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Ayurvedic Management of Pittaja Swarabheda: A case study

Background: Voice is a means of communicating verbal messages, which serves as a powerful carrier of personality and emotional, educational, and social status. Dysphonia (impaired voice production) is a very common ailment, affecting nearly one-third of the population at some point in their life. Hoarseness of voice can be correlated to swarabheda in Ayurveda. The management provided by contemporary medicine for this condition is either conservative or surgical in nature, which is expensive. Aims and Objectives: The Aim of this study was to assess the efficacy of Ayurvedic management of pittaja swarabheda. Materials and Methods: A 43-year-old man approached to Ayurvedic hospital with complaints of burning sensation and irritation in the throat, hoarseness of voice and difficulty and pain while deglutition and talking. He was diagnosed with Pittaja swarabheda and was treated with panchakarma treatment like Baladi Ghruta Nasya and shamana Chikitsa. The treatment was continued for consecutive 1 month. Results: Hoarseness of voice was assessed after 15 days with the help of Buffalo III Voice Profile and satisfactory outcome was found especially in the quality and loudness of voice, mental strength, and confidence of patient. Conclusion: The collaborative approach of the aforementioned therapy gives symptomatic relief in Swarabheda.


INTRODUCTION:
Voice is a primary means of communication. The human voice is an extraordinary attainment, which is capable of conveying not only complex though but also refined emotion. Voice is the primary mechanism through which most of the people project their personalities and influence their environment. Vocal production is a multiplex behavioural act involving coordination between the systems of respiration, phonation, and articulation. These are influenced by an individual's vocal technique and emotional status.
Hoarseness of voice is the most commonly occurring entity in voice disorders. Hoarseness (dysphonia) is defined as a disorder characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication or reduces voicerelated quality of life. Dysphonia is a broad clinical term, which refers to abnormal functioning of voice. [1] Although hoarseness is used interchangeably with the term dysphonia, it is important to note that the two are not synonymous. Hoarseness is merely a subjective term to explain the perceptual quality (or sound) of a dysphonic voice, [2] whereas dysphonia characterizes impaired voice production as recognized by a clinician. [3] Dysphonia, with the cardinal symptom of hoarseness, affects nearly one-third of the population at some point in their lives. [4] It occurs more frequently in females and the elderly. [5] Dysphonia primarily affects quality of life. Affected patients often experience social isolation, depression, anxiety, missed work, lost wages, and lifestyle changes. [6] Hoarseness of voice includes pathological origin from irritants and inflammatory process due to systemic or local causes due to exposure to trauma (physical or mental) or any chemical exposure or any obstruction due to foreign body or local entity (e.g., neoplasm) or any systemic disorders (e.g., thyroiditis and Hashimoto's disease). [7] It is an important fact that benign lesions are numerically more common causes of hoarseness than malignant. [8] In most cases, it is self-limiting condition but it may be progressive or serious in nature in advanced condition of disease. Hoarseness lasting longer than 2 weeks must be evaluated completely. [9] So it is essential to diagnose the condition first and then its radical cure to avoid further discomfort to the patient.
In Ayurvedic preview, hoarseness of voice can be correlated to swarabheda, which had been described as separate entity by Sushruta. [10] It is further subclassified into six types according to the types of pathological and vitiation of Doshas. The voice affected by Vata becomes rough, feeble, and unstable and that affected by Pitta is associated with burning sensation in palate and throat and aversion to speaking, also characterised by yellowish discolouration of face, eyes, stools and urine. Due to Kapha, the voice becomes slow, obstructed, and stertorous. The voice obstructed by Rakta becomes depressed and rises with difficulty. Due to excessive impulse of cough, the voice damages the throat. Sannipataja is a type which is asadhya (incurable) due to the involvement of all three doshas i.e. vata pitta and kapha predominance. Kshyaja Swarabheda is characterised by feeble voice, associated with feeling of hot fumes coming out of the throat. In Medaja swarabheda, the voice appears as though coming from depth, unclear word and the voice is associated with accumulation of fat in the throat, lips and palate. [11] Till date the treatment remedies available for the hoarseness of voice in contemporary medicine are generally decided on the basis of the type and extent of pathology or causative factors, but it is quite expensive in nature and many patients are not willing to undergo surgery. [12] To overcome these lacunae, it will be novel to search a safe, cost-effective alternative therapy in ancient science such as Ayurveda. Through this paper, humble efforts are taken to focus over the utility of Ayurvedic treatment (Shodhana and Shamana) for the management of Pittaja Swarabheda with a safe and effective manner.

AIM AND OBJECTIVE:
The aim of this study was to assess the efficacy of Ayurvedic management of Pittaja Swarabheda including Shodhana and Shamana Chikitsa.

MATERIALS AND METHOD:
It is a single case study.

HISTORY OF PRESENT ILLNESS:
Demographic details of the patient are mentioned in Table 1. A 43-year-old man was apparently healthy before 1 year, then he started complaints of burning sensation and irritation in throat, hoarseness of voice, difficulty and mild pain while deglutition and talking for 1 year. These chief complaints are mentioned in Table 2. Patient had also taken allopathic medicine for the above complaints after consulting a physician for consecutive 7 months, but there was no improvement in the symptoms and so he stopped taking the medicines from last 3 months. There was severe discomfort and increasing severity of the symptoms. So, he approached to out patient department of shalakyatantra, Y.M.T Ayurvedic Medical Hospital, Kharghar, Navi Mumbai, for ayurvedic treatment and he was advised to stay close to the hospital so he can visit daily for treatment since he was not willing for admission due to family responsibilities. Appropriate treatment was advised to him. Vitals and Ashtavidha Pariksha of the patient are mentioned in Table 4. and 5., respectively.

