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Kshara application for turbinate hypertrophy

Nasapratinaha (nasal obstruction) is a commonly encountered disease in clinical practice. It is one of the nasal disorders, explained in Ayurveda, having nasal obstruction leading to difficulty in breathing as the main cardinal feature. In contemporary science, this condition can be correlated with various diseases such as turbinate hypertrophy, deviated nasal septum, nasal mass, mucosal congestion, allergic rhinitis, and others; among which turbinate hypertrophy is a common cause. Turbinate hypertrophy can be treated with surgical and medical methods. The medical treatment has limitation for prolonged use because of health purpose, surgical approaches too have failed to achieve desired results in turbinate hypertrophy due to complications and high recurrence rate. The medical and surgical managements have their own limitations, merits, and demerits like synechiae formation, rhinitis sicca, severe bleeding, or osteonecrosis of the turbinate bone A parasurgical treatment explained in Ayurveda, known as kshara pratisarana, which is a minimal invasive and precise procedure for this ailment, tried to overcome this problem. ‘Kshara Karma’ is a popular treatment modality in Ayurveda, which has been advocated in disorders of nose like arbuda (tumor) and adhimamsa (muscular growth). Clinical observation has shown its effectiveness in the management of turbinate hypertrophy. A case report of 45-year-old male who presented with complaints of frequent nasal obstruction, nasal discharge, discomfort in nose, and headache; and diagnosed as turbinate hypertrophy has been presented here. The patient was treated with one application of Kshara over the turbinates. The treatment was effective and no recurrence was noticed in the follow up.


INTRODUCTION
Nasal obstruction is a very common and troublesome complaint in ear, nose, and throat (ENT) practice. The main causative factor for this condition is turbinate hypertrophy. Other etiological factors involved are nasal allergy, vasomotor rhinitis, rhinitis medicamentosa, nasal mass, and deviated nasal septum. Hypertrophied turbinates are responsible for nasal obstruction more often than is commonly thought. The inferior turbinates are the largest turbinates and are responsible for the majority of airfl ow direction, humidifi cation, heating, and fi ltering of air inhaled through the nose. Allergies, exposure to environmental irritants, or a persistent infl ammation within the sinuses can lead to turbinate swelling. Deformity of the nasal septum can also result in enlarged turbinates. Enlargement can be due to increase in soft tissues of turbinate or due to thickened bone. The medical management includes a variety of antihistamines, decongestants, and topical and systemic corticosteroids. These drugs provide only symptomatic improvement; they cannot cure the condition. They also can create side effects such as drowsiness, bleeding, drying, and crusting. [1] Among the many surgical procedures that have been used for the treatment of nasal obstruction are the trimming of the inferior turbinates, laser therapy, linear cautery, submucosal diathermy, and turbinate cryotherapy. All of them have been reported to be effective over the short-term, but they provide no sustained benefit. [2] Radiofrequency ablation (somnoplasty) and microdebridement of the turbinates are two of the newer techniques, but long-term data on their effectiveness are not yet available. [3] Thus a wide variety of surgical procedures have been performed on the turbinates for the relief of chronic nasal obstruction due to their hypertrophy, but the results have been universally unsatisfactory. This condition is not fatal, however increased rapidly resulting in high rates of morbidity and has many adverse sequelae including mouth breathing, dryness of the oropharynx, nasal speech, disordered sleep, restlessness, malaise, an adverse effect on quality of life, and reduced lung volumes. [4,5] As per ayurvedic classics, in nasapratinaha the vitiated kapha dosha along with vata dosha blocks the inspired air, leading to nasal obstruction. Based on the classical symptom it can be considered as one of the nasal obstructive lesion hypertrophied turbinate, in which there is enlargement of the sub mucosa and very rarely, the bone itself. [6] 'Kshara Karma' is a popular treatment modality in Ayurveda, which has been advocated in disorders of nose like arbuda (tumor) and adhimamsa (muscular growth) [7] besides many other diseases which are the results of unhealthy or undesirable growth of body tissues. [8] Kshara has properties of mainly chhedan (excision), bhedhan (incision), and lekhan (scraping), [9] and so serves the purpose of cutting, dividing, puncturing, scratching etc., moreover it is fi t to be used in places where sharp instruments can be used with diffi culty [10] like the nose. Hence considering this point it is assumed that the use of ksharapratisarana can be an effective solution in the management of nasapratinaha w.s.r. to turbinate hypertrophy. This case showed good results.

CASE REPORT
A 45-year-old male presented with the complaints of frequent nasal obstruction, nasal discharge, discomfort in nose, and headache since 3 years.

