name of university maharashtra university of health
TRANSCRIPT
Name of University Maharashtra University of Health
Sciences Nashik
Name of Course MS (Shalakyatantra)
Name of Subject Shalakyatantra
Admission Year (Academic) of
the student
2018-2019
Submission Year (Academic) of
the student
2020-2021
Topic Randomized Comparative
Clinical Trial to Study the
Efficacy of Agaruwadi
Dhoopana and Guggula
Dhoopana in Karnasrava wsr
to Otomycosis
Page | 1
INDEX
No Chapter Page No
1 Introduction 2-5
Study Rationale
Epidemiological data
2 Aims and objectives 6
3 Research Question 6
4 Previous work done 7
5 Review of Literature 8-73
i Literary Review
ii Disease Review
iii Drug Review
iv Procedure review
6 Materials and methods 74-91
7 Observations and Results 92-122
8 Discussion 123-136
9 Summary and conclusion 137-142
10 References 143-155
11 Bibliography 156-157
12 Annexures 158-182
i Case Record Form
ii Consents
iii Master Charts
Page | 2
INTRODUCTION
Page | 3
Ayurveda is ancient science of life a system of health and medicine
which aims to assist people in living a healthy life It is a person-centered
medicine which deals with healthy lifestyle systemic diseases prevention
diagnosis and treatment Ayurveda is divided into eight branches[1] It has
a separate branch of clinical and surgical specialization concerning ENT and
ophthalmology known as Shalakyatantra One out of the eight branches of
Ayurveda Shalakyatantra deal with the etiology diagnosis prognosis
prevention treatment and complication of diseases which are located at
Urdhwang Pradesh[2]
Karna is one among the Panchendriya (sense organ) situated at
Urdhwang Pradesha [3] It is originated from Akash Mahabhuta Aachary
Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga Vigyniyam
Aadhaya[4] He mentioned Karnasrava as separate diseases[5] Aacharya
Charaka explain 4 Karnaroga He had not described Karnasrava as
independent diseases but explain Karnasrava as a symptom under four
Karnaroga Acharya Vagbhata mentioned Karnasrava as a symptom in
Karnashoola according to Dosha He included this into Kaphaj Karnashoola
itself[6] Karnasrava means discharge through ear The Samanya Hetu of
Karnaroga are Avashaya or Pratishaya that is common cold Sheeta Vihara
or exposure to cold environment Karnakandu or self-inflicted trauma by
use of ear bud or pine to clean itching in ear Shabda Shashtra Mithyayoga
that is misuse of instrument or listening to high sound frequencies[7] The
other predisposing factors are such as abuse of nonspecific broad-spectrum
antibiotics steroids and immune suppressed disorders
Classical features of Karnasrava can be compared with otomycosis
Otomycosis is acute sub-acute or chronic fungal infection in external ear
which rarely involves the middle ear[8] Otomycosis is characterized by pain
itching discharge conductive deafness of mild to moderate in nature
Fungal spores invade in the epithelial layer of EAC In response to that
inflammatory process starts which will reflect as pain Itching is due to
immune reaction of body during inflammatory process As a result of
Page | 4
inflammatory process exudates were produced which will mix up with
fungal colonies and appear as discharge In initial stage of disease ear
discharge is watery but if there is secondary bacterial infection occur it
becomes mucopurulent Ear blockage and conductive type of hearing loss
are due to accumulation of fungal mass in external auditory canal
Fungal mass appears white or black or brown and is like a wet piece
of filter paper Examination with otoscope Aspergillus Niger appears black
headed filaments growth Aspergillus fumigates as a pale blue or green and
candida as a white or creamy deposit[9]
Otomycosis is a common condition and it mostly occurs in humid
area According to American academy of otolaryngology prevalence of
otomycosis is 52 all over a world and 09 in India 5-25 otitis externa
cases are due to otomycosis Nearly 61 types of fungal species being involve
in otitis externa 90 of fungal infection cases involve Aspergillus species
and the rest candida species[10]
In Ayurveda The common treatment Principle for all is Ghritapana
Rasayana Bhramacharaya Avyayama (Excessive exercise)
Ashirasnana(Head bath) Atibhashashya(Excessive speaking) This can be
used for the prevention and management of Karnaroga[11] Acharya
Sushruta explain specific treatment modality for Karnasrava is
Karnaprakshalana Karnapoorana Karnadhoopana Shirovirechana
Karnadhavana[12]These therapeutic procedure can be updated according to
different stages of these condition
In routine OPD it is observed that patient of otomycosis respond
more frequently to topical therapy than to systemic therapy Among all the
treatment modality Karnadhoopana is an effective and simple procedure
In this regard Karnadhoopana with Agaruwadi Varti or uggula had explain
in Ashtang Samgraha Agaruwadi Varti contain Agaru Yawa Madanphala
All these contains of Agaruwadi Varti and Guggula acts as Ruksha Ushna
Teekshana Laghu Guna acts as effective Shodhaka keeps ear dry reduce
Page | 5
pain discharge foul smell and thus control the infection Dhoopana is also
useful as Adhidaivika Chikitsa to protect the patient from external attack of
visible and invisible organism The principal treatment modality adopted in
Allopathic system of medicine is oral antibiotics and topical antibiotic drop
Long term use of oral antibiotic causes adverse effect like gastric irritation
reduce immunity and resistance to drug Long term use of topical antibiotic
drops cause Ph change in external canal which become prone to fungal
infection
Hence the therapeutic procedure with Guggula or Agaruwadi Varti
Karnadhoopana are cost effective safe and easy procedure and it can be
used more effectively
Page | 6
AIM OF STUDY
To evaluate the effect of Agaruwadi Varti Dhoopana and Guggula Varti
Dhoopana in management of Karnasrava
OBJECTIVE
To compare the efficacy of Agaruwadi Dhoopana and Guggula Dhoopana in
Karnasrava
HYPOTHESIS
NULL HYPOTHESIS -
H0- Agaruwadi Dhoopana is not effective than Guggula Dhoopana in
Karnasrava
ALTERNATE HYPOTHESIS -
H1- Agaruwadi Dhoopana is more or equally effective than Guggula
Dhoopana in Karnasrava
RESEARCH QUESTION
Whether there is significant difference between Agaruwadi Dhoopana and
Guggula Dhoopana in Karnasrava
Page | 7
PREVIOUS WORK DONE -
1 Anupama Patra B Effect Of Arka Taila In The Management Of
Karnasrava With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2007
2 Palmer Komalben K Further Study On Role Of Arka Taila In The
Management Of Karnasrava With Special Reference To
Otomycosis Shalakya Tantra Institute for Post Graduate Teaching amp
Research in Ayurveda Gujarat Ayurved University Jamnagar 2010
3 Sathisha Shankar B Management Of Karnasrava With Sthanika
Guggulu Dhoopana And Rasnaadi Guggulu-A Comparitive Study Shalakya
Tantra Government Ayurvedic Medical College Bangalore 2011
4 Shashikala DK Comparative Study On The Efficacy Of Vacha
Lashunaadi Taila Karna Pichu And Nimba Patraadi Dhoopana In The
Management Of Karna Srava Shalakya Tantra Government Ayurvedic
Medical College Bangalore 2014
5 Javale Anant A Clinical Study On The Efficacy Of Arka Taila In The
Management Of Karna-Srava Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2005
6 Pournima V Koti Management Of Karnasrava With Priyangvadi Taila
Pichu With And Without Saarivadi Vati Shalakya Tantra Sri Jagadguru
Gavisiddeswar Ayurvedic Medical College Koppal 2015
7 Amisha Patel A Clinical Evaluation Of Honey In The Management Of
Karna Shoola With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching and Research in Ayurveda
Gujarat Ayurved University Jamnagar 2016
Page | 8
REVIEW OF LITRATURE
Page | 9
Ayurvedic literature Ayurveda is a science of life practice since
thousands of years The ancient Indian system of medicine and surgery is
commonly known as Ayurveda This was given the status of Upaveda or
fifth Veda in the next stage of growth Among the available literature three
Samhita that is Charaka Samhita Sushrut Samhita Ashtang Hrudayam and
Ashtang Samgraha are the chief source of knowledge of Ayurveda
Ayurveda consist of eight branches Shalakyatantra is one among them
Shalakyatantra is one of its specialized branch deals with science of
ophthalmology otorhinolaryngology Oro dental surgery and head Acharya
Sushruta himself a practical surgeon was the first to advocate dissection of
dead bodies is indispensable for a successful student of surgery He had
described gross anatomy in the first chapter of Uttartantra Shalakyatantra
define by different Acharys as follows
शालाकय नामोरधवजतरगताना रोगाणा शरणनयनदनघराणाददसशरशरताना वयाशरिनामपशमनारव
स स ११०
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत [13]
चस १७१२
Shalakya Tantra Nirukti and Parichaya
शलाकायााः कमव शालाकय ततपपरिान शलाकयम डलहण [14]
The term Shalakyatantra is derived from Shalakya and Tantra
The word Shalakya means A probe and Tantra denotes teaching and
practices found in scripturesThe compendium in which application of
Shalaka in various surgical procedures is principally described is called as
Shalakya tantra
दनदटिवशारदााः शालाककनाः डलहण ( सउ ११३)[15]
An eye specialist is termed as Shalaki by Dalhana
Page | 10
Synonyms of Shalakya Tantra
Uttamanga Chikitsa Jatrurdhwa Chikitsa Urdhwang Chikitsa Shalakya
Chikitsa
Importance of Shalakyatantra-
Life of living being and all the Indriyas are situated in the head hence it is
known as Uttamanga
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत
चस १७१२
The treatment given to this part of the body is described specially in
Shalakya tantra While describing the importance of Shiras Vagbhata
correlates it to the root of tree (Urdhwa Mula) and body to the trunk of tree
(Adha Shaka)
Sushruta has deal with Mukha Roga in Nidan Shan and its treatment in
Chikitsasthan The description regarding the disease of eye ear nose and
head are found only in UttaraSthan Sushruta specially describes the
disease of Shalakyatantra as told by Videha in the beginning of Uttartantra
itself[16]
Shalakyatantra Itihas-
India Exhibits traditional of more than thousands of years in art literature
language logic and philosophy etc The convention was in its sophisticated
and advanced attire throughout the Vedic period
Vedic period ndash
1 Natush was treated for deafness by Ashwinikumars (Rigveda)
2 Rujaswa and Kanva were treated for blindness by Ashwani Kumaras
(Rigvedas)
Page | 11
3 There are several prayers mentioned for normal functioning of sense
organs (Yajurveda)
4 Structures and functions of Mastishka are described (Atharveda)
5 Mantras having reference to disease of Eye Ear Oral cavity etc are
found (Atharvaveda)
Upanishada Period ndash
1 Samhita Period
a) Sushrut Samhita ndash
bull Explanation regarding Netra Nasa and Shirorogas (Uttartantra 1-
26th chapter)
bull Details regarding Mukha and Karna Roga Nidan and
Chikitsa(Nidansthan 16th and Chikitsasthan 22nd chapter)
bull Description regarding Karna Chedana Sandhana Nasa
Ostasandhana Sutra Sthan 16th chapter
b) Charaka Samhita -
bull Explanation regarding Shirorogas (Sutrasthan 17th chapter)
bull Explanation of Gala rogas like Upajivika Galshundi and Rohini
bull Nasa Shiro Mukha Karna and Netra Chikitsa (Chikitsa sthan 26th
chapter)
bull Description regarding Lakshana and Chikitsa of Shankhaka
Ardhavbhedaka Shirovirechana and Shiro basti (siddhi sthan 9th
chapter)
c)Ashtnga Sangraha ndash
bull Detailed description regarding Shalakyatantara (Uttartantra 11-28
chapter)
bull Description of Kriyakalpa (Sutrasthan 32nd and 33rd)
Page | 12
d)Ashtang Hrudayam
bull Detailed description on Shalakya Tantra (Uttar tantra 8-24 chapters)
bull Kriyakalpas (Sutrasthan 23rd and 24th chapter)
e) Bhela Samhita
bull Chakshushya Vaisheshik and Buddhi Vaisheshik Alochaka pitta
f) Harita Samhita- Branch of Medical science offering elaborating
information about the procedure like Nasya Anjan Gandusha etc
comprehended with their applications in disease of Head Eyes Ears
Eyebrows Throat Temporal region and cervical spine is known as
Shalakyatantara
शशरोरोगा नतररोगा कणवरोगा वशषताः भरकरठशङकमरयास य रोगा समिनदरत दह १३
तषा परततकारकम व नसतयतपयवणजनातन च अभयङगमखगणडषकियााः शालकयसशमतााः १४
इतत शालाकयनाम [17]
Documentation of different ancient literature gives various references
regarding all aspects of Karnasrava in various periods It is very much
important to know the history of Karnasrava from Vedic Pauranic Samhita
and Samgraha period
Vedic period ndash The Vedas being the oldest source of knowledge have no
direct mentioning of Karnasrava
Page | 13
Samhita and Samgraha period ndash
Aacharya Sushruta described about Karnaroga Karnasrava Nidan
Roopa and Chikitsa The detail description is available in Sushrut
Samhita Uttartantra 20 and 21st chapters
Aacharya Charaka did not specify Karnasrava but mentioned 4 types
of Karnarogas that is Vataj Pittaj Kaphaja and Sannipataja and their
treatment in 26th chapter of Chikitsasthan
In Ashtang Hrudaya karnasrava is not explained as a separate disease
but Chikitsa is mentioned in 18th chapter of Astanga Hrudaya
uttartantra
In Ashtang Samgraha Chikitsa is mentioned in 22nd chapter of Astang
Samgraha Uttartantra
The details about Karnasrava are explained in Bhavprakasha
Madhyamakhanda 64th chapter
Madhavakara has explained about Karnasrava in 57th chapter of
Madhymakhanda
Karnasrava is also explained in Sharangadara Samhita Uttarkhand 11th
chapter
The reference for treatment of Karnasrava is available in
Yogaratnakara
In Gadhnigraha Karnasrava and its treatment is mentioned in
Karnarogadhikara Adhaya
Vangasena had mentioned about the disease and treatment in 69th
chapter
Chakradatta explained Karnasrava in 57th chapter
Dalhana has given commentary on Sushrut Samhita Uttartantra 20th
and 21st chapter
Sankhya Samprapti of Karnasrava ndash
Aachary Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga
Vigyniyam Aadhaya Aacharya charaka explain 4 Karnaroga in
Page | 14
Karnarohvigyniyam Adhaya based on doshas Acharya Vagabhata in
Ashtang Hrudaya explain 25 Karnaroga in Adhyaya
कणवशल परणादशरच बाशरियव कषड ए च
कणवसरााः कणवकणडाः कणव चवसतततर च
कशमकणवपरततनाहौ विशरिदवविसततरा
कणवपाकाः पततकणवसततराशवशरचतवविम
कणावबवद सपतवि शोफशरचावप चतवविाः
ऎत कणवगता रोगा अटिावशततरीररतााः
स उ २०- ३ त ५[18]
ातकणवरोग वपततकणवरोग कफकणवरोग
रकतकणवरोग सनदरनपातकणवरोग कणवनाद
बशरिरतप परततनाह कणडाः शोफ पततकणवक
किशमकणवक उियरपविरधयअशो अबवद
कशरचकणवक वपपपली वदाररका पाळीशोष
ततिका पररपोिो उतपपातो उरमरर दाःखिवन
शलहाखयााः परचवशनदरतकणवरोगा उकतााः
इदिीका अ स उ २१ [19]
चतपाराः कणवरोगााः
च स [20]
Page | 15
KARNA
Karna ndash करोतत शबद गरहण [21]
The organ of hearing
Karnasrava- कणवसतय कणवयोाव ससराा [22]
Discharge from the ear is referred as Karnasrava
KARNA SHAREERA
bull Nirukti
कणयवत अकणयवत अनन इती [23]
It means reception and conduction of sound waves
These are the functions of external and middle ear
bull Nirukti of Sravanam
शरयत अनन इती शरणम[24]
It means perception of sound
It can be attributed to the internal ear function
bull Karna Utpatti-
Karna is an organ formed by Akash Mahabhuta[25]
The fundamental characteristic is as follows
Indriya ndash Srotram [26]
Indriya Adhisthan ndash Karna [27]
Indriya Dravy ndash Akasha [28]
Indriya Arth ndashShabdha [29]
Indriya buddhi ndash Srotobyddhi
Page | 16
bull Paryaya of Karna- Shabdapatha Srotrapatha Sravanam shruti
Kuhuram Dwanigraham etc
bull Definition of Karna-
कणवशटकलयनदछिरनमिटिोपगरदहत शरोतरमछयत [30]
मा तन ५७१
The definition of Karna is stated in Madhav Nidanam Indriya which is not
seen with naked eye along with Shashkuli is called Shrotra that is Karna
Indriya is so minute that it is not perceived with any sense organ
In Charak Samhita the word Karna explain as the Indriya Adhisthan of
Shabdha Karna is described as one of the Prathyangas of the body He
emphasizes that all Indriyas manifest during the 3rd month of gestation
period
Acharya Sushruta while describing formation of Purusha from Prakriti or
Avyakta narrated that all Indriyas are developing from the Vikarika and
Taijas Ahankara Both Vagabhata and Sushruta stated that Karna as one of
the Bahirsrotas
शरण नयन दन घराण गदमढराणण न सततरोताशसराणा बदहमवखातन [31]
स शा ५-१०
In Ashtang Hradaya Vagbhata has states that all Indriyas are Atmaja
According to him lower lobule elevated helix projected posterior portion
fleshy and adherent ear are indications of long span of life[32]
ततरखातखातन दह अनदसतमन शरोतर शबद ववकतता [33]
ा शा ३-३
शबदाः शबदनदरिय सवनदछििसमहो ववकतता [34]
स शा १-२६
Page | 17
Ear has the prominence of Akash Mahabhuta The prominent dosha of ear
is Vata It is important seat of Vata The prominent Dhatus are Asthi and
Mamsa Karna is one of the Panchgnanendriyas and it meant for hearing
Sushruta narrated that Karnasthita Asthi and Sandhi
घराणकणवगरीाकषिकोषष तरणातन [35]
सशा ५-२२
शरोतरशरगािकष शखाताव [36]
सशा ५-३२
गडकणवशखटककम [37]
स शा ५-२२
One Sandhi and one Tarunasthi in ear
Sandhi ndash Karna contain two Sandhi one in each ear Type of Sandhi is
Shankhavartha which is present in Shringataka
Mansapeshi ndash 2[38]
Siras ndash 10 [39]
Vataj Sira - 4
Pittaj sira - 2
Kaphaj sira - 2
Raktaj Sira - 2
Avedhya sira-
कणवयोदवश तासा शबदादहनीनामकका पररहरत
सशा ७-२५[40]
Amongst above mentioned ten Siras each Karna lodges one Shabdavaha
Sira It is Avedhya
Page | 18
Dhamani -2
Length of ear is 4 Angula
Karna moola ndash 2 Angula
कणाविरतर चतदवशअगलम
स शा ३५-१४[41]
The distance between two ears through the back of the neck is 14 Angula
bull Marmas of Karna-
1 Vidhuras-
कणवपटठतो अिाःसशरशरत विर ततर बशरियवम
सशा ६-३७[42]
कणतपयादद सतनायममवणी ककनदचचनदरनममनाकर कलयकररणणच
डलहणाचयव[43]
अिसततात कणवयोतनवमन विर शरततहाररणण
ा शा ४-२९[44]
Sankhya-2
Vistara- frac12 Angula
Type- Snayumarma (Susha)
- Dhamanimarma(AH)
- Vaikalykar
Sthana- It is situated in the depressed portion in the back of the ear
Injury to them causes loss of hearing
Page | 19
2 Shringataka marma-
नदजवहाकषिनाशसकाशरोतरखचतटियसरमम
तालरयासतयातन चतपारर सरोतसा तष ममवस
वदि शरगातकाखयष सददसततपयजतत जीवतम
मा तन ५७१ [45]
Sankhya- 4
Type- Siramarma
Sthana- It is in head that is amidst Siras (blood vessels) nursing sense
organ
A palm size area near Talu
Injury to this Marma causes death
In modern anatomy ear divides into Bhayakarna or External ear Mdhyakarn
or Middle ear Antahkarna or Internal ear This is extremely appropriate
Even though the ear is divided into three divisions in the point of modern
anatomy Ayurveda denotes ear organ is one Ayurveda treats disease by
way of assessing Dosha and Dushya Here Dushya is one that is Karnendria
Dosha difference will call for different treatment for different disease Hence
treating the vitiated Dosha will cure the disease irrespective whether it is in
external middle or internal ear The thought is based on different
fundamental principle from Ayurveda
bull Parts of Karna
In Ayurveda classics detailed description about anatomy of ear is not
available But the various parts are mentioned as follows
Bhayakarna- External ear
Mdhyakarna ndash Middle ear
Antahkarna- Internal ear
Page | 20
द कणवशटकशलक दॊ कणवपतरकौ
च शा 7-11[46]
कणवशटकशलक कणवगतातवकौ कणवपतरकौ त बाहयकणा
चिदतत च शा 7-11[47]
शटकली बाहयपालयाशरिटिानम
डलहन- स शरच 25-1 12[48]
Karna Shashkulika ndash It is also called as Karna Shashakuli Charaka has
mentioned this term while describing different Pratyngas of the body
Acharaya Gananatha sen has given the clarification for it as a pinna or
auricle[49]
Karnapali ndash It is popularly known as lobule of the ear Daivakrita Chidra is
present in it
Karnaputrika- Ayurvedic scholars accepted two terms in this cortex They
are Karnaputrika and Karnaputrika The former is considered as Tragus and
antitragus[50]
Karna Prushtha- It can be taken as the cranial surface of mastoid or
auricle[51]
Karnapeetha- Aacharaya Sushruta firstly mention the term Karnapeetha
It is mentioned first by Sushruta while describing the procedure of
Karnavyadana Vagbhata has mentioned that it is Adhobhaga of Karna
Dalhana has clarified that it is the region above the Karnaputrika that is the
region which is at the bottom of the concha
Karnamoola ndash It can be considered as parotid region[52]
Karna lathika ndashAcharaya Dalhana mentioned lobule as a Karna Lathika
Page | 21
Karnaavatu ndashThis term is used by Sushruta while describing the
measurements of different Angapratyangas where he has mentioned that
the distance between the Karnaavatu is 14 Angul Dalhana has comments
that it can be taken as the distance between two ears from behind[53]
Shabdhavahasrotas ndash It also called as Shabdapatha or Srotapatha The
whole passage through which the sound waves pass can be taken as
Shabdavahasrotas[54]
Shrotashringataka ndash It can be taken as the labyrinth of ear[55]
bull Dosha in context to Karna-
Karna is principal location of Vayu
1 Prana Vayu- Prana Vayu circulating in oral cavity is responsible for
Dehadhruka that is keeping all body parts active Indriyadruka that is
keeping all Dnyanendriya healthy by proper nourishment (Purana) helps in
deglutition of food material and convey the stimulation of Indriyabuddhi
and atma
2 Udana Vayu- Bala(strength) Varna speech singing are its function It
is responsible for facial expressions due to pleasure sorrow anger love
frustration etc in general its circulation and actions are just opposite to
Pranavayu
3 Vyana Vayu- Its principal functions are circulation of Rasa and Rakta
through body and various movements Its main location is Hrudaya Five
types of movements for which it is responsible are expansion contraction
upward downward and oblique other activities are opening closure of
eyelid yawning perspiration During circulation if it gets obstructed due
to Srotodushti it generates disease of that Srotas Vyana Vayu gets vitiated
by disease of Rasa Rakta Oja and Chetanadhatu
Page | 22
4 Samana Vayu- It is circulating in the vicinity of stomach and intestine
and helps in keeping the Jatharagni (digestive juices and enzymes) in
equilibrium Disturbance in Jatharagni precipitates disease
5 Tarpaka Kapha- Entire body functions movements are controlled and
executed by various centers in the brain Sensation perceived by sense
organs is conveyed to Mann and Aatma residing in Hrudaya The motor
signals from them are then conveyed to the functioning
organsKarmendriya through Prana Vayu Shira head is therefore a
location of continuous activities motions of Vata All these centers are in
unctuous Majjadhatu in the Shira For stabilizing this ever-active Vata and
to nourish the Majja dhatu very unctuous Tarpaka Kapha situated in Shira
plays an important role
bull Ayurvedic aspect of sound perception [56]
According to Ayurveda Pratyaksha Dnyan or Perception of any sensation
including Shabda occurs due to interaction of the Karnendriya and the
Indriya- Arth -Karma resulting in Sravana
External Environmental acquaintance with living body is executed by five
sense organs namely Netra Karna Nasa Jivha and Twaka All
Dnyanendriya that is sense organ are Panchmahabhautic combination
Despite this fact every Indrya sense organ perceives object Tanmatra of
that Mahabhuta only from which it is originated from Akash Mahabhuta and
hence perceives Shabd only that is audio perception Shrotrendriya is one
of the principal locations of Vata and its function is to perceive Shabda that
is sound waves This sensation is conveyed through Shabdavahi Dhamanis
to Mana and Atma through Pranavayu and the sequence is responsible for
perception of sound in this way external sound is perceived and interpreted
when Atma is linked with Mann Mann is linked with Indriyabuddhi that is
minute virtual Dnyanendriya located in brain Indriyabuddhi is linked with
Adhishthana with prominent Mahabhuta and lastly with Indriya
ArthShabdatanmatra that is sense object Once this sequence is completed
Page | 23
the meaning of a particular sound is interpreted and understood In this
entire process of perception and interpretation of sound waves Pranavayu
and Tarpaka Kapha located in Shira play extremely important role Hence
the healthy status of all the sense organ depends upon the normal
physiologically homeostatic condition of Pranavayu and Tarpaka Kapha
MANAS
ATAMA
BUDDHI
AHANKARA
ARTHA
Page | 24
EAR ANATOMY
bull Embryology of the Ear [57]
1 The sound conducting apparatus develops from the branchial apparatus
whereas the sound perceptive apparatus from the ectodermal otocyst
2 The pinna develops from the six hillocks around the 1st branchial cleft
3 External auditory canal develops from 1st branchial cleft
4 The outpouching of the 1st pharyngeal pouch gives rise to a proximal
narrow part that forms the eustachian tube and distal dilated part that
forms the middle ear cavity
5 Prussakrsquos space is a potential space lateral to the Shrapnellrsquos membrane
and medically by the neck of malleus that can be involved during the
extension of cholesteatoma
6 Development starts in the 3rd week of the intrauterine life and is
completed by 16th week of intrauterine life Membranous and boney
labyrinth develops from the otic capsule
The Ear is divided into
1 External Ear
2 Middle Ear
3 Internal Ear or the labyrinth
Page | 25
Fig 1 Ear Anatomy
EXTERNAL EAR [58]
The outside ear contains pinna and lobule
Pinna is the noticeable piece of outer ear made from single sheet of yellow
flexible ligament covered by subcutaneous tissue and skin It has two
surfaces average and parallel It is intently disciple to perichondrium on its
sidelong surface while it is somewhat free on average surface Pinna
incorporates tragus helix against helix fossa three-sided scaphoid fossa
incisura terminalis
External auditory Canal ndash It extends from the bottom of the conchea to
the tympanic membrane and measures about 24 mm along its posterior
wallit is S shaped
Parts 1 Cartilaginous part
2 Bony part
Page | 26
Cartilaginous part ndash The outer one third is cartilaginous consist of fibro
cartilage is directed first inward backward and upward It has Fissure of
Santorium The skin of this part of the canal contains hair follicles
sebaceous gland and cruminous gland
Bony part ndash The inner two third part is boney It goes forward downward
and medially skin lined in this part is very thin Isthmus is the narrowest
part of the canal lying medial to junction of bony and cartilaginous part
nearly 5 mm lateral to tympanic membrane
The roof and posterior wall of the external auditory canal shorter than floor
and anterior wall The skin lining the tympanic membrane and boney canal
has a self-cleansing property due to migration of keratin layer of epithelium
from drum towards the cartilaginous portion
Relations- Anteriorly- Temporomandibular joint and parotid gland
Superiorly- Middle cranial fossa
Inferiorly- parotid gland
Posterior- Mastoid antrum mastoid air cells and facial nerve
Nerve supply ndashSensory nerve supply of the external ear The auricle
supplied by fibers of the great auricular nerve (C2 and C3) and lesser
occipital nerve (C2) Auriculo temporal branch of the 5th cranial nerve and
auricle branch of the vagus (Arnoldrsquos nerve) supply external canal Facial
nerve has small sensory contribution on posterior-inferior wall
Tympanic Membrane -It is the partition between EAC and middle ear It
is a thin semitranslucent membrane pearly white in colored lying obliquely
in the medial end of EAC with the angle of 55 It is forming major part of
lateral wall of middle ear Annulus tympanicus is attached at its
circumference to the sulcus The TM is oval shape It measures
approximately 10 mm in vertical diameter and 90 mm in horizontal
diameter
Page | 27
Layers ndash Tympanic membrane consist of three layers
1 Outer Epithelium or cuticular layer which is continuous with skin of
external ear
2 Middle fibrous layer has both circular and radial fibers middle layer
missing in upper part
3 Inner layer- Inner mucosal layer which is continuous with middle ear
mucosa
Parts ndash Tympanic membrane consist of two parts
1 Pars tensa -It is largest part below the malleolar folds The inner
surface at the center attached to the handle of malleus Angle of cone
is most illuminated part in the pars tensa at anteroinferior part of pars
tensa
2 Pars flaccida Sharpnells membrane -it is triangular area above the
malleolar folds which are thin and devoid of fibrous tissue and
annulus It fits into notch of Rivinous
Nerve supply 1 Anterior half of lateral surface Auriculotemporal V3
2 Posterior half of lateral surface Auricular branch of vagus cn 10
3 Medial Surface Tympanic branch of CN 9 (Jacobsons nerve)
Fig 2 Tympanic membrane of ear
Page | 28
MIDDLE EAR [59]
The middle ear or tympanic cavity is an irregular laterally compressed
space within the temporal bone It is filled with air that is supplied to you
from the nasal part of the throat through the ear canal It contains a chain
of mobile bones that connect its side with the medial wall and serve to
transmit vibrations transmitted to the eardrum through the cavity to the
inner ear Including the parapet the vertical and anteroposterior diameters
of the cavity are each approximately 15 mm The transverse diameter
measures about 6mm at the top and 4mm at the bottom Compared to the
eardrum it is only about 2mm The eardrum is limited laterally by the
eardrum medially by the lateral wall of the inner ear It communicates
behind with the tympanic antrum and through it with the air cells of the
mastoid and in front with the auditory canal The middle ear together with
the Eustachian tube aditus antral and mastoid air cells is called the
middle ear cleft It is lined by mucus membrane and filled with air
It is divided into 3 parts
1 Mesotympanum (located in front of the pars tensa)
2 Epitympanum or attic (located above the pars tensa but medial to
Sharpnells membrane and the lateral bony wall of the attic)
3 Hypotympanum (located under pars tensa) The middle ear is like a
hexagonal box with a roof
Carotid or Anterior wall- It separates middle ear cavity from internal
carotid artery The various structure passing through anterior wall of
tympanic cavity
bull Canal of chorda tympani nerve
bull Canal of tensor tympani muscle
bull Eustachian tube
bull Anterior malleolar ligament
bull Anterior tympanic artery
Page | 29
Posterior or mastoid wall ndash The upper part of the back wall shows the
opening of the auditorium Below the auditory is a triangular bony
projection known as the pyramidalis processors The stapedial tendon is
transmitted through the apex of the pyramidalis processes The vertical
portion of the facial nerve descends along the posterior wall until it opens
into the stylomastoid foramen
Roof or Tegmental wall (Pars terminalis)- It is formed by a thin bone
plate called the tegman tympanum that separates the skull and tympanic
cavities It is located on the anterior surface of the rocky part of the
temporal bone near the junction with the temporal shell it extends back to
the roof in the tympanic membrane and anteriorly to cover the half canal
of the tensor tympanic muscle The lateral border corresponds to the
remains of the Petro scaly suture
Floor ndash It is formed by a thin plate of bone which separate middle ear from
the bulb of the internal jugular vein lodged in the jugular fossa
Lateral wall ndash It is formed by tympanic membrane and partly by a portion
of squamous part of the temporal bone It separates the middle ear from
external ear
Medial wall- It separates the middle ear from the inner ear
bull The promontory is the most prominent and convex part formed by the
basal rotation of the cochlea
bull The bony lateral semicircular canal is postero-superior to the promontory
above the oval window
bull The oval window is located between the middle ear and the vestibular
slope of the cochlea It is closed by the stirrup footrest and the annular
ligament
Page | 30
bull The round window is located under and behind the cape The round
window recess is directed to the rear It is closed by the secondary eardrum
and separates the middle ear of the Scala tympani from the cochlea
bull The facial nerve passes through the bony fallopian tube above the oval
window
Mastoid Antrum ndash It is a large space with air in the upper part of the
mastoid and communicates with the attic through the aditus The roof is
formed by the antri tegmen which extends and separates the tympani
tegmen from the middle cranial fossa The lateral wall of the antrum is
formed by a bony plate that is on average 15 cm thick in adults It is
marked externally on the surface of the mastoid by the suprameatal triangle
(MacEwen)
Aditus and Antrum- Aditus is a gap through which the attic communicates
with the antrum The boney prominence of the horizontal canal lies on its
medial aspect even as the fossa incudes to thats attaches the quick system
of incus lies laterally Facial nerve publications simply underneath the
aditus
The mastoid and its air cell system-
The mastoid consists of bone cortex with a honeycomb of air cell
underneath Depending on development of air cell three types of mastoids
have been described
1Well-pneumatized or cellular- Mastoid cells are well developed and
intervening septa are thin
2Diploetic- Mastoid consist of marrow spaces and a few air cells
3Sclerotic or acellular ndash There are no cells or marrow spaces
With any type of mastoid pneumatization antrum is always present In
sclerotic mastoids antrum is usually small and the sigmoid sinus is
anteposed
Page | 31
Depending on the location mastoid air cells are divided into
1 Zygomatic cells (In the root of zygoma)
2 Tegman cell (Extending into tegmen tympani)
3 Perisinus cells (overlying the sinus plate)
4 Retrofecial cells (round the facial nerve)
5 Peri labyrinthine cells (located above below and behind the
labyrinthine some of them pass through the arch of superior
semicircular canal These cells may communicate with the petrous
apex)
6 Peritubal (around the Eustachian tube Along with hypotymoanic
cells they also communicate with the petrous apex)
7 Tip cells (which are quite large and lie medial and lateral to the
digastric ridge in the tip of mastoid)
8 Marginal cells (Lying behind the sinus plate and may extend into
the occipital bone)
9 Squamosal cells (Lying in the squamous part of temporal bone)
Development of Mastoid ndash
The mastoid develops from the scaly petrous bone The petrosquamosal
suture may persist in the form of a bone plate - Korners septum which
separates the superficial squamosal cells from the deep rock cells Korners
septum is surgically important because it can cause problems locating the
antrum and deeper cells and thus lead to incomplete removal of the disease
during mastoidectomy The mastoid antrum can only be reached if Korners
septum is removed
Page | 32
Fig 3 Cross section of Mastoid
Contents of the middle ear
Ossicles ndash Three tiny bones which conduct the sound from eardrum to oval
window
Malleus ndash It is the largest and most lateral ossicle measuring 8 mm in
length It has head neck handle anterior and lateral processes The head
is situated in the epitympanum A lateral process project laterally from the
neck while the handle is firmly fixed to the pars tensa of the ear drum
Incus- It has a body short process and long process The body short
process and long process The body articulate with the head of mallelus in
the attic and the short process project into the attic The long process
projects downwards behind the handle of malleus running parallel to it and
articulate with the head of the stapes via the lenticular process
Stapes ndash It is the smallest ossicle measuring about 35 mm and consist of
head neck footplate and anterior and posterior curcura The footplate of
stapes is held to the oval window by the annular ligament
Page | 33
Muscles ndash
1Tensor tympani ndash It is inserted is a branch of the facial nerve which carries
the sense of taste It is first arch muscle supplied by branch of mandibular
nerve V3
2 Stapedious muscles ndash It is inserted to the neck of stapes It is the second
arch muscle supplied by branch of facial nerve that is nerve to stapedius
Fig 4 Contents of the middle ear
Blood supply of Middle Ear
bull Anterior tympanic branch of maxillary artery which supplies tympanic
membrane
bull Stylomastoid branch of posterior auricular artery which supplies middle
ear and mastoid air cells
Page | 34
Four minor vessels are
bull Petrosal branch of middle meningeal artery runs along greater petrosal
nerve
bull Superior tympanic branch of middle meningeal srtery traversing along
the canal for tensor tympanic muscle
bull Branch of artery of pterygoid carotid
bull Tympanic branch of internal carotid
Lymphatic Drainage of Ear
Lymphatics from the middle ear drain into retropharyngeal and parotid
nodes while those of the Surgical Importance ndash Eustachian tube drain into
retropharyngeal group
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 middle is likely to pass to
middle ear
2 Moreover middle ear suppurative disease may spread to adjacent organs
and produce complication eg Labyrinthitis meningitis facial nerve palsy
etc
3 Lenticular process is vulnerable in suppurative ear diseases and causes
ocular disruption
4 Prussac space is the site of primary acquired cholesteatoma
Page | 35
INNER EAR [60]
Inner ear is divided into two parts
1 Bony Labyrinth
2 Membranous labyrinth
Anatomy of bony labyrinth
It is divided into two parts
1 Vestibule
2 Cochlea
3 Semicircular canal
The vestibule is located between the medial wall of the middle ear and the
lateral to internal acoustic meatus anterior to the semicircular canal and
posterior to the cochlea The vestibule is the central part of the inner ear
On its side is the oval window opening which is closed by the bracket foot
plate The bony cochlea is located in front of the vestibule It has 275 turns
wound around a bony axis called a modiolus The cochlea is about 30 mm
long The hollow center of the modiolus is a spiral canal that contains the
fibers and ganglion cells of the cochlear nerve A thin bony sheet the bony
lamina winda around the modiolus This divides the cochlear duct into two
galleries the Scala vestibuli above and the scala tympani below
There are three semicircular canals superior posterior and lateral They
are semicircular in shape and open into the vestibule One end of the
semicircle is enlarged and is known as the sphere
The membranous labyrinth is in the bony labyrinth It is connected to the
bony labyrinth by fibrous trabeculae and is surrounded by perilymph The
endolymph is located in the membranous labyrinth
Page | 36
The utricle is in the upper part of the vestibule while the saccule is found
below Both the utricle and saccule contain a single sensory patch called
the macula Each macula is covered with a neuroepithelium made up of
neuroepithelium made up of sensory hair cells and support cells these cells
are separated by a basement membrane Fibers of the vestibulo-cochlear
nerve enter the macula and pierce the basement membrane to terminate
at the base of the hair cell or cell bodies The utricle and the saccule with
their macula are called otolith organs Membrane semicircular canals are
the membrane canals of the corresponding bony semicircular canals They
open into the utricle through five openings One end of the opening of each
channel is dilated called the sphere in which the sensory organ of each
channel is located The cross section of the Scala standard looks like a right
angle The base is formed by the basilar membrane Sensory cells are
arranged on the surface of the basilar membrane These sensory cells with
their supporting cells form a complex neuroepithelium called the basilar
papilla or the cortical organ named after an Italian microscopist The
organs of the corti have a gelatinous membrane called the tectorial
membrane and they are supported by the pillar of the corti The cortical
pillars enclose a space called the corti tunnel which contains a fluid called
cortical lymph Vestibule is lies between the medial wall of the middle ear
and lateral to internal acoustic meatus anterior to semicircular canal and
posterior to the cochlea 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 Boney cochlea lies in front of the vestibule It has 275 turns
coiling around boney axis called modiolus Cochlea is approximately 30 mm
in length The hollow center of the modiolus is a spiral canal containing the
fibers and ganglion cells of cochlear nerve A thin boney sheet the osseous
lamina winda around the modiolus This divides the cochlear canal into two
galleries the Scala vestibuli above and the scala tympani below
Page | 37
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 boney labyrinth It is connected
to the bony labyrinth by fibrous trabeculae and is surrounded by perilymph
Endolymph 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 single sensory patch called macula Each
macula is covered by neuroepithelium consist of Neuroepithelium consists
of sensory hair cells and supporting cells these cells are separated by
basement membrane Fibers 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 are referred
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 corti lymph
Page | 38
Fig 5 Inner Ear
Blood supply of labyrinth
Labyrinthine artery
Common cochlear Anterior vestibular Artery
Vestibulocochlear artery Main cochlear artery
Cochlear branch posterior vestibular artery
Page | 39
PHYSIOLOGY OF HEARING [61]
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
bull Mechanical conduction of sound (conductive apparatus)
bull Transduction of mechanical energy to electrical impulses (sensory
system of cochlea)
bull Conduction of electrical impulses to brain (neural
Fig 6 PHYSIOLOGY OF HEARING
Page | 40
Conduction of sound
Under the surface of water we cannot hear the sound made in air because
9995 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 must 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 13 times longer than long process of incus providing
a mechanical advantage of 13
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 beings 211 As the effective
vibratory area of the tympanic membrane is only two- thirds the effective
areal ratio is reduced to 141 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
Page | 41
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 lobe
Page | 42
DISEASES REVIEW
करणसराव
Nirukti - करणसय कणवयोाव ससराा [62]
Nidana- Acharya Sushruta and Vagbhata describe the common etiological
factors for the Karnaroga
अशयाय जलिीडा कणवकणडयन मरत
शमथययोगन शसततरसतय कवपतो अरय च कोपन ||
सउ २० १२
1 Avashaya or Pratishaya
(Excessive exposure to cold)
2 Jalakrida
(Excessive swimming)
3 Karnakandunyanum
(Excessive scracing due to itching)
4 Mithyayogena Shatrasya
(Improper instrumentation during wax removal or foreign body removal)
5Shabdasya
(Louder sound for long durationperverted contact of sound)
6 Abhighata (Trauma)
7 Vitiation of Tridoshas
Page | 43
Samanya Nidana according to different Samhita
Vishesh Nidan of Karnasrava
Acharya Charaka has not mentioned any kind of Nidana regarding Karnaroga
but has described Utapati of Karnaroga from Siroroga in Karnasirasym
Adhyaya[67]
शशरोअशिघातादरा तनमजजतो जल परपकादरा अवप विि
सरतत पय शरणॊ अतनलात स कणवससरा इतत परककतीत
सउ २० १०
असस ३७२५ [68]
1 Shiroabhighatat - Head Injury-Fracture of middle cranial fossa
2 Jala nimajjana - CSF otorrhoea fracture of middle cranial fossa
3 Karnaprapaka
4 Karna Vidhradhi -Puyasrava
Sr
no
Samanya Nidana SU AH[63] AS[64] YR[65] MN[66]
1 Avashaya + + +
2 Pratishaya + +
3 Shabdha
mithyayoga
+
4 Shashtra
mithyayoga
+ + +
5 Karnakandooyan + + + + +
6 Jalkrida + + + + +
7 Abhighata + + +
Page | 44
Samanya samprapti
परापय शरोतरशसरा कयावत शल शरोतशस गान
त कणवगता रोगा अटिावशततरीता
सउ २० १२
Due to common and specific etiology factors the vitiated Doshas gets
Sthanasamshraya in Karna and causes Karnasrava It is the stages of
Samprapti were Doshas gets lodged in Srotas and start processes of Dosh
Dushya Sammurchsna Due to Shiroabhighata Jalanimmajana Karna Paka
Karna Vidhradi vitiated Vata Dosha and Karna becomes Avruta by Vata and
results in Karnasrava Normal physiology of Dosha Dhatus and Malas entirely
depends on the normality of Srotas Dosh Dushya Sammurchana or
manifestation of diseases will not take place if only vitiation of Doshas take
place without deformity of Srotas Here in Karnasrava vitiation of Srotas are