PAST HISTORY:
He had no history of any major medical illness, such as diabetes mellitus, bronchial asthma, hypothyroidism, and dengue, as well as no history of trauma/exposure to any chemical or surgical intervention.

MEDICINAL HISTORY:
The patient had a history of taking allopathic symptomatic medicine for hoarseness of voice (tab Eltocin-BR 500mg twice a day [BD]).

PERSONAL HISTORY:
Food habits: Pure vegetarian with daily intake of stale food and used to consume a lot of spicy and sour food in the past but stopped since 3 months and irregular interval of food.
Sleep: Disturbed sleep due to irritation in throat.
Family History: Not significant.

LOCAL EXAMINATION:
Oral cavity: Mouth opening-three fingers

NIDANA PANCHAKA:
Hetu (aetiology or causative factors): Diet including poha, biscuits, roti, dal, rice, intake of spicy food, pickles, daily intake of stale food, irregular timing of food intake, and excessive intake to ginger tea.
Purvarupa (prodromal symptoms): Burning sensation and irritation in the throat, difficulty in talking and while deglutition. In this clinical entity, there is obstructive pathology occurred in gastrointestinal tract that involves vitiation of pitta and vata dosha due to severe hampering of bio fire; it leads to the formation of various biotoxins and they get saturated in alimentary canal. So, symptoms of this disease occurred in this region which involves various circulatory channels along with disturbance in excretory system due to irregular bowel habit. Due to vitiation of these channels, it further causes more obstruction which ultimately reflects in symptoms.

Diagnosis: Pittaja Swarabheda.
Treatment advised: Overviewing the above pathogenesis of disease in the patient, the following treatment plan was prescribed, which can be subclassified into two categories, i.e. Shodhana and Shamana Chikitsa shown in Tables 5 and 6, respectively.

OBSERVATIONS AND RESULT:
The Shodhana Chikitsa was continued to the patient for consecutive 15 days and shamana Chikitsa was continued for complete 1 month, then assessment of patient was done after 15 days to assess the voice quality of the patient, audio recording of his voice was taken before starting the treatment and after 15 days of completion of treatment. Both recordings reflect that the nature and quality of voice was significantly improved. In addition, there was complete relief in symptoms like burning sensation and irritation in throat, hyperacidity, difficulty while deglutition and talking and mild pain, which were assessed by subjective criteria shown in Table 7.
Assessment of clinical symptoms: His voice was assessed after 15 days and 1 month with the help of Buffalo III Voice Profile [13] shown in Table 8.

DISCUSSION:
Taking into account all the factors associated with Nidanapanchak in this patient, the treatment principle of pittaja swarabheda was adopted by using the basic principle of Ayurveda and miraculous result was observed. As per classics, ideally Shodhana Chikitsa (Vamana, Virechana and Basti) with proper unction is advised in Swarabheda, which should be followed by Nasya, Avapidana, Mukhadhavana, Dhuma, Leha and various types of Kavalagraha. [10] Because of financial crisis, patient was not willing for the purification therapy, so he was advised for Baladi Ghruta Nasya. The probable mode of action of prescribed treatment can be explored as follows.
Baladi Ghruta Nasya: Swarabheda is one of the Urdhwajatrugata vikara and kantha roga. Nasya is the prime Shodhana procedure preferred because this is a unique procedure, which can achieve utthamanga shuddhi. [14] Baladi Ghruta has pittahara, vatanulomana, brumhana, Shoshahara, Snehana properties. Profuse secretions occur after administration of Baladi Ghruta Nasya. Chest, head, palate, and throat are invaded with pitta dosha. Baladi Ghruta firstly reaches to minute channels, drives out the pittadi doshas from their site, then oleation and strengthening action takes place on ligaments and tendons of the upper part of the body. Regular use of Baladi Ghruta helps in clear perception of sense organs and clarity of voice. According to Vagbhata Acharya, Baladi Ghruta is utthama swarya. [14] SHAMANA CHIKITSA: Yashtimadhu phanta: Yashtimadhu (Glycyrrhiza glabra) is sweet, soothing, and has antioxidant, immunostimulatory, antitussive, demulcent, and expectorant properties. [17] Therefore, it improves the quality of voice and also useful for treating throat irritation and burning sensation as it acts as a coolant. According to Sushruta Acharya, Yashtimadhu mula churna with ksheera must be consumed in Swarabheda. [10] Kamdudha Rasa: It has sheeta veerya, so it is useful in every pitta roga classified in Ayurveda. Taking into account all the above discussions, overall effect of the treatment was good and it helped in reducing all the symptoms of pittaja swarabheda, improved quality of voice of the patient. Due to the Balya effect of the treatment the voice of the patient strengthened.

CONCLUSION:
The patient took the treatment for 15 days and got satisfactory relief in symptoms of pittaja swarabheda. The results revealed that swarabheda can be cured effectively with collaborative approach of Panchakarma procedure Nasya with Baladi Ghruta along with shamana Chikitsa without causing any adverse effects. Till date there is no need for the patient to undergo any modern or surgical intervention. This study is about the presentation of a single case only. Further study in large sample size must be recommended for establishing good and standard outcome.