Review Article International Ayurvedic Medical Journal ISSN:2320 5091

THERAPEUTIC EFFECT OF VIRECHANA AND KARNAPOORANA IN MENIERE’S DISEASE-A CASE STUDY Ayanaraj.P1, Sujathamma K2, Mamtha K.V3 1P.G.Scholar, 2Professor & HOD, 3Reader Department of PG studies in ShalakyaTantra, SKAMCH&RC, Bangalore,Karnataka,India.

ABSTRACT Meniere’s disease, synonymously known as endolymphatic hydrops is a disorder of the inner ear where the endolymphatic system is distended with endolymph. It is character- ised by four cardinal features (1) vertigo (2) sensorineural hearing loss (3) tinnitus and (4)aural fullness. The annual incidence of Meniere’s disease is 5-7 / 10,000 with the first attack being most commonly in the third to sixth decade of life. The condition needs to be addressed with proper measures in the initial stage itself as it can affect the psychological wellbeing, hampering the quality of life of sufferers. Current line of management is found to be deficient in providing absolute cure for this disease. In ancient Ayurvedic treatises there is no reference that can be correlated exactly to the meniere’s, but based on the symp- tomatology it has simulation with various manifestations like Bhrama (giddiness), Kar- nanada(karna=ear,Nada=sound,karnanada=perception of different sounds like ring- ing,roaring,hissing in the ear) and Karnabadhirya (hearing loss). Analysis of each of these manifestations proves that it is a vata pitta tridoshaja vyadhi. The ayurvedic treatment given to a patient with intractable meniere’s disease who has approached the out- patient department of ShalakyaTantra of Shri Kalabhyraveshwara swami Medical College Hospital and Research Centre, Bangalore has shown significant results. Consider- ing the dosha pradhanyata of the vyadhi the patient was treated with virechana and kar- napoorana as these are the best pittahara and vatahara chikitsa respectively. As treatment methodology adopted in this case has been encouraging, especially where other systems of treatment failed, the particular case hase been selected for this article. Keywords: Meniere’s disease, Bhrama, Karnanada, Karnabadhirya, virechana, Karnapoorana

INTRODUCTION Meniere’s disease synonymously Either the increased production of endo- known as endolymphatic hydrops is a lymph or its faulty absorption or both disorder of inner ear resulting in impair- together can result in the increased vol- ment of hearing and giddiness. Although ume of endolymph. The vasomotor distur- the disease had been recognised in the bance, sodium and water retention, endo- early 1860s, the details of underlying crinal causes like hypothyroidism, auto mechanism still remains unclear.[1] How- immune and viral causes are the various ever the distension of endolymphatic sys- theories postulated as the aetiological tem due to increased volume of endolymph factors. Nearly 50% of is the most common pathology explained Sufferers have concomitant allergy either in modern science. of food or inhalant or both. [2] Thus- Ayanaraj.P et al: Therapeutic Effect Of Virechana And Karnapoorana In Meniere’s Disease-A Case Study Meniere’s disease is multifactorial, finally the ear[7].Shrama (exertion), dhatuk- ending up in endolymphatic hydrops with shaya(depletion of dhatus) and rooksha manifestation of classical symptoms. The kashayabhojana (excessive intake of dry disease is characterised by the tetrad of and astringent food) are the causes de- symptoms-episodic vertigo, fluctuating scribed for Karnakshweda.[8]When viti- hearing loss, tinnitus and aural fullness. ated vata increases in srotrendriya there The annual incidence of Meniere’s disease will be production of different sounds like is 5-7 / 10,000 with the first attack being bheri/mrudangasabda (sound from differ- most commonly in the third to sixth ent musical instruments like drum) or decade of life.[3]The symptoms of sankhasabda (sound produced from conch Meniere’s varies in intensity from mild to shell) which is described as the disease disabling. The quality of life of the suffer- karna nada.[9] The high pitched ,hissing or ers is severely hampered by the disease rushing sound in ear indicates a pathology especially the psychological well-being, in the inner ear.The hissing sound in the which manifest mainly as anxiety and ear is explained as a of karna depression. There is a vicious cycle of in- nada by Videha Acharya.Thus it can be teraction between somatic symptoms and understood that that the karna nada is psychological disturbances.[4] linked with the inner ear pathology.Karna In ancient ayurvedic treatises there is no nada, if not treated at the proper time can reference that can be correlated exactly to lead to badhirya which is a the Meniere’s, but based on the symptoma- kaphasamsrushta vatavyadhi. Karna is the tology it has simulation with various mani- adhishtana of these manifestations which festations like Bhrama(giddiness), Kar- is the seat of and akashamahab- nakshweda, karna nada(perception of dif- hoota. ). Analysis of each of these mani- ferent sounds like ringing,roaring,hissing festations proves that the disease is a in the ear)and Karnabadhirya (hearing vatapitta pradhana tridoshaja loss). Bhrama manifest as a symptom in vyadhi.Vatapittaharachikitsa should be the many diseases explained in classics such first line of management considering the as pandu, jvara, arshas,grahani etc. adhishtana, stanantaragatadosha and According to Acharya Susruta, bhrama dosha pradhanyata of vyadhi. The manifests due to vitiation of manasika- satwavajayachikitsa should also be dosha and sareerikadoshas like pitta emphasized owing to the dushti of and vata.[5] DalhanaAcharya further ex- manodosha-rajas. plains Bhrama as a subjective feeling of The conservative management is the only rotatory motion as if placed on a revolving available measure for this disease in the wheel.[6]The modern science also reveals modern science and it is found to be that the patients of meniere’s disease gets deficient in providing absolute cure. feeling of rotation of himself or his envi- Vestibular sedatives and vasodilators are ronment. Bhrama is also described as one usually administered to relieve vertigo and among the symptoms of kapha kshaya and to control acute attacks. If attacks are not majjakshaya. As explained by Acharya controlled by these medicines diuretics can Videha Karnakshweda is caused due to the be given to control recurrent attacks.[10] association of vitiated vata along with But vasodilators like histamine can give kapha,pitta and rakta. It is characterised rise to adverse reactions and Intratympanic by hearing venughosha (sound of flute) in gentamicin therapy is associated with