Atipravritti Sanga and Vimargagamana take place Atipravritti is being excess
production of fungus Sanga is obstruction in external acoustic canal
Vimargagamana is the propagation of discharge through ear
Vishesh Samprapti
Karnasrava occurs due to Nij nidana is Pratishaya while Agantuja nidanas are
Avashya Jalkrida and Karnakanduyan Due to etiological factors which are
Vata-Kapha provocative in nature gradual vitiation of Doshas will occur After
vitiation they get accumulated (Sthan samshraya) in external auditory canal
In other hand when patient does Sevana of Agantuj Nidan like water enter in
external ear scratching of ear unsterile instrumentation leads to Dosh
Prakopa These cause Twak and Mamsa Dhatu Dushti which leads to
discontinuity of epithelium of ear canal which creates suitable atmosphere for
fungal pathogen to grow The vitiated Vata will produce symptoms such as
Page | 45
pain hearing impairment and vitiated Kapha causes symptoms like itching
discharge ear blockage By assessing the symptoms it can be said that Kapha
Avrita Vata Dosha is responsible for the manifestation of clinical features like
pain itching discharge Which are seen in Karnasrava that is otomycosis
Acharya Charaka has mentioned while explaining Samanya Chikitsa of
Karnaroga that it should be treated like Vrana when Paka and Srava is present
as a symptom Fungal spores invade in the epithelial layer of EAC In response
to infection inflammatory process is start This is a Paka Avastha After
removing the fungal mass ulceration in external acoustic canal is commonly
seen As a result of infection process exudates was produced which will mix
up- with fungal colonies and appear as discharge As per Dosha involvement
in Vrana Shoola Srava can be differ According to Acharya Sushruta Ruk is
the Samanya Lakshana of Vrana and Vishesha Lakshana of Vrana includes
pain discharge discoloration itching etc according to Dosha involvement
which are also seen in otomycosis In otomycosis mainly watery and purulent
type of discharge is present which indicates Paka avastha If there is Dosha
involve in Vrana is called Dushta Vrana Acharya Sushruta and Acharya
Vagabhata have mentioned verity of Srava in Twak and Mamsa Vranavastu
which is found in otomycosis Based on this description otomycosis can be
correlated with Karnasrava
Page | 46
Representing the Samprapti of Karnasrava
Vishesh Nidana ndash Shiroabhighatat
Jala nimajjana
Prapaka Vidhradhi
Vitited vata
Avarana by kapha
Vimargagamana of Vata
Karnasrava
Samprapti Ghataka
Dosha ndash Kapha and Vata
Dushya ndash Rasa Rakta and Mansa
Strotodushti ndash Vimargagamana and Sang
Adhishthana ndash Karna (Bhayakarna)
Rogmarga ndash Madhyama
Page | 47
Purvarupa
The Purvarupa of Karnasrava are not mentioned separately in any ayurvedic
classics In routine practice cretin Purvarupa are noted
1 Karnakandu
2 Karnagurutwa
3 Alpa karnashoola
4 Discomfort in ear
Rupa
1 Karnashoola
2 Karnakandu
3 Karnasrava
4 karnabadhirya
5 Cotton wool like or wet newspaper like grayish brown or black colored mass
is seen
6 External auditory canal skin appears edematous and red
Upashaya and Anupashaya
Appropriate application of Aushadhi Ahara and Vihara when produces relief in
the symptom is called as Upashaya and when aggravates the symptoms is
called Anaupashaya There is not any reference available in the classics about
the Upashaya and Anupashaya of karnasrava
Sadhyasadhyata
Sushruta has not mentioned specially the Sadhyasadhyata of Karnarogas But
Vagbhata has mentioned Karnasrava as a Sadhyavyadhi[69]
Sadhysadhyatagives the clear picture of prognosis of the disease It depends
on many factors like nature of disease severity of disease Vaya Prakriti Bala
of the patient etc
Page | 48
Upadrava of Karnasrava
In Samhita there is no reference available regarding the Upadrava of
Karnasrava
Samanya Chikitsa ndash
The common treatment principle for all Karnaroga is Ghritapana Use of
Rasayana Bhrahmacharya Avyayama Shirasnana and Atibhashaya
सामरय कणवरोगष घतपान रसयनम
अवयायमो शशराःसतनान बरमहचयवम कतपरनम
स उ२१३
Ghratapana - Ghrita is a Yogavahi and follow Sanskara in addition to these
acquired properties and capable of retaining its own properties So Ghritapana
is effective in Karnasrava
Rasayana - Rasayana represent the basic approach of Ayurveda which
comprise preventive promotive and curative aspect of health
Brahmacharyaapalana -It is like Sadvrittapalana and is equals to Rasayana
effect
Vyayama - It leads to vitiation if Vatas a Karna is a Sthana of vata and
exercise causes Kshayaj Samprapti hence it is important to avoid exercise in
Karnasrava
Shirasnana- In Shirasnana water enters in external acoustic canal it changes
the PH of meatus skin from acid to alkali which favors the growth of pathogens
Atibhashya - Excessive speaking causes Vata Prakopa and Vatapraokopa is
basic Samprapti for Karnasrava as the preventive aspect avoidance of
excessive speaking is necessary
Page | 49
Ghritapana Rasayana and Brahmacharyapalana should be followed for
preservation of dhatu Samyata and restriction of vitiation of Vata Vayayama
Shirasnana and Atibhashaya should be avoided in Karnasrava to protect the
Siras from the affliction of Vata and Kapha
Vishesha Chikitsa ndash
The general treatment principle of Karnasrava described in classics is closely
related to Dushtavrana Chikitsa
शशरोवरचन च ए िपन परण तरा
परमाजवन िान च ीकषय ीकषय़ाचारत [70]
स उ २१४०
कणवसततरा ोददत कयावत पततकशमकणवयो [71]
ाउ १८३५
उपददि च सततरोत साय परात वपचततवशि परमजय
य अगर मदन सघत गगलना ा िपतयतपा मिना परयत [72]
असउ २२४२४३
In addition to that Shirovirechana Karnadhoopana Karnapurana
karnapramarjana Karnadhavana are also indicated
Page | 50
Treatment is also mentioned for Karnasrava
1 Karnaprakshalana Yoga - with Aargawadadi Gana Kashaya and Surasadi
Gana Kashaya [73]
2 Avachurnana Yoga ndash with Aargawadadi Gana Churna and Surasadi Gana
Churna[74]
3 Karnapoorna Yoga ndash
bull Rasanjana Laksha with Sarjachoorna[75]
bull Panchkashaya with Kapittha swarasa and Madhu[76]
bull Jambu AmrapallavShivalaKshuodra Mahavriksha and Madhuki 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 done[77]
bull Sarjatwak Choorna with Karpashiphalarasa and Madhu[78]
bull Abhaya LodraTindukaSamanga(Manjista) Kwatha of this Dravyas mixed
with Madhu and Kapittha Rasa[79]
bull Yogratnakara mention the following drugs for Karnapoorana-
a Samudraphena Churna[80]
b Jambwambpatra Yoga
4 Karnadhoopana Yoga ndash
bull Dhoopana with Churna of Bilvapatra Haridra Palandu[81]
bull Vartak Dhoopana [82]
5 Internal Medications-
bull Rasnadi Guggula [83]
bull Triphala Guggula [84]
bull Sarivadi Vati [85]
bull Gandhaka Rasayana [86]
Page | 51
According to Vagbhata-
Ear should be cleaned with the Pichu and Varti followed by Guggula Dhoopana
and then Karnapoorana with Madhu Followed by Avachurnanana with
Sukshmachootana of Surasadigana
Pathyaapathya ndash Pathya and Apathy mentioned for Samanya Karnaroga is
recommended in Karnasrava also
पथय[87]
सतदो वरको मन नसतय िमाः शशरावयिाः
गोिमाः शालयो मदगााः याशच परतन हवाः 80
लाो मयरो हररणानदसततततरो नकककिाः
पिोल शशगर ातावक सतनषराण कदठललकम
रसायनातन सवणण बरमहचयवमिाषणाम |
उपयकत यरादोषशमद कणावमय दहतम ||81||
िापर २१
Aharaja Upacharaja
bull Godhuma bull Vamana
bull Shala bull Virechana
bull Mudga bull Nasya
bull Yava bull Dhoomapana
bull Puranagitra bull Kavala
bull Lava Harina Tittiramamsa
Page | 52
अपथय[88]
दरत काटठ शशरसतनान वययाम शलटमल गर
कणडयन तषारशच कणवरोगी पररतपयजत
िापर २१
Viharaja
bull Patola ShigruVartaka bull Bhramacharaya
bull Sunishannaka bull Avyayama
bull Katthlika bull Aakthanam
bull All types of Rasayana bull Upacharaja
bull Vamana
Apathyas
bull Abhishyandakara Aharas
bull Shirasnana
bull Karna kandooyana
bull Tushara sevana
bull Guru Kaphakaraka Aaharas
bull Dantdhavana
Page | 53
OTOMYCOSIS
Definition-
Otomycosis is a superficial acute sub-acute or chronic infection of external
ear canal It is mostly unilateral It is characterized by inflammation purities
and scaling Otomycosis is a common condition encountered in ENT practice
more in chronic and persistent ear infection
The Fungal infections are not communicable in the usual sense but the
humans become an accidental host by their introduction into tissue trauma
The virulence factors favoring colonization of fungus in human host are yet to
be identified Ability of the fungus to grow at 37 C and elaboration of a variety
of enzymes and toxins are speculated to contribute to virulence Only 100 to
150 species are generally recognized as a cause of disease in humans[89]
Prevalence-
Otomycosis is a word wide in distribution and in various record stated that 5
to 20 of all cases of infective otitis externa Otomycosis prevalent is more in
warm and humid climates It is one of the commonest manifestations in India
during rainy season It occurs mostly in humid atmosphere otitis externa due
to fungal infection may resembles the desquamative form of diffuse infective
otitis externa The incidence in temperature climates has increased in
proportion to the use of topical antibiotics which have a medium sterilized of
other organism in which the fungus may flourish
Page | 54
Predisposing factors- [90]
1 Environmental factors such as climate contagious and polluting hygiene
more frequently during rainy season as the humidity increases
2 Individual susceptibility ndashGeneral Immunological status of the Individual
eg HIV infection Radiotherapy chemotherapy Diabetes mellitus
3 Self-inflicted trauma that is use of pins to clean the itching ear or use of ear
bud to clean the wax
4 Wide spread of topical antibiotics steroid preparations which have medium
sterilized of other organism in which the fungus may grow
5 Failure of defense mechanism in External auditory canal
6 During swimming or head bath water enters in External acoustic canal
causes quantitative and qualitative change in ear wax It causes change in pH
7 Long term use of hearing aids
Pathophysiology ndash
The life cycle of the average mold encountered in the ear may be reckoned
as two weeks and flare ups may be anticipated at such intervals Swimming is
held responsible for infection in many cases The sequence sequence of
pathogenic changes produced by molds in the external ear is as follows ndash
1 Implantation of the organism in external ear
2 Growth of organism follows the rate depending on condition of temperature
moisture or preexisting irritation
3 Invasion of epithelium occurs with attendant itching and discomfort which
may be quite severe
Page | 55
4 Exfoliation of epithelium occurs as nature attempts to overcome the
infection by casting off upper most cells
5 Denudation occurs from exfoliation as the top layers of epithelium are cast
off and the canal becomes filled with debris
6 Superficial ulceration and lizematoid dermatitis results if the pathologic
process goes for enough The changes do not always proceed through the
entire sequence sometimes the molds produce changes of the mildest
imaginable character which may be overlooked[91]
Clinical features -
Symptoms-
1 Irritation and itching ndash Irritation is mostly found when the infective
organism is aspergillus niger There is sensation of discomfort which is more
diffuse in the ear canal then localized in the deeper part Candida infection
causes marked itching In external ear it is intense and worse at night
2 Discharge through ear- Intermittent scanty colorless discharge through
ear Mucus being a fungal metabolic product appears as discharge Excessive
discharge is associated with mixed infection
3 Pain and discomfort ndash Mild to severe pain in the ear occasionally Mostly
seen in cases where ear is infected with Aspergillus flavus mixed infection
with gram negative organism or mixed infection with candida and aspergillus
Headache is sometimes associated with pain
4 Deafness- Varying degree of mild to moderate conductive deafness
5 A sensation of fullness in ear
6 Tinnitus 7 Vertigo
Page | 56
Signs ndash
1 The external acoustic meatus may contain a mass formed of epithelial
debris exudates cerumen and fungus
2 Erythematous external canal
Fungal appearance
A Niger - The color of the mass which is usually grey or black is mainly
determined by the type of fungus concerned Its appearance is like wet
newspaper or blotting paper or a cotton wool It has a peculiar musty odor In
this infection fruiting heads may be seen as black specks in the debris
Occasionally as inactive form occurs in which the canal is lined by mold giving
a fluffy appearance due to the presence of tiny mycelia
Candida ndash Candida infections generally show as white deposits on magenta
colored skin when the debris is removed it rapidly recovers in 24 hrs
The underlying canal skin is often inflamed and granular due to invasion by
fungal mycelia and be seen in all cases In rare cases excoriation and
ulceration with marked extensive shedding of the epithelium and deep
ulceration can be seen usually associated with a flavus and with pathogenic
bacteria[92]
Otoscope Appearance
1 Aspergillus Niger ndash Black headed
2 Aspergillus Fumigators ndash pale blue or green
3 Candida Albicans ndash White- or cream-colored deposits
Page | 57
4 Auricle is normal in most cases In severe cases small ulceration with crust
formation may be present on lateral surface
5 Tympanic Membrane
In most cases it is normal with normal mobility and normal hearing In a few
cases the surface of the tympanic membrane is congested and scaly There is
erosion or ulceration of the external epithelial layer and the membrane itself
may be edematous
Diagnosis
1 Above mentioned symptoms and signs
2 In the stage at which patient with otitis externa usually first present
themselves mycelia threads conidiophors not visible to naked eye may
sometimes be identified with the microscope
3 Confirmed by culture
Page | 58
Fig7 Aspergillus Niger Fig8 Candida Albicans
Fig9 Aspergillus Fumigators Fig 10 Wet Paper like appearance
Page | 59
Treatment
1 Antibiotic or steroid drops should be discontinued if they are being instilled
since long time
2 Removal of fungal mass epithelial debris and discharge from the external
canal or mastoid cavity repeatedly and thoroughly by forcepa or suction or
syringing or cautiously blow a stream of air into the canal through a fine
cannula and dry thoroughly by swabbing liquid petroleum on swab used in
cleaning the ear lessens the burning sensation when metacresy acetate is to
be employed in the subsequent treatment
Furuncle is developed as a complication if there is no gentleness in cleaning
Cleansing may have to be delayed until local sensitiveness is lessened which
can usually be accomplished within twenty-four hours If there is excessive
epithelial debris along with otomycosis then metacresyl acetate which is a
keratolytic in introduction into the external auditory canal on cotton wick and
is allowed to remain for twenty-four hours After twenty-four hours the cotton
wick is removed at which time the canal can usually be cleansed with little
discomfort as the medication is also anesthetic The epithelium of the canal
was white from contact with the drug The top layer was detached and this
epithelial debris can be easily wiped away The wick is reinserted and wet with
metacresyl acetate
The treatment is employed for three to four days in succession and then a
bland application is substituted Icthyol iodine is of value at this stage Iodine
ointment 2 in combination with Tannic acid 2 is also an excellent local
application following cresatin treatment
Next one of the fungicides may be applied
Page | 60
1 Nystin Effective for candida infection but less active against aspergillus
group Nystatin in boric powder consisting of 100000units of nystatingm of
powder 3 times week for 3 weeks
2 Clotrimazole Available as 11 cream or drops or lotions Phenyl
(zchlorophenyl) 1 ndash imidazole ndash methane is a chlorinated trityl imidazol 1
effective against candida and dermatophytes and for aspergilli infection
3 Amphotericin B Available as cream and as 3 solution and 015 drops
for topical application Very effective for candida infection can be fungistatic
or fungicidal
4 Econazole Available as solution (Econazole nitrate) and as cream (1)
Broad spectrum ndash more effective for Aspergillus Also active against some
gram-positive bacteria (Staphylococci and Streptococci and Dermatophytes)
5 Miconazole Highly effective against dermatophytes and candida infections
used as a 21 cream applied once or twice a day for 10 days
6 Gentian violet 21 Available as drops (recently some evidence of
carcinogenicity) Discolors the ear canal and this interfere with clinical
examination
Other topical antifungal agents are ketoconazole Natamycin Tolciclat Bifonas
zole Fenticonzole Oxiconazole Tioconazole ciclopiroxolomine Tolnafate
Haloprogin Flucytosine Acetic acid Whit field ointment selenium sulfide
undcyclenic acid triacetin etc
Page | 61
Minimal length of treatment
A month of drug treatment is usually required because the antifungal agents
used are not sporicidal and it is necessary that the period of treatment covers
germination time It may be advisable to give short gaps in the period of
treatment to ensure all spores have germinated before deciding to terminate
therapy
Prevention
Accomplished by strict attention to the predisposing causes
1 Water should be prevented from entering the ear
2 Avoidance of external ear trauma
3 Use of alcohol medicated or plain in the ears after swimming mercuric
cyanide (15000) in ethyl alcohol (70) is a satisfactory liquid to use
Ear stoppers do no good unless their use is followed by some antiseptic in the
canal Divers exposed to water for long periods of time may also use acidic
alcohol
4 During Summer months with their high humidity special efforts are needed
to maintain ear dry 5 Indiscriminate use of topical antibiotics steroid
preparations should be avoided
Page | 62
DRUG REVIEW
1 GUGGULA
Fig11 - Guggula
Historical review of Guggula [93]
bull Atharvaveda one of the well-known Vedas of Hindus The earliest
reference given by Atharvaveda medicinal and therapeutic properties of
Guggula Guggula has long history of use in Ayurveda
bull Acharya Charaka Sushruta and Vagbhata describe detail regarding the
actions uses and indication as well as the variety of Guggula
Page | 63
bull Various Nighantus (Medical lexicons) were written between 12th and 14th
centuries AD was based on the Ayurvedic literature also describes
Guggula
bull The explanation of word Guggula is that Gunjo Vyadhegurdti Rakshati
which means to relief against different diseases
bull Guggula is the best medicine because it develops through the rays of
hot sun on specific circumstances
bull Guggula has an aromatic odor
गगलो कणवदौगवररधय िपन शरटठमछयत[94]
स उ २२११२
Latin name- Commiphora mukul
Family ndash Burseraceae
Rasa- Tikta Katu
Guna ndash Laghu Rukshasukshma vishada sara
Veerya ndash Ushna
Vipaka ndash Katu
Action- Rasayana Lekhana
Doshaghanta - Tridoshhara
Page | 64
Chemical composition [95]
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Oleoresin-Z-Guggulsterone E-Guggulsterone
Gum- guggulignans 1 and 2 guggula Tetrols mukulol allylcembrol c
27
Guggulusterol 1 2 ans 3 Z and E ndash guggulusterol
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Parts Used ndash Gum oleoresin
Guggula purity test
1 Yellowish brown emulsion is obtained when Guggula is triturated with
water
2 An ethereal solution of the drug attains reddish colour when treated
with br2 vapors and purple colour when moistened with nitric acid
Biochemical action ndash Antiseptic Anti-inflammatory Disinfectant Diuretic
Immunostimulant stimulating expectorant Ant suppurative Antipyretic
Enhance phagocytosis
Karma- Rasayana cardiovascular disease
Page | 65
2 AGARU-
Fig 12 Agaru
Historical review of Agaru [96]
bull The word Agaru literally means the one which is the heaviest and no
aromatic wood is heavier than it Since thousands of years Agaru lsquoThe
wood of Godrsquo has been used for multiple purpose like commercial
medicinal spiritual aromatic historical
bull The medicinal use of Agaru have been recorded in many pieces of India
Greek Roman Chinese Middle eastern and European since ancient times
bull Acharya Charaka used Agaru and pest of Rasna to counteract the effect of
cold in Agraya Dravyas
bull Acharya Sushruta used Agaru as a Dhoopana Dravya along with Guggula
Ral and Shoma in the treatment of Karnasweda and Vrana
Page | 66
Types-
bull Dhanwantsri Nighantu describes Kaleyaka as a type of Agaru
bull Sodhala Nighantu describes three types of Agaru ndash Agaru Krishna
Agaru Kakatunda Agaru
bull Raj Nighantu describes five types of Agaru ndash Krishna Agaru Kasht
Agaru Daha Agaru Mangalya Agaru and Agurusaar
bull Arthashasstra describes three Agaru wood product
1 Jongaka ndash Black or variegated black in colour and having variegated
spots
2 Dongaka ndash Black in color
3 Parasamudraka- Black in colour and smells like Navamallika
अगर उटण कि तपछय ततकत ततकषण च वपततलम
लघ कणाविरोगघन शीत ात कफपरणत
िापर २१ [97]
Family- Thymelaccensis
Latin name- Aquilaria agallocha
Guna- Laghu Ruksha Tikshan
Rasa- Katu Tikta
Vipaka ndash Katu
Virya ndash Ushna
Karma- Sheetaprasasmana Vranaorasadan Tvachya Pittavardhaka
Shirovirechana Mangalya Sugandhik and Rochaka in properties [100]
Krishna Agaru karma- Katu Tikta rasa Ushna Sheeta when applied externally
and Pittahara when taken orally
Page | 67
Chemical Constituents -
Agaru hardwood is rich in essential oil resins alkaloids saponins Steroids
terpenoids tannins flavonoids and phenolic compound Agaru wood
predominantly contains 2-[-2-phenylethy]-4H-chromen-4-one derivatives and
sesquiterpenes Agaru oil contains selinene dihydroselinene agarnol b-
agarofuran vetispira-2(11)valerianol dihydrokaranone and tetradecanoic
acids[99]
Part Used ndash
Heartwood- Dark resinous wood which is formed when the plant becomes
infected with a type of fungus (ascomycetous mold) Species of Aspergillus
fusarium and penicillium are reported to be associated with the development
of infection Prior to infection the heartwood is odorless relatively light and
pale colored however as the infection progresses the tree produces a dark
aromatic resin in the heartwood The infected resin in response to the attack
which results in accumulation of a very dense dark resin in the heartwood
The infected resin embedded wood is known as Agarwood Infection is more
common on the trunk roots and the area when branches divide The formation
of Agarwood starts when the tree attains the age of 20 years On an average
approximately 30 ml oil is extracted from 100 kg of infected Agarwood[98]
Qualities of best Agaru-
It should be black in color
It should be extremely heavy and aromatic
It should be oily in appearance and test
It should be sink in water
It should burn easily with bright flame with a bright flame giving off a pleasant
smell
Page | 68
3 MADANA
Fig 13 MADANA
Madana consist of dried fruit of Xeromphis spinosa It is a deciduous thorny
shrub or a small tree reaching a high up to 9 m and girth about a meter
branches numerous thick and horizontal found in sub-Himalayan tracts[101]
मदनो मिरनदसततकतो ीयोटणो लखनो लघ
ानदरतिदवििीहर परततशयायवरणारतक
रि कटठकफ़ानाहशोथगलमवरणापह[102]
िा पर १६० १६1
Page | 69
Latin name-Randia dumetorum
Familly ndash Rubiaceae
Rasa - Madhura Tikta
Guna-Laghu Ruksha
Virya- Ushna
Vipaka ndash Katu
Karma- Vamana and Lekhana
Chemical Composition-
Essential Oil Valerianic acid Saponin tannin resin [103]
Page | 70
YAWA [104]
Fig 14 Yawa
1 In Samhitakala Aacharya Charaka Acharya Sushruta explain detail about
medicinal properties of Yawa
2The use of Yawa in Aaharya Dravya mainly described by Dhanwantari
Nighantu Raj Nighantu Bhavprakash Nighantu[105]
Macroscopic Description-
Fruit a caryopsis elliptical oblong Ovoid and tapering at both ends smooth
about 1cm long and 02- 03cm wide dorsally compressed and flattened on
the sides with a shallow longitudinal furrow 3-5 ridges having shallow
depression between them grains tightly enclosed and adhering the lemma
and palea pale greenish yellow odor not distinct taste sweetish acrid
Page | 71
Latin Name ndash Hordenum vulgare
Family- Poaceae
Rasa- Kashaya Madhura
Virya- Sita
Vipaka- Katu
Karma- Vatakrt Pittahara Kaphahara Medahara Balya Visrya
SthairyakaraLekhana
Page | 72
PROCEDURE REVIEW [105]
In Ayurvedic classics there are many references regarding Dhoopana Dravya
Dhoopana is administering Dhuma with the help of Dhoopana Dravya
In Kashyapa Samhita there are 40 types of Dhoopana advised for children
Anesthesia (Mohajananam Dhoopa) is also mentioned For this Dhoopana the
drug used were herbs hairs of animals legs horns old cloths of Buddhist
monks
From the references available regarding Dhoopana we can understand that
Karna can be protected from maggots (krimi) Bactria (Rakshogna) lice etc
References clearly indicate the analgesic and disinfectant effect of Dhoopana
Karma Dhoopana is mentioned for Dushta Vrana Chikitsa It reduces Vedana
Srava Pootigandha of Dushtavrana It also helps in Vranaropana
Dushtavrana Chikitsa is mentioned in the treatment of Karnasrava[106]
Origin of Dhoopana-
In ancient period children of sages were constantly harassed by the
Rakshasas Hence the sages approached lord Agni for shelter Agni in turn
gave them Dhoopana Dravya and asked sages to use the Dhoopana for
protection against Rakshasas bhutas pishachas
Classification of Dhoopana
1 It is classified into Dhupa Anudhupa Pratidhupa
2 On the basis of Origin it is classified into Jangama and Sthavara
Selection of Guggula for Dhoopana
Page | 73
bull Guggul is a best Vatahara
bull It is Krimighana
bull It contains Oleoresin
bull In Ashtang Hrudaya Guggula Dhoopana mentioned for Karnasrava
Selection of Agaru for Dhoopana
bull Agaru is Laghu Ruksha Katu Tikshna
bull Vranaorasadan Tvachya
bull It should burn easily with bright flame with a bright flame giving off a
pleasant smell
Karna Dhoopana Indication
1 Karnaarava
2 Putikarna
3 Krimikarna
4Vataj Karnashula
Contraindications
Especially for Karnadhoopan contraindication is not mentioned in classic texts
But Dhoopana is contraindicated in Pittaj vaydhi Sharad and Grishma Rutu
Page | 74
MATERIAL AND METHOD
Page | 75
For randomize comparative clinical trial to study the effect of Agaruwadi
Karnadhoopana and Guggula Karnadhoopana in Karnasrava following material
and method were required
Source of data
Patient irrespective of gender occupation religion social economic status
signs and symptoms of classical features of Karnasrava (Otomycosis) selected
from the OPD of Shalakyatantra department
Materials ndash
1Patients
2 Drugs-Agaruwadi Dhoopana
Guggula Dhoopana
3Torch
4Otoscope
5 Tuning fork
6Jobson horn probe
7Cotton
8Case record form
DRUG
Group A Trial Group
1Churana of Agaru Yawa Madan
2Ghrita
3Jala
Group B Control Group
1Googula Churna
Page | 76
Properties of Drug
Table no 1 Properties of Drug
Drug
Family
Rasa Veerya Vipaka Effect
on
Dosha
Guna Karma
Agaru
(Aquilegria
Agallocha)
Thymelaca
ceae
Katu
Tikta
Ushna Katu KV Laghu
Ruksha
Tikshna
Shitaprashamana
Shothahara
Vedanasthapak
Durghandhihara
Madan
(Randia
spinosa)
Rubiaceace
Kashaya
Madhur
Tikat
Katu
Ushna Katu KV Ruksha
Laghu
Vatakaphaghana
Shothahara
Vedanasthapak
Vranashodhak
Yawa
Poaceae
Hordeum
Vulgare
Kashaya
Madhur
Sheeta Madhur KP Ruksha
Laghu
Vataghana
Vernashodhana
Raktshodhaka
Guggula
Commiphora
Mukul
Burseracea
e
Tikta
Kashaya
Anushna Katu VPK Laghu
Ruksha
Shothahara
Vedanasthapaka
Kandughna
Ghrita Madhura Sheet Madhur VK Snigdha Vataghana
Shothahara
Vedanasthapaka
Page | 77
METHODOLOGY
SELECTION CRITERIA
1)INCLUSION CRITERIA
1 Patients having signs and symptoms of Karnasrava (Otomycosis) ie करणशल
( pain ) करणकणड ( Itching ) करणसतराव ( Discharge )बाधिरण ( conductive Loss of
hearing )
2 Patient from age group 19 to 70 years
3 Any Gender
2)EXCLUSION CRITERIA
1 Patients suffering from any systemic disease like DM TB HTN
2 Chronic suppurative otitis media (CSOM)
3 Acute supportive otitis media (ASOM)
3 Perforation of Tympanic membrane
4 Chronic otitis media
3)WITHDRAWAL CRITERIA
1If patient develops any adverse effect such as irritation pain burning
sensation in ear loss of hearing and such patients was withdrawn from trial
and receive prompt appropriate medical attention
2If patient shows aggravation in symptoms
3If patient refuses to continue with the treatment
Page | 78
STUDY SETTING
Types of study - Randomized Clinical comparative Trial
Place of work - OPD of Shalakyatantra
Duration of study - 18 months
Study Population - Patients of Karnasrava in Shalakyatantra OPD
SAMPLE SIZE CALCULATION
Sampling Method ndash Purposive sampling followed by random allocation in two
groups
Sample size calculation-
n = z2 p (1-p)
d2
Were
n = sample size
P = prevalence of disease=10
z = standard normal variable ie 196
d = error ie005
desired Sample Size would be
n = Z2 P(1-P)d2
= (196)2x (0021) x(0979)(005)2
= 34
Visiting ENT OPD (ShalakyaTantra) and IPD (ShalakyaTantra) 21 = 34
n raquo34
So one group includes 34patients
Page | 79
Sampling Method
Total 68 patient of Karnasrava are selected by Purposive sampling followed by
random allocation in two groups Written informed consent is taken prior to
commencement of trial They are divided in 2 groups
Group A (Trial Group) 34 patients treated with Agaruwadi Dhoopana for 7
days
Dose 5 minutes twice in a day
Group B (Control Group) 34 patients treated with Guggula Dhoopana for 7
days
Dose 5 minutes twice in a day
STUDY DESIGN ndash
Open labeled Randomized Comparative Clinical trial
STUDY DESIGN
Screening of patient
Inclusion criteria satisfied Exclusion criteria
Initial assessment Excluded
Counseling of patient Treated accordingly
Patient selection by Simple Random Sampling Method
Page | 80
68 Patients were divided in two groups lsquoArsquo and lsquoBrsquo
Trial group A-34 patients were given
Agaruwadi Dhoopana
Control group B- 34 patients were
given Guggul Dhoopana
Informed written consent
Treatment was given for 7 days
Assessment on 1st 4th and 7th day
Post assessments follow up on 15th day
Observation
Data Collection
Statistical analysis of data
Conclusion
Page | 81
(A) Agaruwadi Varti for group A (Trial group)
Table no 2
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
B) Guggula Varti for group B (Control group)
SOP of it is same as above Agaruwadi Varti
Table no 3
Drug Guggula Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
FOLLOW UP
For both groups follow ups were done on 1st 4th and 7th and post
assessment follow up15th day
EXAMINATIONS
Torch for Local examination of ear
Otoscope examination
Tuning fork Test
Page | 82
OBSERVATION TABLE
Table no 4
Sr no Subjective criteria Day 1 Day 4 Day 7 Day 15
1 करणशल
(pain)
2 करणकणड
(Itching)
3 करणसतराव (Discharge )
4 बाधिरण (Conductive Deafness)
OBSERVATIONS
a) करणशल (Pain) -
0 - Absent
1 ndash Present
b) करणकणड (Itching) -
0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
Page | 83
c) करणसतराव (Discharge)
0- Absent
1- Mild -Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाधिरण (conductive Loss of hearing)
0 - Absent
1- Present
Observations were carried out before and after completion of treatment and
during each follow up After observations the data collected and presented in
the form of graphs charts and table
Page | 84
TRIAL DRUG
Authentication and standardization of raw drug material done After
authentication and standardizing of raw drug material Agaruwadi Varti was
prepared by Varti as explained in Ayurvedic classics
Method of Varti preparations
Panchavidh Kashaya Kalpana that is five method of pharmaceutical
preparation constitutes the fundamental process of Ayurvedic pharmaceutics
which is well explained in Sushrut Samhita Varti Kalpana is one among them
which can be included in Kalka Kalpana
तीररसतरपतपतीनामपरककव तीत [106]
स डलहण शरच 151
Medicines are powered triturated and given the Varti shape that is like wick
of lamp so it is called as Varti Kalpana
Drug content Agaru Madan Yawa
Route of Administration Local
Dose Two times a day
Duration 7 days
Page | 85
Methodology
Standard operating procedure (SOP) of Agaruwadi Varti
Agaruwadi Varti is prepared according to the classical text
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization was done as recommended in pharmacy procedure The
raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 mixed together in
equal quantity to make Agaruwadi churn
Quantity of each churn is 4 grams all are mixed when the Varti get dry total
weight of Varti was 10gram
STEP 4 - Agaruwadi churn triturated with appropriate quantity of water or
Ghrita and prepared Varti in GMP Certified Ayurvedic pharmacy Standard
aseptic precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Varti was packed in sterile air packed container
STEP 6 - Agaruwadi Dhoopana was given with the help of Dhoopana yantra
Authentication and Standardization of raw drug of Agaruwadi Varti was done
Sterilization was done as recommended in pharmacy procedure Sterile
preparation packed in sterile container of suitable size Under all aseptic
precaution Karnadhoopana given to infected ear
Page | 86
Containers for packaging and their sterilization-
Sterilization of the containers for storing Varties was done by Ethylene Oxide
(Eto) method
Ethylene Oxide (Eto) procedure-
It includes exposure of materials to ethylene oxide gas under vacuum in a
sealed chamber It consists of four primary variables
1Gas Concentration
2Humidity
3Temperature
4 Time
EtO gas is an alkylating agent which disturbs the DNA of microorganism
preventing them from reproducing It penetrates the breathable packaging
and sterilizes all the accessible surface of the product to render products
sterility by alkylation of essentials proteins for cell reproduction
Most Eto sterilization methods involves three different stages These can be
separated into three different on the size or number of devices to treat
1Preconditioning stage-
First products are passed through a preconditioning phase to make
microorganism grow The batch load goes through a well time under a
controlled environment of temperature and humidity
2Sterilizer stage-
Performed using process phase specially designed to provide the required level
of EtO exposure to assure sterility for a device or family of devices
3Degasser Aerration stage-
Finally products need to go through a degassing phase to remove any residual
particles of Eto The batch load goes over well time under a temperature-
controlled environment
The sterile containers were then used to store Agaruwadi Varti and handed to
patients included in the study
Page | 87
Packing of Agaruwadi Varti
The ETO sterilize plastic container were used for packing of Agaruwadi Varti
Varti was filled into these sterilize containers (7 in each) In an aseptic
environment plugging and capping was done under aseptic precautions In this
way packing of Agaruwadi Varti done These Varti were given to patient and
advise to take two times a day under all hygienic precautions
History and Examination
bull Proper history and presenting complains was recorded on case record form
bull Ear examination with otoscope was done during initial assessment and each
follow up
bull Otoscopic examination was done during initial assessment and each follow
up
bull Systemic Examination that is Blood Pressure Temperature Respiration
rate Pulse was recorded on case record form
Page | 88
Raw material
Fig14 यव चरण Fig15 मदनफळ चरण
Fig16 अगर चरण Fig17 गगगळ चरण
Page | 89
Preparation of Agaruwadi Varti
Fig18 Preparation of Agaruwadi Varti
Fig19 अगरवादी वरती
Page | 90
Fig20 Instruments used for examination of Karnasrava
Fig19 Karnadhoopana Yantra
Page | 91
Karnadhoopana Procedure
Fig 22 Karnadhoopana Procedure
Page | 92
OBSERVATIONS AND RESULTS
Page | 93
BASED ON DRUGS
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 94
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
AUTHENTICATION CERTIFICATE
Page | 95
BASED ON STASTICIAL ANALYSIS OF DEMOGRAPHIC DATA
68 patients of Karnasrava ndash Otomycosis
Table no 5
No of Patients Total
Group A Group B
Registered 38 37 75
Completed 34 34 68
Discontinue 04 03 07
Total 68 patients were enrolled in study 38 patients registered in group A
amongst them 34 patients completed the treatment and04 patients
discontinued the treatment However in group B 37 patients completed the
treatment and 03 patients discontinued the treatment out of 37 registered
patients
Hence the total number of patients registered in the present study was 75
and out of which 68 patients were discontinued the treatment So they
dropped out from the study While 68 patients were successfully completed
the treatment So observations and result of 68 patients were given below
Here we are going to discuss the statistical analysis of the data obtained in
the form of master chart that was prepared in accordance with the data
collected from the patients that had been included in the study The purpose
of statistical analysis was to analyzed the relation between age gender
occupation diet addiction and education
Page | 96
1 Age wise distribution of patients
Table no 6
In trial group 10 (29412) patients were from age group 18-25 years 14
(41176) patients were from age group 25-35 years 8 (23529) patients
were from age group 35-45 years and 2 (58824) patients were from age
group 45-60 yearsIn control group 6 (17647) patients were from age group
18-25 years 14 (41176) patients were from age group 25-35 years 7
(20588) patients were from age group 35-45 years and 7 (20588)
patients were from age group 45-60 years
Fig 23 Age wise distribution of patients
0
2
4
6
8
10
12
14
15 -25 25-35 35-45 45-60
10
14
8
2
6
14
7 7
Age Distribution
Trial Group N Control Group N
Age Distribution
Trial Group Control Group
N N
18 -25 10 29412 6 17647
25-35 14 41176 14 41176
35-45 8 23529 7 20588
45-60 2 58824 7 20588
Total 34 100 34 100
Page | 97
1 Gender wise distribution of patients
Table no 7
Sex
Trial Group Control Group
N N
Female 23 67647 15 44118
Male 11 32353 19 55882
Total 34 100 34 100
In trial group 23 (67647) patients were female and 11 (32353) patients
were male
In Control group 15 (44118) patients were female and 19 (55882)
patients were male
Fig 24 Gender wise distribution of patients
0
5
10
15
20
25
N N
TRIAL GROUP CONTROL GROUP
23
15
11
19
Gender
Female Male
Page | 98
2 Education wise distribution of patients
Table no 8
Education
Trial Group Control Group
N N
Illiterate 4 11765 3 88235
SSC 4 11765 3 88235
HSC 8 23529 9 26471
Graduation 16 47059 10 29412
Primary 1 29412 3 88235
Post-Graduation 1 29412 6 17647
Total 34 100 34 100
In trial group 4 (11765) patients were illiterate 4 (11765) patients were
SSC educated 8 (23529) patients were HSC educated 16 (47059)
patients were graduated 1 (29412) patients were primary educated and
1(29412) patients were post graduated
In control grou 3 (88235) patients were illiterate 3 (88235) patients
were SSC educated 9 (26471) patients were HSC educated 10 (29412)
patients were graduated 3 (88235) patients were primary educated and
6 (17647) patients were post graduated
Page | 99
Fig 25 Education wise distribution of patients
0
2
4
6
8
10
12
14
16
ILLITERATE SSC HSC GRADUATION PRIMARY POST GRADUATION
4 4
8
16
1 1
3 3
910
3
6
Education
Trial Group N Control Group N
Page | 100
3 Occupation wise distribution of patients
Table no 9
Occupation
Trial Group Control Group
N N
Accountant 1 294 2 588
Housewife 11 3235 8 2353
Engineer 1 294 1 294
Job 1 294 4 1176
Labor 1 294 3 882
Mess 1 294 0 000
Naturotherapyst 1 294 0 000
Pharma 1 294 0 000
Shopkeeper 4 1176 2 588
Singer 1 294 0 000
Student 8 2353 4 1176
Tailor 1 294 1 294
Teacher 1 294 1 294
Worker 1 294 3 882
Farmer 0 000 1 294
Lab Tech 0 000 1 294
Page | 101
Daily Collection 0 000 1 294
Fruit seller 0 000 1 294
Bus Driver 0 000 1 294
Total 34 10000 34 10000
In trial group 11 (3235 ) were housewife 8(2353) were students
4(1176) were shopkeeper 1(294) was accountant 1(294) was
engineer 1(294) was doing job 1(294)was labour 1(294) was
catering 1(294) was Naturotherapyst 1(294) was Pharma 1(294)
was Singer 1(294) was Tailor 1(294) was Teacher and 1(294) was
worker
In Control group 8 (2353)were housewife 4(1176) were students
2(588) were shopkeeper 2(588) was accountant 1(294) was
engineer 4( 1176) was doing job 3(882)was labor 1(294) was
Farmer 1(294) was Lab tech 1(294) was Daily collection 1(294)
was Tailor 1(294) was Teacher and 3(882) was worker 1(294) was
Fruit seller and 1(294) Bus driver
Fig 26 Education wise distribution of patients
0
2
4
6
8
10
12
1
11
1 1 1 1 1 1
4
1
8
1 1 10 0 0 0 0
2
8
1
43
0 0 02
0
4
1 13
1 1 1 1 1
Occupation
Trial Group N Control Group N
Page | 102
4 Religion wise distribution of patients
Table no 10
Religion
Trial Group Control Group
N N
Hindu 31 9118 33 9706
Muslim 3 882 1 294
Total 34 10000 34 10000
In trial group 31 (9118) patients were Hindu and 3 (882) patients were
Muslim
In control group 33 (9706) patients were Hindu and 1 (294) patient
were Muslim
Fig 27 Religion wise distribution of patients
0
5
10
15
20
25
30
35
N N
TRIAL GROUP CONTROL GROUP
3133
31
Religion
Hindu Muslim
Page | 103
5 Diet wise distribution of patients
Table no 11
Diet
Trial Group Control Group
N N
Veg 14 4118 20 5882
Non-Veg 20 5882 14 4118
Total 34 10000 34 10000
In trial group 14 (4118) patients were vegetarian and 20 (5882)
patients were Non vegetarian
In control group 20 (5882) patients were vegetarian and 14 (4118)
patients were Non-Veg
Fig 28 Diet wise distribution of patients
0
5
10
15
20
N N
TRIAL GROUP CONTROL GROUP
14
2020
14
Diet
Veg Non Veg
Page | 104
6 Addiction wise distribution of patients
Table no 12
Addiction
Trial Group Control Group
N N
None 30 8824 27 7941
Alcohol 2 588 0 000
Tobacco 1 294 2 588
Mishri 0 000 1 294
Smoking 1 294 4 1176
Total 34 10000 34 10000
In trial group 30 (8824) patients have no addiction 2 (588) patients
have addiction of alcohol 1 (294) patients have addiction of Tobacco 0
(0) patients have addiction of Mishri and 1 (294) patients have addiction
of smoking
In control group 27 (7941) patients have no addiction 0 (0) patients
have addiction of alcohol 2 (588) patients have addiction of Tobacco 1
(294) patients have addiction of Mishri and 11 (1176) patients have
addiction of smoking
Page | 105
Fig 29 Addiction wise distribution of patients
0
5
10
15
20
25
30
NONE ALCOHOL TOBACCO MISHRI SMOKING
30
21
01
27
0
21
4
Addiction
Trial Group N Control Group N
Page | 106
Statistical Analysis and Results
Effect of study on Karnashoola-
Table no 13
Karnashoola
Group A Group B
BT AT BT AT
N N N N
Grade 2 0 000 0 000 0 000 0 000
Grade 1 30 10000 7 2333 32 10667 5 1667
Grade 0 4 1333 27 9000 2 667 29 9667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 30 Effect of study on Karnashoola
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
30
7
32
54
27
2
29
Karnashoola
Grade 2 Grade 1 Grade 0
Page | 107
Table no 14
Karnashoola Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 088 100 033 006
969 2829E-
08 7667 HS
AT 021 000 041 007
Group
B
BT 094 100 024 004
1037 7103E-
11 8438 HS
AT 015 000 036 007
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 31
000010020030040050060070080090100
BT AT BT AT
GROUP A GROUP B
088
021
094
015
Karnashoola
Mean
Page | 108
Table no 15
Karnashoola
Mean SD Effect
Group
A
Group
B Trial Control Trial Control
Day 1 088 094 033 024 000 000
Day 3 065 071 049 046 2667 2500
Day 5 024 038 043 049 7333 5938
Day 14 021 015 041 036 7667 8438
000
010
020
030
040
050
060
070
080
090
100
Day 1 Day 3 Day 5 Day 14
Karnashoola
Mean Group A Mean Group B
Page | 109
Table no 16
Karnashoola N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3250 110500
510000 275 Control group 34 3650 124100
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 110
Effect of study on Karnakandu
Table no 17
Karnakandu
Group A Group B
BT AT BT AT
N N N N
Grade 3 7 2333 0 000 4 1333 0 000
Grade 2 18 6000 0 000 18 6000 0 000
Grade 1 7 2333 7 2333 10 3333 15 5000
Grade 0 2 667 27 9000 2 667 19 6333
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 32 Effect of study on Karnakandu
0
5
10
15
20
25
30
N N N N
BT AT BT AT
GROUP A GROUP B
7
0
4
0
18
0
18
0
7 7
10
15
2
27
2
19
karnakandu
Grade 3 Grade 2 Grade 1 Grade 0
Page | 111
Table no 18
Karnakandu Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 188 200 081 015
