Out of 45 patients, 6 (40%) each in group A, B and C had mild perforation in right ear

7 (46.6%) in group B, 6(40%) each in group A and Group C had mild perforation in

left ear.

3(20%) each in group A and group C, 4 (26.67%) in group B had moderate perforation

in right ear.

4(26.67%) in group A and 2(13.34%) each in group B and group C had moderate

perforation in left ear.



1 (6.67%) in group A, 2(13.34%) each in group B and Group C had severe perforation

right ear.

1(6.67%) each in all 3 groups had severe perforation in left ear.

Diagram-13 Showing distribution of perforation

1214

1820

108

53

0

5

10

15

20


Perforation incidence

Right Left

Table-18: Showing distribution of conductive deafness by pure tone audiometry in percentage

Group A Group B Group C Total Percentage Pure tone

Rt Left Rt Left Rt left Rt Left Rt Left

Nil 5 4 3 5 4 5 12 14 26.67% 31.12%

Mild 9 10 9 9 9 9 27 28 60% 62.23%

Moderate 1 1 3 1 2 1 6 3 13.33% 6.67%

Severe 0 0 0 0 0 0 0 0 0.0% 0.0%

Total 15 15 15 15 15 15 45 45 100% 100%

Out of 45 patients selected 19 had bilateral conductive deafness 12 had conductive deafness

only in left ear.

14 had only right ear conductive deafness.

In total 31 patients had left ear conductive deafness and 33 had right ear conductive

deafness.



Out of 45 patients, 9(60%) each in group A, B and C had mild conductive deafness in right

ear

10 (66.67%) in group A, 9(60%) each in group B and Group C had mild conductive

deafness in left ear.

1(6.67%) in group A, 3 (20%) in group B, 2 (13.34%) in group C had moderate conductive

deafness in right ear.

1 patient (6.67%) in all the 3 groups had moderate conductive deafness in left ear.

None of the patients included in the study had suffered from severe conductive deafness.

Diagram-14 Showing Distribution of conductive deafness

1214

2728

63

0 00

5

10

15

20

25

30

Nil Mild Moderate severe

Conductive deafness

Right Left

Table-19: Distribution of impaired hearing in trial group

Group A Group B Group C Total Percentage Distribution

Rt left Rt left Rt left Rt left Rt left

Nil 9 8 5 8 7 9 21 25 46.66% 55.55%

Mild 5 6 7 6 6 5 18 17 40% 37.37%

Moderate 1 1 3 1 2 1 6 3 13.34% 6.67%

Severe 0 0 0 0 0 0 0 0 0.0% 0.0%

Total 15 15 15 15 15 15 45 45 100% 100%



Out of 45 patients selected 26(57.77%) patients presented with the impaired hearing as a

symptom. 18(40%) suffered from impaired hearing in both the ears. 8(17.78%) had

unilateral involvement.

In total 24(53.34%) had impaired hearing right ear

20(44.45%) had impaired hearing in left ear.

5(33.33%) patients in Group A, 7(46.67%) in Group B, 6(40%) and Group C had mild

impaired hearing in right ear.

6 (40%) each group A and group B, 5(33.34%) in Group C had mild impaired hearing in

left ear.

1(6.67%) in group A, 3 (20%) in group B, 2 (13.34%) in group C had moderate impaired

hearing in right ear.

1 patient (6.67%) in all the 3 groups had moderate impaired hearing in left ear.

None of the patients included in the study had suffered from severe impaired hearing.

Diagram-15 Showing distribution of Impaired hearing

2125

1817

63

0 005

10152025


Impaired hearing

Right Left



Table-20

Distribution of observations in the follow up period in trail group

Observations Group A Group B Group C Total

Recurrence 4 12 3 19 42.23

Non

reoccurrence 11 3 12 26 57.77

Total 15 15 15 15 100

Out of 45patients selected 19 had (42.23%) reoccurrence, 26 (57.77%) had non-

recurrence.

In Group A, 4 (26.67%) had reoccurrence, 11 (73.33%) had non-recurrence.

In Group B, 12 (80%) had reoccurrence, 3(20%) had non-recurring.In Group C,

3(20%) had recurrence, 12 (80%) had non-recurrence.

follow up

19

26

reoccurence non reocurence

Diagram-16 showing the distribution of observations noticed in the follow up

period.