1168 www.iamj.in IAMJ: Volume 3; Issue 4; April- 2015 Ayanaraj.P et al: Therapeutic Effect Of Virechana And Karnapoorana In Meniere’s Disease-A Case Study severe hearing loss in 4-30% of patients. hamper the quality of life and psychologi- Risk of mild to severe hearing loss is cal well being of the patient. reported with Endolymphatic sac surgery, Investigations available (Pure tone audi- vestibular nerve section, transmastoid ometry on 13-6-2013) were showing labyrinthectomy. moderate sensorineural hearing loss in Thus the disease demands an right ear and severe sensor neural hearing appropriate measure which can loss in left ear. Craniocorpography tests reverse the pathology without like standing test, tandem walking, unter- causing any side effects. Virechana burger’s test were showing changes and karnapoorana has been selected suggestive of peripheral vestibular lesion. to treat this particular case as these The patient was under the medication of are the best pittahara and vatahara- Tab.Ditide(1-0-0),Tab. Vertin 24mg chikitsa respectively. (1-1),and Tab. Nexito 5mg(1-0-0) for past CASE REPORT three years. None of these medications A 52-year-old male patient approached the were able to resolve his complaints. outpatient department of ShalakyaTantra Diagnosis of ShriKalabyraveshwara swami Ayurveda The case had been diagnosed as definite Medical College Hospital and Research meniere’s as it fulfils the criteria explained Centre, Bangalore on 3-10-2014.The by AAOHNS as follows: patient was presented with complaints of  Two or more definitive spontaneous recurrent episodes of vertigo, hearing loss episodes of vertigo lasting 20 minutes and ringing sound in both the ears. or longer. History of the patient revealed that  Audiometrically documented hearing giddiness was developed four years back loss on at least one occasion. along with difficulty in hearing in his left  Tinnitus or aural fullness in the ear. He also noticed weird sounds in the affected ear. ear which aggravate during the attack. The  All other causes excluded. giddiness was associated with imbalance, Intervention positional vertigo, nausea, vomiting and The patient was subjected to the treatment- loose stools. During the initial stage, each virechana with trivritavaleha followed by episode of vertigo lasted for 30min-1hrs karnapoorana with katutaila.The patient and gradually progressed to current was instructed to follow pathyaahara and duration of 2-3hrs.The frequency of attack vihara. progressed from once in a month to two to Dose and duration three times in a week. The hearing loss  Deepanapachana: Panchakola- was gradual in onset and two years back it choorna-0-¼-¼ tsp half an hr before affected the right ear also. The hearing im- food for 3 days. proved after the attack initially but for the  Snehapana: Mahathiktaka ghrita- last one year, there is hearing loss even  1st day :30ml during the period between the attacks. The 2nd day: 60ml patient was unable to perform his day to 3rd day: 120ml day activities and he was forced to take  Sarvanga abhyanga with rest most of the time. The tinnitus even Dhanvantara taila and Bashpasweda impairs his sleep. Thus the above issues for 3 days.  Virechana:Trivrit avaleha-60gm