1091 3119E-
10 8906 HS
AT 021 000 041 007
Group
B
BT 171 200 076 014
1032 4746E-
09 7414 HS
AT 044 000 050 009
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Page | 112
Fig 33
Table no 19
Karnakandu
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 188 171 081 076 000 000
Day 3 126 118 057 058 3281 3103
Day 5 071 074 046 051 6250 5690
Day 14 021 044 041 050 8906 7414
000
020
040
060
080
100
120
140
160
180
200
BT AT BT AT
GROUP A GROUP B
188
021
171
044
Karnakandu
Mean
Page | 113
Table no 20
Karnakandu N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 4051 137750
373500 006 Control group 34 2849 96850
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is less than
005 Hence we conclude that there is significant difference between Trial
Group and Control Group
000
020
040
060
080
100
120
140
160
180
200
Day 1 Day 3 Day 5 Day 14
Karnakandu
Mean Group A Mean Group B
Page | 114
Effect of study on Karnasrava
Table no 21
Karnasrava
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 11 3667 0 000 8 2667 0 000
Grade 1 23 7667 3 1000 26 8667 2 667
Grade 0 0 000 31 10333 0 000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 34
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
11
0
8
0
23
3
26
20
31
0
32
Karnasrava
Grade 3 Grade 2 Grade 1 Grade 0
Page | 115
Table no 22
Karnasrava Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 132 100 047 009
1122 4356E-
13 9333 HS
AT 009 000 029 005
Group
B
BT 124 100 043 008
1130 9364E-
14 9524 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 35
000
020
040
060
080
100
120
140
BT AT BT AT
GROUP A GROUP B
132
009
124
006
Karnasrava
Mean
Page | 116
Table no 23
Karnasrava
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 132 124 047 043 000 000
Day 3 100 100 025 025 2444 1905
Day 5 047 038 051 049 6444 6905
Day 14 009 006 029 024 9333 9524
000
020
040
060
080
100
120
140
Day 1 Day 3 Day 5 Day 14
Karnasrava
Mean Group A Mean Group B
Page | 117
Table no 24
Karnasrava N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3535 120200
549000 655 Control
group 34 3365 114400
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 118
Effect of study on Karnabadhirya
Table no 25
Karn
Badhirya
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 0 000 0 000 0 000 0 000
Grade 1 13 4333 0 000 16 5333 2 667
Grade 0 21 7000 34 11333 18 6000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 36
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 00 0 0 0
13
0
16
2
21
34
18
32
Karnabadhirya
Grade 3 Grade 2 Grade 1 Grade 0
Page | 119
Table no 26
Karn
Badhirya Mean Median SD SE
Wilcoxon
W P-Value
Effect Result
Group
A
BT 038 000 049 009
799 7173E-
05 10000 HS
AT 000 000 000 000
Group
B
BT 047 000 051 009
816 0000138 8750 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 38
000
005
010
015
020
025
030
035
040
045
050
BT AT BT AT
GROUP A GROUP B
038
000
047
006
Karnbadhirya
Mean
Page | 120
Table no 27
Karn
Badhirya
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 038 047 049 051 000 000
Day 3 009 006 029 024 7692 8750
Day 5 003 006 017 024 9231 8750
Day 14 000 006 000 024 10000 8750
000
005
010
015
020
025
030
035
040
045
050
Day 1 Day 3 Day 5 Day 14
Karn Badhirya
Mean Group A Mean Group B
Page | 121
Table no 28
Karn
Badhirya N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3400 115600
561000 806 Control
group 34 3500 119000
Total 68
Page | 122
COMPARISION BETWEEN GROUP A AND GROUP B
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Table no 29
Overall Effect
Trial Group Control Group
N N
Marked Improvement 21 6176 16 4706
Moderate Improvement 8 2353 13 3824
Mild Improvement 4 1176 5 1471
No Change 1 2941 0 0
TOTAL 34 100 34 100
Fig 39
0
5
10
15
20
25
MARKED IMPROVEMENT
MODERATE IMPROVEMENT
MILD IMPROVEMENT NO CHANGE
21
8
41
1613
5
0
Overall Effect
Trial Group N Control Group N
Page | 123
DISCUSSION
Page | 124
Discussion is nothing but the logical reasoning of observations In
every research work discussion part is very important because it brings into
light about the logical analysis which are helpful in filling the research gap in
the scientific world
The discussion is categorized into following ways for the ease of
understanding
1 Discussion on selection of topic
2 Discussion on review of literature
3 Discussion on drugs their mode of action on the disease mode of action
of Karnadhoopana
4 Discussion on observation and results
1 Discussion on selection of topic
Otomycosis is commonly encountered in day-to-day practice Majority
of Indian people affected with this pathology This disease commonly
manifests in developing countries low socio-economic standard and lack
of hygiene Now a days due to busy lifestyle people are not able to follow
the proper instruction of care of ear which may be responsible for the
recurrent nature of disease So for the management of this we use
Karnadhoopana with the help of Agaruwadi Varti Dhoopana is simple
easy cost-effective procedure which can be done even at OPD levelso
for the disease Karnasrava we selected Karna Dhoopana as therapeutic
procedure Karnadhoopana was done with Agaruwadi Varti and Guggula
Varti which was very effective for treatment
Page | 125
2 Discussion on review of literature
Karnasrava is one such disease among 28 Karnarogas mentioned by
Acharya Sushruta in the chapter named Karna Roga Vigyana Acharya
Charaka included Karnasrava as symptom under the four types of
Karnarogas due to vitiation of different doshas Acharya Vagbhata has
not described Karnasrava separately It is a fact that systemic
description of Karnarogas is available in all the ancients of pus from a
Vata afflicted ear may results from head injury or immersion in water
Karnasrava is a clinical entity which can be correlated with Otomycosis
Karnasrava is explained as symptom as well as a disease in Ayurveda
Nidana- Karnasrava occur due to Samanya Nidana and Vishesh Nidana
Vishesh Nidana like Shirobhighata Nimmajato jale Mithyayoga of Shashtra
The exact pathology behind Karnasrava is not understood clearly
Purvarupa ndash No specific Purvarupa are found for Karnasrava in classical
literature Acharya Madhukara describe Purvarupa as expression of
Rupa(lakshana) with less intensity that is less intensity itching sound in ear
may considered as Purvarupa of Lakshana
Samprapti- Aacharya Sushruta not explained the Samprapti of Karnasrava
separately and we must consider the general Samprapti of Karnaroga Due to
various aetiologias as cited above ear afflicted by Vata dosha causes Twak
Rakta Mamsa dushti results in Karnasrava According to Acharya Sushruta
Vata-Kapha dose is dominance in Karnasrava
Page | 126
Nidan
Nija Agantuja
Vata ndash kapha prakopak nidana Shirobhighata Nimmajato-jale
Mithya yoga of Shastra
Vata- kapha Prakopaka(Chaya prakopak) Vata-kapha prakopaka
( Achay prakopak)
Twak Rakta Mamsa dushti
Karnasrava
Page | 127
Chikitsa
The curative aspect and this must be done simultaneously giving due
importance to Nidan Parivarjana that is preventive measures So Nidan
Parivarjana that is avoidance of causative factors like Jalkrida Mithyayogen
shashtrasya Karnakandu Shirasnan Pratishaya is the first step in combating
the disease and form the part of line of treatment
Above Samprapti helps us to proceed towards the treatment of Karnasrava
The main protocol of treatment is removal of fungus and wound management
which include various measures to keep area day clean clear of microbes and
providing ideal condition for healing
Samany Chikitsa- Acharya Sushruta described general treatment for
Karnaroga as Snehapana (Drinking ghee) Rasayana (Rejuvenation therapy)
Bhramacharya Avoid excessive speaking Avoidance of physical exercise and
head bath
Vishesha Chikitsa ndash Acharya Sushruta mentioned some procedures in the
treatment of Karnasrava which is Shirovirechana Karnadhoopana
Karnapurana Karanpramarjana Dhavan Avachurnana Karnapurana Above
various procedures described in Ayurveda for management of fungus growth
in ear discharging ear fulfill these requirements of wound management
Page | 128
Discussion on observation and Result
Out of 68 patients 34 patients included for the trial The incidence of
Karnasrava is observed in trial and control groups
The statistical analysis provided the following data
AGE
Trial group- Maximum no of patients that is 14 (41176) patients were from
age group 25-35 years followed by 29412 patients were from age group
18-25 years 23529patients were from age group 35-45 years and
58824 patients were from age group 45-60 years
Control group - Maximum no of patients that is 14 (41176) patients were
from age group 25-35 years followed by 20588 patients were from age
group 35-45 years and 20588 patients were from age group 45-60 years
17647 patients were from age group 15-25 years
The maximum no of cases of Karnasrava found in age group between 25 to
35 years The reason behind this is repeated use of ear bud or emersed water
in ear More use of earphone or working more in cold environment
GENDER
Trial group ndash A higher prevalence seen in females 6764 and 3235 in
males
Control group - A higher prevalence seen in males 5588 and 4411 in
females
Females and males both are prone to disease
Page | 129
EDUCATION
Trial group-It is observed that amongst 34 patients maximum ie16
(47059) patients were graduated 8 (23529) patients were HSC
educated 4 (11765) patients were SSC educated 4 (11765) patients
were illiterate 1 (29412) patient were primary educated and 1(29412)
patient were post graduated
Control group- It is observed that 10 (29412) patients were graduated 9
(26471) patients were HSC educated 6 (17647) patients were post
graduated 3 (88235) patients were SSC educated 3 (88235) patients
were primary educated3 (88235) patients were illiterate
There is no direct relation between education and Otomycosis
RELIGION
Trial group- The incidence of patients of Hindu religion are 9118 and Muslim
religion are 882
Control group- The incidence of patients of Hindu religion are 9706 and
Muslim religion are 294
There is no probable explanation for this maximum number of patients in
Hindu religion it depends upon the patients attend the hospital and
community residing there
Page | 130
DIET
Trial group It was found that maximum ie5882 patients were taking
mixed diet while 4118 were taking vegetarian diet
Control group It was found that maximum ie5882 were taking
vegetarian diet while 4118 patients were taking mixed diet
The dietary habit of person is based on choice availability and religious
customs of the person
ADDICTION-
Trial group- It was found that maximum ie 30 (8824) patients have no
addiction 2 (588) patients have addiction of alcohol 1 (294) patients
have addiction of Tobacco 1 (294) patients have addiction of smoking and
0 (0) patients have addiction of Mishri
Control group - It was found that maximum ie 27 (7941) patients have
no addiction 4(1176) patients have addiction of smoking 2 (588)
patients have addiction of Tobacco 1 (294) patients have addiction of
Mishri and 0 (0) patients have addiction of alcohol
Very few patients were addicted to Alcohol Smoking Tobacco and Mishri
These factors can be taken as provoking factors for Otomycosis
Page | 131
Discussion based on probable Mode of action of Karnadhoopana
In Ayurveda classics Karna Dhoopana is therapeutic procedure explain for
Karnasrava Dhoopana is administration of Dhooma (Fumes) with the help of
Dhoopan Dravya References indicates that analgesic and disinfectant effect
of Dhoopana karma and mention for Dushta Vrana Chikitsa It reduces
Vedana Srava amp also does Vrana Ropana action
Various Dhoopanas and Dhoopan Dravas for different element in various
Samhitas of Ayurveda but there is a lacuna of availability of reference
regarding how to do it and method of procedure Matra Kala Contraindication
etc
Currently simple modified way of Karnadhoopana according to Yukti Praman
and experience but there is lac of standardization
Karnadhoopana is one among the topical Bahiparimajan type of treatment
Karna Parmarjana is procedure of cleaning ear with the help of cotton or gauze
piece soaked in honey
Page | 132
Dhoopan
The fumes coming out on burning Agaruwadi Varti
Administrated directly into external ear canal
Causes vasodilation
Due to this increase blood supply in external ear canal
It helps in absorption of drug
Fumes dries up Srava and bring the analgesic effect
Karnagata Kapha amp Avrut Vata Dosha Shaman
Decrease in signs and symptoms like karnasrava Karnshool Karnabadhirya amp
Karnandu
Page | 133
3 Discussion based on probable mode of action of Agaruwadi
Dhoopana
Agaru ndash
I Agaru is a fragrant tree aroma is a result of fungal pathogenesis when the
wood of tree is contaminated by fungi at wounds it develops scrap filled
with resin and turn out to be aroma Medicinal use of Agaru have been
recorded in ancient medicinal science in in inflammatory disease and some
infective disease
II Acharya Charaka has referred to Agaru as an Ushna dravya despite having
Tikta Rasa Ashtang Samgraha used Agaru as Dhupana Dravya along with
Madan and Yawa in Karnasrava Nighantu recommended is use as a
Dhoopana
III In various Samhitas and Nighantus Agaru described as Tikta Snighdha
Sheetaprashamana Vranaprasadana Tvachya Due to these properties
Agaru is used in the treatment of Karna-Akashi Roga and Dushta Vrana
Shodhaka
IV Agaru is reported to have Antimicrobial Analgesic Antioxidants
Antihistaminic and anxiolytic properties Its Antihistaminic property gives
relief from itching which is cardinal feature of Otomycosis Due to Katu
Ushna Tikta Guna improves blood circulation Bheda stage develop It is
Niram Awastha of Dosha Karnagata kapha and vata get decrease and
symptoms like karnashoolakarnasrava get decrease Agaru also have a
Antioxidant properties
V Chemically Agaru Contain 2-(2-Phenylethyl) Chromones Terpenoids
Flavonoids
VI Natural Agarwood had inhibitive activities towards Staphylococcus Aures
The chloroform extract of Agarwood prolongs the pain threshold[108]
Page | 134
Madan
I Madanphala have therapeutic properties like Anti-inflammatory
Antiallergic Analgesic and Wound healing
II It is Useful in treatment of disease like Shotha (inflammation) Vidradhi
(Abscess) Pratishaya (Common cold) Kushta(Skin disease)
III Extract of Madanphala mainly contain Glcosides Tritorpenct
Glycosides Saponin
IV Saponin glycosides are act as fire extinguisher This property is helpful
for vartiIt also act as a detergent which clean the surface of fungus
V Tritorpenct act as a anti-inflammatory antimicrobial and
immunomodulator compound Interaction of glycosides with sterol
causes disturbance of selective permeability in plasmic membraneso
exudates and discharge get decrease
VI Pharmacological activity [109]
Antibacterial Activity The preliminary antibacterial activity of Methanolic
extract of Randia D lam was done on some standard and wild pathogenic
strains The inhibition of the bacterial growth was more pronounced on E coli
as compared to the other tested organism This shows the antibacterial action
of Randia D secondary infection can prevent
Anti-Allergic Activity In Ayurveda Randia D Extract and its fraction of milk
induced leukocytosis and eosinophilia in mice
Anti-Inflammatory Activity The crude methanol extract of fruit of Randia D
effectively reduced the carrageenin induced oedema in hind paw of the rats
significant reduction in granular tissue formation was recorded This activity
seems to be significant at various acute phases of inflammation and om
formation of granular tissue This proves action of Madanaphala in shopa
(inflammation)
Page | 135
Analgesic Activity Analgesic activity was tested in mice weighing between 20-
250 with six number of animals in each group Methanlic extract of fruit Randia
d give analgesic activity in both models This proves its Shoolanashaka (pain
killer) action
Immunomodulatory Activity Randia D has immunostimulant activity and
chloroform fraction which strongly affected immune system seems to be
bioactive fraction of this plant
The overall effect of Agaru Mandanphala Yawa having Anti-inflammatory
Antiseptic Antimicrobial Property Active ingredient shows these properties
Agaru Yawa Madanphala
Vatakaphaghna
Act as
Vranashodhak
Vedanasthapaka
Sheetaprashamana
Shothara
Avarana of Vata get decrease so helps to Shaman of Vata dosha
Karnakandu Karnashoola Karnasrava
Prashamana
Page | 136
This fact can be taken into consideration and probably acknowledge that
Karnadhoopana with Agaruwadi Varti had not leave any residue in the ear
Removal of fibrin keratinocyte migration and in growth of epithelial tissue
plays a major role in healing It is technique of fumigation of ear with the
smoke of anti-infective drug In Karnadhoopana Sthanik Swedana increase the
blood supply and helps in absorption of the drug reduce Karnakandu amp
Karnshoola associated with infection
Page | 137
SUMMARY AND CONCLUSION
Page | 138
The dissertation entitled randomize comparative clinical trial to study the
effect of Agaruwadi Karnadhoopan and Guggula Karnadhoopan In Karnasrava
wsr to Otomycosis
The dissertation is divided into fallowing parts
Introduction
Review of literature
Ayurvedic review
Modern Review
Drug review
Procedure review
Material and Method
Observation and result
Discussion
Summary and conclusion
bull INTRODUCTION
It includes importance of Shalakyatantra in Sushrut Samhita Charka
Samhita And Ashtang Samgraha
Common and specific causes of Karnasrava
Karnasrava is a clinical entity which can be corelate with Otomycosis
In Ashtang Samgraha stated the procedure like Karnadhoopana with
Agaru Yawa Madanphala in Karnasrava
Page | 139
bull REVIEW OF LITERATURE
1 Ayurvedic review
2 Modern review
3 Drug review
Ayurvedic review-
It includes Rachana-Sharir and Kriya-Sharir of Karna detail description of
Karnaroga and its types Karnaroga Samanya hetu Poorvaroopa Rupa
Samprapti Upadrava Pathya-Apathya of Karnasrava Vishesh Nidan and
Chikitsa of Karnasrava Detail description of Karnadhoopana according to
various Acharays have been mentioned
Modern review-
It includes anatomy and physiology of Ear brief anatomy of ear anatomy of
External middle and Internal ear Detail description of the disease
Otomycosis mechanism of fungal infection in external canal pathophysiology
investigations diagnosis and management
Drug review-
Detail description of Agaru Yawa Madan Guggula and its synonyms
Ayurvedic properties Karma uses Pharmacological action and their
pharmacodynamic properties
Page | 140
MATERIAL AND METHOD
It includes description regarding materials required for the study Preparation
of Agaruwadi Varti its Standardization Sterilization and packaging
Plan of study
1 Total 68 patients completed the treatment Age criteria was kept
between 18-60 years Patient selection was done by done by simple
random sampling method and divided into two groups A (Trial) and
Group B (Control) 34 patients in each group
2 Patients in Group A were treated with Karnadhoopana with Agaruwadi
Varti for 7 days two times in a day while patients in Group B were treated
with Karnadhoopana with Guggula for 7 days two times in a day
3 Clinical examination done during each follow up ie 0th 4rd 7th and
observation were recorded
Page | 141
OBSERVATIONS AND RESULTS
Page | 142
1 It was observed that higher incidence of disease Karnasrava ie
Otomycosis found in age group 25-35 years
2 Disease otomycosis was equal in both male and female
3 The trial group there was significant relief in Karnakandu (8906)
Karnasrava(9333) Karnashoola(7667) and karnabadhirya(100)
4 In control group there was significant relief in Karnakandu (7414)
Karnasrava(9524) Karnashoola(8438) and
karnabadhirya(8750)
Page | 143
REFERANCES
Page | 144
1 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published byChaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 17 page no
5
2 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 19 page no
6
3 DRNarayan Vidwas Shero-Karna-Nasa and MukhrogaAnand publication
edition 4th 2014 Page no-52
4 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-205
page no 111
5 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 111
6 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Shlok no2012
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 112
8 Dr KBBhargavaDr SK BhargavaDr TMShahaA Short book of ENT
diseases Usha publication edition 10th
9 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 8 Page no -52
Page | 145
10 Research and Review Journal of Ayurvedic science yoga and
Naturopathy 2017 4(3) 1-5 pA Critical review of Otomycosis in cortex to
Karnaroga described in Ayurvedic classic by amisha patel D B Vaghala
Chandani goswami Vol4 no3 (2017)
11 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogpratished Adhaya Shlok no-213
page no127
12 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedh Adhaya Shlok no-
2140 page no 131
13 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyant shirasiya adhaya Shlok no 1712 page no-
258
14 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
15 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
16 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Aupadravik Adhaya Shlok no-15 page no
2
17 Vaidya Jaymini panday Harit Samhita hindi commentaryChaukhamba
vidhyabhartiVaranasiedition 2010 Shlok no- 13-14page no-10
18 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 146
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-20345
page no 112
19 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Karnarogavigyniyam Shlok
no 21 Page no-731
20 Charak
21 Pandit Harigovind Shashtri Namalinganusasana Amarkosha of
Amarsimha hindi commentary published by Chaukhamba Sanskrit
Sansthan page no- 463
22 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
23 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 37
24 Shree Taranath-Trkavachspati-Bhattacharyen Vchaspatym published
by Rashtriya Samskrit Sansthandelhi Volume 4 page no- 5149
25 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
26 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
27 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
28 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Page | 147
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
29 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Indriyaopakramaniya Adhaya Shlok no 811
page no- 125
30 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243
31 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-510 page no56
32 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no3108 page no- 385
33 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no33 page no- 366
34 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sarvabhutachintasharir Adhaya
Shlok no-126 page no9
35 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-522 page no60
36 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-532 page no61
37 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Page | 148
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-521page no58
38 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-527 page no61
39 VdBramhand Tripathi Ashtanghradaya Sharirsthansthan Published by
Chaukhamba prakashana 2005 Shlok no331 page no-372
40 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Siravarnavibhaktisharir Adhaya
Shlok no-725 page no83
41 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Sharirsankhyavykaransharir Adhaya Shlok
no-512
42 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Pratekmarmanirdeshsharir
Adhaya Shlok no-628 page no75
43 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
44 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Marmasharirsthan Shlok no429 page
no- 393
45 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243244
Page | 149
46 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
47 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan pu blished by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711
48 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
49 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
50 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Shlok no 711 page no- 847
51 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Adhaya Shlok no-628 page no- 75
52 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Gandushavidhiadhaya Shlok no2232
page no- 261
53 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Karnavydhbandhvidhi Adhaya Shlok no-
1611 page no- 86
54 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Nidansthan Published by Chaukhamba
Page | 150
Sanskrit SansthanVaranasi Vatvydhinidansa Adhaya Shlok no183 page
no- 304
55 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavaykaransharir
Adhaya Shlok no-532 page no61
56 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Tristaisniya adhaya Shlok no 1120 page no-
163
57 P Hazarika Dr Nayaka R Balkrishnan Textbook of EarNoseThroat and
Head-Neck Surgery CBS Publication Anatomy of Ear
58 DrKB Bhargava DrSKBhargava DrTMShaha A short book of ENT
Diseases Published by Usha Publication 10th edition page no10
59 MrSalah Mansour MrJacques MagnanMr Hassan Haidar MrKaren
Nicolas MRStephan Louryan Comprehensive and clinical anatomy of the
Middle Ear Published by Springer publication Chapter -Middle Ear cavity
Page no 19 to 121
60 DrPLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 7
61 James OPickles An introduction to Physiology of Hearing Published by
Emerald publication 4th edition page no- 1 to 265
62 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
63 VdBramhand Tripathi Ashtanghradaya Uttarsthan Published by
Chaukhamba prakashana 2005 Karnaroga vigyniyam adhaya Shlok
no1713 page no- 998
Page | 151
64 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Shlok no- 212 page no-
730
65 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no
1-2 page no- 309
66 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana
67 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyantshirasiya Adhaya Shlok no 1713 page no-
258
68 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no-
6 page no- 310
69 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Karnarogavigyniym Shlok no- 1725-26 Page no-
1003
70 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2140 page
no 131
71 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Adhyay 18 shlok 35
72 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt
Karnarogapratishedhoadhya Shlok no-2211 Page no- 735
73 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 152
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2141 page
no 131
74 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2142 page
no 131
75 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2144 page
no 131
76 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 34 page no- 649
77 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2145page
no 131
78 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 37 page no- 649
79 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2146page
no
80 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
81 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 153
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2143page
no
82 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publication Krnarogadhikara adhaya page no-
318
83 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary
Madhyamkhand Vatkalpana shlok no- 782-83 page no- 137
84 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 72-77 page no- 651
85 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
86 Vd Shree Laxmipatishastri Yogratnakara
87 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
Karnarogadhikara Shlok no- 808182 page no- 652
88 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 83 page no- 652
89 (PDF) Otomycosis A Comprehensive Review (researchgatenet)
90 httpswwwncbinlmnihgovpubmed24948980
91 A Simon Carney Scott-Browns Otorhinolaryngology Head and Neck
Surgery CRC press 8th publication Otitis externa and otomycosis
92 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no Page no -
93 wwwguggulipidcomtradhtm
Page | 154
94 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
95 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-28 page no-
43
96 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009Agaru page
no726-728
97 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishra chapter Karpuradi varga Shlok no-31-
43 Page no- 116
98 httpswwwthiemeinimagecatlogsample_chapter_GOMPpdf
99 (PDF) Chemical Constituents and Pharmacological Activity of Agarwood
and Aquilaria Plants (researchgatenet)
100 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 4 chapter no-2 page no-4
101 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 chapter no-152 Madanpage
no376-379
102 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
103 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-54 page no-
84
104 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 page no697-699
patol-yawa
Page | 155
105 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
106 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
Dhoompanvidhi page no- 252-254
107 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012Chikitasasthan Shlok
no- 151page no-406
108 httpswwwmdpicom1420-3049232342pdf
109 httpswwwijamcoinindexphpijamarticledownload0610201530
0
Page | 156
BIBILOGRAPHY
Page | 157
1 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
2 Scott-Brown WG Diseases of the EarNose and Throat Landon
Botterworth and co(publishers) Ltd1952 Volume 2
3 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012
4 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009
5 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi commantry
Purvakhand and Madhyamkhand
6 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Published by Chaukhamba Sanskrit
SansthanVaranasi
8 The Ayurvedic Pharmacopeia of India Ministry of Health and family welfare
department of Ayush Part 1 and part 4
9 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005
10 Acharya Trivedi Raguveer Prasad Ashtang sangrah published by
Vaidyanath Ayurveda bhavan pvt
11 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition
12 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary published by Chaukhamba
Orientalia
Page | 158
ANNEXURE
Page | 159
ANNEXURE- 1
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
CASE RECORD FORM
RESEARCH PROFORMA FOR MS (AYU) DESSERTATION
DEPARTMENT OF SHALAKYATANTRA
NAME -
ADDRESS -
GENDER - AGE - OCCUPATION-
RELIGION - EDUCATION - MARITAL STATUS-
OPD IPD NO-
DATE OF ADMISSIONCOMMESEMENT-
DATE OF DISCHARGECOMPLITION-
DATE OF COUNSELLING-
TEL NO-
CHIEF COMPLAINTS-
PAST MEDICAL AND SURGICAL HISTORY-
TREATMENT HISTORY-
FAMILY HISTORY-
Page | 160
PERSONAL HISTORY-
a) Ahar(Diet)
b) Vihar
c) History of addiction
GENERAL EXAMINATION
PULSE - MIN BP - mm of hg
TEMP - 0F RR - MIN
ASHATAVIDHA PARIKSHANA
Nadi- Mutra- Mala-
Jivha- Shabda- Sparsha-
Drik- Aakruti-
SYSTEMIC EXAMINATION
RS ndash
CNS-
CVS ndash
Page | 161
LOCAL EXAMINATION (KARNA PARIKSHAN)
OBSERVATION TABLE FOR SUBJECTIVE CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching )
RIGHT EAR LEFT EAR
KARNASHASHUKULI
KARNAPUTRAK
KARNAPALI
KARNAKUHARA -
SRAVA
GANDH
VARNA
SWARUPA
KARNAPATALA (TM)
Page | 162
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
Hearing Test
1Renne Test ndash
2 Weber Test -
Examination of Ear-
Pathological Investigation-
Other Examination-
Nidan Panchak-
1Hetu-
2Purvarup-
3Rupa-
4Upashayanupashaya-
5Samprapti
Signature of Guide Signature of Doctor(Researcher)
Page | 163
ANNEXURE 12
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Dhoopana Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization were done as recommended in pharmacy procedure
The raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 were mixed together
in equal quantity to make Agaruwadi churn
STEP 4 - Agaruwadi churn were triturated with appropriate quantity of water
and prepared Varti in GMP Certified Ayurvedic pharmacy Standard aseptic
precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Dhoopana Varti was packed in sterile air packed
container
STEP 6 - Agaruwadi Dhoopan was given with the help of Dhoopan yantra
TREATMENT DETAIL-
Purvakarma -
1 The patient is asked to sit comfortably on chair having sufficient light and
less amount of dust
2 The EAC is cleaned thoroughly by Pichu Varti (cotton swab) to remove the
discharge and other debris
Pradhankarma -
1 The patient is asked to relax completely on the chair
Page | 164
2 Fumes are passed to the ear with Dhoopana Yantra
3 Dhoopana yantra is funnel shaped and its one end will keep the ear covered
for the passage of Dhooma into the ear canal and other end where Agaruwadi
Dhoopana Varti were placed which produces fumes
4 This Dhoopana was given for 5 min
Pashchat karma -
1 The patient were advised to avoid cold refrigerated food drinks cold water
bath cold wind fog and prevent water from entering the ear
(A) Agaruwadi Dhoopana Varti
B) Guggula Dhoopana Varti SOP of it is same as above Agaruwadi Dhoopana
Varti
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Page | 165
ANNEXURE 21
INFORMED CONSENT DOCUMENT
Study Title
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
Introduction
- You are invited to take part in a research study RANDOMSIED COMPARATIVE
CLINICAL TRIAL TO STUDY THE EFFECT OF AGARUWADI DHOOPANA AND
GUGGULA DHOOPANA IN KARNASRAVA
- Before you decide it is important for you to understand why the
research is being done and what it will involve
- Please take time to read the following information carefully and discuss
it with friends relatives and your doctor if you wish
- Ask us if there is anything that is not clear or if you would like more
information
Purpose amp Nature of Study
- In this research project by examine you and ldquoKarnasravardquo (Otomycosis)
disease were treated
- In the part of treatment Agaruwadi Dhoopana or Guggula Dhoopan were
given
- Dhoopana means medicated drug fumes were given in ear with the help of
Dhoopan Yantra
Page | 166
- Treatment was given for 7 days
Study Duration
7days
Participation
- Your participation is entirely voluntary
- If you do decide to take part you were given this information sheet to keep
and be asked to sign a informed consent form
- If you decide to take part you are still free to withdraw at any time and
without giving a reason This will not affect the standard of current or future
medical care you may receive
Confidentiality
- All information which is collected about you during the research were
kept strictly confidential
- Any information about you which is collected from the center will have
your identity in the form of a code number so that it will remain confidential
Benefits Of Study
- The results obtained from this study would be helpful for providing better
quality of treatment amp other essential facilities for Karnasrava (Discharge)
patients
- You will get clinical benefit from the study
Page | 167
Risks Of Study
- In this treatment there are few chances of Irritation of Ear Nose and
congestion at EAC if any of these happens then treatment were given
Results Of Study
- If the Results obtained are profitable then they may get published
without disclosing your details
Signature of patient
Date
Time
Phone no of Researcher
Page | 168
रण मादहती पतरक
सशोिनाच शीषवक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE
EFFECT OF AGARUWADI DHOOPANA AND GUGGULA DHOOPANA
IN KARNASRAVA
परसतताना
- आपणास या सशोिनातपमक अभयासात सहिागी होणय़ाच आाहन करणयात यत आह
- सशोिनातील सहिाग तननदशचत करणयापी सशोिनाच उददश समजन घया
- खालील मादहती काळजीपवक ाचा आणण आशयक ािलयास आपलया डॉकिराशी कका
दहतशरचतकाशी चचाव करा
- काही सददिता असलयास कका आणखी मादहती ही असलयास आमछयाशी चचाव करा
सशोिनाच उददीटि सतरप
- सदर सशोिन परकलपामरधय आपलयाला तपासणी करन कणवसरा या वयाशरिची शरचककतपसा दणयात
यणार आह
- सदर वयाशरिची शरचककतपसा महणन आपणास अगरादी िपन कका गगल िपन
दणयात यणार आह
- सदर औषि आपणास 7 ददस घयायाच आह
Page | 169
कालािी
- 7 ददस
सहिाग
- आपला सहिाग हा पणवपण ऎनदछिक आह
- आपला सहिाग तननदशचत असलयास आपणास ही मादहती पतरतरका दणयात यईल आपणास यातील
समती पतरकार सही कराी लागल
- सहिाग तननदशचत असनही आपण कोणतपयाही ळस कोणतही कारण न दता माघार घ शकता
याचा आपलया दयकीय सविर कोणताही पररणाम होणार नाही
गोपनीयता
- सशोिना दरमयान गोळा कलली आपलया वषयाची सव मादहती गोपनीय ठणयात यईल
- आपली यनदकतक मादहती साकततक सतरपात गोपनीय ठणयात यईल
सशोिनाच फ़ायद
- सशोिनाच तनटकषव कणवसरा बाशरित रणाछया दयकीय इतर सविाचा दजाव सिारणयास
फायदशीर ठरतील
सशोिनातील जोणखम
- य़ा शरचककतपसमरधय कान दखण डॊळय़ातन नाकातन पाणी य़ण नाकात जळजळण डोक जड
होण ही लिण ददस शकतात यापकी लिण तनमावण झालयास तपयाची शरचककतपसा कली जाईल
Page | 170
सशोिनाच तनटकषव
सशोिनाच तनटकषव फ़ायदशीर ठरलयास आपली मादहती गोपनीय ठन परकाशशत करणय़ात यईल
रण सतािरी-
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
Page | 171
ANNEXURE 31
INFORMED CONSENT FORM
Patient OPD no __________
Subjectrsquos Identifier
Date of Birth Age Gender
I _____________________________________ age___________ years
exercising my free power of choice hereby give my consent to be included
as a participant in the clinical study entitled
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
1 I confirm that I have read have been read and understood the information
sheet for the above study and can ask questions
2 I understand that my participation in the study is voluntary and that I am
free to withdraw at any time without giving any reason without affecting my
medical care or legal rights
3 I understand that the Ethics Committee members investigators and study
doctors will not need my permission to look at my health records both in
respect of the current study and any further research that may be conducted
in relation to it even if I withdraw from the trial I agree to his access
However I understand that my identity will not be revealed in information
released to third parties or published
4I agree not to restrict the use of any data or results that arisefrom this study
provided such a use only for scientific purpose
5 I agree to take part in the above study
Page | 172
signature with Date-
Left hand thumb impression
Name amp signature of the witness ndash
Name amp signature of the student ndash
Page | 173
ANNEXURE 32
समतीपतरक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
वयकतीच य
ददनाक जरमददनाक
1) मी ह तननदशचत कररत आह ककसदर सशोिन परकलपाबाबतची सपणव मदहती मी ाचली असनमला ती
समजली आहतपयाबददल मला परशन वचारणयाची पणव मिा आह सदर मादहतीन माझ समािान झाल
आह
2) मी सदर सशोिनातन माझया मजीनसार किीही बाहर पड शकतो या माझया अशरिकाराची मला कलपना
आह
3) माझी दयककय मादहती तपासणयाची कागदपतर कळ सशोिनाकररता ापरली जाणार आहत याची
मला मादहती आहसदर सशोिन परकलपातील सबशरित घिकाना माझी दयककय मादहती पाहणयाची मी
समती दत आहतरावप या सदिावतील माझी ओळख दशववणारी मादहती कोणासही ददली जाणार नाहीयाची
मला कलपना दणयात आली आह
4) सदर अभयासातन शमळणारी मादहती अरा तनटकषव कळ शासततरीय हतसाठी ापरल जाणयासाठी माझी
समती आह
5) रील अभयासात सहिागी होणयास माझी समती आह
रण सतािरी-
Page | 174
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
ASSESSMENT CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching)
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
a) कणवशल ( pain )- 0 - Absent
1 ndash Present
Page | 175
b) कणवकणड (Itching)- 0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
c) कणवसततरा ( Discharge )
0- Absent
1-Mild- Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाशरियव ( conductive Loss of hearing )
0 - Present
1 - Absent
Page | 176
Page | 177
Page | 178
Page | 179
Page | 180
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
Page | 181
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 182
AUTHENTIFICATION CERTIFICATE
Page | 1
INDEX
No Chapter Page No
1 Introduction 2-5
Study Rationale
Epidemiological data
2 Aims and objectives 6
3 Research Question 6
4 Previous work done 7
5 Review of Literature 8-73
i Literary Review
ii Disease Review
iii Drug Review
iv Procedure review
6 Materials and methods 74-91
7 Observations and Results 92-122
8 Discussion 123-136
9 Summary and conclusion 137-142
10 References 143-155
11 Bibliography 156-157
12 Annexures 158-182
i Case Record Form
ii Consents
iii Master Charts
Page | 2
INTRODUCTION
Page | 3
Ayurveda is ancient science of life a system of health and medicine
which aims to assist people in living a healthy life It is a person-centered
medicine which deals with healthy lifestyle systemic diseases prevention
diagnosis and treatment Ayurveda is divided into eight branches[1] It has
a separate branch of clinical and surgical specialization concerning ENT and
ophthalmology known as Shalakyatantra One out of the eight branches of
Ayurveda Shalakyatantra deal with the etiology diagnosis prognosis
prevention treatment and complication of diseases which are located at
Urdhwang Pradesh[2]
Karna is one among the Panchendriya (sense organ) situated at
Urdhwang Pradesha [3] It is originated from Akash Mahabhuta Aachary
Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga Vigyniyam
Aadhaya[4] He mentioned Karnasrava as separate diseases[5] Aacharya
Charaka explain 4 Karnaroga He had not described Karnasrava as
independent diseases but explain Karnasrava as a symptom under four
Karnaroga Acharya Vagbhata mentioned Karnasrava as a symptom in
Karnashoola according to Dosha He included this into Kaphaj Karnashoola
itself[6] Karnasrava means discharge through ear The Samanya Hetu of
Karnaroga are Avashaya or Pratishaya that is common cold Sheeta Vihara
or exposure to cold environment Karnakandu or self-inflicted trauma by
use of ear bud or pine to clean itching in ear Shabda Shashtra Mithyayoga
that is misuse of instrument or listening to high sound frequencies[7] The
other predisposing factors are such as abuse of nonspecific broad-spectrum
antibiotics steroids and immune suppressed disorders
Classical features of Karnasrava can be compared with otomycosis
Otomycosis is acute sub-acute or chronic fungal infection in external ear
which rarely involves the middle ear[8] Otomycosis is characterized by pain
itching discharge conductive deafness of mild to moderate in nature
Fungal spores invade in the epithelial layer of EAC In response to that
inflammatory process starts which will reflect as pain Itching is due to
immune reaction of body during inflammatory process As a result of
Page | 4
inflammatory process exudates were produced which will mix up with
fungal colonies and appear as discharge In initial stage of disease ear
discharge is watery but if there is secondary bacterial infection occur it
becomes mucopurulent Ear blockage and conductive type of hearing loss
are due to accumulation of fungal mass in external auditory canal
Fungal mass appears white or black or brown and is like a wet piece
of filter paper Examination with otoscope Aspergillus Niger appears black
headed filaments growth Aspergillus fumigates as a pale blue or green and
candida as a white or creamy deposit[9]
Otomycosis is a common condition and it mostly occurs in humid
area According to American academy of otolaryngology prevalence of
otomycosis is 52 all over a world and 09 in India 5-25 otitis externa
cases are due to otomycosis Nearly 61 types of fungal species being involve
in otitis externa 90 of fungal infection cases involve Aspergillus species
and the rest candida species[10]
In Ayurveda The common treatment Principle for all is Ghritapana
Rasayana Bhramacharaya Avyayama (Excessive exercise)
Ashirasnana(Head bath) Atibhashashya(Excessive speaking) This can be
used for the prevention and management of Karnaroga[11] Acharya
Sushruta explain specific treatment modality for Karnasrava is
Karnaprakshalana Karnapoorana Karnadhoopana Shirovirechana
Karnadhavana[12]These therapeutic procedure can be updated according to
different stages of these condition
In routine OPD it is observed that patient of otomycosis respond
more frequently to topical therapy than to systemic therapy Among all the
treatment modality Karnadhoopana is an effective and simple procedure
In this regard Karnadhoopana with Agaruwadi Varti or uggula had explain
in Ashtang Samgraha Agaruwadi Varti contain Agaru Yawa Madanphala
All these contains of Agaruwadi Varti and Guggula acts as Ruksha Ushna
Teekshana Laghu Guna acts as effective Shodhaka keeps ear dry reduce
Page | 5
pain discharge foul smell and thus control the infection Dhoopana is also