CHANGES IN SEVERITY OF SYMPTOMS IN RESPONSE TO

TREATMENT

Table-21

Data related to periodical changes in Signs& Symptoms during treatment in

Group A

Before treatment 15th Day 30th Day

Relief Relief S Mo Mi Total S Mo Mi

No. % S Mo Mi

No. %

Rt

Ear 5 6 0 10 2 1 4 3 30 0 0 2 8 80

Ear

Discharge Left

Ear 6 5 0 11 1 3 4 3 27.3 0 2 1 8 72.3

Rt

Ear 1 3 6 10 1 3 3 3 30 1 3 3 3 30

Perforation Left

Ear 1 4 6 11 1 4 4 2 18.2 1 4 2 4 36.6

Rt

Ear 0 1 9 10 0 1 7 2 20 0 1 6 3 30

Pure tone

audiometry Left

Ear 0 1 10 11 0 1 9 1 9.9 0 1 6 4 36.6

Rt

Ear 0 1 5 6 0 1 4 1 16.6

0 1 3 2 33.4

Impaired

Hearing Left

Ear 0 1 6 7 0 1 4 2 28.5 0 1 4 2 28.5



Note: Rt-Right ear, Left-Left ear, Mod-Moderate

Group A:

Before Treatment

Ear discharge:

5 patients in right ear, 6 patients in left ear presented with severe ear discharge and 6

in right and 5 in left presented with moderate ear discharge, no one had mild ear

discharge.

After 15th day:

2 patients in right, 1 patient in left ear had severe ear discharge. 1 patient in right, 3

patients in left had moderate ear discharge. 4 patients each in right and left ear had

mild ear discharge. 3 patients each in right and left ear got relief.

After 30th day:

No patients had severe ear discharge. 2 patients had moderate left ear discharge. 2

in right ear 1 in left ear had mild ear discharge. 8 patients both in right ear and left

ear got relieved from ear discharge.

Perforation:

Before Treatment:

1 patient each in right and left ear had severe perforation 3 in right and 4 in left had

moderate perforation. 6 in both right and left ear had mild peroration

After 15th day:

1 each in right ear and left ear remained severe. 3 in right and 4 in left had mild

perforation. 3 from right and 2 in left got relieved.



After 30th day:

1 each in right and left ear remained severe. 3 in right and 4 in left remained

moderate. 3 in right and 2 in left had mild perforation. 3 in right and 4 in left got

relieved..

Pure tone Audiometry:

Before treatment:

One Patient both in Right and Left ear had moderate conductive deafness.9 in right

ear and 10 in left ear had mild conductive deafness.

After 15th day:

One Patient both in right and Left ear had moderate conductive deafness.7 in Right

and 9 in left had mild conductive deafness.Two in Right and one in left got

Improvement.

After 30th day:

One patient both in Right ear and Left ear had moderate conductive deafness.6 in

both Right and left Ear had mild conductive deafness.3 in Right and 4 in Left got

improvement.

Impaired hearing:

Before treatment:

1 in both right and left ear had moderate impaired hearing.5 in right and 6 in left

hearing had mild impaired hearing impaired hearing..



After 15th day:

1 in both right and left ear had moderate impaired hearing 4 patients in both right

and left ear had mild impaired hearing, 1 in right and 2 in left ear got improvement.

After 30th day:

1 in both right and left ear had moderate impaired hearing.3 in right and 4 in left had

mild impaired hearing. 2 patients each in right and left ear got improvement.

28.5

9.9

18.2

27.3

16.6

20

3030

0

5

10

15

20

25

30

Rt Ear Lt Ear

% in Relief after 15 days

Ear dischargePerforationPure tone audiometry

Diagram-17 showing relief in percentage after 15 days in

Group A

Diagram-18 showing relief in percentage after 30 days

01020304050607080

Rt ear Leftear

Ear discharge

Perforation

Audiometry

Impairedhearing Impairedhearing




TREATMENT

Table-22


Group B


Relief Relief S Mo Mi Total S Mo Mi

No. % S Mo Mi

No. %

Rt

Ear 7 4 1 12 6 4 2 0 0 2 4 3 3 25

Ear

Discharge Left

Ear 5 3 2 10 5 3 2 0 0 2 2 4 2 20

Rt

Ear 2 4 6 12 2 4 6 0 0 2 4 4 2 16.6

Perforation Left

Ear 1 2 7 10 1 2 7 0 0 1 2 6 1 10

Rt

Ear 0 3 9 12 0 3 9 0 0 0 3 7 2 16.6

Pure tone

audiometry Left

Ear 0 1 9 10 0 1 9 0 0 0 1 8 1 10

Rt

Ear 0 3 7 10 0 3 6 0 0 0 2 6 2 20

Impaired

Hearing Left

Ear 0 1 6 7 0 1 5 0 0 0 1 5 1 16.6



Group B

Before treatment:

Ear discharge:

7 in right ear and 5 in left ear had severe ear discharge. 4 in right and 3 in left had

moderate ear discharge 1 in right and 2 in left had mild ear discharge.

After 15th Day:

6 in right and 5 in left had severe ear discharge. 4 in right and 3 in left ear had

moderate ear discharge. 2 each in both right and left ear had mild ear discharge.