On examination
On local examination of the nose [ Table 1] the external nose was normal with widened anterior nares. On anterior rhinoscopic examination, inferior turbinate in left side of the cavity was markedly hypertrophied with congestion of the nasal mucous membrane [ Figure 1]. In right side of the nasal cavity also there was mild hypertrophy of middle turbinate present. Routine hematology tests (hemoglobin, total count, differential count, erythrocyte sedimentation rate, and absolute eosinophil count) investigations were done. The erythrocyte sedimentation rate and absolute eosinophil count were slightly increased. Hemoglobin, total count, and differential count were within normal limits.

Past history
Patient had taken medical management which included a variety of antihistamines, decongestants, and topical and systemic corticosteroids since 3 years; but was of no use. After discontinuation of medication recurrence of the nasanaha was observed.
As the disease was not manageable with medical treatment and leading to complications like sleep apnea and mouth breathing, kshara application was selected in this case.

Procedures administered to the patient 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 for 2 min. [11] After sometime, the color changed to reddish Mild deviation - Figure 1: Before treatment 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 turbinate to neutralize the remaining kshara. Yastimadhu ghrita was applied over the burnt wound to overcome daha (burning sensation).

Paschat Karma
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.

RESULTS
Burning sensation was observed during and after the application of kshara, which was managed with local application of lemon juice for 15 min followed by nasal wash and after 30 min application of Yashtimadhughrita. The patient was complained of dark brown colored watery discharge on the next day which was self-controlled, in 4 days. The complete reduction in the size of hypertrophied turbinate was observed on the next day [ Figure 2]. Along with nasal obstruction the other associated complaints, like nasal discharge, discomfort in nose, and headache were completely reduced within 1 week. After 1 week, once again the blood investigations (erythrocyte sedimentation rate and absolute eosinophil count) were done, which were found to be within normal limits. The patient was advised to avoid exposure to cold wind, dust, intake of cold items, etc., which are considered as pratishyaya (rhinitis) causative factors. With a follow-up for a period of 6 months, the patient had not got even a single time nasal obstruction and other symptoms. Meanwhile, he was prescribed oral medication viz., Sitophaladi churna, Talisadi churna along with Hareetaki churna [2:2:1/2 proportion] one teaspoon twice daily for 1 month with lukewarm water.

DISCUSSION
Nasal cavities provide conduction, filtration, heating, humidifi cation, and chemosensation of air which is mainly performed through mucosa and contours of the turbinates. The turbinates undergo cyclical increase and decrease in their size as part of the nasal cycle. Both allergic and nonallergic rhinitis can lead to pathological, persistent increase in turbinate size. This often causes a marked restriction in airfl ow through the valve region with a concomitant sensation of severe nasal blockage. [12] Hence, nasal obstruction by turbinate hypertrophy causes signifi cant diffi culty affecting the daily activities of the patients. Nasal obstruction in chronic nonallergic or hypertrophic rhinitis is usually caused by submucosal or mucosal hypertrophy and bogginess due to increased vascularity as anterior end of the inferior turbinate is erectile tissue. [13] The infl ammatory response or infl ammation is an important body response to injury. When bacteria, toxins, burns, or other culprits damage tissue; the injured tissues leak chemicals, including histamine and other substances. This chemical cocktail causes blood vessels around the damaged area to leak fl uid into the injured tissues and make them swell. Here, the enlargement of turbinate is almost always due to swelling of the submucosa and mucosa. Thus, this increase in turbinate size as well as submucosal or mucosal hypertrophy can be taken as adhimamsa and according Acharya Charaka, the line of treatment for arbuda (tumor), adhimamsa (extra muscular growth) is kshara application. Hence, ksharapratisarana was selected for the treatment.
Local application of kshara acts on hypertrophied turbinate in two ways:  It cauterizes hypertrophied mass directly because of its corrosive nature. Thus, produces shrinking effect on hypertrophied tissue  It penetrates in to the bogginess which is produced due to increased vascularity, as anterior end of the inferior turbinate is erectile tissue and coagulates protein in increased vascularity. The coagulation of protein leads to disintegration of hemoglobin into heme and globin. Synergy of these actions results in decreasing the size of the turbinate hypertrophy. Further, necrosis of the tissue occurs. This necrosed tissue sloughs out as blackish brown discharge for 3-7 days. The submucosal or mucosal hypertrophy and bogginess obliterates permanently and there was no recurrence of turbinate hypertrophy.

CONCLUSION
There are certain methods of using kshara. One of them is application of kshara, which has been proved very effective in the treatment of unhealthy or undesirable growth of body tissues, and is being practiced widely. In this present case report, apamarga (Achyranthus aspera Linn.) kshara, one among the best ksharas, was locally applied on the hypertrophied turbinate to fi nd out its effi cacy and adverse effects. It has given excellent results in the treatment of turbinate hypertrophy. This effectiveness of kshara application can be attributed only to the potency of the particular content. kshara application is the best one, taking into the consideration of its convenience, easy adoptability, cost-effectiveness, and curative results. Accordingly, the Apamarga kshara is said to be very useful in treating the turbinate hypertrophy locally.