useful as Adhidaivika Chikitsa to protect the patient from external attack of
visible and invisible organism The principal treatment modality adopted in
Allopathic system of medicine is oral antibiotics and topical antibiotic drop
Long term use of oral antibiotic causes adverse effect like gastric irritation
reduce immunity and resistance to drug Long term use of topical antibiotic
drops cause Ph change in external canal which become prone to fungal
infection
Hence the therapeutic procedure with Guggula or Agaruwadi Varti
Karnadhoopana are cost effective safe and easy procedure and it can be
used more effectively
Page | 6
AIM OF STUDY
To evaluate the effect of Agaruwadi Varti Dhoopana and Guggula Varti
Dhoopana in management of Karnasrava
OBJECTIVE
To compare the efficacy of Agaruwadi Dhoopana and Guggula Dhoopana in
Karnasrava
HYPOTHESIS
NULL HYPOTHESIS -
H0- Agaruwadi Dhoopana is not effective than Guggula Dhoopana in
Karnasrava
ALTERNATE HYPOTHESIS -
H1- Agaruwadi Dhoopana is more or equally effective than Guggula
Dhoopana in Karnasrava
RESEARCH QUESTION
Whether there is significant difference between Agaruwadi Dhoopana and
Guggula Dhoopana in Karnasrava
Page | 7
PREVIOUS WORK DONE -
1 Anupama Patra B Effect Of Arka Taila In The Management Of
Karnasrava With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2007
2 Palmer Komalben K Further Study On Role Of Arka Taila In The
Management Of Karnasrava With Special Reference To
Otomycosis Shalakya Tantra Institute for Post Graduate Teaching amp
Research in Ayurveda Gujarat Ayurved University Jamnagar 2010
3 Sathisha Shankar B Management Of Karnasrava With Sthanika
Guggulu Dhoopana And Rasnaadi Guggulu-A Comparitive Study Shalakya
Tantra Government Ayurvedic Medical College Bangalore 2011
4 Shashikala DK Comparative Study On The Efficacy Of Vacha
Lashunaadi Taila Karna Pichu And Nimba Patraadi Dhoopana In The
Management Of Karna Srava Shalakya Tantra Government Ayurvedic
Medical College Bangalore 2014
5 Javale Anant A Clinical Study On The Efficacy Of Arka Taila In The
Management Of Karna-Srava Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2005
6 Pournima V Koti Management Of Karnasrava With Priyangvadi Taila
Pichu With And Without Saarivadi Vati Shalakya Tantra Sri Jagadguru
Gavisiddeswar Ayurvedic Medical College Koppal 2015
7 Amisha Patel A Clinical Evaluation Of Honey In The Management Of
Karna Shoola With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching and Research in Ayurveda
Gujarat Ayurved University Jamnagar 2016
Page | 8
REVIEW OF LITRATURE
Page | 9
Ayurvedic literature Ayurveda is a science of life practice since
thousands of years The ancient Indian system of medicine and surgery is
commonly known as Ayurveda This was given the status of Upaveda or
fifth Veda in the next stage of growth Among the available literature three
Samhita that is Charaka Samhita Sushrut Samhita Ashtang Hrudayam and
Ashtang Samgraha are the chief source of knowledge of Ayurveda
Ayurveda consist of eight branches Shalakyatantra is one among them
Shalakyatantra is one of its specialized branch deals with science of
ophthalmology otorhinolaryngology Oro dental surgery and head Acharya
Sushruta himself a practical surgeon was the first to advocate dissection of
dead bodies is indispensable for a successful student of surgery He had
described gross anatomy in the first chapter of Uttartantra Shalakyatantra
define by different Acharys as follows
शालाकय नामोरधवजतरगताना रोगाणा शरणनयनदनघराणाददसशरशरताना वयाशरिनामपशमनारव
स स ११०
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत [13]
चस १७१२
Shalakya Tantra Nirukti and Parichaya
शलाकायााः कमव शालाकय ततपपरिान शलाकयम डलहण [14]
The term Shalakyatantra is derived from Shalakya and Tantra
The word Shalakya means A probe and Tantra denotes teaching and
practices found in scripturesThe compendium in which application of
Shalaka in various surgical procedures is principally described is called as
Shalakya tantra
दनदटिवशारदााः शालाककनाः डलहण ( सउ ११३)[15]
An eye specialist is termed as Shalaki by Dalhana
Page | 10
Synonyms of Shalakya Tantra
Uttamanga Chikitsa Jatrurdhwa Chikitsa Urdhwang Chikitsa Shalakya
Chikitsa
Importance of Shalakyatantra-
Life of living being and all the Indriyas are situated in the head hence it is
known as Uttamanga
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत
चस १७१२
The treatment given to this part of the body is described specially in
Shalakya tantra While describing the importance of Shiras Vagbhata
correlates it to the root of tree (Urdhwa Mula) and body to the trunk of tree
(Adha Shaka)
Sushruta has deal with Mukha Roga in Nidan Shan and its treatment in
Chikitsasthan The description regarding the disease of eye ear nose and
head are found only in UttaraSthan Sushruta specially describes the
disease of Shalakyatantra as told by Videha in the beginning of Uttartantra
itself[16]
Shalakyatantra Itihas-
India Exhibits traditional of more than thousands of years in art literature
language logic and philosophy etc The convention was in its sophisticated
and advanced attire throughout the Vedic period
Vedic period ndash
1 Natush was treated for deafness by Ashwinikumars (Rigveda)
2 Rujaswa and Kanva were treated for blindness by Ashwani Kumaras
(Rigvedas)
Page | 11
3 There are several prayers mentioned for normal functioning of sense
organs (Yajurveda)
4 Structures and functions of Mastishka are described (Atharveda)
5 Mantras having reference to disease of Eye Ear Oral cavity etc are
found (Atharvaveda)
Upanishada Period ndash
1 Samhita Period
a) Sushrut Samhita ndash
bull Explanation regarding Netra Nasa and Shirorogas (Uttartantra 1-
26th chapter)
bull Details regarding Mukha and Karna Roga Nidan and
Chikitsa(Nidansthan 16th and Chikitsasthan 22nd chapter)
bull Description regarding Karna Chedana Sandhana Nasa
Ostasandhana Sutra Sthan 16th chapter
b) Charaka Samhita -
bull Explanation regarding Shirorogas (Sutrasthan 17th chapter)
bull Explanation of Gala rogas like Upajivika Galshundi and Rohini
bull Nasa Shiro Mukha Karna and Netra Chikitsa (Chikitsa sthan 26th
chapter)
bull Description regarding Lakshana and Chikitsa of Shankhaka
Ardhavbhedaka Shirovirechana and Shiro basti (siddhi sthan 9th
chapter)
c)Ashtnga Sangraha ndash
bull Detailed description regarding Shalakyatantara (Uttartantra 11-28
chapter)
bull Description of Kriyakalpa (Sutrasthan 32nd and 33rd)
Page | 12
d)Ashtang Hrudayam
bull Detailed description on Shalakya Tantra (Uttar tantra 8-24 chapters)
bull Kriyakalpas (Sutrasthan 23rd and 24th chapter)
e) Bhela Samhita
bull Chakshushya Vaisheshik and Buddhi Vaisheshik Alochaka pitta
f) Harita Samhita- Branch of Medical science offering elaborating
information about the procedure like Nasya Anjan Gandusha etc
comprehended with their applications in disease of Head Eyes Ears
Eyebrows Throat Temporal region and cervical spine is known as
Shalakyatantara
शशरोरोगा नतररोगा कणवरोगा वशषताः भरकरठशङकमरयास य रोगा समिनदरत दह १३
तषा परततकारकम व नसतयतपयवणजनातन च अभयङगमखगणडषकियााः शालकयसशमतााः १४
इतत शालाकयनाम [17]
Documentation of different ancient literature gives various references
regarding all aspects of Karnasrava in various periods It is very much
important to know the history of Karnasrava from Vedic Pauranic Samhita
and Samgraha period
Vedic period ndash The Vedas being the oldest source of knowledge have no
direct mentioning of Karnasrava
Page | 13
Samhita and Samgraha period ndash
Aacharya Sushruta described about Karnaroga Karnasrava Nidan
Roopa and Chikitsa The detail description is available in Sushrut
Samhita Uttartantra 20 and 21st chapters
Aacharya Charaka did not specify Karnasrava but mentioned 4 types
of Karnarogas that is Vataj Pittaj Kaphaja and Sannipataja and their
treatment in 26th chapter of Chikitsasthan
In Ashtang Hrudaya karnasrava is not explained as a separate disease
but Chikitsa is mentioned in 18th chapter of Astanga Hrudaya
uttartantra
In Ashtang Samgraha Chikitsa is mentioned in 22nd chapter of Astang
Samgraha Uttartantra
The details about Karnasrava are explained in Bhavprakasha
Madhyamakhanda 64th chapter
Madhavakara has explained about Karnasrava in 57th chapter of
Madhymakhanda
Karnasrava is also explained in Sharangadara Samhita Uttarkhand 11th
chapter
The reference for treatment of Karnasrava is available in
Yogaratnakara
In Gadhnigraha Karnasrava and its treatment is mentioned in
Karnarogadhikara Adhaya
Vangasena had mentioned about the disease and treatment in 69th
chapter
Chakradatta explained Karnasrava in 57th chapter
Dalhana has given commentary on Sushrut Samhita Uttartantra 20th
and 21st chapter
Sankhya Samprapti of Karnasrava ndash
Aachary Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga
Vigyniyam Aadhaya Aacharya charaka explain 4 Karnaroga in
Page | 14
Karnarohvigyniyam Adhaya based on doshas Acharya Vagabhata in
Ashtang Hrudaya explain 25 Karnaroga in Adhyaya
कणवशल परणादशरच बाशरियव कषड ए च
कणवसरााः कणवकणडाः कणव चवसतततर च
कशमकणवपरततनाहौ विशरिदवविसततरा
कणवपाकाः पततकणवसततराशवशरचतवविम
कणावबवद सपतवि शोफशरचावप चतवविाः
ऎत कणवगता रोगा अटिावशततरीररतााः
स उ २०- ३ त ५[18]
ातकणवरोग वपततकणवरोग कफकणवरोग
रकतकणवरोग सनदरनपातकणवरोग कणवनाद
बशरिरतप परततनाह कणडाः शोफ पततकणवक
किशमकणवक उियरपविरधयअशो अबवद
कशरचकणवक वपपपली वदाररका पाळीशोष
ततिका पररपोिो उतपपातो उरमरर दाःखिवन
शलहाखयााः परचवशनदरतकणवरोगा उकतााः
इदिीका अ स उ २१ [19]
चतपाराः कणवरोगााः
च स [20]
Page | 15
KARNA
Karna ndash करोतत शबद गरहण [21]
The organ of hearing
Karnasrava- कणवसतय कणवयोाव ससराा [22]
Discharge from the ear is referred as Karnasrava
KARNA SHAREERA
bull Nirukti
कणयवत अकणयवत अनन इती [23]
It means reception and conduction of sound waves
These are the functions of external and middle ear
bull Nirukti of Sravanam
शरयत अनन इती शरणम[24]
It means perception of sound
It can be attributed to the internal ear function
bull Karna Utpatti-
Karna is an organ formed by Akash Mahabhuta[25]
The fundamental characteristic is as follows
Indriya ndash Srotram [26]
Indriya Adhisthan ndash Karna [27]
Indriya Dravy ndash Akasha [28]
Indriya Arth ndashShabdha [29]
Indriya buddhi ndash Srotobyddhi
Page | 16
bull Paryaya of Karna- Shabdapatha Srotrapatha Sravanam shruti
Kuhuram Dwanigraham etc
bull Definition of Karna-
कणवशटकलयनदछिरनमिटिोपगरदहत शरोतरमछयत [30]
मा तन ५७१
The definition of Karna is stated in Madhav Nidanam Indriya which is not
seen with naked eye along with Shashkuli is called Shrotra that is Karna
Indriya is so minute that it is not perceived with any sense organ
In Charak Samhita the word Karna explain as the Indriya Adhisthan of
Shabdha Karna is described as one of the Prathyangas of the body He
emphasizes that all Indriyas manifest during the 3rd month of gestation
period
Acharya Sushruta while describing formation of Purusha from Prakriti or
Avyakta narrated that all Indriyas are developing from the Vikarika and
Taijas Ahankara Both Vagabhata and Sushruta stated that Karna as one of
the Bahirsrotas
शरण नयन दन घराण गदमढराणण न सततरोताशसराणा बदहमवखातन [31]
स शा ५-१०
In Ashtang Hradaya Vagbhata has states that all Indriyas are Atmaja
According to him lower lobule elevated helix projected posterior portion
fleshy and adherent ear are indications of long span of life[32]
ततरखातखातन दह अनदसतमन शरोतर शबद ववकतता [33]
ा शा ३-३
शबदाः शबदनदरिय सवनदछििसमहो ववकतता [34]
स शा १-२६
Page | 17
Ear has the prominence of Akash Mahabhuta The prominent dosha of ear
is Vata It is important seat of Vata The prominent Dhatus are Asthi and
Mamsa Karna is one of the Panchgnanendriyas and it meant for hearing
Sushruta narrated that Karnasthita Asthi and Sandhi
घराणकणवगरीाकषिकोषष तरणातन [35]
सशा ५-२२
शरोतरशरगािकष शखाताव [36]
सशा ५-३२
गडकणवशखटककम [37]
स शा ५-२२
One Sandhi and one Tarunasthi in ear
Sandhi ndash Karna contain two Sandhi one in each ear Type of Sandhi is
Shankhavartha which is present in Shringataka
Mansapeshi ndash 2[38]
Siras ndash 10 [39]
Vataj Sira - 4
Pittaj sira - 2
Kaphaj sira - 2
Raktaj Sira - 2
Avedhya sira-
कणवयोदवश तासा शबदादहनीनामकका पररहरत
सशा ७-२५[40]
Amongst above mentioned ten Siras each Karna lodges one Shabdavaha
Sira It is Avedhya
Page | 18
Dhamani -2
Length of ear is 4 Angula
Karna moola ndash 2 Angula
कणाविरतर चतदवशअगलम
स शा ३५-१४[41]
The distance between two ears through the back of the neck is 14 Angula
bull Marmas of Karna-
1 Vidhuras-
कणवपटठतो अिाःसशरशरत विर ततर बशरियवम
सशा ६-३७[42]
कणतपयादद सतनायममवणी ककनदचचनदरनममनाकर कलयकररणणच
डलहणाचयव[43]
अिसततात कणवयोतनवमन विर शरततहाररणण
ा शा ४-२९[44]
Sankhya-2
Vistara- frac12 Angula
Type- Snayumarma (Susha)
- Dhamanimarma(AH)
- Vaikalykar
Sthana- It is situated in the depressed portion in the back of the ear
Injury to them causes loss of hearing
Page | 19
2 Shringataka marma-
नदजवहाकषिनाशसकाशरोतरखचतटियसरमम
तालरयासतयातन चतपारर सरोतसा तष ममवस
वदि शरगातकाखयष सददसततपयजतत जीवतम
मा तन ५७१ [45]
Sankhya- 4
Type- Siramarma
Sthana- It is in head that is amidst Siras (blood vessels) nursing sense
organ
A palm size area near Talu
Injury to this Marma causes death
In modern anatomy ear divides into Bhayakarna or External ear Mdhyakarn
or Middle ear Antahkarna or Internal ear This is extremely appropriate
Even though the ear is divided into three divisions in the point of modern
anatomy Ayurveda denotes ear organ is one Ayurveda treats disease by
way of assessing Dosha and Dushya Here Dushya is one that is Karnendria
Dosha difference will call for different treatment for different disease Hence
treating the vitiated Dosha will cure the disease irrespective whether it is in
external middle or internal ear The thought is based on different
fundamental principle from Ayurveda
bull Parts of Karna
In Ayurveda classics detailed description about anatomy of ear is not
available But the various parts are mentioned as follows
Bhayakarna- External ear
Mdhyakarna ndash Middle ear
Antahkarna- Internal ear
Page | 20
द कणवशटकशलक दॊ कणवपतरकौ
च शा 7-11[46]
कणवशटकशलक कणवगतातवकौ कणवपतरकौ त बाहयकणा
चिदतत च शा 7-11[47]
शटकली बाहयपालयाशरिटिानम
डलहन- स शरच 25-1 12[48]
Karna Shashkulika ndash It is also called as Karna Shashakuli Charaka has
mentioned this term while describing different Pratyngas of the body
Acharaya Gananatha sen has given the clarification for it as a pinna or
auricle[49]
Karnapali ndash It is popularly known as lobule of the ear Daivakrita Chidra is
present in it
Karnaputrika- Ayurvedic scholars accepted two terms in this cortex They
are Karnaputrika and Karnaputrika The former is considered as Tragus and
antitragus[50]
Karna Prushtha- It can be taken as the cranial surface of mastoid or
auricle[51]
Karnapeetha- Aacharaya Sushruta firstly mention the term Karnapeetha
It is mentioned first by Sushruta while describing the procedure of
Karnavyadana Vagbhata has mentioned that it is Adhobhaga of Karna
Dalhana has clarified that it is the region above the Karnaputrika that is the
region which is at the bottom of the concha
Karnamoola ndash It can be considered as parotid region[52]
Karna lathika ndashAcharaya Dalhana mentioned lobule as a Karna Lathika
Page | 21
Karnaavatu ndashThis term is used by Sushruta while describing the
measurements of different Angapratyangas where he has mentioned that
the distance between the Karnaavatu is 14 Angul Dalhana has comments
that it can be taken as the distance between two ears from behind[53]
Shabdhavahasrotas ndash It also called as Shabdapatha or Srotapatha The
whole passage through which the sound waves pass can be taken as
Shabdavahasrotas[54]
Shrotashringataka ndash It can be taken as the labyrinth of ear[55]
bull Dosha in context to Karna-
Karna is principal location of Vayu
1 Prana Vayu- Prana Vayu circulating in oral cavity is responsible for
Dehadhruka that is keeping all body parts active Indriyadruka that is
keeping all Dnyanendriya healthy by proper nourishment (Purana) helps in
deglutition of food material and convey the stimulation of Indriyabuddhi
and atma
2 Udana Vayu- Bala(strength) Varna speech singing are its function It
is responsible for facial expressions due to pleasure sorrow anger love
frustration etc in general its circulation and actions are just opposite to
Pranavayu
3 Vyana Vayu- Its principal functions are circulation of Rasa and Rakta
through body and various movements Its main location is Hrudaya Five
types of movements for which it is responsible are expansion contraction
upward downward and oblique other activities are opening closure of
eyelid yawning perspiration During circulation if it gets obstructed due
to Srotodushti it generates disease of that Srotas Vyana Vayu gets vitiated
by disease of Rasa Rakta Oja and Chetanadhatu
Page | 22
4 Samana Vayu- It is circulating in the vicinity of stomach and intestine
and helps in keeping the Jatharagni (digestive juices and enzymes) in
equilibrium Disturbance in Jatharagni precipitates disease
5 Tarpaka Kapha- Entire body functions movements are controlled and
executed by various centers in the brain Sensation perceived by sense
organs is conveyed to Mann and Aatma residing in Hrudaya The motor
signals from them are then conveyed to the functioning
organsKarmendriya through Prana Vayu Shira head is therefore a
location of continuous activities motions of Vata All these centers are in
unctuous Majjadhatu in the Shira For stabilizing this ever-active Vata and
to nourish the Majja dhatu very unctuous Tarpaka Kapha situated in Shira
plays an important role
bull Ayurvedic aspect of sound perception [56]
According to Ayurveda Pratyaksha Dnyan or Perception of any sensation
including Shabda occurs due to interaction of the Karnendriya and the
Indriya- Arth -Karma resulting in Sravana
External Environmental acquaintance with living body is executed by five
sense organs namely Netra Karna Nasa Jivha and Twaka All
Dnyanendriya that is sense organ are Panchmahabhautic combination
Despite this fact every Indrya sense organ perceives object Tanmatra of
that Mahabhuta only from which it is originated from Akash Mahabhuta and
hence perceives Shabd only that is audio perception Shrotrendriya is one
of the principal locations of Vata and its function is to perceive Shabda that
is sound waves This sensation is conveyed through Shabdavahi Dhamanis
to Mana and Atma through Pranavayu and the sequence is responsible for
perception of sound in this way external sound is perceived and interpreted
when Atma is linked with Mann Mann is linked with Indriyabuddhi that is
minute virtual Dnyanendriya located in brain Indriyabuddhi is linked with
Adhishthana with prominent Mahabhuta and lastly with Indriya
ArthShabdatanmatra that is sense object Once this sequence is completed
Page | 23
the meaning of a particular sound is interpreted and understood In this
entire process of perception and interpretation of sound waves Pranavayu
and Tarpaka Kapha located in Shira play extremely important role Hence
the healthy status of all the sense organ depends upon the normal
physiologically homeostatic condition of Pranavayu and Tarpaka Kapha
MANAS
ATAMA
BUDDHI
AHANKARA
ARTHA
Page | 24
EAR ANATOMY
bull Embryology of the Ear [57]
1 The sound conducting apparatus develops from the branchial apparatus
whereas the sound perceptive apparatus from the ectodermal otocyst
2 The pinna develops from the six hillocks around the 1st branchial cleft
3 External auditory canal develops from 1st branchial cleft
4 The outpouching of the 1st pharyngeal pouch gives rise to a proximal
narrow part that forms the eustachian tube and distal dilated part that
forms the middle ear cavity
5 Prussakrsquos space is a potential space lateral to the Shrapnellrsquos membrane
and medically by the neck of malleus that can be involved during the
extension of cholesteatoma
6 Development starts in the 3rd week of the intrauterine life and is
completed by 16th week of intrauterine life Membranous and boney
labyrinth develops from the otic capsule
The Ear is divided into
1 External Ear
2 Middle Ear
3 Internal Ear or the labyrinth
Page | 25
Fig 1 Ear Anatomy
EXTERNAL EAR [58]
The outside ear contains pinna and lobule
Pinna is the noticeable piece of outer ear made from single sheet of yellow
flexible ligament covered by subcutaneous tissue and skin It has two
surfaces average and parallel It is intently disciple to perichondrium on its
sidelong surface while it is somewhat free on average surface Pinna
incorporates tragus helix against helix fossa three-sided scaphoid fossa
incisura terminalis
External auditory Canal ndash It extends from the bottom of the conchea to
the tympanic membrane and measures about 24 mm along its posterior
wallit is S shaped
Parts 1 Cartilaginous part
2 Bony part
Page | 26
Cartilaginous part ndash The outer one third is cartilaginous consist of fibro
cartilage is directed first inward backward and upward It has Fissure of
Santorium The skin of this part of the canal contains hair follicles
sebaceous gland and cruminous gland
Bony part ndash The inner two third part is boney It goes forward downward
and medially skin lined in this part is very thin Isthmus is the narrowest
part of the canal lying medial to junction of bony and cartilaginous part
nearly 5 mm lateral to tympanic membrane
The roof and posterior wall of the external auditory canal shorter than floor
and anterior wall The skin lining the tympanic membrane and boney canal
has a self-cleansing property due to migration of keratin layer of epithelium
from drum towards the cartilaginous portion
Relations- Anteriorly- Temporomandibular joint and parotid gland
Superiorly- Middle cranial fossa
Inferiorly- parotid gland
Posterior- Mastoid antrum mastoid air cells and facial nerve
Nerve supply ndashSensory nerve supply of the external ear The auricle
supplied by fibers of the great auricular nerve (C2 and C3) and lesser
occipital nerve (C2) Auriculo temporal branch of the 5th cranial nerve and
auricle branch of the vagus (Arnoldrsquos nerve) supply external canal Facial
nerve has small sensory contribution on posterior-inferior wall
Tympanic Membrane -It is the partition between EAC and middle ear It
is a thin semitranslucent membrane pearly white in colored lying obliquely
in the medial end of EAC with the angle of 55 It is forming major part of
lateral wall of middle ear Annulus tympanicus is attached at its
circumference to the sulcus The TM is oval shape It measures
approximately 10 mm in vertical diameter and 90 mm in horizontal
diameter
Page | 27
Layers ndash Tympanic membrane consist of three layers
1 Outer Epithelium or cuticular layer which is continuous with skin of
external ear
2 Middle fibrous layer has both circular and radial fibers middle layer
missing in upper part
3 Inner layer- Inner mucosal layer which is continuous with middle ear
mucosa
Parts ndash Tympanic membrane consist of two parts
1 Pars tensa -It is largest part below the malleolar folds The inner
surface at the center attached to the handle of malleus Angle of cone
is most illuminated part in the pars tensa at anteroinferior part of pars
tensa
2 Pars flaccida Sharpnells membrane -it is triangular area above the
malleolar folds which are thin and devoid of fibrous tissue and
annulus It fits into notch of Rivinous
Nerve supply 1 Anterior half of lateral surface Auriculotemporal V3
2 Posterior half of lateral surface Auricular branch of vagus cn 10
3 Medial Surface Tympanic branch of CN 9 (Jacobsons nerve)
Fig 2 Tympanic membrane of ear
Page | 28
MIDDLE EAR [59]
The middle ear or tympanic cavity is an irregular laterally compressed
space within the temporal bone It is filled with air that is supplied to you
from the nasal part of the throat through the ear canal It contains a chain
of mobile bones that connect its side with the medial wall and serve to
transmit vibrations transmitted to the eardrum through the cavity to the
inner ear Including the parapet the vertical and anteroposterior diameters
of the cavity are each approximately 15 mm The transverse diameter
measures about 6mm at the top and 4mm at the bottom Compared to the
eardrum it is only about 2mm The eardrum is limited laterally by the
eardrum medially by the lateral wall of the inner ear It communicates
behind with the tympanic antrum and through it with the air cells of the
mastoid and in front with the auditory canal The middle ear together with
the Eustachian tube aditus antral and mastoid air cells is called the
middle ear cleft It is lined by mucus membrane and filled with air
It is divided into 3 parts
1 Mesotympanum (located in front of the pars tensa)
2 Epitympanum or attic (located above the pars tensa but medial to
Sharpnells membrane and the lateral bony wall of the attic)
3 Hypotympanum (located under pars tensa) The middle ear is like a
hexagonal box with a roof
Carotid or Anterior wall- It separates middle ear cavity from internal
carotid artery The various structure passing through anterior wall of
tympanic cavity
bull Canal of chorda tympani nerve
bull Canal of tensor tympani muscle
bull Eustachian tube
bull Anterior malleolar ligament
bull Anterior tympanic artery
Page | 29
Posterior or mastoid wall ndash The upper part of the back wall shows the
opening of the auditorium Below the auditory is a triangular bony
projection known as the pyramidalis processors The stapedial tendon is
transmitted through the apex of the pyramidalis processes The vertical
portion of the facial nerve descends along the posterior wall until it opens
into the stylomastoid foramen
Roof or Tegmental wall (Pars terminalis)- It is formed by a thin bone
plate called the tegman tympanum that separates the skull and tympanic
cavities It is located on the anterior surface of the rocky part of the
temporal bone near the junction with the temporal shell it extends back to
the roof in the tympanic membrane and anteriorly to cover the half canal
of the tensor tympanic muscle The lateral border corresponds to the
remains of the Petro scaly suture
Floor ndash It is formed by a thin plate of bone which separate middle ear from
the bulb of the internal jugular vein lodged in the jugular fossa
Lateral wall ndash It is formed by tympanic membrane and partly by a portion
of squamous part of the temporal bone It separates the middle ear from
external ear
Medial wall- It separates the middle ear from the inner ear
bull The promontory is the most prominent and convex part formed by the
basal rotation of the cochlea
bull The bony lateral semicircular canal is postero-superior to the promontory
above the oval window
bull The oval window is located between the middle ear and the vestibular
slope of the cochlea It is closed by the stirrup footrest and the annular
ligament
Page | 30
bull The round window is located under and behind the cape The round
window recess is directed to the rear It is closed by the secondary eardrum
and separates the middle ear of the Scala tympani from the cochlea
bull The facial nerve passes through the bony fallopian tube above the oval
window
Mastoid Antrum ndash It is a large space with air in the upper part of the
mastoid and communicates with the attic through the aditus The roof is
formed by the antri tegmen which extends and separates the tympani
tegmen from the middle cranial fossa The lateral wall of the antrum is
formed by a bony plate that is on average 15 cm thick in adults It is
marked externally on the surface of the mastoid by the suprameatal triangle
(MacEwen)
Aditus and Antrum- Aditus is a gap through which the attic communicates
with the antrum The boney prominence of the horizontal canal lies on its
medial aspect even as the fossa incudes to thats attaches the quick system
of incus lies laterally Facial nerve publications simply underneath the
aditus
The mastoid and its air cell system-
The mastoid consists of bone cortex with a honeycomb of air cell
underneath Depending on development of air cell three types of mastoids
have been described
1Well-pneumatized or cellular- Mastoid cells are well developed and
intervening septa are thin
2Diploetic- Mastoid consist of marrow spaces and a few air cells
3Sclerotic or acellular ndash There are no cells or marrow spaces
With any type of mastoid pneumatization antrum is always present In
sclerotic mastoids antrum is usually small and the sigmoid sinus is
anteposed
Page | 31
Depending on the location mastoid air cells are divided into
1 Zygomatic cells (In the root of zygoma)
2 Tegman cell (Extending into tegmen tympani)
3 Perisinus cells (overlying the sinus plate)
4 Retrofecial cells (round the facial nerve)
5 Peri labyrinthine cells (located above below and behind the
labyrinthine some of them pass through the arch of superior
semicircular canal These cells may communicate with the petrous
apex)
6 Peritubal (around the Eustachian tube Along with hypotymoanic
cells they also communicate with the petrous apex)
7 Tip cells (which are quite large and lie medial and lateral to the
digastric ridge in the tip of mastoid)
8 Marginal cells (Lying behind the sinus plate and may extend into
the occipital bone)
9 Squamosal cells (Lying in the squamous part of temporal bone)
Development of Mastoid ndash
The mastoid develops from the scaly petrous bone The petrosquamosal
suture may persist in the form of a bone plate - Korners septum which
separates the superficial squamosal cells from the deep rock cells Korners
septum is surgically important because it can cause problems locating the
antrum and deeper cells and thus lead to incomplete removal of the disease
during mastoidectomy The mastoid antrum can only be reached if Korners
septum is removed
Page | 32
Fig 3 Cross section of Mastoid
Contents of the middle ear
Ossicles ndash Three tiny bones which conduct the sound from eardrum to oval
window
Malleus ndash It is the largest and most lateral ossicle measuring 8 mm in
length It has head neck handle anterior and lateral processes The head
is situated in the epitympanum A lateral process project laterally from the
neck while the handle is firmly fixed to the pars tensa of the ear drum
Incus- It has a body short process and long process The body short
process and long process The body articulate with the head of mallelus in
the attic and the short process project into the attic The long process
projects downwards behind the handle of malleus running parallel to it and
articulate with the head of the stapes via the lenticular process
Stapes ndash It is the smallest ossicle measuring about 35 mm and consist of
head neck footplate and anterior and posterior curcura The footplate of
stapes is held to the oval window by the annular ligament
Page | 33
Muscles ndash
1Tensor tympani ndash It is inserted is a branch of the facial nerve which carries
the sense of taste It is first arch muscle supplied by branch of mandibular
nerve V3
2 Stapedious muscles ndash It is inserted to the neck of stapes It is the second
arch muscle supplied by branch of facial nerve that is nerve to stapedius
Fig 4 Contents of the middle ear
Blood supply of Middle Ear
bull Anterior tympanic branch of maxillary artery which supplies tympanic
membrane
bull Stylomastoid branch of posterior auricular artery which supplies middle
ear and mastoid air cells
Page | 34
Four minor vessels are
bull Petrosal branch of middle meningeal artery runs along greater petrosal
nerve
bull Superior tympanic branch of middle meningeal srtery traversing along
the canal for tensor tympanic muscle
bull Branch of artery of pterygoid carotid
bull Tympanic branch of internal carotid
Lymphatic Drainage of Ear
Lymphatics from the middle ear drain into retropharyngeal and parotid
nodes while those of the Surgical Importance ndash Eustachian tube drain into
retropharyngeal group
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 middle is likely to pass to
middle ear
2 Moreover middle ear suppurative disease may spread to adjacent organs
and produce complication eg Labyrinthitis meningitis facial nerve palsy
etc
3 Lenticular process is vulnerable in suppurative ear diseases and causes
ocular disruption
4 Prussac space is the site of primary acquired cholesteatoma
Page | 35
INNER EAR [60]
Inner ear is divided into two parts
1 Bony Labyrinth
2 Membranous labyrinth
Anatomy of bony labyrinth
It is divided into two parts
1 Vestibule
2 Cochlea
3 Semicircular canal
The vestibule is located between the medial wall of the middle ear and the
lateral to internal acoustic meatus anterior to the semicircular canal and
posterior to the cochlea The vestibule is the central part of the inner ear
On its side is the oval window opening which is closed by the bracket foot
plate The bony cochlea is located in front of the vestibule It has 275 turns
wound around a bony axis called a modiolus The cochlea is about 30 mm
long The hollow center of the modiolus is a spiral canal that contains the
fibers and ganglion cells of the cochlear nerve A thin bony sheet the bony
lamina winda around the modiolus This divides the cochlear duct into two
galleries the Scala vestibuli above and the scala tympani below
There are three semicircular canals superior posterior and lateral They
are semicircular in shape and open into the vestibule One end of the
semicircle is enlarged and is known as the sphere
The membranous labyrinth is in the bony labyrinth It is connected to the
bony labyrinth by fibrous trabeculae and is surrounded by perilymph The
endolymph is located in the membranous labyrinth
Page | 36
The utricle is in the upper part of the vestibule while the saccule is found
below Both the utricle and saccule contain a single sensory patch called
the macula Each macula is covered with a neuroepithelium made up of
neuroepithelium made up of sensory hair cells and support cells these cells
are separated by a basement membrane Fibers of the vestibulo-cochlear
nerve enter the macula and pierce the basement membrane to terminate
at the base of the hair cell or cell bodies The utricle and the saccule with
their macula are called otolith organs Membrane semicircular canals are
the membrane canals of the corresponding bony semicircular canals They
open into the utricle through five openings One end of the opening of each
channel is dilated called the sphere in which the sensory organ of each
channel is located The cross section of the Scala standard looks like a right
angle The base is formed by the basilar membrane Sensory cells are
arranged on the surface of the basilar membrane These sensory cells with
their supporting cells form a complex neuroepithelium called the basilar
papilla or the cortical organ named after an Italian microscopist The
organs of the corti have a gelatinous membrane called the tectorial
membrane and they are supported by the pillar of the corti The cortical
pillars enclose a space called the corti tunnel which contains a fluid called
cortical lymph Vestibule is lies between the medial wall of the middle ear
and lateral to internal acoustic meatus anterior to semicircular canal and
posterior to the cochlea 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 Boney cochlea lies in front of the vestibule It has 275 turns
coiling around boney axis called modiolus Cochlea is approximately 30 mm
in length The hollow center of the modiolus is a spiral canal containing the
fibers and ganglion cells of cochlear nerve A thin boney sheet the osseous
lamina winda around the modiolus This divides the cochlear canal into two
galleries the Scala vestibuli above and the scala tympani below
Page | 37
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 boney labyrinth It is connected
to the bony labyrinth by fibrous trabeculae and is surrounded by perilymph
Endolymph 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 single sensory patch called macula Each
macula is covered by neuroepithelium consist of Neuroepithelium consists
of sensory hair cells and supporting cells these cells are separated by
basement membrane Fibers 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 are referred
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 corti lymph
Page | 38
Fig 5 Inner Ear
Blood supply of labyrinth
Labyrinthine artery
Common cochlear Anterior vestibular Artery
Vestibulocochlear artery Main cochlear artery
Cochlear branch posterior vestibular artery
Page | 39
PHYSIOLOGY OF HEARING [61]
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
bull Mechanical conduction of sound (conductive apparatus)
bull Transduction of mechanical energy to electrical impulses (sensory
system of cochlea)
bull Conduction of electrical impulses to brain (neural
Fig 6 PHYSIOLOGY OF HEARING
Page | 40
Conduction of sound
Under the surface of water we cannot hear the sound made in air because
9995 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 must 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 13 times longer than long process of incus providing
a mechanical advantage of 13
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 beings 211 As the effective
vibratory area of the tympanic membrane is only two- thirds the effective
areal ratio is reduced to 141 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
Page | 41
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 lobe
Page | 42
DISEASES REVIEW
करणसराव
Nirukti - करणसय कणवयोाव ससराा [62]
Nidana- Acharya Sushruta and Vagbhata describe the common etiological
factors for the Karnaroga
अशयाय जलिीडा कणवकणडयन मरत
शमथययोगन शसततरसतय कवपतो अरय च कोपन ||
सउ २० १२
1 Avashaya or Pratishaya
(Excessive exposure to cold)
2 Jalakrida
(Excessive swimming)
3 Karnakandunyanum
(Excessive scracing due to itching)
4 Mithyayogena Shatrasya
(Improper instrumentation during wax removal or foreign body removal)
5Shabdasya
(Louder sound for long durationperverted contact of sound)
6 Abhighata (Trauma)
7 Vitiation of Tridoshas
Page | 43
Samanya Nidana according to different Samhita
Vishesh Nidan of Karnasrava
Acharya Charaka has not mentioned any kind of Nidana regarding Karnaroga
but has described Utapati of Karnaroga from Siroroga in Karnasirasym
Adhyaya[67]
शशरोअशिघातादरा तनमजजतो जल परपकादरा अवप विि
सरतत पय शरणॊ अतनलात स कणवससरा इतत परककतीत
सउ २० १०
असस ३७२५ [68]
1 Shiroabhighatat - Head Injury-Fracture of middle cranial fossa
2 Jala nimajjana - CSF otorrhoea fracture of middle cranial fossa
3 Karnaprapaka
4 Karna Vidhradhi -Puyasrava
Sr
no
Samanya Nidana SU AH[63] AS[64] YR[65] MN[66]
1 Avashaya + + +
2 Pratishaya + +
3 Shabdha
mithyayoga
+
4 Shashtra
mithyayoga
+ + +
5 Karnakandooyan + + + + +
6 Jalkrida + + + + +
7 Abhighata + + +
Page | 44
Samanya samprapti
परापय शरोतरशसरा कयावत शल शरोतशस गान
त कणवगता रोगा अटिावशततरीता
सउ २० १२
Due to common and specific etiology factors the vitiated Doshas gets
Sthanasamshraya in Karna and causes Karnasrava It is the stages of
Samprapti were Doshas gets lodged in Srotas and start processes of Dosh
Dushya Sammurchsna Due to Shiroabhighata Jalanimmajana Karna Paka
Karna Vidhradi vitiated Vata Dosha and Karna becomes Avruta by Vata and
results in Karnasrava Normal physiology of Dosha Dhatus and Malas entirely
depends on the normality of Srotas Dosh Dushya Sammurchana or
manifestation of diseases will not take place if only vitiation of Doshas take
place without deformity of Srotas Here in Karnasrava vitiation of Srotas are
Atipravritti Sanga and Vimargagamana take place Atipravritti is being excess
production of fungus Sanga is obstruction in external acoustic canal
Vimargagamana is the propagation of discharge through ear
Vishesh Samprapti
Karnasrava occurs due to Nij nidana is Pratishaya while Agantuja nidanas are
Avashya Jalkrida and Karnakanduyan Due to etiological factors which are
Vata-Kapha provocative in nature gradual vitiation of Doshas will occur After
vitiation they get accumulated (Sthan samshraya) in external auditory canal
In other hand when patient does Sevana of Agantuj Nidan like water enter in
external ear scratching of ear unsterile instrumentation leads to Dosh
Prakopa These cause Twak and Mamsa Dhatu Dushti which leads to
discontinuity of epithelium of ear canal which creates suitable atmosphere for
fungal pathogen to grow The vitiated Vata will produce symptoms such as
Page | 45
pain hearing impairment and vitiated Kapha causes symptoms like itching
discharge ear blockage By assessing the symptoms it can be said that Kapha
Avrita Vata Dosha is responsible for the manifestation of clinical features like
pain itching discharge Which are seen in Karnasrava that is otomycosis
Acharya Charaka has mentioned while explaining Samanya Chikitsa of
Karnaroga that it should be treated like Vrana when Paka and Srava is present
as a symptom Fungal spores invade in the epithelial layer of EAC In response
to infection inflammatory process is start This is a Paka Avastha After
removing the fungal mass ulceration in external acoustic canal is commonly
seen As a result of infection process exudates was produced which will mix
up- with fungal colonies and appear as discharge As per Dosha involvement
in Vrana Shoola Srava can be differ According to Acharya Sushruta Ruk is
the Samanya Lakshana of Vrana and Vishesha Lakshana of Vrana includes
pain discharge discoloration itching etc according to Dosha involvement
which are also seen in otomycosis In otomycosis mainly watery and purulent
type of discharge is present which indicates Paka avastha If there is Dosha
involve in Vrana is called Dushta Vrana Acharya Sushruta and Acharya
Vagabhata have mentioned verity of Srava in Twak and Mamsa Vranavastu
which is found in otomycosis Based on this description otomycosis can be
correlated with Karnasrava
Page | 46
Representing the Samprapti of Karnasrava
Vishesh Nidana ndash Shiroabhighatat
Jala nimajjana
Prapaka Vidhradhi
Vitited vata
Avarana by kapha
Vimargagamana of Vata
Karnasrava
Samprapti Ghataka
Dosha ndash Kapha and Vata
Dushya ndash Rasa Rakta and Mansa
Strotodushti ndash Vimargagamana and Sang
Adhishthana ndash Karna (Bhayakarna)
Rogmarga ndash Madhyama
Page | 47
Purvarupa
The Purvarupa of Karnasrava are not mentioned separately in any ayurvedic
classics In routine practice cretin Purvarupa are noted
1 Karnakandu
2 Karnagurutwa
3 Alpa karnashoola
4 Discomfort in ear
Rupa
1 Karnashoola
2 Karnakandu
3 Karnasrava
4 karnabadhirya
5 Cotton wool like or wet newspaper like grayish brown or black colored mass
is seen
6 External auditory canal skin appears edematous and red
Upashaya and Anupashaya
Appropriate application of Aushadhi Ahara and Vihara when produces relief in
the symptom is called as Upashaya and when aggravates the symptoms is
called Anaupashaya There is not any reference available in the classics about
the Upashaya and Anupashaya of karnasrava
Sadhyasadhyata
Sushruta has not mentioned specially the Sadhyasadhyata of Karnarogas But
Vagbhata has mentioned Karnasrava as a Sadhyavyadhi[69]
Sadhysadhyatagives the clear picture of prognosis of the disease It depends
on many factors like nature of disease severity of disease Vaya Prakriti Bala
of the patient etc
Page | 48
Upadrava of Karnasrava
In Samhita there is no reference available regarding the Upadrava of
Karnasrava
Samanya Chikitsa ndash
The common treatment principle for all Karnaroga is Ghritapana Use of
Rasayana Bhrahmacharya Avyayama Shirasnana and Atibhashaya
सामरय कणवरोगष घतपान रसयनम
अवयायमो शशराःसतनान बरमहचयवम कतपरनम
स उ२१३
Ghratapana - Ghrita is a Yogavahi and follow Sanskara in addition to these
acquired properties and capable of retaining its own properties So Ghritapana
is effective in Karnasrava
Rasayana - Rasayana represent the basic approach of Ayurveda which
comprise preventive promotive and curative aspect of health
Brahmacharyaapalana -It is like Sadvrittapalana and is equals to Rasayana
effect
Vyayama - It leads to vitiation if Vatas a Karna is a Sthana of vata and
exercise causes Kshayaj Samprapti hence it is important to avoid exercise in
Karnasrava
Shirasnana- In Shirasnana water enters in external acoustic canal it changes
the PH of meatus skin from acid to alkali which favors the growth of pathogens
Atibhashya - Excessive speaking causes Vata Prakopa and Vatapraokopa is
basic Samprapti for Karnasrava as the preventive aspect avoidance of
excessive speaking is necessary
Page | 49
Ghritapana Rasayana and Brahmacharyapalana should be followed for
preservation of dhatu Samyata and restriction of vitiation of Vata Vayayama