After 30th day:

2 each in right and left ear had severe ear discharge. 4 in right and 2 in left ear had

moderate ear discharge. 3 in right and 4 in left had mild ear discharge. 3 in right and

2 in left got relief.

Perforation:

Before treatment:

2 in 1 right in left ear had severe perforation. 4 in right and 2 in left ear had

moderate perforation. 6 in right and 7 in left ear had mild perforation.

After 15th days:

2 in right, 1 in left ear remained severe. 4 in right and 2 in left had moderate

perforation. 6 in right and 7 in left ear had mild perforation.

After 30th day:

2 in right 1 in left ear had severe perforation. 4 in right and 6 in left ear had mild

perforation. 2 in right ear, 1 in left ear got relieved.




Before treatment:

3 in right and 1 in left ear had moderate conductive deafness. 9 each in right and left

ear had mild conductive deafness.

After 15th day:

3 in right ear and 1 in left ear had moderate conductive deafness 9 each in right and

left ear had mild conductive deafness.

After 30th day:

3 in right ear 1 in left ear had moderate conductive deafness. 7 in right ear and 8 in

left ear had mild conductive deafness. 2 in right ear and 1 in left ear got

improvement

Impaired hearing:

Before treatment:

3 in right 1 in left ear had moderate impaired hearing. 7 in right ear and 6 in left ear

had mild impaired hearing.

After 15th day:

3 in right, 1 in left had moderate impaired hearing 6 in right and 5 in left had mild

impaired hearing no patient in right and left ear got improvement.

After 30th day:

2 in right 1 in left ear had moderate impaired hearing, 6 in right and 5 in left had

mild impaired hearing 2 in right ear and 1 in left ear got improvement.



0

0.2

0.4

0.6

0.8

1

Rt ear Leftear

Ear discharge

Perforation

Pure toneAudiometryImpairedhearing


Diagram-20 showing Relief in percentage after 30 days

0

5

10

15

20

25

Rt ear Rt ear Leftear

Ear discharge

Perforation

PuretoneaudiometryImpairedhearing




TREATMENT

Table-23


Group C


Relief Relief Severe Mod Mild Total Severe Mod Mild

No. % Severe Mod Mild

No. %

Rt

Ear 6 4 1 11 1 2 4 4 36.4 0 0 1 10 90.9

Ear

Discharge Left

Ear 5 3 2 10 0 3 2 5 50 0 0 1 9 90

Rt

Ear 2 3 6 11 2 3 3 3 27.3 2 3 2 4 36.4

Perforation Left

Ear 1 2 7 10 1 2 5 2 20 1 2 3 4 40

Rt

Ear 0 2 9 11 0 2 7 2 18.2 0 2 5 4 36.4

Pure tone

audiometry Left

Ear 0 1 9 10 0 1 8 1 10 0 1 5 4 40

Rt

Ear 0 2 6 8 0 1 6 1 12.5 0 0 4 4 50

Impaired

Hearing Left

Ear 0 1 5 6 0 0 5 1 16.7 0 0 3 3 50



Group C

Ear discharge:

Before treatment:

6 patients from right ear and 5 in left ear had severe ear discharge. 4 in right ear and

3 in left ear had moderate ear discharge. 1 in right ear and 2 in left ear had mild ear

discharge.

After 15th day:

1 in right ear remained severe. 2 in right ear 3 in left ear had moderate discharge, 4

in right ear, 2 in left ear had mild ear discharge. 4 in right and 5 in left got relieved.

After 30th day:

1 in both right and left ear had mild ear discharge .10 in right and 9 in left got relief.

Perforation:

Before treatment:

2 in right ear and 1 in left ear got severe perforation. 3 in right ear 2 in left ear got

moderate perforation. 6 in right ear 7 in left ear got mild perforation.

After 15th day:

2 in right ear and 1 in left ear remained severe. 3 in right ear 2 in left ear remained

moderate. 3 in right ear 5 in left ear had mild perforation .3 in right ear and 2 in left

ear got relieved

After 30th day:

2 in right ear 1 in left ear remained severe. 3 in right ear 2 in left ear had moderate

perforation .2 in right ear 3 in left ear had mild perforation 4 in both ears got

relieved.




2 in right ear 1 in left ear had moderate conductive deafness. 9 each in both right and

left ears had mild conductive deafness.

After 15th day:

2 in right ear 1 in left ear had moderate conductive deafness. 7 in right 8 in left ear

had mild conductive deafness. 2 in right ear 1 in left ear got improvement.

After 30th day:

2 in right ear 1 in left ear remained moderate. 5 in both right and left ear had mild

conductive deafness .4 in both right and left ear got improvement.

Impaired hearing:

Before treatment:

2 in right ear and 1 in left ear had moderate impaired hearing .7 in right ear and 6 in

left ear had mild impaired hearing.