1169 www.iamj.in IAMJ: Volume 3; Issue 4; April- 2015 Ayanaraj.P et al: Therapeutic Effect Of Virechana And Karnapoorana In Meniere’s Disease-A Case Study  Samsarjanakrama-followed for 3days. Assessment of the effect of treatment on  Karnapoorana:Sarshapataila for signs and symptoms have been done based 7days. on subjective and objective parameters by Follow up adapting a grading pattern before and after The case had been followed up twice in a the treatment as follows: month after the course of treatment for 2 Table 1. GRADING OF SIGNS AND months. SYMPTOMS Criteria for assessment SYMPTOMS 0 1 2 3 4

TINNITUS No Audible Audible only in Audible in all - tinnitus only in ordinary acoustic acoustic envi- silent environment,but ronments, dis- environment masked by loud turbs falling environmental asleep,can sounds; can dis- disturb sleep turb falling in general and asleep,but not is dominating sleep in general. problem that affects quality of life. VERTIGO No Vertigo not Associated with Associated - vertigo associated nausea&vomiting. with pallor/ with any Remission lasting bradycardia/ other symp- for months. abdominal toms. cramp/ cold/ diarrhoea/ sweat. Remission lasting for weeks. FUNCTIONAL Does not During the During the attack Patient is dis- - LEVEL affect attack pa- patient has to stop abled and un- day to tient has to the activity, can able to do day day stop the ac- resume the work to day activi- activities tivity, can after the attack. ties. resume the But patient has to work after compromise in the attack. some activities. HEARING No Mild Moderate Moderate Severe LOSS hearing (26-40dB) (41-55dB) (41-55dB) (71-91dB) loss Observations and results Table 2.Effect Of Treatment In Tinnitus And Hearing Loss

1170 www.iamj.in IAMJ: Volume 3; Issue 4; April- 2015 Ayanaraj.P et al: Therapeutic Effect Of Virechana And Karnapoorana In Meniere’s Disease-A Case Study (BT-Before Treatment, AT-After Treatment, AT1-After Follow Up) Parameter Right Ear Left Ear BT AT % AT1 % BT AT % AT1 % Relief Relief Relief Relief Tinnitus 3 1 67% 1 67% 3 1 67% 1 67% Hearing Loss 2 2 0% 2 0% 4 2 50% 2 50%

Table3.Effect Of Treatment In Vertigo &Functional Level (BT-Before Treatment, AT-After Treatment, AT1-After Follow Up) PARAMETERS BT AT % AT1 % Relief Relief VERTIGO 3 0 100 0 100 FUNCTIONAL LEVEL 3 1 67 1 67 Table 4: Pure Tone Average Before And After Treatment(BT-Before Treatment, AT-After Treatment,PTA-Pure Tone Average): RIGHT EAR LEFT EAR BT AT BT AT PTA 45 45 73.3 50 treatment and during follow up. Tinnitus in There was significant reduction in the both ear also showed significant reduction symptoms after treatment especially in the from grade 3 to grade 1 after treatment and vertigo. There was complete reduction in during follow up. Even though the hearing vertigo immediately after virechana, which enhanced the functional level of the loss in the right ear showed no change af- patient. The vertigo reduced from the ter treatment, hearing loss in the left ear grade-3 to grade 0 after the treatment. was reduced from severe to moderate There were no episodes of vertigo after hearing loss i.e., from grade 4 to grade 2.