Shirasnana and Atibhashaya should be avoided in Karnasrava to protect the
Siras from the affliction of Vata and Kapha
Vishesha Chikitsa ndash
The general treatment principle of Karnasrava described in classics is closely
related to Dushtavrana Chikitsa
शशरोवरचन च ए िपन परण तरा
परमाजवन िान च ीकषय ीकषय़ाचारत [70]
स उ २१४०
कणवसततरा ोददत कयावत पततकशमकणवयो [71]
ाउ १८३५
उपददि च सततरोत साय परात वपचततवशि परमजय
य अगर मदन सघत गगलना ा िपतयतपा मिना परयत [72]
असउ २२४२४३
In addition to that Shirovirechana Karnadhoopana Karnapurana
karnapramarjana Karnadhavana are also indicated
Page | 50
Treatment is also mentioned for Karnasrava
1 Karnaprakshalana Yoga - with Aargawadadi Gana Kashaya and Surasadi
Gana Kashaya [73]
2 Avachurnana Yoga ndash with Aargawadadi Gana Churna and Surasadi Gana
Churna[74]
3 Karnapoorna Yoga ndash
bull Rasanjana Laksha with Sarjachoorna[75]
bull Panchkashaya with Kapittha swarasa and Madhu[76]
bull Jambu AmrapallavShivalaKshuodra Mahavriksha and Madhuki 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 done[77]
bull Sarjatwak Choorna with Karpashiphalarasa and Madhu[78]
bull Abhaya LodraTindukaSamanga(Manjista) Kwatha of this Dravyas mixed
with Madhu and Kapittha Rasa[79]
bull Yogratnakara mention the following drugs for Karnapoorana-
a Samudraphena Churna[80]
b Jambwambpatra Yoga
4 Karnadhoopana Yoga ndash
bull Dhoopana with Churna of Bilvapatra Haridra Palandu[81]
bull Vartak Dhoopana [82]
5 Internal Medications-
bull Rasnadi Guggula [83]
bull Triphala Guggula [84]
bull Sarivadi Vati [85]
bull Gandhaka Rasayana [86]
Page | 51
According to Vagbhata-
Ear should be cleaned with the Pichu and Varti followed by Guggula Dhoopana
and then Karnapoorana with Madhu Followed by Avachurnanana with
Sukshmachootana of Surasadigana
Pathyaapathya ndash Pathya and Apathy mentioned for Samanya Karnaroga is
recommended in Karnasrava also
पथय[87]
सतदो वरको मन नसतय िमाः शशरावयिाः
गोिमाः शालयो मदगााः याशच परतन हवाः 80
लाो मयरो हररणानदसततततरो नकककिाः
पिोल शशगर ातावक सतनषराण कदठललकम
रसायनातन सवणण बरमहचयवमिाषणाम |
उपयकत यरादोषशमद कणावमय दहतम ||81||
िापर २१
Aharaja Upacharaja
bull Godhuma bull Vamana
bull Shala bull Virechana
bull Mudga bull Nasya
bull Yava bull Dhoomapana
bull Puranagitra bull Kavala
bull Lava Harina Tittiramamsa
Page | 52
अपथय[88]
दरत काटठ शशरसतनान वययाम शलटमल गर
कणडयन तषारशच कणवरोगी पररतपयजत
िापर २१
Viharaja
bull Patola ShigruVartaka bull Bhramacharaya
bull Sunishannaka bull Avyayama
bull Katthlika bull Aakthanam
bull All types of Rasayana bull Upacharaja
bull Vamana
Apathyas
bull Abhishyandakara Aharas
bull Shirasnana
bull Karna kandooyana
bull Tushara sevana
bull Guru Kaphakaraka Aaharas
bull Dantdhavana
Page | 53
OTOMYCOSIS
Definition-
Otomycosis is a superficial acute sub-acute or chronic infection of external
ear canal It is mostly unilateral It is characterized by inflammation purities
and scaling Otomycosis is a common condition encountered in ENT practice
more in chronic and persistent ear infection
The Fungal infections are not communicable in the usual sense but the
humans become an accidental host by their introduction into tissue trauma
The virulence factors favoring colonization of fungus in human host are yet to
be identified Ability of the fungus to grow at 37 C and elaboration of a variety
of enzymes and toxins are speculated to contribute to virulence Only 100 to
150 species are generally recognized as a cause of disease in humans[89]
Prevalence-
Otomycosis is a word wide in distribution and in various record stated that 5
to 20 of all cases of infective otitis externa Otomycosis prevalent is more in
warm and humid climates It is one of the commonest manifestations in India
during rainy season It occurs mostly in humid atmosphere otitis externa due
to fungal infection may resembles the desquamative form of diffuse infective
otitis externa The incidence in temperature climates has increased in
proportion to the use of topical antibiotics which have a medium sterilized of
other organism in which the fungus may flourish
Page | 54
Predisposing factors- [90]
1 Environmental factors such as climate contagious and polluting hygiene
more frequently during rainy season as the humidity increases
2 Individual susceptibility ndashGeneral Immunological status of the Individual
eg HIV infection Radiotherapy chemotherapy Diabetes mellitus
3 Self-inflicted trauma that is use of pins to clean the itching ear or use of ear
bud to clean the wax
4 Wide spread of topical antibiotics steroid preparations which have medium
sterilized of other organism in which the fungus may grow
5 Failure of defense mechanism in External auditory canal
6 During swimming or head bath water enters in External acoustic canal
causes quantitative and qualitative change in ear wax It causes change in pH
7 Long term use of hearing aids
Pathophysiology ndash
The life cycle of the average mold encountered in the ear may be reckoned
as two weeks and flare ups may be anticipated at such intervals Swimming is
held responsible for infection in many cases The sequence sequence of
pathogenic changes produced by molds in the external ear is as follows ndash
1 Implantation of the organism in external ear
2 Growth of organism follows the rate depending on condition of temperature
moisture or preexisting irritation
3 Invasion of epithelium occurs with attendant itching and discomfort which
may be quite severe
Page | 55
4 Exfoliation of epithelium occurs as nature attempts to overcome the
infection by casting off upper most cells
5 Denudation occurs from exfoliation as the top layers of epithelium are cast
off and the canal becomes filled with debris
6 Superficial ulceration and lizematoid dermatitis results if the pathologic
process goes for enough The changes do not always proceed through the
entire sequence sometimes the molds produce changes of the mildest
imaginable character which may be overlooked[91]
Clinical features -
Symptoms-
1 Irritation and itching ndash Irritation is mostly found when the infective
organism is aspergillus niger There is sensation of discomfort which is more
diffuse in the ear canal then localized in the deeper part Candida infection
causes marked itching In external ear it is intense and worse at night
2 Discharge through ear- Intermittent scanty colorless discharge through
ear Mucus being a fungal metabolic product appears as discharge Excessive
discharge is associated with mixed infection
3 Pain and discomfort ndash Mild to severe pain in the ear occasionally Mostly
seen in cases where ear is infected with Aspergillus flavus mixed infection
with gram negative organism or mixed infection with candida and aspergillus
Headache is sometimes associated with pain
4 Deafness- Varying degree of mild to moderate conductive deafness
5 A sensation of fullness in ear
6 Tinnitus 7 Vertigo
Page | 56
Signs ndash
1 The external acoustic meatus may contain a mass formed of epithelial
debris exudates cerumen and fungus
2 Erythematous external canal
Fungal appearance
A Niger - The color of the mass which is usually grey or black is mainly
determined by the type of fungus concerned Its appearance is like wet
newspaper or blotting paper or a cotton wool It has a peculiar musty odor In
this infection fruiting heads may be seen as black specks in the debris
Occasionally as inactive form occurs in which the canal is lined by mold giving
a fluffy appearance due to the presence of tiny mycelia
Candida ndash Candida infections generally show as white deposits on magenta
colored skin when the debris is removed it rapidly recovers in 24 hrs
The underlying canal skin is often inflamed and granular due to invasion by
fungal mycelia and be seen in all cases In rare cases excoriation and
ulceration with marked extensive shedding of the epithelium and deep
ulceration can be seen usually associated with a flavus and with pathogenic
bacteria[92]
Otoscope Appearance
1 Aspergillus Niger ndash Black headed
2 Aspergillus Fumigators ndash pale blue or green
3 Candida Albicans ndash White- or cream-colored deposits
Page | 57
4 Auricle is normal in most cases In severe cases small ulceration with crust
formation may be present on lateral surface
5 Tympanic Membrane
In most cases it is normal with normal mobility and normal hearing In a few
cases the surface of the tympanic membrane is congested and scaly There is
erosion or ulceration of the external epithelial layer and the membrane itself
may be edematous
Diagnosis
1 Above mentioned symptoms and signs
2 In the stage at which patient with otitis externa usually first present
themselves mycelia threads conidiophors not visible to naked eye may
sometimes be identified with the microscope
3 Confirmed by culture
Page | 58
Fig7 Aspergillus Niger Fig8 Candida Albicans
Fig9 Aspergillus Fumigators Fig 10 Wet Paper like appearance
Page | 59
Treatment
1 Antibiotic or steroid drops should be discontinued if they are being instilled
since long time
2 Removal of fungal mass epithelial debris and discharge from the external
canal or mastoid cavity repeatedly and thoroughly by forcepa or suction or
syringing or cautiously blow a stream of air into the canal through a fine
cannula and dry thoroughly by swabbing liquid petroleum on swab used in
cleaning the ear lessens the burning sensation when metacresy acetate is to
be employed in the subsequent treatment
Furuncle is developed as a complication if there is no gentleness in cleaning
Cleansing may have to be delayed until local sensitiveness is lessened which
can usually be accomplished within twenty-four hours If there is excessive
epithelial debris along with otomycosis then metacresyl acetate which is a
keratolytic in introduction into the external auditory canal on cotton wick and
is allowed to remain for twenty-four hours After twenty-four hours the cotton
wick is removed at which time the canal can usually be cleansed with little
discomfort as the medication is also anesthetic The epithelium of the canal
was white from contact with the drug The top layer was detached and this
epithelial debris can be easily wiped away The wick is reinserted and wet with
metacresyl acetate
The treatment is employed for three to four days in succession and then a
bland application is substituted Icthyol iodine is of value at this stage Iodine
ointment 2 in combination with Tannic acid 2 is also an excellent local
application following cresatin treatment
Next one of the fungicides may be applied
Page | 60
1 Nystin Effective for candida infection but less active against aspergillus
group Nystatin in boric powder consisting of 100000units of nystatingm of
powder 3 times week for 3 weeks
2 Clotrimazole Available as 11 cream or drops or lotions Phenyl
(zchlorophenyl) 1 ndash imidazole ndash methane is a chlorinated trityl imidazol 1
effective against candida and dermatophytes and for aspergilli infection
3 Amphotericin B Available as cream and as 3 solution and 015 drops
for topical application Very effective for candida infection can be fungistatic
or fungicidal
4 Econazole Available as solution (Econazole nitrate) and as cream (1)
Broad spectrum ndash more effective for Aspergillus Also active against some
gram-positive bacteria (Staphylococci and Streptococci and Dermatophytes)
5 Miconazole Highly effective against dermatophytes and candida infections
used as a 21 cream applied once or twice a day for 10 days
6 Gentian violet 21 Available as drops (recently some evidence of
carcinogenicity) Discolors the ear canal and this interfere with clinical
examination
Other topical antifungal agents are ketoconazole Natamycin Tolciclat Bifonas
zole Fenticonzole Oxiconazole Tioconazole ciclopiroxolomine Tolnafate
Haloprogin Flucytosine Acetic acid Whit field ointment selenium sulfide
undcyclenic acid triacetin etc
Page | 61
Minimal length of treatment
A month of drug treatment is usually required because the antifungal agents
used are not sporicidal and it is necessary that the period of treatment covers
germination time It may be advisable to give short gaps in the period of
treatment to ensure all spores have germinated before deciding to terminate
therapy
Prevention
Accomplished by strict attention to the predisposing causes
1 Water should be prevented from entering the ear
2 Avoidance of external ear trauma
3 Use of alcohol medicated or plain in the ears after swimming mercuric
cyanide (15000) in ethyl alcohol (70) is a satisfactory liquid to use
Ear stoppers do no good unless their use is followed by some antiseptic in the
canal Divers exposed to water for long periods of time may also use acidic
alcohol
4 During Summer months with their high humidity special efforts are needed
to maintain ear dry 5 Indiscriminate use of topical antibiotics steroid
preparations should be avoided
Page | 62
DRUG REVIEW
1 GUGGULA
Fig11 - Guggula
Historical review of Guggula [93]
bull Atharvaveda one of the well-known Vedas of Hindus The earliest
reference given by Atharvaveda medicinal and therapeutic properties of
Guggula Guggula has long history of use in Ayurveda
bull Acharya Charaka Sushruta and Vagbhata describe detail regarding the
actions uses and indication as well as the variety of Guggula
Page | 63
bull Various Nighantus (Medical lexicons) were written between 12th and 14th
centuries AD was based on the Ayurvedic literature also describes
Guggula
bull The explanation of word Guggula is that Gunjo Vyadhegurdti Rakshati
which means to relief against different diseases
bull Guggula is the best medicine because it develops through the rays of
hot sun on specific circumstances
bull Guggula has an aromatic odor
गगलो कणवदौगवररधय िपन शरटठमछयत[94]
स उ २२११२
Latin name- Commiphora mukul
Family ndash Burseraceae
Rasa- Tikta Katu
Guna ndash Laghu Rukshasukshma vishada sara
Veerya ndash Ushna
Vipaka ndash Katu
Action- Rasayana Lekhana
Doshaghanta - Tridoshhara
Page | 64
Chemical composition [95]
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Oleoresin-Z-Guggulsterone E-Guggulsterone
Gum- guggulignans 1 and 2 guggula Tetrols mukulol allylcembrol c
27
Guggulusterol 1 2 ans 3 Z and E ndash guggulusterol
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Parts Used ndash Gum oleoresin
Guggula purity test
1 Yellowish brown emulsion is obtained when Guggula is triturated with
water
2 An ethereal solution of the drug attains reddish colour when treated
with br2 vapors and purple colour when moistened with nitric acid
Biochemical action ndash Antiseptic Anti-inflammatory Disinfectant Diuretic
Immunostimulant stimulating expectorant Ant suppurative Antipyretic
Enhance phagocytosis
Karma- Rasayana cardiovascular disease
Page | 65
2 AGARU-
Fig 12 Agaru
Historical review of Agaru [96]
bull The word Agaru literally means the one which is the heaviest and no
aromatic wood is heavier than it Since thousands of years Agaru lsquoThe
wood of Godrsquo has been used for multiple purpose like commercial
medicinal spiritual aromatic historical
bull The medicinal use of Agaru have been recorded in many pieces of India
Greek Roman Chinese Middle eastern and European since ancient times
bull Acharya Charaka used Agaru and pest of Rasna to counteract the effect of
cold in Agraya Dravyas
bull Acharya Sushruta used Agaru as a Dhoopana Dravya along with Guggula
Ral and Shoma in the treatment of Karnasweda and Vrana
Page | 66
Types-
bull Dhanwantsri Nighantu describes Kaleyaka as a type of Agaru
bull Sodhala Nighantu describes three types of Agaru ndash Agaru Krishna
Agaru Kakatunda Agaru
bull Raj Nighantu describes five types of Agaru ndash Krishna Agaru Kasht
Agaru Daha Agaru Mangalya Agaru and Agurusaar
bull Arthashasstra describes three Agaru wood product
1 Jongaka ndash Black or variegated black in colour and having variegated
spots
2 Dongaka ndash Black in color
3 Parasamudraka- Black in colour and smells like Navamallika
अगर उटण कि तपछय ततकत ततकषण च वपततलम
लघ कणाविरोगघन शीत ात कफपरणत
िापर २१ [97]
Family- Thymelaccensis
Latin name- Aquilaria agallocha
Guna- Laghu Ruksha Tikshan
Rasa- Katu Tikta
Vipaka ndash Katu
Virya ndash Ushna
Karma- Sheetaprasasmana Vranaorasadan Tvachya Pittavardhaka
Shirovirechana Mangalya Sugandhik and Rochaka in properties [100]
Krishna Agaru karma- Katu Tikta rasa Ushna Sheeta when applied externally
and Pittahara when taken orally
Page | 67
Chemical Constituents -
Agaru hardwood is rich in essential oil resins alkaloids saponins Steroids
terpenoids tannins flavonoids and phenolic compound Agaru wood
predominantly contains 2-[-2-phenylethy]-4H-chromen-4-one derivatives and
sesquiterpenes Agaru oil contains selinene dihydroselinene agarnol b-
agarofuran vetispira-2(11)valerianol dihydrokaranone and tetradecanoic
acids[99]
Part Used ndash
Heartwood- Dark resinous wood which is formed when the plant becomes
infected with a type of fungus (ascomycetous mold) Species of Aspergillus
fusarium and penicillium are reported to be associated with the development
of infection Prior to infection the heartwood is odorless relatively light and
pale colored however as the infection progresses the tree produces a dark
aromatic resin in the heartwood The infected resin in response to the attack
which results in accumulation of a very dense dark resin in the heartwood
The infected resin embedded wood is known as Agarwood Infection is more
common on the trunk roots and the area when branches divide The formation
of Agarwood starts when the tree attains the age of 20 years On an average
approximately 30 ml oil is extracted from 100 kg of infected Agarwood[98]
Qualities of best Agaru-
It should be black in color
It should be extremely heavy and aromatic
It should be oily in appearance and test
It should be sink in water
It should burn easily with bright flame with a bright flame giving off a pleasant
smell
Page | 68
3 MADANA
Fig 13 MADANA
Madana consist of dried fruit of Xeromphis spinosa It is a deciduous thorny
shrub or a small tree reaching a high up to 9 m and girth about a meter
branches numerous thick and horizontal found in sub-Himalayan tracts[101]
मदनो मिरनदसततकतो ीयोटणो लखनो लघ
ानदरतिदवििीहर परततशयायवरणारतक
रि कटठकफ़ानाहशोथगलमवरणापह[102]
िा पर १६० १६1
Page | 69
Latin name-Randia dumetorum
Familly ndash Rubiaceae
Rasa - Madhura Tikta
Guna-Laghu Ruksha
Virya- Ushna
Vipaka ndash Katu
Karma- Vamana and Lekhana
Chemical Composition-
Essential Oil Valerianic acid Saponin tannin resin [103]
Page | 70
YAWA [104]
Fig 14 Yawa
1 In Samhitakala Aacharya Charaka Acharya Sushruta explain detail about
medicinal properties of Yawa
2The use of Yawa in Aaharya Dravya mainly described by Dhanwantari
Nighantu Raj Nighantu Bhavprakash Nighantu[105]
Macroscopic Description-
Fruit a caryopsis elliptical oblong Ovoid and tapering at both ends smooth
about 1cm long and 02- 03cm wide dorsally compressed and flattened on
the sides with a shallow longitudinal furrow 3-5 ridges having shallow
depression between them grains tightly enclosed and adhering the lemma
and palea pale greenish yellow odor not distinct taste sweetish acrid
Page | 71
Latin Name ndash Hordenum vulgare
Family- Poaceae
Rasa- Kashaya Madhura
Virya- Sita
Vipaka- Katu
Karma- Vatakrt Pittahara Kaphahara Medahara Balya Visrya
SthairyakaraLekhana
Page | 72
PROCEDURE REVIEW [105]
In Ayurvedic classics there are many references regarding Dhoopana Dravya
Dhoopana is administering Dhuma with the help of Dhoopana Dravya
In Kashyapa Samhita there are 40 types of Dhoopana advised for children
Anesthesia (Mohajananam Dhoopa) is also mentioned For this Dhoopana the
drug used were herbs hairs of animals legs horns old cloths of Buddhist
monks
From the references available regarding Dhoopana we can understand that
Karna can be protected from maggots (krimi) Bactria (Rakshogna) lice etc
References clearly indicate the analgesic and disinfectant effect of Dhoopana
Karma Dhoopana is mentioned for Dushta Vrana Chikitsa It reduces Vedana
Srava Pootigandha of Dushtavrana It also helps in Vranaropana
Dushtavrana Chikitsa is mentioned in the treatment of Karnasrava[106]
Origin of Dhoopana-
In ancient period children of sages were constantly harassed by the
Rakshasas Hence the sages approached lord Agni for shelter Agni in turn
gave them Dhoopana Dravya and asked sages to use the Dhoopana for
protection against Rakshasas bhutas pishachas
Classification of Dhoopana
1 It is classified into Dhupa Anudhupa Pratidhupa
2 On the basis of Origin it is classified into Jangama and Sthavara
Selection of Guggula for Dhoopana
Page | 73
bull Guggul is a best Vatahara
bull It is Krimighana
bull It contains Oleoresin
bull In Ashtang Hrudaya Guggula Dhoopana mentioned for Karnasrava
Selection of Agaru for Dhoopana
bull Agaru is Laghu Ruksha Katu Tikshna
bull Vranaorasadan Tvachya
bull It should burn easily with bright flame with a bright flame giving off a
pleasant smell
Karna Dhoopana Indication
1 Karnaarava
2 Putikarna
3 Krimikarna
4Vataj Karnashula
Contraindications
Especially for Karnadhoopan contraindication is not mentioned in classic texts
But Dhoopana is contraindicated in Pittaj vaydhi Sharad and Grishma Rutu
Page | 74
MATERIAL AND METHOD
Page | 75
For randomize comparative clinical trial to study the effect of Agaruwadi
Karnadhoopana and Guggula Karnadhoopana in Karnasrava following material
and method were required
Source of data
Patient irrespective of gender occupation religion social economic status
signs and symptoms of classical features of Karnasrava (Otomycosis) selected
from the OPD of Shalakyatantra department
Materials ndash
1Patients
2 Drugs-Agaruwadi Dhoopana
Guggula Dhoopana
3Torch
4Otoscope
5 Tuning fork
6Jobson horn probe
7Cotton
8Case record form
DRUG
Group A Trial Group
1Churana of Agaru Yawa Madan
2Ghrita
3Jala
Group B Control Group
1Googula Churna
Page | 76
Properties of Drug
Table no 1 Properties of Drug
Drug
Family
Rasa Veerya Vipaka Effect
on
Dosha
Guna Karma
Agaru
(Aquilegria
Agallocha)
Thymelaca
ceae
Katu
Tikta
Ushna Katu KV Laghu
Ruksha
Tikshna
Shitaprashamana
Shothahara
Vedanasthapak
Durghandhihara
Madan
(Randia
spinosa)
Rubiaceace
Kashaya
Madhur
Tikat
Katu
Ushna Katu KV Ruksha
Laghu
Vatakaphaghana
Shothahara
Vedanasthapak
Vranashodhak
Yawa
Poaceae
Hordeum
Vulgare
Kashaya
Madhur
Sheeta Madhur KP Ruksha
Laghu
Vataghana
Vernashodhana
Raktshodhaka
Guggula
Commiphora
Mukul
Burseracea
e
Tikta
Kashaya
Anushna Katu VPK Laghu
Ruksha
Shothahara
Vedanasthapaka
Kandughna
Ghrita Madhura Sheet Madhur VK Snigdha Vataghana
Shothahara
Vedanasthapaka
Page | 77
METHODOLOGY
SELECTION CRITERIA
1)INCLUSION CRITERIA
1 Patients having signs and symptoms of Karnasrava (Otomycosis) ie करणशल
( pain ) करणकणड ( Itching ) करणसतराव ( Discharge )बाधिरण ( conductive Loss of
hearing )
2 Patient from age group 19 to 70 years
3 Any Gender
2)EXCLUSION CRITERIA
1 Patients suffering from any systemic disease like DM TB HTN
2 Chronic suppurative otitis media (CSOM)
3 Acute supportive otitis media (ASOM)
3 Perforation of Tympanic membrane
4 Chronic otitis media
3)WITHDRAWAL CRITERIA
1If patient develops any adverse effect such as irritation pain burning
sensation in ear loss of hearing and such patients was withdrawn from trial
and receive prompt appropriate medical attention
2If patient shows aggravation in symptoms
3If patient refuses to continue with the treatment
Page | 78
STUDY SETTING
Types of study - Randomized Clinical comparative Trial
Place of work - OPD of Shalakyatantra
Duration of study - 18 months
Study Population - Patients of Karnasrava in Shalakyatantra OPD
SAMPLE SIZE CALCULATION
Sampling Method ndash Purposive sampling followed by random allocation in two
groups
Sample size calculation-
n = z2 p (1-p)
d2
Were
n = sample size
P = prevalence of disease=10
z = standard normal variable ie 196
d = error ie005
desired Sample Size would be
n = Z2 P(1-P)d2
= (196)2x (0021) x(0979)(005)2
= 34
Visiting ENT OPD (ShalakyaTantra) and IPD (ShalakyaTantra) 21 = 34
n raquo34
So one group includes 34patients
Page | 79
Sampling Method
Total 68 patient of Karnasrava are selected by Purposive sampling followed by
random allocation in two groups Written informed consent is taken prior to
commencement of trial They are divided in 2 groups
Group A (Trial Group) 34 patients treated with Agaruwadi Dhoopana for 7
days
Dose 5 minutes twice in a day
Group B (Control Group) 34 patients treated with Guggula Dhoopana for 7
days
Dose 5 minutes twice in a day
STUDY DESIGN ndash
Open labeled Randomized Comparative Clinical trial
STUDY DESIGN
Screening of patient
Inclusion criteria satisfied Exclusion criteria
Initial assessment Excluded
Counseling of patient Treated accordingly
Patient selection by Simple Random Sampling Method
Page | 80
68 Patients were divided in two groups lsquoArsquo and lsquoBrsquo
Trial group A-34 patients were given
Agaruwadi Dhoopana
Control group B- 34 patients were
given Guggul Dhoopana
Informed written consent
Treatment was given for 7 days
Assessment on 1st 4th and 7th day
Post assessments follow up on 15th day
Observation
Data Collection
Statistical analysis of data
Conclusion
Page | 81
(A) Agaruwadi Varti for group A (Trial group)
Table no 2
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
B) Guggula Varti for group B (Control group)
SOP of it is same as above Agaruwadi Varti
Table no 3
Drug Guggula Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
FOLLOW UP
For both groups follow ups were done on 1st 4th and 7th and post
assessment follow up15th day
EXAMINATIONS
Torch for Local examination of ear
Otoscope examination
Tuning fork Test
Page | 82
OBSERVATION TABLE
Table no 4
Sr no Subjective criteria Day 1 Day 4 Day 7 Day 15
1 करणशल
(pain)
2 करणकणड
(Itching)
3 करणसतराव (Discharge )
4 बाधिरण (Conductive Deafness)
OBSERVATIONS
a) करणशल (Pain) -
0 - Absent
1 ndash Present
b) करणकणड (Itching) -
0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
Page | 83
c) करणसतराव (Discharge)
0- Absent
1- Mild -Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाधिरण (conductive Loss of hearing)
0 - Absent
1- Present
Observations were carried out before and after completion of treatment and
during each follow up After observations the data collected and presented in
the form of graphs charts and table
Page | 84
TRIAL DRUG
Authentication and standardization of raw drug material done After
authentication and standardizing of raw drug material Agaruwadi Varti was
prepared by Varti as explained in Ayurvedic classics
Method of Varti preparations
Panchavidh Kashaya Kalpana that is five method of pharmaceutical
preparation constitutes the fundamental process of Ayurvedic pharmaceutics
which is well explained in Sushrut Samhita Varti Kalpana is one among them
which can be included in Kalka Kalpana
तीररसतरपतपतीनामपरककव तीत [106]
स डलहण शरच 151
Medicines are powered triturated and given the Varti shape that is like wick
of lamp so it is called as Varti Kalpana
Drug content Agaru Madan Yawa
Route of Administration Local
Dose Two times a day
Duration 7 days
Page | 85
Methodology
Standard operating procedure (SOP) of Agaruwadi Varti
Agaruwadi Varti is prepared according to the classical text
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization was done as recommended in pharmacy procedure The
raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 mixed together in
equal quantity to make Agaruwadi churn
Quantity of each churn is 4 grams all are mixed when the Varti get dry total
weight of Varti was 10gram
STEP 4 - Agaruwadi churn triturated with appropriate quantity of water or
Ghrita and prepared Varti in GMP Certified Ayurvedic pharmacy Standard
aseptic precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Varti was packed in sterile air packed container
STEP 6 - Agaruwadi Dhoopana was given with the help of Dhoopana yantra
Authentication and Standardization of raw drug of Agaruwadi Varti was done
Sterilization was done as recommended in pharmacy procedure Sterile
preparation packed in sterile container of suitable size Under all aseptic
precaution Karnadhoopana given to infected ear
Page | 86
Containers for packaging and their sterilization-
Sterilization of the containers for storing Varties was done by Ethylene Oxide
(Eto) method
Ethylene Oxide (Eto) procedure-
It includes exposure of materials to ethylene oxide gas under vacuum in a
sealed chamber It consists of four primary variables
1Gas Concentration
2Humidity
3Temperature
4 Time
EtO gas is an alkylating agent which disturbs the DNA of microorganism
preventing them from reproducing It penetrates the breathable packaging
and sterilizes all the accessible surface of the product to render products
sterility by alkylation of essentials proteins for cell reproduction
Most Eto sterilization methods involves three different stages These can be
separated into three different on the size or number of devices to treat
1Preconditioning stage-
First products are passed through a preconditioning phase to make
microorganism grow The batch load goes through a well time under a
controlled environment of temperature and humidity
2Sterilizer stage-
Performed using process phase specially designed to provide the required level
of EtO exposure to assure sterility for a device or family of devices
3Degasser Aerration stage-
Finally products need to go through a degassing phase to remove any residual
particles of Eto The batch load goes over well time under a temperature-
controlled environment
The sterile containers were then used to store Agaruwadi Varti and handed to
patients included in the study
Page | 87
Packing of Agaruwadi Varti
The ETO sterilize plastic container were used for packing of Agaruwadi Varti
Varti was filled into these sterilize containers (7 in each) In an aseptic
environment plugging and capping was done under aseptic precautions In this
way packing of Agaruwadi Varti done These Varti were given to patient and
advise to take two times a day under all hygienic precautions
History and Examination
bull Proper history and presenting complains was recorded on case record form
bull Ear examination with otoscope was done during initial assessment and each
follow up
bull Otoscopic examination was done during initial assessment and each follow
up
bull Systemic Examination that is Blood Pressure Temperature Respiration
rate Pulse was recorded on case record form
Page | 88
Raw material
Fig14 यव चरण Fig15 मदनफळ चरण
Fig16 अगर चरण Fig17 गगगळ चरण
Page | 89
Preparation of Agaruwadi Varti
Fig18 Preparation of Agaruwadi Varti
Fig19 अगरवादी वरती
Page | 90
Fig20 Instruments used for examination of Karnasrava
Fig19 Karnadhoopana Yantra
Page | 91
Karnadhoopana Procedure
Fig 22 Karnadhoopana Procedure
Page | 92
OBSERVATIONS AND RESULTS
Page | 93
BASED ON DRUGS
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 94
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
AUTHENTICATION CERTIFICATE
Page | 95
BASED ON STASTICIAL ANALYSIS OF DEMOGRAPHIC DATA
68 patients of Karnasrava ndash Otomycosis
Table no 5
No of Patients Total
Group A Group B
Registered 38 37 75
Completed 34 34 68
Discontinue 04 03 07
Total 68 patients were enrolled in study 38 patients registered in group A
amongst them 34 patients completed the treatment and04 patients
discontinued the treatment However in group B 37 patients completed the
treatment and 03 patients discontinued the treatment out of 37 registered
patients
Hence the total number of patients registered in the present study was 75
and out of which 68 patients were discontinued the treatment So they
dropped out from the study While 68 patients were successfully completed
the treatment So observations and result of 68 patients were given below
Here we are going to discuss the statistical analysis of the data obtained in
the form of master chart that was prepared in accordance with the data
collected from the patients that had been included in the study The purpose
of statistical analysis was to analyzed the relation between age gender
occupation diet addiction and education
Page | 96
1 Age wise distribution of patients
Table no 6
In trial group 10 (29412) patients were from age group 18-25 years 14
(41176) patients were from age group 25-35 years 8 (23529) patients
were from age group 35-45 years and 2 (58824) patients were from age
group 45-60 yearsIn control group 6 (17647) patients were from age group
18-25 years 14 (41176) patients were from age group 25-35 years 7
(20588) patients were from age group 35-45 years and 7 (20588)
patients were from age group 45-60 years
Fig 23 Age wise distribution of patients
0
2
4
6
8
10
12
14
15 -25 25-35 35-45 45-60
10
14
8
2
6
14
7 7
Age Distribution
Trial Group N Control Group N
Age Distribution
Trial Group Control Group
N N
18 -25 10 29412 6 17647
25-35 14 41176 14 41176
35-45 8 23529 7 20588
45-60 2 58824 7 20588
Total 34 100 34 100
Page | 97
1 Gender wise distribution of patients
Table no 7
Sex
Trial Group Control Group
N N
Female 23 67647 15 44118
Male 11 32353 19 55882
Total 34 100 34 100
In trial group 23 (67647) patients were female and 11 (32353) patients
were male
In Control group 15 (44118) patients were female and 19 (55882)
patients were male
Fig 24 Gender wise distribution of patients
0
5
10
15
20
25
N N
TRIAL GROUP CONTROL GROUP
23
15
11
19
Gender
Female Male
Page | 98
2 Education wise distribution of patients
Table no 8
Education
Trial Group Control Group
N N
Illiterate 4 11765 3 88235
SSC 4 11765 3 88235
HSC 8 23529 9 26471
Graduation 16 47059 10 29412
Primary 1 29412 3 88235
Post-Graduation 1 29412 6 17647
Total 34 100 34 100
In trial group 4 (11765) patients were illiterate 4 (11765) patients were
SSC educated 8 (23529) patients were HSC educated 16 (47059)
patients were graduated 1 (29412) patients were primary educated and
1(29412) patients were post graduated
In control grou 3 (88235) patients were illiterate 3 (88235) patients
were SSC educated 9 (26471) patients were HSC educated 10 (29412)
patients were graduated 3 (88235) patients were primary educated and
6 (17647) patients were post graduated
Page | 99
Fig 25 Education wise distribution of patients
0
2
4
6
8
10
12
14
16
ILLITERATE SSC HSC GRADUATION PRIMARY POST GRADUATION
4 4
8
16
1 1
3 3
910
3
6
Education
Trial Group N Control Group N
Page | 100
3 Occupation wise distribution of patients
Table no 9
Occupation
Trial Group Control Group
N N
Accountant 1 294 2 588
Housewife 11 3235 8 2353
Engineer 1 294 1 294
Job 1 294 4 1176
Labor 1 294 3 882
Mess 1 294 0 000
Naturotherapyst 1 294 0 000
Pharma 1 294 0 000
Shopkeeper 4 1176 2 588
Singer 1 294 0 000
Student 8 2353 4 1176
Tailor 1 294 1 294
Teacher 1 294 1 294
Worker 1 294 3 882
Farmer 0 000 1 294
Lab Tech 0 000 1 294
Page | 101
Daily Collection 0 000 1 294
Fruit seller 0 000 1 294
Bus Driver 0 000 1 294
Total 34 10000 34 10000
In trial group 11 (3235 ) were housewife 8(2353) were students
4(1176) were shopkeeper 1(294) was accountant 1(294) was
engineer 1(294) was doing job 1(294)was labour 1(294) was
catering 1(294) was Naturotherapyst 1(294) was Pharma 1(294)
was Singer 1(294) was Tailor 1(294) was Teacher and 1(294) was
worker
In Control group 8 (2353)were housewife 4(1176) were students
2(588) were shopkeeper 2(588) was accountant 1(294) was
engineer 4( 1176) was doing job 3(882)was labor 1(294) was
Farmer 1(294) was Lab tech 1(294) was Daily collection 1(294)
was Tailor 1(294) was Teacher and 3(882) was worker 1(294) was
Fruit seller and 1(294) Bus driver
Fig 26 Education wise distribution of patients
0
2
4
6
8
10
12
1
11
1 1 1 1 1 1
4
1
8
1 1 10 0 0 0 0
2
8
1
43
0 0 02
0
4
1 13
1 1 1 1 1
Occupation
Trial Group N Control Group N
Page | 102
4 Religion wise distribution of patients
Table no 10
Religion
Trial Group Control Group
N N
Hindu 31 9118 33 9706
Muslim 3 882 1 294
Total 34 10000 34 10000
In trial group 31 (9118) patients were Hindu and 3 (882) patients were
Muslim
In control group 33 (9706) patients were Hindu and 1 (294) patient
were Muslim
Fig 27 Religion wise distribution of patients
0
5
10
15
20
25
30
35
N N
TRIAL GROUP CONTROL GROUP
3133
31
Religion
Hindu Muslim
Page | 103
5 Diet wise distribution of patients
Table no 11
Diet
Trial Group Control Group
N N
Veg 14 4118 20 5882
Non-Veg 20 5882 14 4118
Total 34 10000 34 10000
In trial group 14 (4118) patients were vegetarian and 20 (5882)
patients were Non vegetarian
In control group 20 (5882) patients were vegetarian and 14 (4118)
patients were Non-Veg
Fig 28 Diet wise distribution of patients
0
5
10
15
20
N N
TRIAL GROUP CONTROL GROUP
14
2020
14
Diet
Veg Non Veg
Page | 104
6 Addiction wise distribution of patients
Table no 12
Addiction
Trial Group Control Group
N N
None 30 8824 27 7941
Alcohol 2 588 0 000
Tobacco 1 294 2 588
Mishri 0 000 1 294
Smoking 1 294 4 1176
Total 34 10000 34 10000
In trial group 30 (8824) patients have no addiction 2 (588) patients
have addiction of alcohol 1 (294) patients have addiction of Tobacco 0
(0) patients have addiction of Mishri and 1 (294) patients have addiction
of smoking
In control group 27 (7941) patients have no addiction 0 (0) patients
have addiction of alcohol 2 (588) patients have addiction of Tobacco 1
(294) patients have addiction of Mishri and 11 (1176) patients have
addiction of smoking
Page | 105
Fig 29 Addiction wise distribution of patients
0
5
10
15
20
25
30
NONE ALCOHOL TOBACCO MISHRI SMOKING
30
21
01
27
0
21
4
Addiction
Trial Group N Control Group N
Page | 106
Statistical Analysis and Results
Effect of study on Karnashoola-
Table no 13
Karnashoola
Group A Group B
BT AT BT AT
N N N N
Grade 2 0 000 0 000 0 000 0 000
Grade 1 30 10000 7 2333 32 10667 5 1667
Grade 0 4 1333 27 9000 2 667 29 9667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 30 Effect of study on Karnashoola
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
30
7
32
54
27
2
29
Karnashoola
Grade 2 Grade 1 Grade 0
Page | 107
Table no 14
Karnashoola Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 088 100 033 006
969 2829E-
08 7667 HS
AT 021 000 041 007
Group
B
BT 094 100 024 004
1037 7103E-
11 8438 HS
AT 015 000 036 007
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 31
000010020030040050060070080090100
BT AT BT AT
GROUP A GROUP B
088
021
094
015
Karnashoola
Mean
Page | 108
Table no 15
Karnashoola
Mean SD Effect
Group
A
Group
B Trial Control Trial Control
Day 1 088 094 033 024 000 000
Day 3 065 071 049 046 2667 2500
Day 5 024 038 043 049 7333 5938
Day 14 021 015 041 036 7667 8438
000
010
020
030
040
050
060
070
080
090
100
Day 1 Day 3 Day 5 Day 14
Karnashoola
Mean Group A Mean Group B
Page | 109
Table no 16
Karnashoola N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3250 110500
510000 275 Control group 34 3650 124100
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 110
Effect of study on Karnakandu
Table no 17
Karnakandu
Group A Group B
BT AT BT AT
N N N N
Grade 3 7 2333 0 000 4 1333 0 000
Grade 2 18 6000 0 000 18 6000 0 000
Grade 1 7 2333 7 2333 10 3333 15 5000
Grade 0 2 667 27 9000 2 667 19 6333
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 32 Effect of study on Karnakandu
0
5
10
15
20
25
30
N N N N
BT AT BT AT
GROUP A GROUP B
7
0
4
0
18
0
18
0
7 7
10
15
2
27
2
19
karnakandu
Grade 3 Grade 2 Grade 1 Grade 0
Page | 111
Table no 18
Karnakandu Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 188 200 081 015
1091 3119E-
10 8906 HS
AT 021 000 041 007
Group
B
BT 171 200 076 014
1032 4746E-
09 7414 HS
AT 044 000 050 009
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Page | 112
Fig 33
Table no 19
Karnakandu
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 188 171 081 076 000 000
Day 3 126 118 057 058 3281 3103
Day 5 071 074 046 051 6250 5690
Day 14 021 044 041 050 8906 7414
000
020
040
060
080
100
120
140
160
180
200
BT AT BT AT
GROUP A GROUP B
188
021
171
044
Karnakandu
Mean
Page | 113
Table no 20
Karnakandu N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 4051 137750
373500 006 Control group 34 2849 96850
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is less than
005 Hence we conclude that there is significant difference between Trial
Group and Control Group
000
020
040
060
080
100
120
140
160
180
200
Day 1 Day 3 Day 5 Day 14
Karnakandu
Mean Group A Mean Group B
Page | 114
Effect of study on Karnasrava
Table no 21
Karnasrava
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 11 3667 0 000 8 2667 0 000
Grade 1 23 7667 3 1000 26 8667 2 667
Grade 0 0 000 31 10333 0 000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 34
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
11
0
8
0
23
3
26
20
31
0
32
Karnasrava
Grade 3 Grade 2 Grade 1 Grade 0
Page | 115
Table no 22
Karnasrava Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 132 100 047 009
1122 4356E-
13 9333 HS
AT 009 000 029 005
Group
B
BT 124 100 043 008
1130 9364E-
14 9524 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 35
000
020
040
060
080
100
120
140
BT AT BT AT
GROUP A GROUP B
132
009
124
006
Karnasrava
Mean
Page | 116
Table no 23
Karnasrava
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 132 124 047 043 000 000
Day 3 100 100 025 025 2444 1905
Day 5 047 038 051 049 6444 6905
Day 14 009 006 029 024 9333 9524
000
020
040
060
080
100
120
140
Day 1 Day 3 Day 5 Day 14
Karnasrava
Mean Group A Mean Group B
Page | 117
Table no 24
Karnasrava N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3535 120200
549000 655 Control
group 34 3365 114400
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 118
Effect of study on Karnabadhirya
Table no 25
Karn
Badhirya
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 0 000 0 000 0 000 0 000
Grade 1 13 4333 0 000 16 5333 2 667
Grade 0 21 7000 34 11333 18 6000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 36
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 00 0 0 0
13
0
16
2
21
34
18
32
Karnabadhirya
Grade 3 Grade 2 Grade 1 Grade 0
Page | 119
Table no 26
Karn
Badhirya Mean Median SD SE
Wilcoxon
W P-Value
Effect Result
Group
A
BT 038 000 049 009
799 7173E-
05 10000 HS
AT 000 000 000 000
Group
B
BT 047 000 051 009
816 0000138 8750 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 38
000
005
010
015
020
025
030
035
040
045
050
BT AT BT AT
GROUP A GROUP B
038
000
047
006
Karnbadhirya
Mean
Page | 120
Table no 27
Karn
Badhirya
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 038 047 049 051 000 000
Day 3 009 006 029 024 7692 8750
Day 5 003 006 017 024 9231 8750
Day 14 000 006 000 024 10000 8750
000
005
010
015
020
025
030
035
040
045
050
Day 1 Day 3 Day 5 Day 14
Karn Badhirya
Mean Group A Mean Group B
Page | 121
Table no 28
Karn
Badhirya N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3400 115600
561000 806 Control
group 34 3500 119000
Total 68
Page | 122
COMPARISION BETWEEN GROUP A AND GROUP B
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Table no 29
Overall Effect
Trial Group Control Group
N N
Marked Improvement 21 6176 16 4706
Moderate Improvement 8 2353 13 3824
Mild Improvement 4 1176 5 1471
No Change 1 2941 0 0
TOTAL 34 100 34 100
Fig 39
0
5
10
15
20
25
MARKED IMPROVEMENT
MODERATE IMPROVEMENT
MILD IMPROVEMENT NO CHANGE
21
8
41
1613
5
0
Overall Effect
Trial Group N Control Group N
Page | 123
DISCUSSION
Page | 124
Discussion is nothing but the logical reasoning of observations In
every research work discussion part is very important because it brings into
light about the logical analysis which are helpful in filling the research gap in
the scientific world
The discussion is categorized into following ways for the ease of
understanding
1 Discussion on selection of topic
2 Discussion on review of literature
3 Discussion on drugs their mode of action on the disease mode of action
of Karnadhoopana
4 Discussion on observation and results
1 Discussion on selection of topic
Otomycosis is commonly encountered in day-to-day practice Majority
of Indian people affected with this pathology This disease commonly
manifests in developing countries low socio-economic standard and lack
of hygiene Now a days due to busy lifestyle people are not able to follow
the proper instruction of care of ear which may be responsible for the
recurrent nature of disease So for the management of this we use
Karnadhoopana with the help of Agaruwadi Varti Dhoopana is simple
easy cost-effective procedure which can be done even at OPD levelso
for the disease Karnasrava we selected Karna Dhoopana as therapeutic
procedure Karnadhoopana was done with Agaruwadi Varti and Guggula