After 15th day:

1 in right ear had moderate impaired hearing 6 in right ear and 5 in left ear had mild

impaired hearing .1 each in both ears got improvement..

After 30th day:

4 in right ear and 3 in left ear had mild impaired hearing. 4 in right ear and 3 in left

ear got improvement.



05

101520253035404550

Ear discharge

Perforation

Pure toneAudiometryImpairedhearing


0102030405060708090

Rt ear Leftear

Ear discharge

Perforation

Pure toneaudiometryImpaired hearing

Diagram-22 Showing relief in percentage after 30 days



Statistical analysis was done and results was drawn using student‘t’ test of

significance.

Table-24 Showing Statistical analysis of parameters in Group A:

Group A Mean

BT

Mean

AT

Mean

differenceSD SE

T

Value P value

Ear discharge 1.73 0.234 1.496 0.86 0.1569 9.53 <0.001

Conductive deafness

(pure tone audiometry) 0.766 0.466 0.3 0.458 0.0836 3.5885 <0.05

Perforation 1.06 0.766 0.294 0.455 0.084 3.515 <0.05

Impaired hearing 0.5 0.366 0.134 0.340 0.062 2.16 <0.05

Effect of guggulu dhoopana on Ear discharge:-

Before and after treatment shows changes from 1.7 to 0.234, showing a mean

reduction of 1.496 which is statistically significant at the level of p<0.001.

Effect of guggulu dhoopana on conductive deafness:-

Before and after treatment shows changes from 0.766 to 0.466 showing a mean

reduction of 0.3 which is statistically significant at the level of p < 0.05.

Effect of guggulu dhoopana on perforation:-



Effect of guggulu dhoopana on impaired Hearing:-





Diagram-23 Showing Statistical Analysis of Parameters in Group A

Table-25 Showing Statistical analysis of parameters in Group B:

Group B Mean

BT

Main

AT

Mean

differenceSD SE

T

Value P value

Ear discharge 1.76 1.03 0.73 0.443 0.0810 9.00 <0.001

Conductive deafness

(pure tone audiometry) 0.86 0.76 0.10 0.30 0.054 1.85 >0.05

Perforation 1.13 1.03 0.10 0.30 0.034 1.85 >0.05

Impaired hearing 0.7 0.56 0.14 0.347 0.0633 2.12 >0.05

Effect of Rasnadi guggulu on Ear discharge:-



Effect of Rasnadi guggulu on conductive deafness:-


reduction of 0.10, which is statistically insignificant at p >0.05.



Effect of Rasnadi guggulu on perforation :-


reduction of 0.10 which is statistically insignificant at p > 0.05.

Effect of Rasnadi guggulu on Impaired Hearing :-

Before and after treatment shows changes from 0.7 to 0.56 showing a reduction of

0.14 which is statistically significant at p< 0.05.

Diagram-24 Showing Statistical analysis of Parameters in Group B



Table-26 Showing Statistical analysis of parameters in Group C:

Group C Mean

BT

Main

AT

Mean

differenceSD SE

T

Value P value

Ear discharge 1.6 0.06 1.533 0.909 0.163 9.63 <0.001

Conductive

deafness (pure

tone audiometry)

0.8 0.46 0.34 0.508 0.0928 3.695 <0.05

Perforation 1.067 0.73 0.337 0.509 0.0928 3.631 <0.05

Impaired hearing 0.566 0.2 0.366 0.232 0.042 8.7142 <0.001

Effect of combined therapy on Ear discharge:-


reduction of 1.533 which is statistically significant at p < 0.001.

Effect of combined therapy on conductive deafness:-


reduction of 0.337 which is statistically significant at p < 0.05.

Effect of combined therapy on perforation :-


0.337 which is statistically significant at the level of p < 0.05.

Effect of combined therapy on Impaired Hearing :-


0.366 which is statistically significant at the level of p < 0.05.



Diagram-25 Showing Statistical analysis of Parameters in Group C



ASSESSMENT OF OVERALL RESULTS:

Table-27

Assessment of overall results in Group A, B and C at the end of treatment

Response Group A Group B Group C Total

No %

Marked 3 1 5 9 20.00%

Moderate 8 3 7 18 40.00%

Mild 2 4 2 08 17.77%

poor 2 7 1 10 22.23%

Total 15 15 15 45 100%

In Group A, out of 15 patients 3(20.00%) had marked response. 8(53.34%) had

moderate response. 2 (13.34%) had mild response. 2(13.34%) had poor response.

In Group B out of 15 patients 1 (6.67%) had marked response. 3 (20.0%) had

moderate response.4 (26.66%). had mild response.7 had (46.67%) poor responce

In Group C out of 15 patients 5(33.34%) had marked response. 7 (46.67%) had

moderate response. 2(13.34%) had mild response. And 1(6.67%) had poor response.