120 100 100 100 100 100 100 80 60 50 50 50 40 33 33 33 20 BT 0 0 AT

1171 www.iamj.in IAMJ: Volume 3; Issue 4; April- 2015 Ayanaraj.P et al: Therapeutic Effect Of Virechana And Karnapoorana In Meniere’s Disease-A Case Study Figure 1 : SEVERITY OF SYMPTOMS indicated also in bhrama[11].It is having IN PERCENTAGE srotoshodhana and raktaprasadana- There was 100% reduction in vertigo after . As it contains tiktarasa treatment and 67% reduction in the tinnitus pradhanadravyas, it does the and functional level. The hearing loss in upashoshana of the kleda,shleshma right ear showed no change whereas the and pitta.There by it may reduce the same in left ear had 50% improvement. increased dravaguna and sara guna of pitta and kleda which may help to DISCUSSION reduce the excessively produced endo- The patient presented as a case of lymph.The ghrita itself is the best intractable Meniere’s disease with medicine to alleviate pitta and impairment in the quality of life by the vata.When it is processed with tikta disease especially, the psychological well- rasa ,it also alleviate dooshita- being. Challenge was that whether kapha. Ayurveda can cure and improve the quality of life of such patients? ACTION OF TRIVRIT AVALEHA  Trivrit avaleha is having pitta- Even though the tetrad of symptoms of kaphasamana,vatanulomana and sro- Meniere’sdisease cannot be found together toshodhanaproperty. Trivrit is having in any of the diseases explained in kashayamadhura rasa and rooksha- Ayurveda, the manifestations of Bhrama, guna and it is the best formulation to karna nada, karnakshweda and badhirya induce the sukhavirechana[12].By have simulations with symptoms of virtue of these properties, it helped to Meniere’sdisease. Analysis of these eliminate the dooshita pitta and kapha manifestations proves that the condition is along with vatanulomanakarma.The a vata pittapradhana tridoshavyadhi. above said properties helped to bring The patient was administered snehapana back doshas to normalcy and there by with mahatiktakaghrita and virechana relief in symptoms. with trivrit avaleha followed by karnapoorana with katutaila.The results PROBABLE ACTION OF VIRE- obtained immediately after virechana was CHANA IN MENIERE’S DISEASE  Virechanadravya due to its noteworthy especially as there ushna,teekshna and sukshmaguna was complete relief in vertigo. The reaches the sookshmasrotas[13]i.e., the tinnitus also reduced to greater extent after target area;vascular epithelium in karnapoorana. The reduction in both these striavascularis and cause vishyandana symptoms enhanced the patient’s quality of doshas ultimately eliminating them of life and confidence. The comparison of from the body. Thevirechana brought audiometry reports before and after treat- about srotosudhi by removing dooshita ment also revealed significant reduction in pitta and kapha and thereby removing hearing loss in left ear. the margavarodha.Virechana also ACTION OF MAHATIKTAKA GHRITA brings vata in anulomagati.Thus the  Mahatiktakaghrita explained in vata vrudhi in the srotrendriya which Ashtangahrudaya was selected for is a seat of vayu and mahab- snehapana as it is an excellent hoota will be inhibited. Due to these formulation for paittikavikaras and