Varti which was very effective for treatment
Page | 125
2 Discussion on review of literature
Karnasrava is one such disease among 28 Karnarogas mentioned by
Acharya Sushruta in the chapter named Karna Roga Vigyana Acharya
Charaka included Karnasrava as symptom under the four types of
Karnarogas due to vitiation of different doshas Acharya Vagbhata has
not described Karnasrava separately It is a fact that systemic
description of Karnarogas is available in all the ancients of pus from a
Vata afflicted ear may results from head injury or immersion in water
Karnasrava is a clinical entity which can be correlated with Otomycosis
Karnasrava is explained as symptom as well as a disease in Ayurveda
Nidana- Karnasrava occur due to Samanya Nidana and Vishesh Nidana
Vishesh Nidana like Shirobhighata Nimmajato jale Mithyayoga of Shashtra
The exact pathology behind Karnasrava is not understood clearly
Purvarupa ndash No specific Purvarupa are found for Karnasrava in classical
literature Acharya Madhukara describe Purvarupa as expression of
Rupa(lakshana) with less intensity that is less intensity itching sound in ear
may considered as Purvarupa of Lakshana
Samprapti- Aacharya Sushruta not explained the Samprapti of Karnasrava
separately and we must consider the general Samprapti of Karnaroga Due to
various aetiologias as cited above ear afflicted by Vata dosha causes Twak
Rakta Mamsa dushti results in Karnasrava According to Acharya Sushruta
Vata-Kapha dose is dominance in Karnasrava
Page | 126
Nidan
Nija Agantuja
Vata ndash kapha prakopak nidana Shirobhighata Nimmajato-jale
Mithya yoga of Shastra
Vata- kapha Prakopaka(Chaya prakopak) Vata-kapha prakopaka
( Achay prakopak)
Twak Rakta Mamsa dushti
Karnasrava
Page | 127
Chikitsa
The curative aspect and this must be done simultaneously giving due
importance to Nidan Parivarjana that is preventive measures So Nidan
Parivarjana that is avoidance of causative factors like Jalkrida Mithyayogen
shashtrasya Karnakandu Shirasnan Pratishaya is the first step in combating
the disease and form the part of line of treatment
Above Samprapti helps us to proceed towards the treatment of Karnasrava
The main protocol of treatment is removal of fungus and wound management
which include various measures to keep area day clean clear of microbes and
providing ideal condition for healing
Samany Chikitsa- Acharya Sushruta described general treatment for
Karnaroga as Snehapana (Drinking ghee) Rasayana (Rejuvenation therapy)
Bhramacharya Avoid excessive speaking Avoidance of physical exercise and
head bath
Vishesha Chikitsa ndash Acharya Sushruta mentioned some procedures in the
treatment of Karnasrava which is Shirovirechana Karnadhoopana
Karnapurana Karanpramarjana Dhavan Avachurnana Karnapurana Above
various procedures described in Ayurveda for management of fungus growth
in ear discharging ear fulfill these requirements of wound management
Page | 128
Discussion on observation and Result
Out of 68 patients 34 patients included for the trial The incidence of
Karnasrava is observed in trial and control groups
The statistical analysis provided the following data
AGE
Trial group- Maximum no of patients that is 14 (41176) patients were from
age group 25-35 years followed by 29412 patients were from age group
18-25 years 23529patients were from age group 35-45 years and
58824 patients were from age group 45-60 years
Control group - Maximum no of patients that is 14 (41176) patients were
from age group 25-35 years followed by 20588 patients were from age
group 35-45 years and 20588 patients were from age group 45-60 years
17647 patients were from age group 15-25 years
The maximum no of cases of Karnasrava found in age group between 25 to
35 years The reason behind this is repeated use of ear bud or emersed water
in ear More use of earphone or working more in cold environment
GENDER
Trial group ndash A higher prevalence seen in females 6764 and 3235 in
males
Control group - A higher prevalence seen in males 5588 and 4411 in
females
Females and males both are prone to disease
Page | 129
EDUCATION
Trial group-It is observed that amongst 34 patients maximum ie16
(47059) patients were graduated 8 (23529) patients were HSC
educated 4 (11765) patients were SSC educated 4 (11765) patients
were illiterate 1 (29412) patient were primary educated and 1(29412)
patient were post graduated
Control group- It is observed that 10 (29412) patients were graduated 9
(26471) patients were HSC educated 6 (17647) patients were post
graduated 3 (88235) patients were SSC educated 3 (88235) patients
were primary educated3 (88235) patients were illiterate
There is no direct relation between education and Otomycosis
RELIGION
Trial group- The incidence of patients of Hindu religion are 9118 and Muslim
religion are 882
Control group- The incidence of patients of Hindu religion are 9706 and
Muslim religion are 294
There is no probable explanation for this maximum number of patients in
Hindu religion it depends upon the patients attend the hospital and
community residing there
Page | 130
DIET
Trial group It was found that maximum ie5882 patients were taking
mixed diet while 4118 were taking vegetarian diet
Control group It was found that maximum ie5882 were taking
vegetarian diet while 4118 patients were taking mixed diet
The dietary habit of person is based on choice availability and religious
customs of the person
ADDICTION-
Trial group- It was found that maximum ie 30 (8824) patients have no
addiction 2 (588) patients have addiction of alcohol 1 (294) patients
have addiction of Tobacco 1 (294) patients have addiction of smoking and
0 (0) patients have addiction of Mishri
Control group - It was found that maximum ie 27 (7941) patients have
no addiction 4(1176) patients have addiction of smoking 2 (588)
patients have addiction of Tobacco 1 (294) patients have addiction of
Mishri and 0 (0) patients have addiction of alcohol
Very few patients were addicted to Alcohol Smoking Tobacco and Mishri
These factors can be taken as provoking factors for Otomycosis
Page | 131
Discussion based on probable Mode of action of Karnadhoopana
In Ayurveda classics Karna Dhoopana is therapeutic procedure explain for
Karnasrava Dhoopana is administration of Dhooma (Fumes) with the help of
Dhoopan Dravya References indicates that analgesic and disinfectant effect
of Dhoopana karma and mention for Dushta Vrana Chikitsa It reduces
Vedana Srava amp also does Vrana Ropana action
Various Dhoopanas and Dhoopan Dravas for different element in various
Samhitas of Ayurveda but there is a lacuna of availability of reference
regarding how to do it and method of procedure Matra Kala Contraindication
etc
Currently simple modified way of Karnadhoopana according to Yukti Praman
and experience but there is lac of standardization
Karnadhoopana is one among the topical Bahiparimajan type of treatment
Karna Parmarjana is procedure of cleaning ear with the help of cotton or gauze
piece soaked in honey
Page | 132
Dhoopan
The fumes coming out on burning Agaruwadi Varti
Administrated directly into external ear canal
Causes vasodilation
Due to this increase blood supply in external ear canal
It helps in absorption of drug
Fumes dries up Srava and bring the analgesic effect
Karnagata Kapha amp Avrut Vata Dosha Shaman
Decrease in signs and symptoms like karnasrava Karnshool Karnabadhirya amp
Karnandu
Page | 133
3 Discussion based on probable mode of action of Agaruwadi
Dhoopana
Agaru ndash
I Agaru is a fragrant tree aroma is a result of fungal pathogenesis when the
wood of tree is contaminated by fungi at wounds it develops scrap filled
with resin and turn out to be aroma Medicinal use of Agaru have been
recorded in ancient medicinal science in in inflammatory disease and some
infective disease
II Acharya Charaka has referred to Agaru as an Ushna dravya despite having
Tikta Rasa Ashtang Samgraha used Agaru as Dhupana Dravya along with
Madan and Yawa in Karnasrava Nighantu recommended is use as a
Dhoopana
III In various Samhitas and Nighantus Agaru described as Tikta Snighdha
Sheetaprashamana Vranaprasadana Tvachya Due to these properties
Agaru is used in the treatment of Karna-Akashi Roga and Dushta Vrana
Shodhaka
IV Agaru is reported to have Antimicrobial Analgesic Antioxidants
Antihistaminic and anxiolytic properties Its Antihistaminic property gives
relief from itching which is cardinal feature of Otomycosis Due to Katu
Ushna Tikta Guna improves blood circulation Bheda stage develop It is
Niram Awastha of Dosha Karnagata kapha and vata get decrease and
symptoms like karnashoolakarnasrava get decrease Agaru also have a
Antioxidant properties
V Chemically Agaru Contain 2-(2-Phenylethyl) Chromones Terpenoids
Flavonoids
VI Natural Agarwood had inhibitive activities towards Staphylococcus Aures
The chloroform extract of Agarwood prolongs the pain threshold[108]
Page | 134
Madan
I Madanphala have therapeutic properties like Anti-inflammatory
Antiallergic Analgesic and Wound healing
II It is Useful in treatment of disease like Shotha (inflammation) Vidradhi
(Abscess) Pratishaya (Common cold) Kushta(Skin disease)
III Extract of Madanphala mainly contain Glcosides Tritorpenct
Glycosides Saponin
IV Saponin glycosides are act as fire extinguisher This property is helpful
for vartiIt also act as a detergent which clean the surface of fungus
V Tritorpenct act as a anti-inflammatory antimicrobial and
immunomodulator compound Interaction of glycosides with sterol
causes disturbance of selective permeability in plasmic membraneso
exudates and discharge get decrease
VI Pharmacological activity [109]
Antibacterial Activity The preliminary antibacterial activity of Methanolic
extract of Randia D lam was done on some standard and wild pathogenic
strains The inhibition of the bacterial growth was more pronounced on E coli
as compared to the other tested organism This shows the antibacterial action
of Randia D secondary infection can prevent
Anti-Allergic Activity In Ayurveda Randia D Extract and its fraction of milk
induced leukocytosis and eosinophilia in mice
Anti-Inflammatory Activity The crude methanol extract of fruit of Randia D
effectively reduced the carrageenin induced oedema in hind paw of the rats
significant reduction in granular tissue formation was recorded This activity
seems to be significant at various acute phases of inflammation and om
formation of granular tissue This proves action of Madanaphala in shopa
(inflammation)
Page | 135
Analgesic Activity Analgesic activity was tested in mice weighing between 20-
250 with six number of animals in each group Methanlic extract of fruit Randia
d give analgesic activity in both models This proves its Shoolanashaka (pain
killer) action
Immunomodulatory Activity Randia D has immunostimulant activity and
chloroform fraction which strongly affected immune system seems to be
bioactive fraction of this plant
The overall effect of Agaru Mandanphala Yawa having Anti-inflammatory
Antiseptic Antimicrobial Property Active ingredient shows these properties
Agaru Yawa Madanphala
Vatakaphaghna
Act as
Vranashodhak
Vedanasthapaka
Sheetaprashamana
Shothara
Avarana of Vata get decrease so helps to Shaman of Vata dosha
Karnakandu Karnashoola Karnasrava
Prashamana
Page | 136
This fact can be taken into consideration and probably acknowledge that
Karnadhoopana with Agaruwadi Varti had not leave any residue in the ear
Removal of fibrin keratinocyte migration and in growth of epithelial tissue
plays a major role in healing It is technique of fumigation of ear with the
smoke of anti-infective drug In Karnadhoopana Sthanik Swedana increase the
blood supply and helps in absorption of the drug reduce Karnakandu amp
Karnshoola associated with infection
Page | 137
SUMMARY AND CONCLUSION
Page | 138
The dissertation entitled randomize comparative clinical trial to study the
effect of Agaruwadi Karnadhoopan and Guggula Karnadhoopan In Karnasrava
wsr to Otomycosis
The dissertation is divided into fallowing parts
Introduction
Review of literature
Ayurvedic review
Modern Review
Drug review
Procedure review
Material and Method
Observation and result
Discussion
Summary and conclusion
bull INTRODUCTION
It includes importance of Shalakyatantra in Sushrut Samhita Charka
Samhita And Ashtang Samgraha
Common and specific causes of Karnasrava
Karnasrava is a clinical entity which can be corelate with Otomycosis
In Ashtang Samgraha stated the procedure like Karnadhoopana with
Agaru Yawa Madanphala in Karnasrava
Page | 139
bull REVIEW OF LITERATURE
1 Ayurvedic review
2 Modern review
3 Drug review
Ayurvedic review-
It includes Rachana-Sharir and Kriya-Sharir of Karna detail description of
Karnaroga and its types Karnaroga Samanya hetu Poorvaroopa Rupa
Samprapti Upadrava Pathya-Apathya of Karnasrava Vishesh Nidan and
Chikitsa of Karnasrava Detail description of Karnadhoopana according to
various Acharays have been mentioned
Modern review-
It includes anatomy and physiology of Ear brief anatomy of ear anatomy of
External middle and Internal ear Detail description of the disease
Otomycosis mechanism of fungal infection in external canal pathophysiology
investigations diagnosis and management
Drug review-
Detail description of Agaru Yawa Madan Guggula and its synonyms
Ayurvedic properties Karma uses Pharmacological action and their
pharmacodynamic properties
Page | 140
MATERIAL AND METHOD
It includes description regarding materials required for the study Preparation
of Agaruwadi Varti its Standardization Sterilization and packaging
Plan of study
1 Total 68 patients completed the treatment Age criteria was kept
between 18-60 years Patient selection was done by done by simple
random sampling method and divided into two groups A (Trial) and
Group B (Control) 34 patients in each group
2 Patients in Group A were treated with Karnadhoopana with Agaruwadi
Varti for 7 days two times in a day while patients in Group B were treated
with Karnadhoopana with Guggula for 7 days two times in a day
3 Clinical examination done during each follow up ie 0th 4rd 7th and
observation were recorded
Page | 141
OBSERVATIONS AND RESULTS
Page | 142
1 It was observed that higher incidence of disease Karnasrava ie
Otomycosis found in age group 25-35 years
2 Disease otomycosis was equal in both male and female
3 The trial group there was significant relief in Karnakandu (8906)
Karnasrava(9333) Karnashoola(7667) and karnabadhirya(100)
4 In control group there was significant relief in Karnakandu (7414)
Karnasrava(9524) Karnashoola(8438) and
karnabadhirya(8750)
Page | 143
REFERANCES
Page | 144
1 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published byChaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 17 page no
5
2 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 19 page no
6
3 DRNarayan Vidwas Shero-Karna-Nasa and MukhrogaAnand publication
edition 4th 2014 Page no-52
4 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-205
page no 111
5 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 111
6 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Shlok no2012
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 112
8 Dr KBBhargavaDr SK BhargavaDr TMShahaA Short book of ENT
diseases Usha publication edition 10th
9 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 8 Page no -52
Page | 145
10 Research and Review Journal of Ayurvedic science yoga and
Naturopathy 2017 4(3) 1-5 pA Critical review of Otomycosis in cortex to
Karnaroga described in Ayurvedic classic by amisha patel D B Vaghala
Chandani goswami Vol4 no3 (2017)
11 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogpratished Adhaya Shlok no-213
page no127
12 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedh Adhaya Shlok no-
2140 page no 131
13 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyant shirasiya adhaya Shlok no 1712 page no-
258
14 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
15 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
16 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Aupadravik Adhaya Shlok no-15 page no
2
17 Vaidya Jaymini panday Harit Samhita hindi commentaryChaukhamba
vidhyabhartiVaranasiedition 2010 Shlok no- 13-14page no-10
18 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 146
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-20345
page no 112
19 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Karnarogavigyniyam Shlok
no 21 Page no-731
20 Charak
21 Pandit Harigovind Shashtri Namalinganusasana Amarkosha of
Amarsimha hindi commentary published by Chaukhamba Sanskrit
Sansthan page no- 463
22 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
23 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 37
24 Shree Taranath-Trkavachspati-Bhattacharyen Vchaspatym published
by Rashtriya Samskrit Sansthandelhi Volume 4 page no- 5149
25 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
26 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
27 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
28 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Page | 147
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
29 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Indriyaopakramaniya Adhaya Shlok no 811
page no- 125
30 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243
31 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-510 page no56
32 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no3108 page no- 385
33 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no33 page no- 366
34 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sarvabhutachintasharir Adhaya
Shlok no-126 page no9
35 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-522 page no60
36 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-532 page no61
37 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Page | 148
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-521page no58
38 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-527 page no61
39 VdBramhand Tripathi Ashtanghradaya Sharirsthansthan Published by
Chaukhamba prakashana 2005 Shlok no331 page no-372
40 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Siravarnavibhaktisharir Adhaya
Shlok no-725 page no83
41 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Sharirsankhyavykaransharir Adhaya Shlok
no-512
42 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Pratekmarmanirdeshsharir
Adhaya Shlok no-628 page no75
43 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
44 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Marmasharirsthan Shlok no429 page
no- 393
45 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243244
Page | 149
46 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
47 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan pu blished by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711
48 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
49 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
50 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Shlok no 711 page no- 847
51 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Adhaya Shlok no-628 page no- 75
52 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Gandushavidhiadhaya Shlok no2232
page no- 261
53 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Karnavydhbandhvidhi Adhaya Shlok no-
1611 page no- 86
54 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Nidansthan Published by Chaukhamba
Page | 150
Sanskrit SansthanVaranasi Vatvydhinidansa Adhaya Shlok no183 page
no- 304
55 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavaykaransharir
Adhaya Shlok no-532 page no61
56 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Tristaisniya adhaya Shlok no 1120 page no-
163
57 P Hazarika Dr Nayaka R Balkrishnan Textbook of EarNoseThroat and
Head-Neck Surgery CBS Publication Anatomy of Ear
58 DrKB Bhargava DrSKBhargava DrTMShaha A short book of ENT
Diseases Published by Usha Publication 10th edition page no10
59 MrSalah Mansour MrJacques MagnanMr Hassan Haidar MrKaren
Nicolas MRStephan Louryan Comprehensive and clinical anatomy of the
Middle Ear Published by Springer publication Chapter -Middle Ear cavity
Page no 19 to 121
60 DrPLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 7
61 James OPickles An introduction to Physiology of Hearing Published by
Emerald publication 4th edition page no- 1 to 265
62 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
63 VdBramhand Tripathi Ashtanghradaya Uttarsthan Published by
Chaukhamba prakashana 2005 Karnaroga vigyniyam adhaya Shlok
no1713 page no- 998
Page | 151
64 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Shlok no- 212 page no-
730
65 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no
1-2 page no- 309
66 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana
67 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyantshirasiya Adhaya Shlok no 1713 page no-
258
68 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no-
6 page no- 310
69 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Karnarogavigyniym Shlok no- 1725-26 Page no-
1003
70 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2140 page
no 131
71 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Adhyay 18 shlok 35
72 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt
Karnarogapratishedhoadhya Shlok no-2211 Page no- 735
73 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 152
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2141 page
no 131
74 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2142 page
no 131
75 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2144 page
no 131
76 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 34 page no- 649
77 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2145page
no 131
78 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 37 page no- 649
79 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2146page
no
80 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
81 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 153
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2143page
no
82 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publication Krnarogadhikara adhaya page no-
318
83 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary
Madhyamkhand Vatkalpana shlok no- 782-83 page no- 137
84 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 72-77 page no- 651
85 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
86 Vd Shree Laxmipatishastri Yogratnakara
87 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
Karnarogadhikara Shlok no- 808182 page no- 652
88 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 83 page no- 652
89 (PDF) Otomycosis A Comprehensive Review (researchgatenet)
90 httpswwwncbinlmnihgovpubmed24948980
91 A Simon Carney Scott-Browns Otorhinolaryngology Head and Neck
Surgery CRC press 8th publication Otitis externa and otomycosis
92 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no Page no -
93 wwwguggulipidcomtradhtm
Page | 154
94 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
95 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-28 page no-
43
96 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009Agaru page
no726-728
97 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishra chapter Karpuradi varga Shlok no-31-
43 Page no- 116
98 httpswwwthiemeinimagecatlogsample_chapter_GOMPpdf
99 (PDF) Chemical Constituents and Pharmacological Activity of Agarwood
and Aquilaria Plants (researchgatenet)
100 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 4 chapter no-2 page no-4
101 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 chapter no-152 Madanpage
no376-379
102 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
103 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-54 page no-
84
104 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 page no697-699
patol-yawa
Page | 155
105 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
106 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
Dhoompanvidhi page no- 252-254
107 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012Chikitasasthan Shlok
no- 151page no-406
108 httpswwwmdpicom1420-3049232342pdf
109 httpswwwijamcoinindexphpijamarticledownload0610201530
0
Page | 156
BIBILOGRAPHY
Page | 157
1 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
2 Scott-Brown WG Diseases of the EarNose and Throat Landon
Botterworth and co(publishers) Ltd1952 Volume 2
3 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012
4 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009
5 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi commantry
Purvakhand and Madhyamkhand
6 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Published by Chaukhamba Sanskrit
SansthanVaranasi
8 The Ayurvedic Pharmacopeia of India Ministry of Health and family welfare
department of Ayush Part 1 and part 4
9 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005
10 Acharya Trivedi Raguveer Prasad Ashtang sangrah published by
Vaidyanath Ayurveda bhavan pvt
11 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition
12 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary published by Chaukhamba
Orientalia
Page | 158
ANNEXURE
Page | 159
ANNEXURE- 1
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
CASE RECORD FORM
RESEARCH PROFORMA FOR MS (AYU) DESSERTATION
DEPARTMENT OF SHALAKYATANTRA
NAME -
ADDRESS -
GENDER - AGE - OCCUPATION-
RELIGION - EDUCATION - MARITAL STATUS-
OPD IPD NO-
DATE OF ADMISSIONCOMMESEMENT-
DATE OF DISCHARGECOMPLITION-
DATE OF COUNSELLING-
TEL NO-
CHIEF COMPLAINTS-
PAST MEDICAL AND SURGICAL HISTORY-
TREATMENT HISTORY-
FAMILY HISTORY-
Page | 160
PERSONAL HISTORY-
a) Ahar(Diet)
b) Vihar
c) History of addiction
GENERAL EXAMINATION
PULSE - MIN BP - mm of hg
TEMP - 0F RR - MIN
ASHATAVIDHA PARIKSHANA
Nadi- Mutra- Mala-
Jivha- Shabda- Sparsha-
Drik- Aakruti-
SYSTEMIC EXAMINATION
RS ndash
CNS-
CVS ndash
Page | 161
LOCAL EXAMINATION (KARNA PARIKSHAN)
OBSERVATION TABLE FOR SUBJECTIVE CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching )
RIGHT EAR LEFT EAR
KARNASHASHUKULI
KARNAPUTRAK
KARNAPALI
KARNAKUHARA -
SRAVA
GANDH
VARNA
SWARUPA
KARNAPATALA (TM)
Page | 162
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
Hearing Test
1Renne Test ndash
2 Weber Test -
Examination of Ear-
Pathological Investigation-
Other Examination-
Nidan Panchak-
1Hetu-
2Purvarup-
3Rupa-
4Upashayanupashaya-
5Samprapti
Signature of Guide Signature of Doctor(Researcher)
Page | 163
ANNEXURE 12
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Dhoopana Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization were done as recommended in pharmacy procedure
The raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 were mixed together
in equal quantity to make Agaruwadi churn
STEP 4 - Agaruwadi churn were triturated with appropriate quantity of water
and prepared Varti in GMP Certified Ayurvedic pharmacy Standard aseptic
precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Dhoopana Varti was packed in sterile air packed
container
STEP 6 - Agaruwadi Dhoopan was given with the help of Dhoopan yantra
TREATMENT DETAIL-
Purvakarma -
1 The patient is asked to sit comfortably on chair having sufficient light and
less amount of dust
2 The EAC is cleaned thoroughly by Pichu Varti (cotton swab) to remove the
discharge and other debris
Pradhankarma -
1 The patient is asked to relax completely on the chair
Page | 164
2 Fumes are passed to the ear with Dhoopana Yantra
3 Dhoopana yantra is funnel shaped and its one end will keep the ear covered
for the passage of Dhooma into the ear canal and other end where Agaruwadi
Dhoopana Varti were placed which produces fumes
4 This Dhoopana was given for 5 min
Pashchat karma -
1 The patient were advised to avoid cold refrigerated food drinks cold water
bath cold wind fog and prevent water from entering the ear
(A) Agaruwadi Dhoopana Varti
B) Guggula Dhoopana Varti SOP of it is same as above Agaruwadi Dhoopana
Varti
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Page | 165
ANNEXURE 21
INFORMED CONSENT DOCUMENT
Study Title
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
Introduction
- You are invited to take part in a research study RANDOMSIED COMPARATIVE
CLINICAL TRIAL TO STUDY THE EFFECT OF AGARUWADI DHOOPANA AND
GUGGULA DHOOPANA IN KARNASRAVA
- Before you decide it is important for you to understand why the
research is being done and what it will involve
- Please take time to read the following information carefully and discuss
it with friends relatives and your doctor if you wish
- Ask us if there is anything that is not clear or if you would like more
information
Purpose amp Nature of Study
- In this research project by examine you and ldquoKarnasravardquo (Otomycosis)
disease were treated
- In the part of treatment Agaruwadi Dhoopana or Guggula Dhoopan were
given
- Dhoopana means medicated drug fumes were given in ear with the help of
Dhoopan Yantra
Page | 166
- Treatment was given for 7 days
Study Duration
7days
Participation
- Your participation is entirely voluntary
- If you do decide to take part you were given this information sheet to keep
and be asked to sign a informed consent form
- If you decide to take part you are still free to withdraw at any time and
without giving a reason This will not affect the standard of current or future
medical care you may receive
Confidentiality
- All information which is collected about you during the research were
kept strictly confidential
- Any information about you which is collected from the center will have
your identity in the form of a code number so that it will remain confidential
Benefits Of Study
- The results obtained from this study would be helpful for providing better
quality of treatment amp other essential facilities for Karnasrava (Discharge)
patients
- You will get clinical benefit from the study
Page | 167
Risks Of Study
- In this treatment there are few chances of Irritation of Ear Nose and
congestion at EAC if any of these happens then treatment were given
Results Of Study
- If the Results obtained are profitable then they may get published
without disclosing your details
Signature of patient
Date
Time
Phone no of Researcher
Page | 168
रण मादहती पतरक
सशोिनाच शीषवक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE
EFFECT OF AGARUWADI DHOOPANA AND GUGGULA DHOOPANA
IN KARNASRAVA
परसतताना
- आपणास या सशोिनातपमक अभयासात सहिागी होणय़ाच आाहन करणयात यत आह
- सशोिनातील सहिाग तननदशचत करणयापी सशोिनाच उददश समजन घया
- खालील मादहती काळजीपवक ाचा आणण आशयक ािलयास आपलया डॉकिराशी कका
दहतशरचतकाशी चचाव करा
- काही सददिता असलयास कका आणखी मादहती ही असलयास आमछयाशी चचाव करा
सशोिनाच उददीटि सतरप
- सदर सशोिन परकलपामरधय आपलयाला तपासणी करन कणवसरा या वयाशरिची शरचककतपसा दणयात
यणार आह
- सदर वयाशरिची शरचककतपसा महणन आपणास अगरादी िपन कका गगल िपन
दणयात यणार आह
- सदर औषि आपणास 7 ददस घयायाच आह
Page | 169
कालािी
- 7 ददस
सहिाग
- आपला सहिाग हा पणवपण ऎनदछिक आह
- आपला सहिाग तननदशचत असलयास आपणास ही मादहती पतरतरका दणयात यईल आपणास यातील
समती पतरकार सही कराी लागल
- सहिाग तननदशचत असनही आपण कोणतपयाही ळस कोणतही कारण न दता माघार घ शकता
याचा आपलया दयकीय सविर कोणताही पररणाम होणार नाही
गोपनीयता
- सशोिना दरमयान गोळा कलली आपलया वषयाची सव मादहती गोपनीय ठणयात यईल
- आपली यनदकतक मादहती साकततक सतरपात गोपनीय ठणयात यईल
सशोिनाच फ़ायद
- सशोिनाच तनटकषव कणवसरा बाशरित रणाछया दयकीय इतर सविाचा दजाव सिारणयास
फायदशीर ठरतील
सशोिनातील जोणखम
- य़ा शरचककतपसमरधय कान दखण डॊळय़ातन नाकातन पाणी य़ण नाकात जळजळण डोक जड
होण ही लिण ददस शकतात यापकी लिण तनमावण झालयास तपयाची शरचककतपसा कली जाईल
Page | 170
सशोिनाच तनटकषव
सशोिनाच तनटकषव फ़ायदशीर ठरलयास आपली मादहती गोपनीय ठन परकाशशत करणय़ात यईल
रण सतािरी-
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
Page | 171
ANNEXURE 31
INFORMED CONSENT FORM
Patient OPD no __________
Subjectrsquos Identifier
Date of Birth Age Gender
I _____________________________________ age___________ years
exercising my free power of choice hereby give my consent to be included
as a participant in the clinical study entitled
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
1 I confirm that I have read have been read and understood the information
sheet for the above study and can ask questions
2 I understand that my participation in the study is voluntary and that I am
free to withdraw at any time without giving any reason without affecting my
medical care or legal rights
3 I understand that the Ethics Committee members investigators and study
doctors will not need my permission to look at my health records both in
respect of the current study and any further research that may be conducted
in relation to it even if I withdraw from the trial I agree to his access
However I understand that my identity will not be revealed in information
released to third parties or published
4I agree not to restrict the use of any data or results that arisefrom this study
provided such a use only for scientific purpose
5 I agree to take part in the above study
Page | 172
signature with Date-
Left hand thumb impression
Name amp signature of the witness ndash
Name amp signature of the student ndash
Page | 173
ANNEXURE 32
समतीपतरक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
वयकतीच य
ददनाक जरमददनाक
1) मी ह तननदशचत कररत आह ककसदर सशोिन परकलपाबाबतची सपणव मदहती मी ाचली असनमला ती
समजली आहतपयाबददल मला परशन वचारणयाची पणव मिा आह सदर मादहतीन माझ समािान झाल
आह
2) मी सदर सशोिनातन माझया मजीनसार किीही बाहर पड शकतो या माझया अशरिकाराची मला कलपना
आह
3) माझी दयककय मादहती तपासणयाची कागदपतर कळ सशोिनाकररता ापरली जाणार आहत याची
मला मादहती आहसदर सशोिन परकलपातील सबशरित घिकाना माझी दयककय मादहती पाहणयाची मी
समती दत आहतरावप या सदिावतील माझी ओळख दशववणारी मादहती कोणासही ददली जाणार नाहीयाची
मला कलपना दणयात आली आह
4) सदर अभयासातन शमळणारी मादहती अरा तनटकषव कळ शासततरीय हतसाठी ापरल जाणयासाठी माझी
समती आह
5) रील अभयासात सहिागी होणयास माझी समती आह
रण सतािरी-
Page | 174
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
ASSESSMENT CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching)
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
a) कणवशल ( pain )- 0 - Absent
1 ndash Present
Page | 175
b) कणवकणड (Itching)- 0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
c) कणवसततरा ( Discharge )
0- Absent
1-Mild- Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाशरियव ( conductive Loss of hearing )
0 - Present
1 - Absent
Page | 176
Page | 177
Page | 178
Page | 179
Page | 180
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
Page | 181
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 182
AUTHENTIFICATION CERTIFICATE
Page | 2
INTRODUCTION
Page | 3
Ayurveda is ancient science of life a system of health and medicine
which aims to assist people in living a healthy life It is a person-centered
medicine which deals with healthy lifestyle systemic diseases prevention
diagnosis and treatment Ayurveda is divided into eight branches[1] It has
a separate branch of clinical and surgical specialization concerning ENT and
ophthalmology known as Shalakyatantra One out of the eight branches of
Ayurveda Shalakyatantra deal with the etiology diagnosis prognosis
prevention treatment and complication of diseases which are located at
Urdhwang Pradesh[2]
Karna is one among the Panchendriya (sense organ) situated at
Urdhwang Pradesha [3] It is originated from Akash Mahabhuta Aachary
Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga Vigyniyam
Aadhaya[4] He mentioned Karnasrava as separate diseases[5] Aacharya
Charaka explain 4 Karnaroga He had not described Karnasrava as
independent diseases but explain Karnasrava as a symptom under four
Karnaroga Acharya Vagbhata mentioned Karnasrava as a symptom in
Karnashoola according to Dosha He included this into Kaphaj Karnashoola
itself[6] Karnasrava means discharge through ear The Samanya Hetu of
Karnaroga are Avashaya or Pratishaya that is common cold Sheeta Vihara
or exposure to cold environment Karnakandu or self-inflicted trauma by
use of ear bud or pine to clean itching in ear Shabda Shashtra Mithyayoga
that is misuse of instrument or listening to high sound frequencies[7] The
other predisposing factors are such as abuse of nonspecific broad-spectrum
antibiotics steroids and immune suppressed disorders
Classical features of Karnasrava can be compared with otomycosis
Otomycosis is acute sub-acute or chronic fungal infection in external ear
which rarely involves the middle ear[8] Otomycosis is characterized by pain
itching discharge conductive deafness of mild to moderate in nature
Fungal spores invade in the epithelial layer of EAC In response to that
inflammatory process starts which will reflect as pain Itching is due to
immune reaction of body during inflammatory process As a result of
Page | 4
inflammatory process exudates were produced which will mix up with
fungal colonies and appear as discharge In initial stage of disease ear
discharge is watery but if there is secondary bacterial infection occur it
becomes mucopurulent Ear blockage and conductive type of hearing loss
are due to accumulation of fungal mass in external auditory canal
Fungal mass appears white or black or brown and is like a wet piece
of filter paper Examination with otoscope Aspergillus Niger appears black
headed filaments growth Aspergillus fumigates as a pale blue or green and
candida as a white or creamy deposit[9]
Otomycosis is a common condition and it mostly occurs in humid
area According to American academy of otolaryngology prevalence of
otomycosis is 52 all over a world and 09 in India 5-25 otitis externa
cases are due to otomycosis Nearly 61 types of fungal species being involve
in otitis externa 90 of fungal infection cases involve Aspergillus species
and the rest candida species[10]
In Ayurveda The common treatment Principle for all is Ghritapana
Rasayana Bhramacharaya Avyayama (Excessive exercise)
Ashirasnana(Head bath) Atibhashashya(Excessive speaking) This can be
used for the prevention and management of Karnaroga[11] Acharya
Sushruta explain specific treatment modality for Karnasrava is
Karnaprakshalana Karnapoorana Karnadhoopana Shirovirechana
Karnadhavana[12]These therapeutic procedure can be updated according to
different stages of these condition
In routine OPD it is observed that patient of otomycosis respond
more frequently to topical therapy than to systemic therapy Among all the
treatment modality Karnadhoopana is an effective and simple procedure
In this regard Karnadhoopana with Agaruwadi Varti or uggula had explain
in Ashtang Samgraha Agaruwadi Varti contain Agaru Yawa Madanphala
All these contains of Agaruwadi Varti and Guggula acts as Ruksha Ushna
Teekshana Laghu Guna acts as effective Shodhaka keeps ear dry reduce
Page | 5
pain discharge foul smell and thus control the infection Dhoopana is also
useful as Adhidaivika Chikitsa to protect the patient from external attack of
visible and invisible organism The principal treatment modality adopted in
Allopathic system of medicine is oral antibiotics and topical antibiotic drop
Long term use of oral antibiotic causes adverse effect like gastric irritation
reduce immunity and resistance to drug Long term use of topical antibiotic
drops cause Ph change in external canal which become prone to fungal
infection
Hence the therapeutic procedure with Guggula or Agaruwadi Varti
Karnadhoopana are cost effective safe and easy procedure and it can be
used more effectively
Page | 6
AIM OF STUDY
To evaluate the effect of Agaruwadi Varti Dhoopana and Guggula Varti
Dhoopana in management of Karnasrava
OBJECTIVE
To compare the efficacy of Agaruwadi Dhoopana and Guggula Dhoopana in
Karnasrava
HYPOTHESIS
NULL HYPOTHESIS -
H0- Agaruwadi Dhoopana is not effective than Guggula Dhoopana in
Karnasrava
ALTERNATE HYPOTHESIS -
H1- Agaruwadi Dhoopana is more or equally effective than Guggula
Dhoopana in Karnasrava
RESEARCH QUESTION
Whether there is significant difference between Agaruwadi Dhoopana and
Guggula Dhoopana in Karnasrava
Page | 7
PREVIOUS WORK DONE -
1 Anupama Patra B Effect Of Arka Taila In The Management Of
Karnasrava With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2007
2 Palmer Komalben K Further Study On Role Of Arka Taila In The
Management Of Karnasrava With Special Reference To
Otomycosis Shalakya Tantra Institute for Post Graduate Teaching amp
Research in Ayurveda Gujarat Ayurved University Jamnagar 2010
3 Sathisha Shankar B Management Of Karnasrava With Sthanika
Guggulu Dhoopana And Rasnaadi Guggulu-A Comparitive Study Shalakya
Tantra Government Ayurvedic Medical College Bangalore 2011
4 Shashikala DK Comparative Study On The Efficacy Of Vacha
Lashunaadi Taila Karna Pichu And Nimba Patraadi Dhoopana In The
Management Of Karna Srava Shalakya Tantra Government Ayurvedic
Medical College Bangalore 2014
5 Javale Anant A Clinical Study On The Efficacy Of Arka Taila In The
Management Of Karna-Srava Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2005
6 Pournima V Koti Management Of Karnasrava With Priyangvadi Taila
Pichu With And Without Saarivadi Vati Shalakya Tantra Sri Jagadguru
Gavisiddeswar Ayurvedic Medical College Koppal 2015
7 Amisha Patel A Clinical Evaluation Of Honey In The Management Of
Karna Shoola With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching and Research in Ayurveda
Gujarat Ayurved University Jamnagar 2016
Page | 8
REVIEW OF LITRATURE
Page | 9
Ayurvedic literature Ayurveda is a science of life practice since
thousands of years The ancient Indian system of medicine and surgery is
commonly known as Ayurveda This was given the status of Upaveda or
fifth Veda in the next stage of growth Among the available literature three
Samhita that is Charaka Samhita Sushrut Samhita Ashtang Hrudayam and
Ashtang Samgraha are the chief source of knowledge of Ayurveda
Ayurveda consist of eight branches Shalakyatantra is one among them
Shalakyatantra is one of its specialized branch deals with science of
ophthalmology otorhinolaryngology Oro dental surgery and head Acharya
Sushruta himself a practical surgeon was the first to advocate dissection of
dead bodies is indispensable for a successful student of surgery He had
described gross anatomy in the first chapter of Uttartantra Shalakyatantra
define by different Acharys as follows
शालाकय नामोरधवजतरगताना रोगाणा शरणनयनदनघराणाददसशरशरताना वयाशरिनामपशमनारव
स स ११०
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत [13]
चस १७१२
Shalakya Tantra Nirukti and Parichaya
शलाकायााः कमव शालाकय ततपपरिान शलाकयम डलहण [14]
The term Shalakyatantra is derived from Shalakya and Tantra
The word Shalakya means A probe and Tantra denotes teaching and
practices found in scripturesThe compendium in which application of
Shalaka in various surgical procedures is principally described is called as
Shalakya tantra
दनदटिवशारदााः शालाककनाः डलहण ( सउ ११३)[15]
An eye specialist is termed as Shalaki by Dalhana
Page | 10
Synonyms of Shalakya Tantra
Uttamanga Chikitsa Jatrurdhwa Chikitsa Urdhwang Chikitsa Shalakya
Chikitsa
Importance of Shalakyatantra-
Life of living being and all the Indriyas are situated in the head hence it is
known as Uttamanga
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत
चस १७१२
The treatment given to this part of the body is described specially in
Shalakya tantra While describing the importance of Shiras Vagbhata
correlates it to the root of tree (Urdhwa Mula) and body to the trunk of tree
(Adha Shaka)
Sushruta has deal with Mukha Roga in Nidan Shan and its treatment in
Chikitsasthan The description regarding the disease of eye ear nose and
head are found only in UttaraSthan Sushruta specially describes the
disease of Shalakyatantra as told by Videha in the beginning of Uttartantra
itself[16]
Shalakyatantra Itihas-
India Exhibits traditional of more than thousands of years in art literature
language logic and philosophy etc The convention was in its sophisticated
and advanced attire throughout the Vedic period
Vedic period ndash
1 Natush was treated for deafness by Ashwinikumars (Rigveda)
2 Rujaswa and Kanva were treated for blindness by Ashwani Kumaras
(Rigvedas)
Page | 11
3 There are several prayers mentioned for normal functioning of sense
organs (Yajurveda)
4 Structures and functions of Mastishka are described (Atharveda)
5 Mantras having reference to disease of Eye Ear Oral cavity etc are
found (Atharvaveda)
Upanishada Period ndash
1 Samhita Period
a) Sushrut Samhita ndash