In total out of 45 patients 9 (20.00%) had marked response. 18(40.00%) had

moderate response. 8(17.77%) had mild response. And 10(22.23%) had poor

response.



02468

1012141618

totalresponse

MarkedModerateMildpoor

Diagram-26 showing assessment of overall results



DISCUSSION

DISCUSSION ON REVIEW OF LITERATURE

Sushruta has explained 28 types of karnarogas and karna srava is one among them.

The features of Karnasrava can be correlated to chronic suppurative otitis media,

because the main symptom in both is ear discharge. Chronic suppurative otitis media

is the most common cause of conductive deafness which is more prevalent in the

population.

According to our classics, Vata dosha is responsible for karnasrava. Madukosha

commmentory of Madava nidana clarifies about the involvement of doshas in

karnasrava. He opines that as there is puya there should be involvement of pitta, the

dense discharge is attributed to kapha and sravana is due to the nature of vata.. As

sravana is main laxana in Karnasrava, vata is considered as predominant dosha.

In the present study it was observed that recurrent attacks of pratishyaya were

present in all the patients. Jalanimajjana, avashyaya were other most prevalent

nidanas.

This study was designed as a comparative study, in order to compare the efficacy of

Guggulu karnadhoopana with internal administration of Rasnadiguggulu and also to

find out the combined effect of these two procedures.



DISCUSSION ON OBSERVATIONS

AGE

In this study slightly more number of patients was in the age group of 15-25 years.

As acute suppurative otitis media is more prevalent in children, repeated attacks of

this would have lead to chronic suppurative otitis media in this age group.

SEX

It was observed that number of male patients (55.55%) suffering from karnasrava

were more than female(45.55%).This may be because the number of males in the

community is more and does not have any significance with the disease karnasrava.

RELIGION

Religion wise distribution of patients showed that majority of patients (82.22%)

were Hindus. This might be because Hindus outnumber other communities in the

general population. Hence it has no research significance.

SOCIOECONOMIC STATUS

Socioeconomic wise distribution of patients in this study showed that karnasrava is

more prevalent in lower class (44.45%) than in middle class (37.77%) and upper

class17.7%. It might be due to the fact that poor living standards, poor nutrition, lack

of health education, lack of timely treatment in lower class predisposes to chronic

suppurative otitis media.



DIET

Dietary wise distribution in the patients of karnasrava showed that 62.22% of the

patients have mixed diet and 37.78% have vegetarian diet. This did not have any

research significance.

OCCUPATION:

Labour class or manual workers were affected more (38.4%). Exposure to dust, poor

nutrition, and poor living standards could be a major reason for such an observation.

LATERALITY

Although karnasrava can be unilateral or bilateral, in the present study, out of 45

patients 26 (57.78%) had unilateral involvement and19 (42.22%) had bilateral

involvement.

PRAKRUTI

Prakruti wise distribution showed that maximum number of patients in this study

were of vatakaphaja (55.55%) followed by kaphavataja prakruti and Vatapittaja

prakruti. This shows that Vata predominent persons are more predisposed to

karnasrava.



DISCUSSION ON CLINICAL FEATURES

The cardinal feature of karnasrava, conductive deafness (evaluated by pure tone

audiometry) and perforation was present in all the patients. Impaired hearing

(subjective) was present in 46.67% of patients in group A, 66% of patients in Group

B, 53.34% in Group C.

Response in Group A after treatment

Karnasrava was relived in 86.54% of patients. There was improvement in

conductive deafness in 39% of patients and perforation was relived in 28.12%.

Improvement inImpaired hearing was seen in 26.7% of patients.

Response in Group B after treatment

Karnasrava was relieved in 41.55% of patients.There was improvement in

Conductive deafness in 8.9%, and perforation was relieved in 11% of patients.

Improvement in Impaired hearing was seen in 19% patients.

Response in Group C after treatment

Karnasrava was relieved in most of the patients. There was improvement in

conductive deafness in 42% of patients. Perforation was relieved in 33% of patients

and improvement in impaired hearing was seen in 64.7% of patients.

It was observed in the present study that most of the patients had mucopurulent ear

discharge.



In our classics only srava is mentioned as a symptom in karnasrava. But it was

observed that all patients had mild- moderate conductive deafness. But in present

study most number of the patients had only mild conductive deafness, because of

this most of the patients presented with ear discharge as a main symptom and

impaired hearing as a associated symptom which was not very significant to the

patient. But it was detected by pure tone audiometry.

Though it is not mentioned directly in our classics, according to the modern textual

information, it is clear that patients with CSOM suffer with deafness of mild to

moderate degrees. The present study also supported this by showing that all the

patients had mild to moderate deafness.

