Ayurvedic Management of Nasha Arsha – A Case Report

Nasal polyp is a chronic inflammatory disease affecting about 1–4% of the general population 1 . Nasal polyps are fleshy benign growth that develop in the mucosal lining of the nasal passage and paranasal sinuses. Polyps vary in size and having shining pink colour and shaped like grapes 23 . The exact etiology remains unclear but it is known to have associations with allergy, asthma, infection. The common features of the disease are nasal obstruction, anosmia, rhinorrhoea, post nasal drip and less commonly facial pain 4 . In Ayurveda; it is closely related to nasa arsha. Nasa arsha is a Kapha vata vyadhi located in Urdwanga which is a kapha sthaan 5 . In this study, a single case 60 years old male patient presented with frequent episodes of nasal obstruction, anosmia mouth breathing and sometimes headache since 2 year was taken for study. An approach was made to treat the patient by sodhana, shamana and sthanika chikitsa with a positive clinical response. Local therapy was the application of Apamarga khara karma over polyps. This study aimed at introducing a new treatment modality with new formulation.


Introduction
Nasal polyps are soft, painless, benign growths arising from the mucosa on the lining of nasal passages or sinuses. They hang down like teardrops or grapes. Nasal polyps are traditionally divided into two types-Antrochoanal polyp and Ethmoidal polyps 6 . Although having an uncertain etiology, they result from chronic manifestation of Rhinosinusitis, Cystic fibrosis, Allergic sinusitis etc.Small nasal polyps may not cause symptoms. Larger growths or groups of nasal polyps can block the nasal passages andlead to breathing problems, a lost sense of smell and taste, facial pain or headache, a sense of pressure over forehead and face, frequent infections and snoring 7 . Nasal polyps can affect anyone, but they are more common in male adults with male-female ratio of 4:1. Polyps can be graded into four stages according to their size 8 : Management of nasal polyp forms a large part of the workload for the otolaryngologist. Medical management is the choice for ethmoidal polyp. Medications can help to shrink or eliminate nasal polyps, but surgery is sometimes needed to remove them. Even after successful treatment, recurrence rate is high.
In Ayurveda, it is closely related to Nasa arsha. This is a condition where patient feels nasal blockage. Sushruta had explained 4 types of nasarsha: Vataja, Pittaja, Kaphaja and Sannipataja as well as 4 types of treatments-Aushadhi, Ksharkarma, Agnikarma and Shastrakarma 9 .In this study aushadha karmaand Ksharkarmahad been followed to treat Nasa arsha. Volume 4, Issue 6, November-December 2022 2 Apamarga Ksharaconsent: Informed consent was taken prior to procedure.

Case Study
A 60 year old male patient (OP-154752) visited shalakya OPD no 4 on 10/07/2022at ITRA Jamnagar with chief complaints of B/L nasal blockage, difficulty in breathing and irritation since 10years. The symptoms were aggravated during evening time and on exposure to dusts and cold. His personality was average built; body weight was 68 kgandbelonging to middle class socioeconomic status. Occupationally, he was a retired after bank job. No significant family history and personal history identified. He consulted many allopathic ENT surgeons where he was diagnosed as bilateral Ethmoidal Polyp Grade IV with chronic sinusitis. He was treated by antibiotics, NSAIDS and steroids nasal spray but got symptomatic relief only. Patient undergone polypectomy 10 years back but after 5 years nasal polyp reoccurred. Further he was advised again for surgical intervention polypectomy. But patient not want to go for surgry again. For above said complaints he came in OPD on the same day for further management. There was no history of diabetes mellitus or hypertension. His vitals were within normal limits. On general examination, there was no pallor, icterus, clubbing of nails, oedema or lymphadenopathy noted. No CNS abnormalities noted on through examination.