bull Explanation regarding Netra Nasa and Shirorogas (Uttartantra 1-
26th chapter)
bull Details regarding Mukha and Karna Roga Nidan and
Chikitsa(Nidansthan 16th and Chikitsasthan 22nd chapter)
bull Description regarding Karna Chedana Sandhana Nasa
Ostasandhana Sutra Sthan 16th chapter
b) Charaka Samhita -
bull Explanation regarding Shirorogas (Sutrasthan 17th chapter)
bull Explanation of Gala rogas like Upajivika Galshundi and Rohini
bull Nasa Shiro Mukha Karna and Netra Chikitsa (Chikitsa sthan 26th
chapter)
bull Description regarding Lakshana and Chikitsa of Shankhaka
Ardhavbhedaka Shirovirechana and Shiro basti (siddhi sthan 9th
chapter)
c)Ashtnga Sangraha ndash
bull Detailed description regarding Shalakyatantara (Uttartantra 11-28
chapter)
bull Description of Kriyakalpa (Sutrasthan 32nd and 33rd)
Page | 12
d)Ashtang Hrudayam
bull Detailed description on Shalakya Tantra (Uttar tantra 8-24 chapters)
bull Kriyakalpas (Sutrasthan 23rd and 24th chapter)
e) Bhela Samhita
bull Chakshushya Vaisheshik and Buddhi Vaisheshik Alochaka pitta
f) Harita Samhita- Branch of Medical science offering elaborating
information about the procedure like Nasya Anjan Gandusha etc
comprehended with their applications in disease of Head Eyes Ears
Eyebrows Throat Temporal region and cervical spine is known as
Shalakyatantara
शशरोरोगा नतररोगा कणवरोगा वशषताः भरकरठशङकमरयास य रोगा समिनदरत दह १३
तषा परततकारकम व नसतयतपयवणजनातन च अभयङगमखगणडषकियााः शालकयसशमतााः १४
इतत शालाकयनाम [17]
Documentation of different ancient literature gives various references
regarding all aspects of Karnasrava in various periods It is very much
important to know the history of Karnasrava from Vedic Pauranic Samhita
and Samgraha period
Vedic period ndash The Vedas being the oldest source of knowledge have no
direct mentioning of Karnasrava
Page | 13
Samhita and Samgraha period ndash
Aacharya Sushruta described about Karnaroga Karnasrava Nidan
Roopa and Chikitsa The detail description is available in Sushrut
Samhita Uttartantra 20 and 21st chapters
Aacharya Charaka did not specify Karnasrava but mentioned 4 types
of Karnarogas that is Vataj Pittaj Kaphaja and Sannipataja and their
treatment in 26th chapter of Chikitsasthan
In Ashtang Hrudaya karnasrava is not explained as a separate disease
but Chikitsa is mentioned in 18th chapter of Astanga Hrudaya
uttartantra
In Ashtang Samgraha Chikitsa is mentioned in 22nd chapter of Astang
Samgraha Uttartantra
The details about Karnasrava are explained in Bhavprakasha
Madhyamakhanda 64th chapter
Madhavakara has explained about Karnasrava in 57th chapter of
Madhymakhanda
Karnasrava is also explained in Sharangadara Samhita Uttarkhand 11th
chapter
The reference for treatment of Karnasrava is available in
Yogaratnakara
In Gadhnigraha Karnasrava and its treatment is mentioned in
Karnarogadhikara Adhaya
Vangasena had mentioned about the disease and treatment in 69th
chapter
Chakradatta explained Karnasrava in 57th chapter
Dalhana has given commentary on Sushrut Samhita Uttartantra 20th
and 21st chapter
Sankhya Samprapti of Karnasrava ndash
Aachary Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga
Vigyniyam Aadhaya Aacharya charaka explain 4 Karnaroga in
Page | 14
Karnarohvigyniyam Adhaya based on doshas Acharya Vagabhata in
Ashtang Hrudaya explain 25 Karnaroga in Adhyaya
कणवशल परणादशरच बाशरियव कषड ए च
कणवसरााः कणवकणडाः कणव चवसतततर च
कशमकणवपरततनाहौ विशरिदवविसततरा
कणवपाकाः पततकणवसततराशवशरचतवविम
कणावबवद सपतवि शोफशरचावप चतवविाः
ऎत कणवगता रोगा अटिावशततरीररतााः
स उ २०- ३ त ५[18]
ातकणवरोग वपततकणवरोग कफकणवरोग
रकतकणवरोग सनदरनपातकणवरोग कणवनाद
बशरिरतप परततनाह कणडाः शोफ पततकणवक
किशमकणवक उियरपविरधयअशो अबवद
कशरचकणवक वपपपली वदाररका पाळीशोष
ततिका पररपोिो उतपपातो उरमरर दाःखिवन
शलहाखयााः परचवशनदरतकणवरोगा उकतााः
इदिीका अ स उ २१ [19]
चतपाराः कणवरोगााः
च स [20]
Page | 15
KARNA
Karna ndash करोतत शबद गरहण [21]
The organ of hearing
Karnasrava- कणवसतय कणवयोाव ससराा [22]
Discharge from the ear is referred as Karnasrava
KARNA SHAREERA
bull Nirukti
कणयवत अकणयवत अनन इती [23]
It means reception and conduction of sound waves
These are the functions of external and middle ear
bull Nirukti of Sravanam
शरयत अनन इती शरणम[24]
It means perception of sound
It can be attributed to the internal ear function
bull Karna Utpatti-
Karna is an organ formed by Akash Mahabhuta[25]
The fundamental characteristic is as follows
Indriya ndash Srotram [26]
Indriya Adhisthan ndash Karna [27]
Indriya Dravy ndash Akasha [28]
Indriya Arth ndashShabdha [29]
Indriya buddhi ndash Srotobyddhi
Page | 16
bull Paryaya of Karna- Shabdapatha Srotrapatha Sravanam shruti
Kuhuram Dwanigraham etc
bull Definition of Karna-
कणवशटकलयनदछिरनमिटिोपगरदहत शरोतरमछयत [30]
मा तन ५७१
The definition of Karna is stated in Madhav Nidanam Indriya which is not
seen with naked eye along with Shashkuli is called Shrotra that is Karna
Indriya is so minute that it is not perceived with any sense organ
In Charak Samhita the word Karna explain as the Indriya Adhisthan of
Shabdha Karna is described as one of the Prathyangas of the body He
emphasizes that all Indriyas manifest during the 3rd month of gestation
period
Acharya Sushruta while describing formation of Purusha from Prakriti or
Avyakta narrated that all Indriyas are developing from the Vikarika and
Taijas Ahankara Both Vagabhata and Sushruta stated that Karna as one of
the Bahirsrotas
शरण नयन दन घराण गदमढराणण न सततरोताशसराणा बदहमवखातन [31]
स शा ५-१०
In Ashtang Hradaya Vagbhata has states that all Indriyas are Atmaja
According to him lower lobule elevated helix projected posterior portion
fleshy and adherent ear are indications of long span of life[32]
ततरखातखातन दह अनदसतमन शरोतर शबद ववकतता [33]
ा शा ३-३
शबदाः शबदनदरिय सवनदछििसमहो ववकतता [34]
स शा १-२६
Page | 17
Ear has the prominence of Akash Mahabhuta The prominent dosha of ear
is Vata It is important seat of Vata The prominent Dhatus are Asthi and
Mamsa Karna is one of the Panchgnanendriyas and it meant for hearing
Sushruta narrated that Karnasthita Asthi and Sandhi
घराणकणवगरीाकषिकोषष तरणातन [35]
सशा ५-२२
शरोतरशरगािकष शखाताव [36]
सशा ५-३२
गडकणवशखटककम [37]
स शा ५-२२
One Sandhi and one Tarunasthi in ear
Sandhi ndash Karna contain two Sandhi one in each ear Type of Sandhi is
Shankhavartha which is present in Shringataka
Mansapeshi ndash 2[38]
Siras ndash 10 [39]
Vataj Sira - 4
Pittaj sira - 2
Kaphaj sira - 2
Raktaj Sira - 2
Avedhya sira-
कणवयोदवश तासा शबदादहनीनामकका पररहरत
सशा ७-२५[40]
Amongst above mentioned ten Siras each Karna lodges one Shabdavaha
Sira It is Avedhya
Page | 18
Dhamani -2
Length of ear is 4 Angula
Karna moola ndash 2 Angula
कणाविरतर चतदवशअगलम
स शा ३५-१४[41]
The distance between two ears through the back of the neck is 14 Angula
bull Marmas of Karna-
1 Vidhuras-
कणवपटठतो अिाःसशरशरत विर ततर बशरियवम
सशा ६-३७[42]
कणतपयादद सतनायममवणी ककनदचचनदरनममनाकर कलयकररणणच
डलहणाचयव[43]
अिसततात कणवयोतनवमन विर शरततहाररणण
ा शा ४-२९[44]
Sankhya-2
Vistara- frac12 Angula
Type- Snayumarma (Susha)
- Dhamanimarma(AH)
- Vaikalykar
Sthana- It is situated in the depressed portion in the back of the ear
Injury to them causes loss of hearing
Page | 19
2 Shringataka marma-
नदजवहाकषिनाशसकाशरोतरखचतटियसरमम
तालरयासतयातन चतपारर सरोतसा तष ममवस
वदि शरगातकाखयष सददसततपयजतत जीवतम
मा तन ५७१ [45]
Sankhya- 4
Type- Siramarma
Sthana- It is in head that is amidst Siras (blood vessels) nursing sense
organ
A palm size area near Talu
Injury to this Marma causes death
In modern anatomy ear divides into Bhayakarna or External ear Mdhyakarn
or Middle ear Antahkarna or Internal ear This is extremely appropriate
Even though the ear is divided into three divisions in the point of modern
anatomy Ayurveda denotes ear organ is one Ayurveda treats disease by
way of assessing Dosha and Dushya Here Dushya is one that is Karnendria
Dosha difference will call for different treatment for different disease Hence
treating the vitiated Dosha will cure the disease irrespective whether it is in
external middle or internal ear The thought is based on different
fundamental principle from Ayurveda
bull Parts of Karna
In Ayurveda classics detailed description about anatomy of ear is not
available But the various parts are mentioned as follows
Bhayakarna- External ear
Mdhyakarna ndash Middle ear
Antahkarna- Internal ear
Page | 20
द कणवशटकशलक दॊ कणवपतरकौ
च शा 7-11[46]
कणवशटकशलक कणवगतातवकौ कणवपतरकौ त बाहयकणा
चिदतत च शा 7-11[47]
शटकली बाहयपालयाशरिटिानम
डलहन- स शरच 25-1 12[48]
Karna Shashkulika ndash It is also called as Karna Shashakuli Charaka has
mentioned this term while describing different Pratyngas of the body
Acharaya Gananatha sen has given the clarification for it as a pinna or
auricle[49]
Karnapali ndash It is popularly known as lobule of the ear Daivakrita Chidra is
present in it
Karnaputrika- Ayurvedic scholars accepted two terms in this cortex They
are Karnaputrika and Karnaputrika The former is considered as Tragus and
antitragus[50]
Karna Prushtha- It can be taken as the cranial surface of mastoid or
auricle[51]
Karnapeetha- Aacharaya Sushruta firstly mention the term Karnapeetha
It is mentioned first by Sushruta while describing the procedure of
Karnavyadana Vagbhata has mentioned that it is Adhobhaga of Karna
Dalhana has clarified that it is the region above the Karnaputrika that is the
region which is at the bottom of the concha
Karnamoola ndash It can be considered as parotid region[52]
Karna lathika ndashAcharaya Dalhana mentioned lobule as a Karna Lathika
Page | 21
Karnaavatu ndashThis term is used by Sushruta while describing the
measurements of different Angapratyangas where he has mentioned that
the distance between the Karnaavatu is 14 Angul Dalhana has comments
that it can be taken as the distance between two ears from behind[53]
Shabdhavahasrotas ndash It also called as Shabdapatha or Srotapatha The
whole passage through which the sound waves pass can be taken as
Shabdavahasrotas[54]
Shrotashringataka ndash It can be taken as the labyrinth of ear[55]
bull Dosha in context to Karna-
Karna is principal location of Vayu
1 Prana Vayu- Prana Vayu circulating in oral cavity is responsible for
Dehadhruka that is keeping all body parts active Indriyadruka that is
keeping all Dnyanendriya healthy by proper nourishment (Purana) helps in
deglutition of food material and convey the stimulation of Indriyabuddhi
and atma
2 Udana Vayu- Bala(strength) Varna speech singing are its function It
is responsible for facial expressions due to pleasure sorrow anger love
frustration etc in general its circulation and actions are just opposite to
Pranavayu
3 Vyana Vayu- Its principal functions are circulation of Rasa and Rakta
through body and various movements Its main location is Hrudaya Five
types of movements for which it is responsible are expansion contraction
upward downward and oblique other activities are opening closure of
eyelid yawning perspiration During circulation if it gets obstructed due
to Srotodushti it generates disease of that Srotas Vyana Vayu gets vitiated
by disease of Rasa Rakta Oja and Chetanadhatu
Page | 22
4 Samana Vayu- It is circulating in the vicinity of stomach and intestine
and helps in keeping the Jatharagni (digestive juices and enzymes) in
equilibrium Disturbance in Jatharagni precipitates disease
5 Tarpaka Kapha- Entire body functions movements are controlled and
executed by various centers in the brain Sensation perceived by sense
organs is conveyed to Mann and Aatma residing in Hrudaya The motor
signals from them are then conveyed to the functioning
organsKarmendriya through Prana Vayu Shira head is therefore a
location of continuous activities motions of Vata All these centers are in
unctuous Majjadhatu in the Shira For stabilizing this ever-active Vata and
to nourish the Majja dhatu very unctuous Tarpaka Kapha situated in Shira
plays an important role
bull Ayurvedic aspect of sound perception [56]
According to Ayurveda Pratyaksha Dnyan or Perception of any sensation
including Shabda occurs due to interaction of the Karnendriya and the
Indriya- Arth -Karma resulting in Sravana
External Environmental acquaintance with living body is executed by five
sense organs namely Netra Karna Nasa Jivha and Twaka All
Dnyanendriya that is sense organ are Panchmahabhautic combination
Despite this fact every Indrya sense organ perceives object Tanmatra of
that Mahabhuta only from which it is originated from Akash Mahabhuta and
hence perceives Shabd only that is audio perception Shrotrendriya is one
of the principal locations of Vata and its function is to perceive Shabda that
is sound waves This sensation is conveyed through Shabdavahi Dhamanis
to Mana and Atma through Pranavayu and the sequence is responsible for
perception of sound in this way external sound is perceived and interpreted
when Atma is linked with Mann Mann is linked with Indriyabuddhi that is
minute virtual Dnyanendriya located in brain Indriyabuddhi is linked with
Adhishthana with prominent Mahabhuta and lastly with Indriya
ArthShabdatanmatra that is sense object Once this sequence is completed
Page | 23
the meaning of a particular sound is interpreted and understood In this
entire process of perception and interpretation of sound waves Pranavayu
and Tarpaka Kapha located in Shira play extremely important role Hence
the healthy status of all the sense organ depends upon the normal
physiologically homeostatic condition of Pranavayu and Tarpaka Kapha
MANAS
ATAMA
BUDDHI
AHANKARA
ARTHA
Page | 24
EAR ANATOMY
bull Embryology of the Ear [57]
1 The sound conducting apparatus develops from the branchial apparatus
whereas the sound perceptive apparatus from the ectodermal otocyst
2 The pinna develops from the six hillocks around the 1st branchial cleft
3 External auditory canal develops from 1st branchial cleft
4 The outpouching of the 1st pharyngeal pouch gives rise to a proximal
narrow part that forms the eustachian tube and distal dilated part that
forms the middle ear cavity
5 Prussakrsquos space is a potential space lateral to the Shrapnellrsquos membrane
and medically by the neck of malleus that can be involved during the
extension of cholesteatoma
6 Development starts in the 3rd week of the intrauterine life and is
completed by 16th week of intrauterine life Membranous and boney
labyrinth develops from the otic capsule
The Ear is divided into
1 External Ear
2 Middle Ear
3 Internal Ear or the labyrinth
Page | 25
Fig 1 Ear Anatomy
EXTERNAL EAR [58]
The outside ear contains pinna and lobule
Pinna is the noticeable piece of outer ear made from single sheet of yellow
flexible ligament covered by subcutaneous tissue and skin It has two
surfaces average and parallel It is intently disciple to perichondrium on its
sidelong surface while it is somewhat free on average surface Pinna
incorporates tragus helix against helix fossa three-sided scaphoid fossa
incisura terminalis
External auditory Canal ndash It extends from the bottom of the conchea to
the tympanic membrane and measures about 24 mm along its posterior
wallit is S shaped
Parts 1 Cartilaginous part
2 Bony part
Page | 26
Cartilaginous part ndash The outer one third is cartilaginous consist of fibro
cartilage is directed first inward backward and upward It has Fissure of
Santorium The skin of this part of the canal contains hair follicles
sebaceous gland and cruminous gland
Bony part ndash The inner two third part is boney It goes forward downward
and medially skin lined in this part is very thin Isthmus is the narrowest
part of the canal lying medial to junction of bony and cartilaginous part
nearly 5 mm lateral to tympanic membrane
The roof and posterior wall of the external auditory canal shorter than floor
and anterior wall The skin lining the tympanic membrane and boney canal
has a self-cleansing property due to migration of keratin layer of epithelium
from drum towards the cartilaginous portion
Relations- Anteriorly- Temporomandibular joint and parotid gland
Superiorly- Middle cranial fossa
Inferiorly- parotid gland
Posterior- Mastoid antrum mastoid air cells and facial nerve
Nerve supply ndashSensory nerve supply of the external ear The auricle
supplied by fibers of the great auricular nerve (C2 and C3) and lesser
occipital nerve (C2) Auriculo temporal branch of the 5th cranial nerve and
auricle branch of the vagus (Arnoldrsquos nerve) supply external canal Facial
nerve has small sensory contribution on posterior-inferior wall
Tympanic Membrane -It is the partition between EAC and middle ear It
is a thin semitranslucent membrane pearly white in colored lying obliquely
in the medial end of EAC with the angle of 55 It is forming major part of
lateral wall of middle ear Annulus tympanicus is attached at its
circumference to the sulcus The TM is oval shape It measures
approximately 10 mm in vertical diameter and 90 mm in horizontal
diameter
Page | 27
Layers ndash Tympanic membrane consist of three layers
1 Outer Epithelium or cuticular layer which is continuous with skin of
external ear
2 Middle fibrous layer has both circular and radial fibers middle layer
missing in upper part
3 Inner layer- Inner mucosal layer which is continuous with middle ear
mucosa
Parts ndash Tympanic membrane consist of two parts
1 Pars tensa -It is largest part below the malleolar folds The inner
surface at the center attached to the handle of malleus Angle of cone
is most illuminated part in the pars tensa at anteroinferior part of pars
tensa
2 Pars flaccida Sharpnells membrane -it is triangular area above the
malleolar folds which are thin and devoid of fibrous tissue and
annulus It fits into notch of Rivinous
Nerve supply 1 Anterior half of lateral surface Auriculotemporal V3
2 Posterior half of lateral surface Auricular branch of vagus cn 10
3 Medial Surface Tympanic branch of CN 9 (Jacobsons nerve)
Fig 2 Tympanic membrane of ear
Page | 28
MIDDLE EAR [59]
The middle ear or tympanic cavity is an irregular laterally compressed
space within the temporal bone It is filled with air that is supplied to you
from the nasal part of the throat through the ear canal It contains a chain
of mobile bones that connect its side with the medial wall and serve to
transmit vibrations transmitted to the eardrum through the cavity to the
inner ear Including the parapet the vertical and anteroposterior diameters
of the cavity are each approximately 15 mm The transverse diameter
measures about 6mm at the top and 4mm at the bottom Compared to the
eardrum it is only about 2mm The eardrum is limited laterally by the
eardrum medially by the lateral wall of the inner ear It communicates
behind with the tympanic antrum and through it with the air cells of the
mastoid and in front with the auditory canal The middle ear together with
the Eustachian tube aditus antral and mastoid air cells is called the
middle ear cleft It is lined by mucus membrane and filled with air
It is divided into 3 parts
1 Mesotympanum (located in front of the pars tensa)
2 Epitympanum or attic (located above the pars tensa but medial to
Sharpnells membrane and the lateral bony wall of the attic)
3 Hypotympanum (located under pars tensa) The middle ear is like a
hexagonal box with a roof
Carotid or Anterior wall- It separates middle ear cavity from internal
carotid artery The various structure passing through anterior wall of
tympanic cavity
bull Canal of chorda tympani nerve
bull Canal of tensor tympani muscle
bull Eustachian tube
bull Anterior malleolar ligament
bull Anterior tympanic artery
Page | 29
Posterior or mastoid wall ndash The upper part of the back wall shows the
opening of the auditorium Below the auditory is a triangular bony
projection known as the pyramidalis processors The stapedial tendon is
transmitted through the apex of the pyramidalis processes The vertical
portion of the facial nerve descends along the posterior wall until it opens
into the stylomastoid foramen
Roof or Tegmental wall (Pars terminalis)- It is formed by a thin bone
plate called the tegman tympanum that separates the skull and tympanic
cavities It is located on the anterior surface of the rocky part of the
temporal bone near the junction with the temporal shell it extends back to
the roof in the tympanic membrane and anteriorly to cover the half canal
of the tensor tympanic muscle The lateral border corresponds to the
remains of the Petro scaly suture
Floor ndash It is formed by a thin plate of bone which separate middle ear from
the bulb of the internal jugular vein lodged in the jugular fossa
Lateral wall ndash It is formed by tympanic membrane and partly by a portion
of squamous part of the temporal bone It separates the middle ear from
external ear
Medial wall- It separates the middle ear from the inner ear
bull The promontory is the most prominent and convex part formed by the
basal rotation of the cochlea
bull The bony lateral semicircular canal is postero-superior to the promontory
above the oval window
bull The oval window is located between the middle ear and the vestibular
slope of the cochlea It is closed by the stirrup footrest and the annular
ligament
Page | 30
bull The round window is located under and behind the cape The round
window recess is directed to the rear It is closed by the secondary eardrum
and separates the middle ear of the Scala tympani from the cochlea
bull The facial nerve passes through the bony fallopian tube above the oval
window
Mastoid Antrum ndash It is a large space with air in the upper part of the
mastoid and communicates with the attic through the aditus The roof is
formed by the antri tegmen which extends and separates the tympani
tegmen from the middle cranial fossa The lateral wall of the antrum is
formed by a bony plate that is on average 15 cm thick in adults It is
marked externally on the surface of the mastoid by the suprameatal triangle
(MacEwen)
Aditus and Antrum- Aditus is a gap through which the attic communicates
with the antrum The boney prominence of the horizontal canal lies on its
medial aspect even as the fossa incudes to thats attaches the quick system
of incus lies laterally Facial nerve publications simply underneath the
aditus
The mastoid and its air cell system-
The mastoid consists of bone cortex with a honeycomb of air cell
underneath Depending on development of air cell three types of mastoids
have been described
1Well-pneumatized or cellular- Mastoid cells are well developed and
intervening septa are thin
2Diploetic- Mastoid consist of marrow spaces and a few air cells
3Sclerotic or acellular ndash There are no cells or marrow spaces
With any type of mastoid pneumatization antrum is always present In
sclerotic mastoids antrum is usually small and the sigmoid sinus is
anteposed
Page | 31
Depending on the location mastoid air cells are divided into
1 Zygomatic cells (In the root of zygoma)
2 Tegman cell (Extending into tegmen tympani)
3 Perisinus cells (overlying the sinus plate)
4 Retrofecial cells (round the facial nerve)
5 Peri labyrinthine cells (located above below and behind the
labyrinthine some of them pass through the arch of superior
semicircular canal These cells may communicate with the petrous
apex)
6 Peritubal (around the Eustachian tube Along with hypotymoanic
cells they also communicate with the petrous apex)
7 Tip cells (which are quite large and lie medial and lateral to the
digastric ridge in the tip of mastoid)
8 Marginal cells (Lying behind the sinus plate and may extend into
the occipital bone)
9 Squamosal cells (Lying in the squamous part of temporal bone)
Development of Mastoid ndash
The mastoid develops from the scaly petrous bone The petrosquamosal
suture may persist in the form of a bone plate - Korners septum which
separates the superficial squamosal cells from the deep rock cells Korners
septum is surgically important because it can cause problems locating the
antrum and deeper cells and thus lead to incomplete removal of the disease
during mastoidectomy The mastoid antrum can only be reached if Korners
septum is removed
Page | 32
Fig 3 Cross section of Mastoid
Contents of the middle ear
Ossicles ndash Three tiny bones which conduct the sound from eardrum to oval
window
Malleus ndash It is the largest and most lateral ossicle measuring 8 mm in
length It has head neck handle anterior and lateral processes The head
is situated in the epitympanum A lateral process project laterally from the
neck while the handle is firmly fixed to the pars tensa of the ear drum
Incus- It has a body short process and long process The body short
process and long process The body articulate with the head of mallelus in
the attic and the short process project into the attic The long process
projects downwards behind the handle of malleus running parallel to it and
articulate with the head of the stapes via the lenticular process
Stapes ndash It is the smallest ossicle measuring about 35 mm and consist of
head neck footplate and anterior and posterior curcura The footplate of
stapes is held to the oval window by the annular ligament
Page | 33
Muscles ndash
1Tensor tympani ndash It is inserted is a branch of the facial nerve which carries
the sense of taste It is first arch muscle supplied by branch of mandibular
nerve V3
2 Stapedious muscles ndash It is inserted to the neck of stapes It is the second
arch muscle supplied by branch of facial nerve that is nerve to stapedius
Fig 4 Contents of the middle ear
Blood supply of Middle Ear
bull Anterior tympanic branch of maxillary artery which supplies tympanic
membrane
bull Stylomastoid branch of posterior auricular artery which supplies middle
ear and mastoid air cells
Page | 34
Four minor vessels are
bull Petrosal branch of middle meningeal artery runs along greater petrosal
nerve
bull Superior tympanic branch of middle meningeal srtery traversing along
the canal for tensor tympanic muscle
bull Branch of artery of pterygoid carotid
bull Tympanic branch of internal carotid
Lymphatic Drainage of Ear
Lymphatics from the middle ear drain into retropharyngeal and parotid
nodes while those of the Surgical Importance ndash Eustachian tube drain into
retropharyngeal group
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 middle is likely to pass to
middle ear
2 Moreover middle ear suppurative disease may spread to adjacent organs
and produce complication eg Labyrinthitis meningitis facial nerve palsy
etc
3 Lenticular process is vulnerable in suppurative ear diseases and causes
ocular disruption
4 Prussac space is the site of primary acquired cholesteatoma
Page | 35
INNER EAR [60]
Inner ear is divided into two parts
1 Bony Labyrinth
2 Membranous labyrinth
Anatomy of bony labyrinth
It is divided into two parts
1 Vestibule
2 Cochlea
3 Semicircular canal
The vestibule is located between the medial wall of the middle ear and the
lateral to internal acoustic meatus anterior to the semicircular canal and
posterior to the cochlea The vestibule is the central part of the inner ear
On its side is the oval window opening which is closed by the bracket foot
plate The bony cochlea is located in front of the vestibule It has 275 turns
wound around a bony axis called a modiolus The cochlea is about 30 mm
long The hollow center of the modiolus is a spiral canal that contains the
fibers and ganglion cells of the cochlear nerve A thin bony sheet the bony
lamina winda around the modiolus This divides the cochlear duct into two
galleries the Scala vestibuli above and the scala tympani below
There are three semicircular canals superior posterior and lateral They
are semicircular in shape and open into the vestibule One end of the
semicircle is enlarged and is known as the sphere
The membranous labyrinth is in the bony labyrinth It is connected to the
bony labyrinth by fibrous trabeculae and is surrounded by perilymph The
endolymph is located in the membranous labyrinth
Page | 36
The utricle is in the upper part of the vestibule while the saccule is found
below Both the utricle and saccule contain a single sensory patch called
the macula Each macula is covered with a neuroepithelium made up of
neuroepithelium made up of sensory hair cells and support cells these cells
are separated by a basement membrane Fibers of the vestibulo-cochlear
nerve enter the macula and pierce the basement membrane to terminate
at the base of the hair cell or cell bodies The utricle and the saccule with
their macula are called otolith organs Membrane semicircular canals are
the membrane canals of the corresponding bony semicircular canals They
open into the utricle through five openings One end of the opening of each
channel is dilated called the sphere in which the sensory organ of each
channel is located The cross section of the Scala standard looks like a right
angle The base is formed by the basilar membrane Sensory cells are
arranged on the surface of the basilar membrane These sensory cells with
their supporting cells form a complex neuroepithelium called the basilar
papilla or the cortical organ named after an Italian microscopist The
organs of the corti have a gelatinous membrane called the tectorial
membrane and they are supported by the pillar of the corti The cortical
pillars enclose a space called the corti tunnel which contains a fluid called
cortical lymph Vestibule is lies between the medial wall of the middle ear
and lateral to internal acoustic meatus anterior to semicircular canal and
posterior to the cochlea 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 Boney cochlea lies in front of the vestibule It has 275 turns
coiling around boney axis called modiolus Cochlea is approximately 30 mm
in length The hollow center of the modiolus is a spiral canal containing the
fibers and ganglion cells of cochlear nerve A thin boney sheet the osseous
lamina winda around the modiolus This divides the cochlear canal into two
galleries the Scala vestibuli above and the scala tympani below
Page | 37
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 boney labyrinth It is connected
to the bony labyrinth by fibrous trabeculae and is surrounded by perilymph
Endolymph 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 single sensory patch called macula Each
macula is covered by neuroepithelium consist of Neuroepithelium consists
of sensory hair cells and supporting cells these cells are separated by
basement membrane Fibers 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 are referred
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 corti lymph
Page | 38
Fig 5 Inner Ear
Blood supply of labyrinth
Labyrinthine artery
Common cochlear Anterior vestibular Artery
Vestibulocochlear artery Main cochlear artery
Cochlear branch posterior vestibular artery
Page | 39
PHYSIOLOGY OF HEARING [61]
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
bull Mechanical conduction of sound (conductive apparatus)
bull Transduction of mechanical energy to electrical impulses (sensory
system of cochlea)
bull Conduction of electrical impulses to brain (neural
Fig 6 PHYSIOLOGY OF HEARING
Page | 40
Conduction of sound
Under the surface of water we cannot hear the sound made in air because
9995 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 must 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 13 times longer than long process of incus providing
a mechanical advantage of 13
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 beings 211 As the effective
vibratory area of the tympanic membrane is only two- thirds the effective
areal ratio is reduced to 141 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
Page | 41
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 lobe
Page | 42
DISEASES REVIEW
करणसराव
Nirukti - करणसय कणवयोाव ससराा [62]
Nidana- Acharya Sushruta and Vagbhata describe the common etiological
factors for the Karnaroga
अशयाय जलिीडा कणवकणडयन मरत
शमथययोगन शसततरसतय कवपतो अरय च कोपन ||
सउ २० १२
1 Avashaya or Pratishaya
(Excessive exposure to cold)
2 Jalakrida
(Excessive swimming)
3 Karnakandunyanum
(Excessive scracing due to itching)
4 Mithyayogena Shatrasya
(Improper instrumentation during wax removal or foreign body removal)
5Shabdasya
(Louder sound for long durationperverted contact of sound)
6 Abhighata (Trauma)
7 Vitiation of Tridoshas
Page | 43
Samanya Nidana according to different Samhita
Vishesh Nidan of Karnasrava
Acharya Charaka has not mentioned any kind of Nidana regarding Karnaroga
but has described Utapati of Karnaroga from Siroroga in Karnasirasym
Adhyaya[67]
शशरोअशिघातादरा तनमजजतो जल परपकादरा अवप विि
सरतत पय शरणॊ अतनलात स कणवससरा इतत परककतीत
सउ २० १०
असस ३७२५ [68]
1 Shiroabhighatat - Head Injury-Fracture of middle cranial fossa
2 Jala nimajjana - CSF otorrhoea fracture of middle cranial fossa
3 Karnaprapaka
4 Karna Vidhradhi -Puyasrava
Sr
no
Samanya Nidana SU AH[63] AS[64] YR[65] MN[66]
1 Avashaya + + +
2 Pratishaya + +
3 Shabdha
mithyayoga
+
4 Shashtra
mithyayoga
+ + +
5 Karnakandooyan + + + + +
6 Jalkrida + + + + +
7 Abhighata + + +
Page | 44
Samanya samprapti
परापय शरोतरशसरा कयावत शल शरोतशस गान
त कणवगता रोगा अटिावशततरीता
सउ २० १२
Due to common and specific etiology factors the vitiated Doshas gets
Sthanasamshraya in Karna and causes Karnasrava It is the stages of
Samprapti were Doshas gets lodged in Srotas and start processes of Dosh
Dushya Sammurchsna Due to Shiroabhighata Jalanimmajana Karna Paka
Karna Vidhradi vitiated Vata Dosha and Karna becomes Avruta by Vata and
results in Karnasrava Normal physiology of Dosha Dhatus and Malas entirely
depends on the normality of Srotas Dosh Dushya Sammurchana or
manifestation of diseases will not take place if only vitiation of Doshas take
place without deformity of Srotas Here in Karnasrava vitiation of Srotas are
Atipravritti Sanga and Vimargagamana take place Atipravritti is being excess
production of fungus Sanga is obstruction in external acoustic canal
Vimargagamana is the propagation of discharge through ear
Vishesh Samprapti
Karnasrava occurs due to Nij nidana is Pratishaya while Agantuja nidanas are
Avashya Jalkrida and Karnakanduyan Due to etiological factors which are
Vata-Kapha provocative in nature gradual vitiation of Doshas will occur After
vitiation they get accumulated (Sthan samshraya) in external auditory canal
In other hand when patient does Sevana of Agantuj Nidan like water enter in
external ear scratching of ear unsterile instrumentation leads to Dosh
Prakopa These cause Twak and Mamsa Dhatu Dushti which leads to
discontinuity of epithelium of ear canal which creates suitable atmosphere for
fungal pathogen to grow The vitiated Vata will produce symptoms such as
Page | 45
pain hearing impairment and vitiated Kapha causes symptoms like itching
discharge ear blockage By assessing the symptoms it can be said that Kapha
Avrita Vata Dosha is responsible for the manifestation of clinical features like
pain itching discharge Which are seen in Karnasrava that is otomycosis
Acharya Charaka has mentioned while explaining Samanya Chikitsa of
Karnaroga that it should be treated like Vrana when Paka and Srava is present
as a symptom Fungal spores invade in the epithelial layer of EAC In response
to infection inflammatory process is start This is a Paka Avastha After
removing the fungal mass ulceration in external acoustic canal is commonly
seen As a result of infection process exudates was produced which will mix
up- with fungal colonies and appear as discharge As per Dosha involvement
in Vrana Shoola Srava can be differ According to Acharya Sushruta Ruk is
the Samanya Lakshana of Vrana and Vishesha Lakshana of Vrana includes
pain discharge discoloration itching etc according to Dosha involvement
which are also seen in otomycosis In otomycosis mainly watery and purulent
type of discharge is present which indicates Paka avastha If there is Dosha
involve in Vrana is called Dushta Vrana Acharya Sushruta and Acharya
Vagabhata have mentioned verity of Srava in Twak and Mamsa Vranavastu
which is found in otomycosis Based on this description otomycosis can be
correlated with Karnasrava
Page | 46
Representing the Samprapti of Karnasrava
Vishesh Nidana ndash Shiroabhighatat
Jala nimajjana
Prapaka Vidhradhi
Vitited vata
Avarana by kapha
Vimargagamana of Vata
Karnasrava
Samprapti Ghataka
Dosha ndash Kapha and Vata
Dushya ndash Rasa Rakta and Mansa
Strotodushti ndash Vimargagamana and Sang
Adhishthana ndash Karna (Bhayakarna)
Rogmarga ndash Madhyama
Page | 47
Purvarupa
The Purvarupa of Karnasrava are not mentioned separately in any ayurvedic
classics In routine practice cretin Purvarupa are noted
1 Karnakandu
2 Karnagurutwa
3 Alpa karnashoola
4 Discomfort in ear
Rupa
1 Karnashoola
2 Karnakandu
3 Karnasrava
4 karnabadhirya
5 Cotton wool like or wet newspaper like grayish brown or black colored mass
is seen
6 External auditory canal skin appears edematous and red
Upashaya and Anupashaya
Appropriate application of Aushadhi Ahara and Vihara when produces relief in
the symptom is called as Upashaya and when aggravates the symptoms is
called Anaupashaya There is not any reference available in the classics about
the Upashaya and Anupashaya of karnasrava
Sadhyasadhyata
Sushruta has not mentioned specially the Sadhyasadhyata of Karnarogas But
Vagbhata has mentioned Karnasrava as a Sadhyavyadhi[69]
Sadhysadhyatagives the clear picture of prognosis of the disease It depends
on many factors like nature of disease severity of disease Vaya Prakriti Bala
of the patient etc
Page | 48
Upadrava of Karnasrava
In Samhita there is no reference available regarding the Upadrava of
Karnasrava
Samanya Chikitsa ndash
The common treatment principle for all Karnaroga is Ghritapana Use of
Rasayana Bhrahmacharya Avyayama Shirasnana and Atibhashaya
सामरय कणवरोगष घतपान रसयनम
अवयायमो शशराःसतनान बरमहचयवम कतपरनम
स उ२१३
Ghratapana - Ghrita is a Yogavahi and follow Sanskara in addition to these
acquired properties and capable of retaining its own properties So Ghritapana
is effective in Karnasrava
Rasayana - Rasayana represent the basic approach of Ayurveda which
comprise preventive promotive and curative aspect of health
Brahmacharyaapalana -It is like Sadvrittapalana and is equals to Rasayana
effect
Vyayama - It leads to vitiation if Vatas a Karna is a Sthana of vata and
exercise causes Kshayaj Samprapti hence it is important to avoid exercise in
Karnasrava
Shirasnana- In Shirasnana water enters in external acoustic canal it changes
the PH of meatus skin from acid to alkali which favors the growth of pathogens
Atibhashya - Excessive speaking causes Vata Prakopa and Vatapraokopa is
basic Samprapti for Karnasrava as the preventive aspect avoidance of
excessive speaking is necessary
Page | 49
Ghritapana Rasayana and Brahmacharyapalana should be followed for
preservation of dhatu Samyata and restriction of vitiation of Vata Vayayama
Shirasnana and Atibhashaya should be avoided in Karnasrava to protect the
Siras from the affliction of Vata and Kapha
Vishesha Chikitsa ndash
The general treatment principle of Karnasrava described in classics is closely
related to Dushtavrana Chikitsa
शशरोवरचन च ए िपन परण तरा
परमाजवन िान च ीकषय ीकषय़ाचारत [70]
स उ २१४०
कणवसततरा ोददत कयावत पततकशमकणवयो [71]
ाउ १८३५
उपददि च सततरोत साय परात वपचततवशि परमजय
य अगर मदन सघत गगलना ा िपतयतपा मिना परयत [72]
असउ २२४२४३
In addition to that Shirovirechana Karnadhoopana Karnapurana
karnapramarjana Karnadhavana are also indicated
Page | 50
Treatment is also mentioned for Karnasrava
1 Karnaprakshalana Yoga - with Aargawadadi Gana Kashaya and Surasadi
Gana Kashaya [73]
2 Avachurnana Yoga ndash with Aargawadadi Gana Churna and Surasadi Gana
Churna[74]
3 Karnapoorna Yoga ndash
bull Rasanjana Laksha with Sarjachoorna[75]
bull Panchkashaya with Kapittha swarasa and Madhu[76]
bull Jambu AmrapallavShivalaKshuodra Mahavriksha and Madhuki 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 done[77]
bull Sarjatwak Choorna with Karpashiphalarasa and Madhu[78]
bull Abhaya LodraTindukaSamanga(Manjista) Kwatha of this Dravyas mixed
with Madhu and Kapittha Rasa[79]
bull Yogratnakara mention the following drugs for Karnapoorana-
a Samudraphena Churna[80]
b Jambwambpatra Yoga
4 Karnadhoopana Yoga ndash
bull Dhoopana with Churna of Bilvapatra Haridra Palandu[81]
bull Vartak Dhoopana [82]
5 Internal Medications-
bull Rasnadi Guggula [83]
bull Triphala Guggula [84]
bull Sarivadi Vati [85]
bull Gandhaka Rasayana [86]
Page | 51
According to Vagbhata-
Ear should be cleaned with the Pichu and Varti followed by Guggula Dhoopana
and then Karnapoorana with Madhu Followed by Avachurnanana with
Sukshmachootana of Surasadigana
Pathyaapathya ndash Pathya and Apathy mentioned for Samanya Karnaroga is
recommended in Karnasrava also
पथय[87]
सतदो वरको मन नसतय िमाः शशरावयिाः
गोिमाः शालयो मदगााः याशच परतन हवाः 80
लाो मयरो हररणानदसततततरो नकककिाः
पिोल शशगर ातावक सतनषराण कदठललकम
रसायनातन सवणण बरमहचयवमिाषणाम |
उपयकत यरादोषशमद कणावमय दहतम ||81||
िापर २१
Aharaja Upacharaja
bull Godhuma bull Vamana
bull Shala bull Virechana
bull Mudga bull Nasya
bull Yava bull Dhoomapana
bull Puranagitra bull Kavala
bull Lava Harina Tittiramamsa
Page | 52
अपथय[88]
दरत काटठ शशरसतनान वययाम शलटमल गर
कणडयन तषारशच कणवरोगी पररतपयजत
िापर २१
Viharaja
bull Patola ShigruVartaka bull Bhramacharaya
bull Sunishannaka bull Avyayama
bull Katthlika bull Aakthanam
bull All types of Rasayana bull Upacharaja
bull Vamana
Apathyas
bull Abhishyandakara Aharas
bull Shirasnana
bull Karna kandooyana
bull Tushara sevana
bull Guru Kaphakaraka Aaharas
bull Dantdhavana
Page | 53
OTOMYCOSIS
Definition-
Otomycosis is a superficial acute sub-acute or chronic infection of external
ear canal It is mostly unilateral It is characterized by inflammation purities
and scaling Otomycosis is a common condition encountered in ENT practice
more in chronic and persistent ear infection
The Fungal infections are not communicable in the usual sense but the
humans become an accidental host by their introduction into tissue trauma
The virulence factors favoring colonization of fungus in human host are yet to
be identified Ability of the fungus to grow at 37 C and elaboration of a variety
of enzymes and toxins are speculated to contribute to virulence Only 100 to
150 species are generally recognized as a cause of disease in humans[89]
Prevalence-
Otomycosis is a word wide in distribution and in various record stated that 5
to 20 of all cases of infective otitis externa Otomycosis prevalent is more in
warm and humid climates It is one of the commonest manifestations in India
during rainy season It occurs mostly in humid atmosphere otitis externa due
to fungal infection may resembles the desquamative form of diffuse infective
otitis externa The incidence in temperature climates has increased in
proportion to the use of topical antibiotics which have a medium sterilized of
other organism in which the fungus may flourish
Page | 54
Predisposing factors- [90]
1 Environmental factors such as climate contagious and polluting hygiene
more frequently during rainy season as the humidity increases
2 Individual susceptibility ndashGeneral Immunological status of the Individual
eg HIV infection Radiotherapy chemotherapy Diabetes mellitus
3 Self-inflicted trauma that is use of pins to clean the itching ear or use of ear
bud to clean the wax
4 Wide spread of topical antibiotics steroid preparations which have medium
sterilized of other organism in which the fungus may grow
5 Failure of defense mechanism in External auditory canal
6 During swimming or head bath water enters in External acoustic canal
causes quantitative and qualitative change in ear wax It causes change in pH
7 Long term use of hearing aids
Pathophysiology ndash
The life cycle of the average mold encountered in the ear may be reckoned
as two weeks and flare ups may be anticipated at such intervals Swimming is
held responsible for infection in many cases The sequence sequence of
pathogenic changes produced by molds in the external ear is as follows ndash
1 Implantation of the organism in external ear
2 Growth of organism follows the rate depending on condition of temperature
moisture or preexisting irritation
3 Invasion of epithelium occurs with attendant itching and discomfort which
may be quite severe
Page | 55
4 Exfoliation of epithelium occurs as nature attempts to overcome the
infection by casting off upper most cells
5 Denudation occurs from exfoliation as the top layers of epithelium are cast
off and the canal becomes filled with debris