Ear ache is not a feature of CSOM It will be present if CSOM is associated with

otitis externa.

It was observed in the present study that large, subtotal perforations were not healed

with either with Guggulu dhoopana or Rasnadiguggulu internally.

Puretone audiometry test showed that patients with only mild conductive deafness

associated with pinhole or small perforation showed changes. Patients with mild-

moderate deafness with large peerforation did not respond.



Discussion on recurrence:

It was observed in the present study that patients who have not followed

pathyapathya like exposure to cold, water entering into the ear etc had more

recurrence. Reccurence rate was also observed in patients in whom tympanic

membrane perforation was not healed. By this we can conclude that following

pathyapathya very important in preventing recurrence.

ASSESMENT OF RESULTS IN COMPARISION WITH GROUP A, B & C

Objective parameters

Ear discharge

Percentage of Success in Group A- 86.54% Group B- 41.5% and Group C-96%

The difference in success between Group A and Group B is statistically highly

significant at (P<0.001) by students‘t’ test of significance

The difference in success between Group C and Group B is also statistically highly

significant at (P<0.001).

The difference in success between Group C and Group A is also statistically


PERFORATION

Percentage of success in Group A-28.12% Group B -8.82%, Group C-33%

The difference in success between Group A and Group B is statistically significant

at (P<0.05).



The difference in success between Group C and Group B is also statistically

significant at (P<0.05)

The difference in success between Group C and Group A is statistically insignificant

at (P>0.05)

PURETONE AUDIOMETRY

Percentage of success in Group A-39%, Group B- 11.5%, Group C-42%

The difference in success between Group A and Group B is statistically significant

at (P<0.05).

The difference in success in Group C and Group B is statistically significant at

(P<0.05)

The difference in success in Group C and Group A is statistically insignificant at

(P>0.05).

SUBJECTIVE CRITERIA

IMPAIRED HEARING

The percentage of success in Group A-26.67% Group B-19% and Group C-50%

The difference in success in Group A and Group B is statistically significant at

(P<0.05).

The difference of success in Group C and Group B is also statistically highly


The difference of success in Group C and Group A is also statistically highly




DISCUSSION ON

PROBABLE MODE OF ACTION OF KARNA DHOOPANA:

Karna dhoopana is a procedure wherein the fumes coming out on burning any drug

is administered directly into the external ear canal. Prior to this procedure the ear

canal is cleaned thoroughly to remove the discharge and other debris to facilitate the

better absorption of the drug. Sushrutha and Vaghbhata has mentioned that

karnasrava can be treated on the lines of Dustavrana. Charaka, while mentioning

dhoopana for dustavrana quotes that dhoopana reduces srava. The fumes of the

dhoopana may bring about the sudative effect and dries up the srava. Another

feature of fumes of dhoopana is that fumes can reach the middle ear where the

pathology of karma srava lies. Heat also causes vasodilation and increased blood

circulation thereby helping in better absorption of the drug and healing. Srava is the

main symptom in karna srava and one of the most important feature of ruksha sweda

is to dry. So in karna srava the karnadhoopana not only dries up the srava but also

creates an unfavourable condition for the growth of the microbes. This not only

helps in controlling the srava but also prevents further progression of the disease.

PROBABLE MODE OF ACTION OF SHUDDA GUGGULU DHOOPANA:

In this study Shudda Guggulu is the drug selected for karna dhoopana.

Guggulu is mentioned as devadhupa in our classics. It tells about importance of

Guggulu as a dhupana dravya. The word meaning of Guggulu is that “Gunjo



vyadegurdti rakshati” which means to give relief against different diseases.

Guggulu also has an aromatic odour. Sushruta says that guggulu has ksharana

property and gives a simile in Mahavatavyadhi chikitsa that Guggulu cures the

diseases as quickly like thunder burns the tree.

As per our classics vitiated vata dosha is mainly responsible in causing karnasrava.

Charaka emphasises that Guggulu is one of the agra dravya in alleviating vata. In

the present study we can infer that control of karnasrava may be because of the

alleviation of vata dosha.

Guggulu is an oleo gum resin having anti inflammatory, antiseptic, antimicrobial

property. Guggulu has volatile oil as one of its main chemical constituent. A new

active ingredient triterpene, myrrhanol A, has been discovered to have potent anti

inflammatory effect. Volatile oil is capable of volatization and they do not leave any

spot on paper on heating. This fact can be taken into consideration and probably

acknowledge that karna dhoopana with shuddha Guggulu will not leave any residue

in the ear. Removal of fibrin, keratinocyte migration and ingrowth of connective

tissue plays a major role in healing of tympanic membrane. Fibrinolytic property of

guggulu may help in removal of fibrin and thereby healing of the tympanic

membrane.