Diagnosis-
When patient came to OPD of Shalakya Tantra, history takimg , nasal examination by thudicum and endoscopic examination was done and patient was diagnosed as nasal polyp( Ethmoidal polyp). After assessing the causes and symptoms, Ayurvedic diagnosis was made"Nasha Arsha". All the aseptic precautions were measured throughout the procedure. Patient was advised not to eat or drink anything (nil by mouth) for 4 h preceding the ksharakarma procedure. Ligno × 10% spray was sprayed into the left nostril to anesthetize the turbinate in order to avoid sneezing refl ex and sensitivity. Patient was placed in supine position with the head extended by placing a pillow under the shoulders to expose the nasal cavity properly. A gauze piece soaked in lime water was placed into the left side of the nasal cavity away from the turbinate to avoid involvement of other normal structures.

Pradhana Karma
The left nasal cavity was exposed using Thudicum's Nasal Speculum and a secretion over the turbinate was wiped out using gauze piece. Apamargakshara was applied over the medial surface of the exposed turbinate, by using the After 1 month of nasya, 7 sitting of Kshara Karma has done with Apamarg kshara over nasal polyp ( Every 3 rd day).
All the aseptic precautions were measured throughout the procedure. Patient was advised not to eat or drink anything (nil by mouth) for 4 h preceding the ksharakarma procedure. Ligno × 10% spray was sprayed into the left nostril to anesthetize the turbinate in order to avoid sneezing reflex and sensitivity. Patient was placed in supine position with the head extended by placing a pillow under the shoulders to expose the nasal cavity properly. A gauze piece soaked in lime water was placed into the left side of the nasal cavity away from the turbinate to avoid involvement of other normal structures.

Pradhana Karma
The left nasal cavity was exposed using Thudicum's Nasal Speculum and a secretion over the turbinate was wiped out using gauze piece. Apamargakshara was applied over the medial surface of the exposed turbinate, by using the cotton rolled over Jobson probe. Applied kshara was kept

Purva karma
All the aseptic precautions were measured throughout the procedure. Patient was advised not to eat or drink anything (nil by mouth) for 4h preceding the ksharakarma procedure. Patient was placed in supine position with the head extended by placing a pillow under the shoulders to expose thenasal cavity properly.A gauze piece soaked in lime water was placed into the left side of the nasal cavity away from the polyp to avoid involvement of other normal structures. Volume 4, Issue 6, November-December 2022 4

Pradhana Karma
The left nasal cavity was exposed using Thudicum's Nasal Speculum and a secretion over the turbinate was wiped out using gauze piece. Apamargakshara was applied over the surface of the nasal polyp,by using the cotton rolled over Jobson probe. Applied kshara was kept for 2min.After sometime,the color changed to reddish brown (Jambuphalavat, i.e. the fruit of Syzizium cumini Linn.).The kshara was then removed with cotton rolled with Jobson probe.Lemon juice was applied over the polyp to neutralize the remaining kshara.

PaschatKarma
The patient was advised to avoid exposure to air or breeze,dust,smoke,etc.,The patient was advised to take light diet.

Follow-up
The patient was advised to follow-up for twice weekly for 15 days

Pathya-Apathya:
Patient was strictly advised not to take chocolates, colddrinks, icecream,fastfood,fermented fooditems,spicyfood,or any color chemical containing items.Patient was advised to take steam inhalation through mouth two times a day with plain water. Intake of lukewarm waterfor the wholeday as a routine.
After 1 month medication, 7 sitting of Kshara Karma has done with Apamarg ksharaover nasal polyp ( Every 3 rd day)

Discussion-
Nasha arsha is kapha predominent tridoshaj vyadhi with rakta and masha dushya, that block the nose which cause symptoms. Drug that shrinken the size of polyp will be helpful.

Kanchanar guggul 11
Kanchanar guggul reduces the size of nasal polyps and eases in breathing. Kanchanar guggul is best in mansha dushti and lekhaniya property . The anupaan of kanchanar is sunthiudak as given in bhavprakash , sunthiudak increase the efficacy of kanchnar guggul.