1172 www.iamj.in IAMJ: Volume 3; Issue 4; April- 2015 Ayanaraj.P et al: Therapeutic Effect Of Virechana And Karnapoorana In Meniere’s Disease-A Case Study properties, it reduces bhrama,badhirya The present case study signifies the role of and karna nada. virechana and karnapoorana in the treat-  The virechana helps in depleting the ment of Meniere’sdisease. The chikitsa fluid volume in the body. As endo- should be pittahara followed by lymph resembles the intracellular vatanulomana considering the adhishtana fluid,it may also be reduced by and doshapradhanyata of vyadhi. The re- virechana. sults obtained after treatment was remark-  The vitiated vata impairs the able as it was a case of intractable conduction of sound while Meniere’s disease. As treatment method- transduction of sound is hampered by ology adopted in this case has been en- vitiated pitta.As this particular mecha- couraging, especially where other systems nism is brought back to normalcy by of treatment failed, it is desirable that the pittahara and vatanulomana karma further studies and clinical trials be con- of virechana;which could be under- ducted in a few more similar cases to ar- stood as the reason for significant im- rive at a decisive conclusion about the provement in hearing following vire- choice of treatment and to improve the chana. success rate.  Virechana, being the best pittahara chikitsa will also correct the dooshita REFERENCES rakta as pitta and rakta are inter re- 1. Mohan Bansal,Diseases of ear, nose lated due to ashraya ashrayi and throat,Jaypee Brothersmedical publisher’s, New bhava.Virechana will also promote the nd functioning of srotrendriya as it is hav- Delhi,2013,Section2,22 Chapter,p241. ing indriyaprasadanakarma.[14] 2. P.LDhingra and Shruti Dhingra: Dis- easesof Ear, Nose and Throat, Elsevier, ACTION OF KARNAPOORANA WITH th KATUTAILA Delhi, 2010, 15 chapter,p.111-112.  Karnapoorana with katutaila is indi- 3. Prashanth cated in nada-badhiryachikitsa in A.S,NadgirDatta,Meniere’sdisese ex- various treatises[15].Katutaila is having ploring its treatment through Ay- kapha vatahara property there by it urveda,IAMJ,Volume1,Issue 2,p.1-5 helps to reduce badhirya which is 4. Dr. Foster Tochukwu Orji,The Influ- described as a kaphavruta vatavyadhi. ence of Psychological Factors in  Karnapoorana is explained as a Meniere's Disease,Annals of dinacharya to prevent vatikakarnaroga medical and healtrh sciences re- and badhirya.It is also described as one search,2014 Jan-Feb,4(1):3-7. among the vicharanasneha.Hence 5. Susrutha:Susruthasamhitha with Ni- katutailakarnapoorana is an excellent bandhasamgraha commentary by Dal- therapy to reduce the vatikakarnaroga hanaacharya, Chaukambhasurab- which could be the reason for signifi- haratiprakashan,Varanasi,Reprint cant reduction in tinnitus and hearing 2012,Sareera Sthana, chapter 4/56, loss following karnapoorana in the p.360 present case. 6. Susrutha:Susruthasamhitha with Ni- bandhasamgraha commentary by Dal- CONCLUSION hanaacharya, Chaukambhasurab-

1173 www.iamj.in IAMJ: Volume 3; Issue 4; April- 2015 Ayanaraj.P et al: Therapeutic Effect Of Virechana And Karnapoorana In Meniere’s Disease-A Case Study haratiprakashan,Varanasi,Reprint aranasi,Reprint2009,Chikitsa 2012,Sareera Sthana,chapter4/56, Dal- Stana,Chapter 19/2-10,p.711 hana commentary,p.360. 12. Vagbhata: Ashtanga Hrudaya with the 7. Madhavakara,Madhavanidhana with commentaries of Sarvangasundara of Madhukosha commentary Chaukamb- Arunadatta and Ayurveda rasayana of haprakashan,Varanasi,Reprint 2007 He- part.2,Chapter 57/4,p 287 madri,ChaukambhaSanskritsansthan,V 8. Susrutha:Susruthasamhithawith Ni- aranasi,Reprint2009, bandhasamgraha commentary by Dal- Stana,Chapter2/3,9,p.742 hanaacharya, Chaukambhasurab- 13. Agnivesha, Carakasamhita with Ay- haratiprakashan,Varanasi,Reprint urveda deepika commentary by Cakra- 2012,Uttara Than- panidatta, Chaukambhasurab- thara,chapter20/9,p.644. haratiprakashan, varnasi, edition 9. Madhavakara,Madhavanidhana with 2008,Kalpasthanam,1/5 p 651 Madhukosha commentary Chaukamb- 14. Agnivesha,Carakasamhita with Ay- haprakashan,Varanasi,Reprint 2007 urveda deepika commentary by Cakra- part.2,Chapter 57/4,p 286. pani- 10. Mohd.Maqbool,Textbook of datta,Chaukambhasurabharatiprakasha Ear,Nose,Throat Dis- n,varnasi,edition2008,Siddhistanam,1/ eases,JaypeeBrothers MedicalPublish- 27,p680 ers,Delhi,9th Edition,Section1,18th 15. YogaRatnakara, edited and translated Chapter,p.95. by Dr. MadhamShetty Suresh Ba- 11. Vagbhata:AshtangaHrudaya with the buChowkhamba Series office commentaries of Sarvangasundara of Varanasi 1stedition,Uttarardha- Arunadatta and Ayurveda rasayana of Volume1, Karnarogachikilsa He- 33,p.1055. madri,ChaukambhaSanskritsansthan,V

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CORRESPONDING AUTHOR Dr. Ayanaraj P P.G.Scholar, Department of PG studies in ShalakyaTantra, SKAMCH&RC, Bangalore, Karnataka, India. Email: [email protected]

Source of support: Nil Conflict of interest: None Declared

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