PROBABLE MODE OF ACTION OF RASNADIGUGGULU INTERNALY:

Rasnadi guggulu was selected for the present study because it has been referred to as

one of the best vata hara dravya in Baishajya Ratnavali. It contains Rasna,

Devadaru, Shunti, Guduchi, Eranda in equal parts and five parts of Guggulu.



Guggulu, because of its katu tiktha rasa and ushna virya reduces vata and medas. It

is proven drug for its anti-inflammatory and antiseptic effect. Guggulu lipid

stimulates the activity of white blood cells in the body contributing to the build up of

the immune system. Rasayana drugs are indicated as samanya chikitsa for all

karnarogas in our classics. Hence it can be inferred that guggulu which is the main

ingredient in the above preparation has cumulative effect of anti-inflammatory and

immunomodulator, thereby bringing relief to the patients suffering from karnasrava.

Plasminogen is a protease enzyme which plays a key role in healing of perforated

tympanic membrane. It is established that guggulu is a plasminogen activator which

in turn helps in healing of tympanic membrane.

Rasnadiguggulu contains Rasna, Guggulu, Devadaru, Eranda, Guduchi. Almost all

drugs have usna veerya, madura vipaka and are kaphavatahara in property whereas

Guggulu and Guduchi has tridoshahara property. The disease Karnasrava taken for

the study is mainly due to Vata and Rasnadiguggulu helps in alleviating Vata and

other doshas associated with it. Thereby reducing srava and other symptoms.

Drugs like Guggulu, Guduchi, Devadaru have Rasayana property, which in turn

helps in alleviating Karnasrava and its symptoms because it is said by our Acharyas

that “Samanyam karnarogeshu grutapanam rasayanam”.



In this study karna dhoopana had better effect than internal administration of

Rasnadiguggulu. This may be because; the absorption of drug taken internally will

be reduced by the action of gastric juices in the G.I system. More over it does not

have local direct effect in the ear canal where the discharge takes place or in the

middle ear where the pathology lies. Dryness of the ear is an important aspect in

arresting ear discharge and further growth of microbes. Guggulu dhoopana has local

antiseptic effect and acts directly in the place of manifestation of karna srava making

the area dry, Thereby making its action better.

Karnadhoopana acts locally as antiseptic, antimicrobial and keeps the ear dry. And

Rasnadiguggulu given internally is also Vatahara and rasayana drug which helps to

further prevents the infection. Hence in my study I have come to a conclusion that

combination of both therapeutic procedure of karnadhoopana and internal

administration of Rasnadi guggulu gives a better result in the management of

karnasrava.



CONCLUSION

Karnasrava can be compared to chronic suppurative otitis media. In both, ear

discharge is the chief complaint.

Most common etiology of karnasrava is recurrent attacks of pratishyaya

followed by jalanimajjana in the present study.

In the present study Karnasrava was found to be more prevalent in the

lower strata of the society and labour class workers.

Theraupetic procedure with Sthanika Guggulu dhoopana along with internal

administration of Rasnadi Guggulu proved more efficacious when compared

to only Shuddha guggulu dhoopana or only internal administration of

Rasnadi guggulu.

Karna dhoopana with shudda guggulu proved to be more efficacious than

internal administration of Rasnadi guggulu.

Karna dhoopana was found to be effective only in the healing of pin hole and

small central perforations of tympanic membrane.



Karna dhoopana with shudda guggulu is cost effective, safe and easy

proceeedure which cane be perfomed at O.P.D.level without any

complications.

Follow up study showed reccurrence of Karnasrava in those who did not

follow pathyaapathya.

RECOMMENDATIONS FOR FURTHER STUDY

Present study pattern can be contributed in the form of prospective clinical

study with increased sample size.

Karna dhoopana with other drugs can be selected for the further study;

The effect of Karna dhoopana along with Nasya or Nasya alone can be tried

in karma srava in future research studies.

The efficacy of the therapeutic procedure karma dhoopana can be established

in A.S.O.M and other external ear infections by further research.



SUMMARY

This dissertation work is entitled “Management of Karnasrava with sthanika

Guggulu dhoopana and Rasnadi guggulu - A comparative study”. This study

comprises of 7 chapters i.e Introduction, Review of literature, Methodology,

Observation and Results, Discussion, Conclusion and lastly Summary.

The introductory part includes the need for selection of the topic, therapy, drug of

present study with its aims and objects.

The review describes historical aspects of karnasrava, anatomical and physiological

considerations of karna as per Ayurveda, followed by anatomy and physiology of

ear. Next chapter deals with disease review of Karnasrava & its management. Its

relation to chronic suppurative otitis media and its management in contemporary

science .In next chapter dhoopana is explained. The drugs for dhoopana and rasnadi

guggulu have been explained in drug review.