Punarnvastak kwatha 12
The contents of Punarnavastak kwath are as follows:

Vyaghri taila 13
The Vyaghri Taila possesses anti-inflammatory, antioxidant, immune modulatory and antiasthmatic properties and also stabilizes mast cells and reduces mucous secretion Then Vyaghri Taila was used as medicine for Nasya purpose. Vyaghri Taila ingredients have same predominant properties as Katu Rasa, LaghuGuna , UshnaVirya, KatuVipaka and KapkaVataShamaka properties. So these have same action on Vata Kapha predominant Vata KaphaPratishyaya. Because of Tikshana and Sukhshma Guna the medicine will penetrate into minute channels does Srotoshodhana . Most of ingredients possess anti-inflammatory activities which also prevent inflammatory Administration of medicated oil will help in reduction of post nasal drip due to high viscosity, reduction in anterior nasal drip, reduction of irritation by soothing recipients and target drug delivery to mucosa for better absorption. Due to high viscosity, there is increase in residual time of oily substance in nasal cavity and enhance bioavailability. Oil instilled in nose prevents its irritation of mucous membrane by pollen, dust, bacteria etc. so it can check the allergy or infection.
The Vyaghri Taila possesses anti-inflammatory, antioxidant, immune modulatory and antiasthmatic properties and also stabilizes mast cells and reduces mucous secretion.
It remove all the unwanted things like allergens from nasal cavity and help to drain nasal cavity, saline warm water help to reduce inflammation and increases blood supply there which help in regaining healthy mucousmembrane. It also improve sensitivity of olfactory nerves, flushes tear duct, cleanses the cilia (present in nasal cavity).

Virechana dhoompana -
It is made by virechnika drvaya that will expel kapha from nose and give relief in obstruction of nose. The Dhoompaan Varti helps in the removal ofresidualKaphaafternasyakarma.

Apamarga kshara -
Burning sensation was observed during and after the application of kshara, which was managed with local application of lemon juice for15min.The patient was complained of dark brown colored watery discharge on the next day which was self-controlled,in 4 days.The same procedure is followed by alternate days for 7 sitting. The mild reduction of size of polyp was observed on.Along with nasal obstruction the other associated complaints, like B/L nasal blockage, difficulty in breathing., irritation in nose was completely reduced.

Conclusion:
Nasal polyp i.e. Nasa arsha is a chronic inflammatory disease. Ayurveda believes in cleansing the body and pacifying the tridoshas from the roots by using unique treatment modalities such as sodhana, shamana and sthanika chikitsa. These treatment approaches create a balanced physiology which regress the size of nasal polyps and thus making the patient symptom free by non invasive method. Ayurveda creates a new hope for treatment of nasal polyps (Nasa arsha) for this era.
All the aseptic precautions were measured throughout the procedure. Patient was advised not to eat or drink anything (nil by mouth) for 4 h preceding the ksharakarma procedure. Ligno × 10% spray was sprayed into the left nostril to anesthetize the turbinate in order to avoid sneezing reflex and sensitivity. Patient was placed in supine position with the head extended by placing a pillow under the shoulders to expose the nasal cavity properly.

Purva Karma
All the aseptic precautions were measured throughout the procedure. Patient was advised not to eat or drink anything (nil by mouth) for 4 h preceding the ksharakarma procedure. Ligno × 10% spray was sprayed into the left nostril to anesthetize the turbinate in order to avoid sneezing refl ex and sensitivity. Patient was placed in supine position with the head extended by placing a pillow under the shoulders to expose the nasal cavity properly. A gauze piece soaked in lime water was placed into the left side of the nasal cavity away from the turbinate to avoid involvement of other normal structures.

Pradhana Karma
The left nasal cavity was exposed using Thudicum's Nasal Speculum and a secretion over the turbinate was wiped out using gauze piece. Apamargakshara was applied over the medial surface of the exposed turbinate, by using the cotton rolled over Jobson probe. Applied kshara was kept