The third part deals with methodology, which was carried out on 45 patients in 3

groups. Group A, Group B, Group C in the biginining, Source of patients, materials,

plan of study and criteria for inclusion, exclusion and assessment of results have

been given.



The 4th part deals with observations and results. Observations made and results

obtained from the study have been presented in table and chart forms. The signs and

symptoms are analysed statisticaly.

The 5th part deals with discussion on literary part, observation and results.

The 6th part deals with conclusion drawn on observation made.



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DEPARTMENT OF SHALAKYATANTRA G.A.M.C BANGALORE

CASE SHEET PROFORMA

Name : Socio economic status:

Age: OPD/I.P No.

Sex: Date:

Religion: Case No.:

Occupation: Address:

Marital Status:

1. Pradhana Vedana:

2. Anubandha Vedana:

3. Poorva vyadi Vruttanta:

4. Kula Vruttanta:

5. Vaiyaktika vrittanta:

6. Adyatana Vyadhi Vruttanta:

(i) Onset of Complaint : Acute / Chronic gradual

(ii) Duration of the complaint :

(iii) Laterality : uni/Bilateral

(iv) Nature of complaint : Continuous / Intermittent

(v) Severity of compliant :

(vi) Treatment taking so far :

(vii) Associated with :



(viii) Discharge : Quantity :

With / without foul smell :

Consistency :

7. Vikruti pareeksha.

8 a. Hetu: Jala nimajjana

Prapakat vidradhi

Shiroabhigata

Exposure to cold wind

Pratishyaya

Jalakreeda

Karnakandooyana

Exessive intake of Ruksha, Sheeta, Laghu aahara

Ratri jagarana

Vega dharana

8b. Aggrevating factors

Ahara

Vihara

Oushada

Rutu

Dina/ratri

8c. Poorvaroopa

8d. Roopa



8e. Upashaya/Anupashaya

9. ASHTAVDIA PAREEKSHA

Nadi Shabda

Mutra Sparsha

Mala Drik

Jihwa Aakriti

10. DASHAVIDA PAREEKSHA

Prakruti Satwa

Vikruti Pramana

Sara Aaharashakti

Samhanana Vyayamashakti

Satmya Vaya

11. UTTAMANGA PAREEKSHA

Facial asymmetry : present / not present

Congenital abnormality : Yes / No

Of face & neck

Skin over face & neck texture : normal / abnormal

Shape of the face :



12. EXAMINATION OF AUDITORY SYSTEM

External examination. Inspection: Deformity:

Swelling :

Discharge:

Palpation: Tenderness around ear;

1.PINNA

a. Shape : normal / abnormal

b. Congenital abnormalities : present / not present

c. Extra growths : present / not present

d. Infectious foci : present / not present

1. External auditory canal

a. Infectious foci : Present / nor present

b. Tumors or any growth : Present / not present

c. Foul smell : Present / not present

d. Wax : Impacted / Not

2.Karna Srava:

(i) Consistency of Srava

: Watery/ mucous / mucopurulent/ purulent.

II Quantity

(1.) Scanty/ moderate/ profuse.

(ii) Stage of discharge : Active / Inactive / Quiescent



(iii) Smell : without foul smell / with foul smell

3.Tympanic membrane:

1. Cone of light. Present / absent

2. Perforation. Present / absent

3. Type of perforation. Central / marginal / total / subtotal

4. Colour:

5. Mobility:

6. Quadrant: anterosupeiror / antierionferior / Postersupirior /

posterioinferior

4. Middle ear

Eustachian tube patency test. Present / absent

5. Examination of mastoid : Swelling : present/Absent

Tenderness: present/Absent

Auditory function

6. Tuning fork tests;

Rinnes test

Webers test

Examination of Nose

6. External nose: Skin, Scar

Vestibule :

7. Anterior. Rhinoscopy : Nasal discharge / deviated septum



Turbinate: Hypertrophy

Posterior Rhinoscopy: Postnasal discharge /adenoids.

8. Examination of paranasal sinus

Tenderness : Present / absent

9. Examination of Throat

10. Investigations. Blood for. Hb% -

TC –

DC –

ESR –

RBS –

Auditory evaluation (Pure Tone Audiometry)

11. SAPEKSHA NIDANA.

Karna srava

Putikarna

Karna vidradi

Sannipataja karnashoola

Kaphaja karnashoola

12. Vyadhi vinischaya

13. Sadya sadhyata

14. Chikitsa



Group A:

Group B:

Group C:

Periodical observation :

Subjective parameters:

A. Impaired hearing:

Objective parameters:

Sl.No. 0th day 15th day 30th day 60th day 90th day

1. Ear discharge

2. Conductive

Deafness

3. Perforation

Follow up = for 3 months

Results = good / moderate / poor

Reoccurrence / non reoccurrence

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A COMPARATIVE CLINICAL STUDY ON THE EFFICACY OF …