6 Superficial ulceration and lizematoid dermatitis results if the pathologic
process goes for enough The changes do not always proceed through the
entire sequence sometimes the molds produce changes of the mildest
imaginable character which may be overlooked[91]
Clinical features -
Symptoms-
1 Irritation and itching ndash Irritation is mostly found when the infective
organism is aspergillus niger There is sensation of discomfort which is more
diffuse in the ear canal then localized in the deeper part Candida infection
causes marked itching In external ear it is intense and worse at night
2 Discharge through ear- Intermittent scanty colorless discharge through
ear Mucus being a fungal metabolic product appears as discharge Excessive
discharge is associated with mixed infection
3 Pain and discomfort ndash Mild to severe pain in the ear occasionally Mostly
seen in cases where ear is infected with Aspergillus flavus mixed infection
with gram negative organism or mixed infection with candida and aspergillus
Headache is sometimes associated with pain
4 Deafness- Varying degree of mild to moderate conductive deafness
5 A sensation of fullness in ear
6 Tinnitus 7 Vertigo
Page | 56
Signs ndash
1 The external acoustic meatus may contain a mass formed of epithelial
debris exudates cerumen and fungus
2 Erythematous external canal
Fungal appearance
A Niger - The color of the mass which is usually grey or black is mainly
determined by the type of fungus concerned Its appearance is like wet
newspaper or blotting paper or a cotton wool It has a peculiar musty odor In
this infection fruiting heads may be seen as black specks in the debris
Occasionally as inactive form occurs in which the canal is lined by mold giving
a fluffy appearance due to the presence of tiny mycelia
Candida ndash Candida infections generally show as white deposits on magenta
colored skin when the debris is removed it rapidly recovers in 24 hrs
The underlying canal skin is often inflamed and granular due to invasion by
fungal mycelia and be seen in all cases In rare cases excoriation and
ulceration with marked extensive shedding of the epithelium and deep
ulceration can be seen usually associated with a flavus and with pathogenic
bacteria[92]
Otoscope Appearance
1 Aspergillus Niger ndash Black headed
2 Aspergillus Fumigators ndash pale blue or green
3 Candida Albicans ndash White- or cream-colored deposits
Page | 57
4 Auricle is normal in most cases In severe cases small ulceration with crust
formation may be present on lateral surface
5 Tympanic Membrane
In most cases it is normal with normal mobility and normal hearing In a few
cases the surface of the tympanic membrane is congested and scaly There is
erosion or ulceration of the external epithelial layer and the membrane itself
may be edematous
Diagnosis
1 Above mentioned symptoms and signs
2 In the stage at which patient with otitis externa usually first present
themselves mycelia threads conidiophors not visible to naked eye may
sometimes be identified with the microscope
3 Confirmed by culture
Page | 58
Fig7 Aspergillus Niger Fig8 Candida Albicans
Fig9 Aspergillus Fumigators Fig 10 Wet Paper like appearance
Page | 59
Treatment
1 Antibiotic or steroid drops should be discontinued if they are being instilled
since long time
2 Removal of fungal mass epithelial debris and discharge from the external
canal or mastoid cavity repeatedly and thoroughly by forcepa or suction or
syringing or cautiously blow a stream of air into the canal through a fine
cannula and dry thoroughly by swabbing liquid petroleum on swab used in
cleaning the ear lessens the burning sensation when metacresy acetate is to
be employed in the subsequent treatment
Furuncle is developed as a complication if there is no gentleness in cleaning
Cleansing may have to be delayed until local sensitiveness is lessened which
can usually be accomplished within twenty-four hours If there is excessive
epithelial debris along with otomycosis then metacresyl acetate which is a
keratolytic in introduction into the external auditory canal on cotton wick and
is allowed to remain for twenty-four hours After twenty-four hours the cotton
wick is removed at which time the canal can usually be cleansed with little
discomfort as the medication is also anesthetic The epithelium of the canal
was white from contact with the drug The top layer was detached and this
epithelial debris can be easily wiped away The wick is reinserted and wet with
metacresyl acetate
The treatment is employed for three to four days in succession and then a
bland application is substituted Icthyol iodine is of value at this stage Iodine
ointment 2 in combination with Tannic acid 2 is also an excellent local
application following cresatin treatment
Next one of the fungicides may be applied
Page | 60
1 Nystin Effective for candida infection but less active against aspergillus
group Nystatin in boric powder consisting of 100000units of nystatingm of
powder 3 times week for 3 weeks
2 Clotrimazole Available as 11 cream or drops or lotions Phenyl
(zchlorophenyl) 1 ndash imidazole ndash methane is a chlorinated trityl imidazol 1
effective against candida and dermatophytes and for aspergilli infection
3 Amphotericin B Available as cream and as 3 solution and 015 drops
for topical application Very effective for candida infection can be fungistatic
or fungicidal
4 Econazole Available as solution (Econazole nitrate) and as cream (1)
Broad spectrum ndash more effective for Aspergillus Also active against some
gram-positive bacteria (Staphylococci and Streptococci and Dermatophytes)
5 Miconazole Highly effective against dermatophytes and candida infections
used as a 21 cream applied once or twice a day for 10 days
6 Gentian violet 21 Available as drops (recently some evidence of
carcinogenicity) Discolors the ear canal and this interfere with clinical
examination
Other topical antifungal agents are ketoconazole Natamycin Tolciclat Bifonas
zole Fenticonzole Oxiconazole Tioconazole ciclopiroxolomine Tolnafate
Haloprogin Flucytosine Acetic acid Whit field ointment selenium sulfide
undcyclenic acid triacetin etc
Page | 61
Minimal length of treatment
A month of drug treatment is usually required because the antifungal agents
used are not sporicidal and it is necessary that the period of treatment covers
germination time It may be advisable to give short gaps in the period of
treatment to ensure all spores have germinated before deciding to terminate
therapy
Prevention
Accomplished by strict attention to the predisposing causes
1 Water should be prevented from entering the ear
2 Avoidance of external ear trauma
3 Use of alcohol medicated or plain in the ears after swimming mercuric
cyanide (15000) in ethyl alcohol (70) is a satisfactory liquid to use
Ear stoppers do no good unless their use is followed by some antiseptic in the
canal Divers exposed to water for long periods of time may also use acidic
alcohol
4 During Summer months with their high humidity special efforts are needed
to maintain ear dry 5 Indiscriminate use of topical antibiotics steroid
preparations should be avoided
Page | 62
DRUG REVIEW
1 GUGGULA
Fig11 - Guggula
Historical review of Guggula [93]
bull Atharvaveda one of the well-known Vedas of Hindus The earliest
reference given by Atharvaveda medicinal and therapeutic properties of
Guggula Guggula has long history of use in Ayurveda
bull Acharya Charaka Sushruta and Vagbhata describe detail regarding the
actions uses and indication as well as the variety of Guggula
Page | 63
bull Various Nighantus (Medical lexicons) were written between 12th and 14th
centuries AD was based on the Ayurvedic literature also describes
Guggula
bull The explanation of word Guggula is that Gunjo Vyadhegurdti Rakshati
which means to relief against different diseases
bull Guggula is the best medicine because it develops through the rays of
hot sun on specific circumstances
bull Guggula has an aromatic odor
गगलो कणवदौगवररधय िपन शरटठमछयत[94]
स उ २२११२
Latin name- Commiphora mukul
Family ndash Burseraceae
Rasa- Tikta Katu
Guna ndash Laghu Rukshasukshma vishada sara
Veerya ndash Ushna
Vipaka ndash Katu
Action- Rasayana Lekhana
Doshaghanta - Tridoshhara
Page | 64
Chemical composition [95]
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Oleoresin-Z-Guggulsterone E-Guggulsterone
Gum- guggulignans 1 and 2 guggula Tetrols mukulol allylcembrol c
27
Guggulusterol 1 2 ans 3 Z and E ndash guggulusterol
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Parts Used ndash Gum oleoresin
Guggula purity test
1 Yellowish brown emulsion is obtained when Guggula is triturated with
water
2 An ethereal solution of the drug attains reddish colour when treated
with br2 vapors and purple colour when moistened with nitric acid
Biochemical action ndash Antiseptic Anti-inflammatory Disinfectant Diuretic
Immunostimulant stimulating expectorant Ant suppurative Antipyretic
Enhance phagocytosis
Karma- Rasayana cardiovascular disease
Page | 65
2 AGARU-
Fig 12 Agaru
Historical review of Agaru [96]
bull The word Agaru literally means the one which is the heaviest and no
aromatic wood is heavier than it Since thousands of years Agaru lsquoThe
wood of Godrsquo has been used for multiple purpose like commercial
medicinal spiritual aromatic historical
bull The medicinal use of Agaru have been recorded in many pieces of India
Greek Roman Chinese Middle eastern and European since ancient times
bull Acharya Charaka used Agaru and pest of Rasna to counteract the effect of
cold in Agraya Dravyas
bull Acharya Sushruta used Agaru as a Dhoopana Dravya along with Guggula
Ral and Shoma in the treatment of Karnasweda and Vrana
Page | 66
Types-
bull Dhanwantsri Nighantu describes Kaleyaka as a type of Agaru
bull Sodhala Nighantu describes three types of Agaru ndash Agaru Krishna
Agaru Kakatunda Agaru
bull Raj Nighantu describes five types of Agaru ndash Krishna Agaru Kasht
Agaru Daha Agaru Mangalya Agaru and Agurusaar
bull Arthashasstra describes three Agaru wood product
1 Jongaka ndash Black or variegated black in colour and having variegated
spots
2 Dongaka ndash Black in color
3 Parasamudraka- Black in colour and smells like Navamallika
अगर उटण कि तपछय ततकत ततकषण च वपततलम
लघ कणाविरोगघन शीत ात कफपरणत
िापर २१ [97]
Family- Thymelaccensis
Latin name- Aquilaria agallocha
Guna- Laghu Ruksha Tikshan
Rasa- Katu Tikta
Vipaka ndash Katu
Virya ndash Ushna
Karma- Sheetaprasasmana Vranaorasadan Tvachya Pittavardhaka
Shirovirechana Mangalya Sugandhik and Rochaka in properties [100]
Krishna Agaru karma- Katu Tikta rasa Ushna Sheeta when applied externally
and Pittahara when taken orally
Page | 67
Chemical Constituents -
Agaru hardwood is rich in essential oil resins alkaloids saponins Steroids
terpenoids tannins flavonoids and phenolic compound Agaru wood
predominantly contains 2-[-2-phenylethy]-4H-chromen-4-one derivatives and
sesquiterpenes Agaru oil contains selinene dihydroselinene agarnol b-
agarofuran vetispira-2(11)valerianol dihydrokaranone and tetradecanoic
acids[99]
Part Used ndash
Heartwood- Dark resinous wood which is formed when the plant becomes
infected with a type of fungus (ascomycetous mold) Species of Aspergillus
fusarium and penicillium are reported to be associated with the development
of infection Prior to infection the heartwood is odorless relatively light and
pale colored however as the infection progresses the tree produces a dark
aromatic resin in the heartwood The infected resin in response to the attack
which results in accumulation of a very dense dark resin in the heartwood
The infected resin embedded wood is known as Agarwood Infection is more
common on the trunk roots and the area when branches divide The formation
of Agarwood starts when the tree attains the age of 20 years On an average
approximately 30 ml oil is extracted from 100 kg of infected Agarwood[98]
Qualities of best Agaru-
It should be black in color
It should be extremely heavy and aromatic
It should be oily in appearance and test
It should be sink in water
It should burn easily with bright flame with a bright flame giving off a pleasant
smell
Page | 68
3 MADANA
Fig 13 MADANA
Madana consist of dried fruit of Xeromphis spinosa It is a deciduous thorny
shrub or a small tree reaching a high up to 9 m and girth about a meter
branches numerous thick and horizontal found in sub-Himalayan tracts[101]
मदनो मिरनदसततकतो ीयोटणो लखनो लघ
ानदरतिदवििीहर परततशयायवरणारतक
रि कटठकफ़ानाहशोथगलमवरणापह[102]
िा पर १६० १६1
Page | 69
Latin name-Randia dumetorum
Familly ndash Rubiaceae
Rasa - Madhura Tikta
Guna-Laghu Ruksha
Virya- Ushna
Vipaka ndash Katu
Karma- Vamana and Lekhana
Chemical Composition-
Essential Oil Valerianic acid Saponin tannin resin [103]
Page | 70
YAWA [104]
Fig 14 Yawa
1 In Samhitakala Aacharya Charaka Acharya Sushruta explain detail about
medicinal properties of Yawa
2The use of Yawa in Aaharya Dravya mainly described by Dhanwantari
Nighantu Raj Nighantu Bhavprakash Nighantu[105]
Macroscopic Description-
Fruit a caryopsis elliptical oblong Ovoid and tapering at both ends smooth
about 1cm long and 02- 03cm wide dorsally compressed and flattened on
the sides with a shallow longitudinal furrow 3-5 ridges having shallow
depression between them grains tightly enclosed and adhering the lemma
and palea pale greenish yellow odor not distinct taste sweetish acrid
Page | 71
Latin Name ndash Hordenum vulgare
Family- Poaceae
Rasa- Kashaya Madhura
Virya- Sita
Vipaka- Katu
Karma- Vatakrt Pittahara Kaphahara Medahara Balya Visrya
SthairyakaraLekhana
Page | 72
PROCEDURE REVIEW [105]
In Ayurvedic classics there are many references regarding Dhoopana Dravya
Dhoopana is administering Dhuma with the help of Dhoopana Dravya
In Kashyapa Samhita there are 40 types of Dhoopana advised for children
Anesthesia (Mohajananam Dhoopa) is also mentioned For this Dhoopana the
drug used were herbs hairs of animals legs horns old cloths of Buddhist
monks
From the references available regarding Dhoopana we can understand that
Karna can be protected from maggots (krimi) Bactria (Rakshogna) lice etc
References clearly indicate the analgesic and disinfectant effect of Dhoopana
Karma Dhoopana is mentioned for Dushta Vrana Chikitsa It reduces Vedana
Srava Pootigandha of Dushtavrana It also helps in Vranaropana
Dushtavrana Chikitsa is mentioned in the treatment of Karnasrava[106]
Origin of Dhoopana-
In ancient period children of sages were constantly harassed by the
Rakshasas Hence the sages approached lord Agni for shelter Agni in turn
gave them Dhoopana Dravya and asked sages to use the Dhoopana for
protection against Rakshasas bhutas pishachas
Classification of Dhoopana
1 It is classified into Dhupa Anudhupa Pratidhupa
2 On the basis of Origin it is classified into Jangama and Sthavara
Selection of Guggula for Dhoopana
Page | 73
bull Guggul is a best Vatahara
bull It is Krimighana
bull It contains Oleoresin
bull In Ashtang Hrudaya Guggula Dhoopana mentioned for Karnasrava
Selection of Agaru for Dhoopana
bull Agaru is Laghu Ruksha Katu Tikshna
bull Vranaorasadan Tvachya
bull It should burn easily with bright flame with a bright flame giving off a
pleasant smell
Karna Dhoopana Indication
1 Karnaarava
2 Putikarna
3 Krimikarna
4Vataj Karnashula
Contraindications
Especially for Karnadhoopan contraindication is not mentioned in classic texts
But Dhoopana is contraindicated in Pittaj vaydhi Sharad and Grishma Rutu
Page | 74
MATERIAL AND METHOD
Page | 75
For randomize comparative clinical trial to study the effect of Agaruwadi
Karnadhoopana and Guggula Karnadhoopana in Karnasrava following material
and method were required
Source of data
Patient irrespective of gender occupation religion social economic status
signs and symptoms of classical features of Karnasrava (Otomycosis) selected
from the OPD of Shalakyatantra department
Materials ndash
1Patients
2 Drugs-Agaruwadi Dhoopana
Guggula Dhoopana
3Torch
4Otoscope
5 Tuning fork
6Jobson horn probe
7Cotton
8Case record form
DRUG
Group A Trial Group
1Churana of Agaru Yawa Madan
2Ghrita
3Jala
Group B Control Group
1Googula Churna
Page | 76
Properties of Drug
Table no 1 Properties of Drug
Drug
Family
Rasa Veerya Vipaka Effect
on
Dosha
Guna Karma
Agaru
(Aquilegria
Agallocha)
Thymelaca
ceae
Katu
Tikta
Ushna Katu KV Laghu
Ruksha
Tikshna
Shitaprashamana
Shothahara
Vedanasthapak
Durghandhihara
Madan
(Randia
spinosa)
Rubiaceace
Kashaya
Madhur
Tikat
Katu
Ushna Katu KV Ruksha
Laghu
Vatakaphaghana
Shothahara
Vedanasthapak
Vranashodhak
Yawa
Poaceae
Hordeum
Vulgare
Kashaya
Madhur
Sheeta Madhur KP Ruksha
Laghu
Vataghana
Vernashodhana
Raktshodhaka
Guggula
Commiphora
Mukul
Burseracea
e
Tikta
Kashaya
Anushna Katu VPK Laghu
Ruksha
Shothahara
Vedanasthapaka
Kandughna
Ghrita Madhura Sheet Madhur VK Snigdha Vataghana
Shothahara
Vedanasthapaka
Page | 77
METHODOLOGY
SELECTION CRITERIA
1)INCLUSION CRITERIA
1 Patients having signs and symptoms of Karnasrava (Otomycosis) ie करणशल
( pain ) करणकणड ( Itching ) करणसतराव ( Discharge )बाधिरण ( conductive Loss of
hearing )
2 Patient from age group 19 to 70 years
3 Any Gender
2)EXCLUSION CRITERIA
1 Patients suffering from any systemic disease like DM TB HTN
2 Chronic suppurative otitis media (CSOM)
3 Acute supportive otitis media (ASOM)
3 Perforation of Tympanic membrane
4 Chronic otitis media
3)WITHDRAWAL CRITERIA
1If patient develops any adverse effect such as irritation pain burning
sensation in ear loss of hearing and such patients was withdrawn from trial
and receive prompt appropriate medical attention
2If patient shows aggravation in symptoms
3If patient refuses to continue with the treatment
Page | 78
STUDY SETTING
Types of study - Randomized Clinical comparative Trial
Place of work - OPD of Shalakyatantra
Duration of study - 18 months
Study Population - Patients of Karnasrava in Shalakyatantra OPD
SAMPLE SIZE CALCULATION
Sampling Method ndash Purposive sampling followed by random allocation in two
groups
Sample size calculation-
n = z2 p (1-p)
d2
Were
n = sample size
P = prevalence of disease=10
z = standard normal variable ie 196
d = error ie005
desired Sample Size would be
n = Z2 P(1-P)d2
= (196)2x (0021) x(0979)(005)2
= 34
Visiting ENT OPD (ShalakyaTantra) and IPD (ShalakyaTantra) 21 = 34
n raquo34
So one group includes 34patients
Page | 79
Sampling Method
Total 68 patient of Karnasrava are selected by Purposive sampling followed by
random allocation in two groups Written informed consent is taken prior to
commencement of trial They are divided in 2 groups
Group A (Trial Group) 34 patients treated with Agaruwadi Dhoopana for 7
days
Dose 5 minutes twice in a day
Group B (Control Group) 34 patients treated with Guggula Dhoopana for 7
days
Dose 5 minutes twice in a day
STUDY DESIGN ndash
Open labeled Randomized Comparative Clinical trial
STUDY DESIGN
Screening of patient
Inclusion criteria satisfied Exclusion criteria
Initial assessment Excluded
Counseling of patient Treated accordingly
Patient selection by Simple Random Sampling Method
Page | 80
68 Patients were divided in two groups lsquoArsquo and lsquoBrsquo
Trial group A-34 patients were given
Agaruwadi Dhoopana
Control group B- 34 patients were
given Guggul Dhoopana
Informed written consent
Treatment was given for 7 days
Assessment on 1st 4th and 7th day
Post assessments follow up on 15th day
Observation
Data Collection
Statistical analysis of data
Conclusion
Page | 81
(A) Agaruwadi Varti for group A (Trial group)
Table no 2
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
B) Guggula Varti for group B (Control group)
SOP of it is same as above Agaruwadi Varti
Table no 3
Drug Guggula Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
FOLLOW UP
For both groups follow ups were done on 1st 4th and 7th and post
assessment follow up15th day
EXAMINATIONS
Torch for Local examination of ear
Otoscope examination
Tuning fork Test
Page | 82
OBSERVATION TABLE
Table no 4
Sr no Subjective criteria Day 1 Day 4 Day 7 Day 15
1 करणशल
(pain)
2 करणकणड
(Itching)
3 करणसतराव (Discharge )
4 बाधिरण (Conductive Deafness)
OBSERVATIONS
a) करणशल (Pain) -
0 - Absent
1 ndash Present
b) करणकणड (Itching) -
0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
Page | 83
c) करणसतराव (Discharge)
0- Absent
1- Mild -Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाधिरण (conductive Loss of hearing)
0 - Absent
1- Present
Observations were carried out before and after completion of treatment and
during each follow up After observations the data collected and presented in
the form of graphs charts and table
Page | 84
TRIAL DRUG
Authentication and standardization of raw drug material done After
authentication and standardizing of raw drug material Agaruwadi Varti was
prepared by Varti as explained in Ayurvedic classics
Method of Varti preparations
Panchavidh Kashaya Kalpana that is five method of pharmaceutical
preparation constitutes the fundamental process of Ayurvedic pharmaceutics
which is well explained in Sushrut Samhita Varti Kalpana is one among them
which can be included in Kalka Kalpana
तीररसतरपतपतीनामपरककव तीत [106]
स डलहण शरच 151
Medicines are powered triturated and given the Varti shape that is like wick
of lamp so it is called as Varti Kalpana
Drug content Agaru Madan Yawa
Route of Administration Local
Dose Two times a day
Duration 7 days
Page | 85
Methodology
Standard operating procedure (SOP) of Agaruwadi Varti
Agaruwadi Varti is prepared according to the classical text
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization was done as recommended in pharmacy procedure The
raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 mixed together in
equal quantity to make Agaruwadi churn
Quantity of each churn is 4 grams all are mixed when the Varti get dry total
weight of Varti was 10gram
STEP 4 - Agaruwadi churn triturated with appropriate quantity of water or
Ghrita and prepared Varti in GMP Certified Ayurvedic pharmacy Standard
aseptic precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Varti was packed in sterile air packed container
STEP 6 - Agaruwadi Dhoopana was given with the help of Dhoopana yantra
Authentication and Standardization of raw drug of Agaruwadi Varti was done
Sterilization was done as recommended in pharmacy procedure Sterile
preparation packed in sterile container of suitable size Under all aseptic
precaution Karnadhoopana given to infected ear
Page | 86
Containers for packaging and their sterilization-
Sterilization of the containers for storing Varties was done by Ethylene Oxide
(Eto) method
Ethylene Oxide (Eto) procedure-
It includes exposure of materials to ethylene oxide gas under vacuum in a
sealed chamber It consists of four primary variables
1Gas Concentration
2Humidity
3Temperature
4 Time
EtO gas is an alkylating agent which disturbs the DNA of microorganism
preventing them from reproducing It penetrates the breathable packaging
and sterilizes all the accessible surface of the product to render products
sterility by alkylation of essentials proteins for cell reproduction
Most Eto sterilization methods involves three different stages These can be
separated into three different on the size or number of devices to treat
1Preconditioning stage-
First products are passed through a preconditioning phase to make
microorganism grow The batch load goes through a well time under a
controlled environment of temperature and humidity
2Sterilizer stage-
Performed using process phase specially designed to provide the required level
of EtO exposure to assure sterility for a device or family of devices
3Degasser Aerration stage-
Finally products need to go through a degassing phase to remove any residual
particles of Eto The batch load goes over well time under a temperature-
controlled environment
The sterile containers were then used to store Agaruwadi Varti and handed to
patients included in the study
Page | 87
Packing of Agaruwadi Varti
The ETO sterilize plastic container were used for packing of Agaruwadi Varti
Varti was filled into these sterilize containers (7 in each) In an aseptic
environment plugging and capping was done under aseptic precautions In this
way packing of Agaruwadi Varti done These Varti were given to patient and
advise to take two times a day under all hygienic precautions
History and Examination
bull Proper history and presenting complains was recorded on case record form
bull Ear examination with otoscope was done during initial assessment and each
follow up
bull Otoscopic examination was done during initial assessment and each follow
up
bull Systemic Examination that is Blood Pressure Temperature Respiration
rate Pulse was recorded on case record form
Page | 88
Raw material
Fig14 यव चरण Fig15 मदनफळ चरण
Fig16 अगर चरण Fig17 गगगळ चरण
Page | 89
Preparation of Agaruwadi Varti
Fig18 Preparation of Agaruwadi Varti
Fig19 अगरवादी वरती
Page | 90
Fig20 Instruments used for examination of Karnasrava
Fig19 Karnadhoopana Yantra
Page | 91
Karnadhoopana Procedure
Fig 22 Karnadhoopana Procedure
Page | 92
OBSERVATIONS AND RESULTS
Page | 93
BASED ON DRUGS
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 94
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
AUTHENTICATION CERTIFICATE
Page | 95
BASED ON STASTICIAL ANALYSIS OF DEMOGRAPHIC DATA
68 patients of Karnasrava ndash Otomycosis
Table no 5
No of Patients Total
Group A Group B
Registered 38 37 75
Completed 34 34 68
Discontinue 04 03 07
Total 68 patients were enrolled in study 38 patients registered in group A
amongst them 34 patients completed the treatment and04 patients
discontinued the treatment However in group B 37 patients completed the
treatment and 03 patients discontinued the treatment out of 37 registered
patients
Hence the total number of patients registered in the present study was 75
and out of which 68 patients were discontinued the treatment So they
dropped out from the study While 68 patients were successfully completed
the treatment So observations and result of 68 patients were given below
Here we are going to discuss the statistical analysis of the data obtained in
the form of master chart that was prepared in accordance with the data
collected from the patients that had been included in the study The purpose
of statistical analysis was to analyzed the relation between age gender
occupation diet addiction and education
Page | 96
1 Age wise distribution of patients
Table no 6
In trial group 10 (29412) patients were from age group 18-25 years 14
(41176) patients were from age group 25-35 years 8 (23529) patients
were from age group 35-45 years and 2 (58824) patients were from age
group 45-60 yearsIn control group 6 (17647) patients were from age group
18-25 years 14 (41176) patients were from age group 25-35 years 7
(20588) patients were from age group 35-45 years and 7 (20588)
patients were from age group 45-60 years
Fig 23 Age wise distribution of patients
0
2
4
6
8
10
12
14
15 -25 25-35 35-45 45-60
10
14
8
2
6
14
7 7
Age Distribution
Trial Group N Control Group N
Age Distribution
Trial Group Control Group
N N
18 -25 10 29412 6 17647
25-35 14 41176 14 41176
35-45 8 23529 7 20588
45-60 2 58824 7 20588
Total 34 100 34 100
Page | 97
1 Gender wise distribution of patients
Table no 7
Sex
Trial Group Control Group
N N
Female 23 67647 15 44118
Male 11 32353 19 55882
Total 34 100 34 100
In trial group 23 (67647) patients were female and 11 (32353) patients
were male
In Control group 15 (44118) patients were female and 19 (55882)
patients were male
Fig 24 Gender wise distribution of patients
0
5
10
15
20
25
N N
TRIAL GROUP CONTROL GROUP
23
15
11
19
Gender
Female Male
Page | 98
2 Education wise distribution of patients
Table no 8
Education
Trial Group Control Group
N N
Illiterate 4 11765 3 88235
SSC 4 11765 3 88235
HSC 8 23529 9 26471
Graduation 16 47059 10 29412
Primary 1 29412 3 88235
Post-Graduation 1 29412 6 17647
Total 34 100 34 100
In trial group 4 (11765) patients were illiterate 4 (11765) patients were
SSC educated 8 (23529) patients were HSC educated 16 (47059)
patients were graduated 1 (29412) patients were primary educated and
1(29412) patients were post graduated
In control grou 3 (88235) patients were illiterate 3 (88235) patients
were SSC educated 9 (26471) patients were HSC educated 10 (29412)
patients were graduated 3 (88235) patients were primary educated and
6 (17647) patients were post graduated
Page | 99
Fig 25 Education wise distribution of patients
0
2
4
6
8
10
12
14
16
ILLITERATE SSC HSC GRADUATION PRIMARY POST GRADUATION
4 4
8
16
1 1
3 3
910
3
6
Education
Trial Group N Control Group N
Page | 100
3 Occupation wise distribution of patients
Table no 9
Occupation
Trial Group Control Group
N N
Accountant 1 294 2 588
Housewife 11 3235 8 2353
Engineer 1 294 1 294
Job 1 294 4 1176
Labor 1 294 3 882
Mess 1 294 0 000
Naturotherapyst 1 294 0 000
Pharma 1 294 0 000
Shopkeeper 4 1176 2 588
Singer 1 294 0 000
Student 8 2353 4 1176
Tailor 1 294 1 294
Teacher 1 294 1 294
Worker 1 294 3 882
Farmer 0 000 1 294
Lab Tech 0 000 1 294
Page | 101
Daily Collection 0 000 1 294
Fruit seller 0 000 1 294
Bus Driver 0 000 1 294
Total 34 10000 34 10000
In trial group 11 (3235 ) were housewife 8(2353) were students
4(1176) were shopkeeper 1(294) was accountant 1(294) was
engineer 1(294) was doing job 1(294)was labour 1(294) was
catering 1(294) was Naturotherapyst 1(294) was Pharma 1(294)
was Singer 1(294) was Tailor 1(294) was Teacher and 1(294) was
worker
In Control group 8 (2353)were housewife 4(1176) were students
2(588) were shopkeeper 2(588) was accountant 1(294) was
engineer 4( 1176) was doing job 3(882)was labor 1(294) was
Farmer 1(294) was Lab tech 1(294) was Daily collection 1(294)
was Tailor 1(294) was Teacher and 3(882) was worker 1(294) was
Fruit seller and 1(294) Bus driver
Fig 26 Education wise distribution of patients
0
2
4
6
8
10
12
1
11
1 1 1 1 1 1
4
1
8
1 1 10 0 0 0 0
2
8
1
43
0 0 02
0
4
1 13
1 1 1 1 1
Occupation
Trial Group N Control Group N
Page | 102
4 Religion wise distribution of patients
Table no 10
Religion
Trial Group Control Group
N N
Hindu 31 9118 33 9706
Muslim 3 882 1 294
Total 34 10000 34 10000
In trial group 31 (9118) patients were Hindu and 3 (882) patients were
Muslim
In control group 33 (9706) patients were Hindu and 1 (294) patient
were Muslim
Fig 27 Religion wise distribution of patients
0
5
10
15
20
25
30
35
N N
TRIAL GROUP CONTROL GROUP
3133
31
Religion
Hindu Muslim
Page | 103
5 Diet wise distribution of patients
Table no 11
Diet
Trial Group Control Group
N N
Veg 14 4118 20 5882
Non-Veg 20 5882 14 4118
Total 34 10000 34 10000
In trial group 14 (4118) patients were vegetarian and 20 (5882)
patients were Non vegetarian
In control group 20 (5882) patients were vegetarian and 14 (4118)
patients were Non-Veg
Fig 28 Diet wise distribution of patients
0
5
10
15
20
N N
TRIAL GROUP CONTROL GROUP
14
2020
14
Diet
Veg Non Veg
Page | 104
6 Addiction wise distribution of patients
Table no 12
Addiction
Trial Group Control Group
N N
None 30 8824 27 7941
Alcohol 2 588 0 000
Tobacco 1 294 2 588
Mishri 0 000 1 294
Smoking 1 294 4 1176
Total 34 10000 34 10000
In trial group 30 (8824) patients have no addiction 2 (588) patients
have addiction of alcohol 1 (294) patients have addiction of Tobacco 0
(0) patients have addiction of Mishri and 1 (294) patients have addiction
of smoking
In control group 27 (7941) patients have no addiction 0 (0) patients
have addiction of alcohol 2 (588) patients have addiction of Tobacco 1
(294) patients have addiction of Mishri and 11 (1176) patients have
addiction of smoking
Page | 105
Fig 29 Addiction wise distribution of patients
0
5
10
15
20
25
30
NONE ALCOHOL TOBACCO MISHRI SMOKING
30
21
01
27
0
21
4
Addiction
Trial Group N Control Group N
Page | 106
Statistical Analysis and Results
Effect of study on Karnashoola-
Table no 13
Karnashoola
Group A Group B
BT AT BT AT
N N N N
Grade 2 0 000 0 000 0 000 0 000
Grade 1 30 10000 7 2333 32 10667 5 1667
Grade 0 4 1333 27 9000 2 667 29 9667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 30 Effect of study on Karnashoola
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
30
7
32
54
27
2
29
Karnashoola
Grade 2 Grade 1 Grade 0
Page | 107
Table no 14
Karnashoola Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 088 100 033 006
969 2829E-
08 7667 HS
AT 021 000 041 007
Group
B
BT 094 100 024 004
1037 7103E-
11 8438 HS
AT 015 000 036 007
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 31
000010020030040050060070080090100
BT AT BT AT
GROUP A GROUP B
088
021
094
015
Karnashoola
Mean
Page | 108
Table no 15
Karnashoola
Mean SD Effect
Group
A
Group
B Trial Control Trial Control
Day 1 088 094 033 024 000 000
Day 3 065 071 049 046 2667 2500
Day 5 024 038 043 049 7333 5938
Day 14 021 015 041 036 7667 8438
000
010
020
030
040
050
060
070
080
090
100
Day 1 Day 3 Day 5 Day 14
Karnashoola
Mean Group A Mean Group B
Page | 109
Table no 16
Karnashoola N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3250 110500
510000 275 Control group 34 3650 124100
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 110
Effect of study on Karnakandu
Table no 17
Karnakandu
Group A Group B
BT AT BT AT
N N N N
Grade 3 7 2333 0 000 4 1333 0 000
Grade 2 18 6000 0 000 18 6000 0 000
Grade 1 7 2333 7 2333 10 3333 15 5000
Grade 0 2 667 27 9000 2 667 19 6333
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 32 Effect of study on Karnakandu
0
5
10
15
20
25
30
N N N N
BT AT BT AT
GROUP A GROUP B
7
0
4
0
18
0
18
0
7 7
10
15
2
27
2
19
karnakandu
Grade 3 Grade 2 Grade 1 Grade 0
Page | 111
Table no 18
Karnakandu Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 188 200 081 015
1091 3119E-
10 8906 HS
AT 021 000 041 007
Group
B
BT 171 200 076 014
1032 4746E-
09 7414 HS
AT 044 000 050 009
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Page | 112
Fig 33
Table no 19
Karnakandu
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 188 171 081 076 000 000
Day 3 126 118 057 058 3281 3103
Day 5 071 074 046 051 6250 5690
Day 14 021 044 041 050 8906 7414
000
020
040
060
080
100
120
140
160
180
200
BT AT BT AT
GROUP A GROUP B
188
021
171
044
Karnakandu
Mean
Page | 113
Table no 20
Karnakandu N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 4051 137750
373500 006 Control group 34 2849 96850
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is less than
005 Hence we conclude that there is significant difference between Trial
Group and Control Group
000
020
040
060
080
100
120
140
160
180
200
Day 1 Day 3 Day 5 Day 14
Karnakandu
Mean Group A Mean Group B
Page | 114
Effect of study on Karnasrava
Table no 21
Karnasrava
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 11 3667 0 000 8 2667 0 000
Grade 1 23 7667 3 1000 26 8667 2 667
Grade 0 0 000 31 10333 0 000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 34
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
11
0
8
0
23
3
26
20
31
0
32
Karnasrava
Grade 3 Grade 2 Grade 1 Grade 0
Page | 115
Table no 22
Karnasrava Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 132 100 047 009
1122 4356E-
13 9333 HS
AT 009 000 029 005
Group
B
BT 124 100 043 008
1130 9364E-
14 9524 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 35
000
020
040
060
080
100
120
140
BT AT BT AT
GROUP A GROUP B
132
009
124
006
Karnasrava
Mean
Page | 116
Table no 23
Karnasrava
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 132 124 047 043 000 000
Day 3 100 100 025 025 2444 1905
Day 5 047 038 051 049 6444 6905
Day 14 009 006 029 024 9333 9524
000
020
040
060
080
100
120
140
Day 1 Day 3 Day 5 Day 14
Karnasrava
Mean Group A Mean Group B
Page | 117
Table no 24
Karnasrava N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3535 120200
549000 655 Control
group 34 3365 114400
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 118
Effect of study on Karnabadhirya
Table no 25
Karn
Badhirya
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 0 000 0 000 0 000 0 000
Grade 1 13 4333 0 000 16 5333 2 667
Grade 0 21 7000 34 11333 18 6000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 36
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 00 0 0 0
13
0
16
2
21
34
18
32
Karnabadhirya
Grade 3 Grade 2 Grade 1 Grade 0
Page | 119
Table no 26
Karn
Badhirya Mean Median SD SE
Wilcoxon
W P-Value
Effect Result
Group
A
BT 038 000 049 009
799 7173E-
05 10000 HS
AT 000 000 000 000
Group
B
BT 047 000 051 009
816 0000138 8750 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 38
000
005
010
015
020
025
030
035
040
045
050
BT AT BT AT
GROUP A GROUP B
038
000
047
006
Karnbadhirya
Mean
Page | 120
Table no 27
Karn
Badhirya
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 038 047 049 051 000 000
Day 3 009 006 029 024 7692 8750
Day 5 003 006 017 024 9231 8750
Day 14 000 006 000 024 10000 8750
000
005
010
015
020
025
030
035
040
045
050
Day 1 Day 3 Day 5 Day 14
Karn Badhirya
Mean Group A Mean Group B
Page | 121
Table no 28
Karn
Badhirya N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3400 115600
561000 806 Control
group 34 3500 119000
Total 68
Page | 122
COMPARISION BETWEEN GROUP A AND GROUP B
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Table no 29
Overall Effect
Trial Group Control Group
N N
Marked Improvement 21 6176 16 4706
Moderate Improvement 8 2353 13 3824
Mild Improvement 4 1176 5 1471
No Change 1 2941 0 0
TOTAL 34 100 34 100
Fig 39
0
5
10
15
20
25
MARKED IMPROVEMENT
MODERATE IMPROVEMENT
MILD IMPROVEMENT NO CHANGE
21
8
41
1613
5
0
Overall Effect
Trial Group N Control Group N
Page | 123
DISCUSSION
Page | 124
Discussion is nothing but the logical reasoning of observations In
every research work discussion part is very important because it brings into
light about the logical analysis which are helpful in filling the research gap in
the scientific world
The discussion is categorized into following ways for the ease of
understanding
1 Discussion on selection of topic
2 Discussion on review of literature
3 Discussion on drugs their mode of action on the disease mode of action
of Karnadhoopana
4 Discussion on observation and results
1 Discussion on selection of topic
Otomycosis is commonly encountered in day-to-day practice Majority
of Indian people affected with this pathology This disease commonly
manifests in developing countries low socio-economic standard and lack
of hygiene Now a days due to busy lifestyle people are not able to follow
the proper instruction of care of ear which may be responsible for the
recurrent nature of disease So for the management of this we use
Karnadhoopana with the help of Agaruwadi Varti Dhoopana is simple
easy cost-effective procedure which can be done even at OPD levelso
for the disease Karnasrava we selected Karna Dhoopana as therapeutic
procedure Karnadhoopana was done with Agaruwadi Varti and Guggula
Varti which was very effective for treatment
Page | 125
2 Discussion on review of literature
Karnasrava is one such disease among 28 Karnarogas mentioned by
Acharya Sushruta in the chapter named Karna Roga Vigyana Acharya
Charaka included Karnasrava as symptom under the four types of
Karnarogas due to vitiation of different doshas Acharya Vagbhata has
not described Karnasrava separately It is a fact that systemic
description of Karnarogas is available in all the ancients of pus from a
Vata afflicted ear may results from head injury or immersion in water
Karnasrava is a clinical entity which can be correlated with Otomycosis
Karnasrava is explained as symptom as well as a disease in Ayurveda
Nidana- Karnasrava occur due to Samanya Nidana and Vishesh Nidana
Vishesh Nidana like Shirobhighata Nimmajato jale Mithyayoga of Shashtra
The exact pathology behind Karnasrava is not understood clearly
Purvarupa ndash No specific Purvarupa are found for Karnasrava in classical
literature Acharya Madhukara describe Purvarupa as expression of
Rupa(lakshana) with less intensity that is less intensity itching sound in ear
may considered as Purvarupa of Lakshana
Samprapti- Aacharya Sushruta not explained the Samprapti of Karnasrava
separately and we must consider the general Samprapti of Karnaroga Due to
various aetiologias as cited above ear afflicted by Vata dosha causes Twak
Rakta Mamsa dushti results in Karnasrava According to Acharya Sushruta
Vata-Kapha dose is dominance in Karnasrava
Page | 126
Nidan
Nija Agantuja
Vata ndash kapha prakopak nidana Shirobhighata Nimmajato-jale
Mithya yoga of Shastra
Vata- kapha Prakopaka(Chaya prakopak) Vata-kapha prakopaka
( Achay prakopak)
Twak Rakta Mamsa dushti
Karnasrava
Page | 127
Chikitsa
The curative aspect and this must be done simultaneously giving due
importance to Nidan Parivarjana that is preventive measures So Nidan
Parivarjana that is avoidance of causative factors like Jalkrida Mithyayogen
shashtrasya Karnakandu Shirasnan Pratishaya is the first step in combating
the disease and form the part of line of treatment
Above Samprapti helps us to proceed towards the treatment of Karnasrava
The main protocol of treatment is removal of fungus and wound management
which include various measures to keep area day clean clear of microbes and
providing ideal condition for healing
Samany Chikitsa- Acharya Sushruta described general treatment for
Karnaroga as Snehapana (Drinking ghee) Rasayana (Rejuvenation therapy)
Bhramacharya Avoid excessive speaking Avoidance of physical exercise and
head bath
Vishesha Chikitsa ndash Acharya Sushruta mentioned some procedures in the
treatment of Karnasrava which is Shirovirechana Karnadhoopana
Karnapurana Karanpramarjana Dhavan Avachurnana Karnapurana Above
various procedures described in Ayurveda for management of fungus growth
in ear discharging ear fulfill these requirements of wound management
Page | 128
Discussion on observation and Result
Out of 68 patients 34 patients included for the trial The incidence of
Karnasrava is observed in trial and control groups
The statistical analysis provided the following data
AGE
Trial group- Maximum no of patients that is 14 (41176) patients were from
age group 25-35 years followed by 29412 patients were from age group
18-25 years 23529patients were from age group 35-45 years and
58824 patients were from age group 45-60 years
Control group - Maximum no of patients that is 14 (41176) patients were
from age group 25-35 years followed by 20588 patients were from age
group 35-45 years and 20588 patients were from age group 45-60 years
17647 patients were from age group 15-25 years
The maximum no of cases of Karnasrava found in age group between 25 to
35 years The reason behind this is repeated use of ear bud or emersed water
in ear More use of earphone or working more in cold environment
GENDER
Trial group ndash A higher prevalence seen in females 6764 and 3235 in
males
Control group - A higher prevalence seen in males 5588 and 4411 in
females
Females and males both are prone to disease
Page | 129
EDUCATION
Trial group-It is observed that amongst 34 patients maximum ie16
(47059) patients were graduated 8 (23529) patients were HSC
educated 4 (11765) patients were SSC educated 4 (11765) patients
were illiterate 1 (29412) patient were primary educated and 1(29412)
patient were post graduated
Control group- It is observed that 10 (29412) patients were graduated 9
(26471) patients were HSC educated 6 (17647) patients were post
graduated 3 (88235) patients were SSC educated 3 (88235) patients
were primary educated3 (88235) patients were illiterate
There is no direct relation between education and Otomycosis
RELIGION
Trial group- The incidence of patients of Hindu religion are 9118 and Muslim
religion are 882
Control group- The incidence of patients of Hindu religion are 9706 and
Muslim religion are 294
There is no probable explanation for this maximum number of patients in
Hindu religion it depends upon the patients attend the hospital and
community residing there
Page | 130
DIET
Trial group It was found that maximum ie5882 patients were taking
mixed diet while 4118 were taking vegetarian diet
Control group It was found that maximum ie5882 were taking
vegetarian diet while 4118 patients were taking mixed diet
The dietary habit of person is based on choice availability and religious
customs of the person
ADDICTION-
Trial group- It was found that maximum ie 30 (8824) patients have no
addiction 2 (588) patients have addiction of alcohol 1 (294) patients
have addiction of Tobacco 1 (294) patients have addiction of smoking and
0 (0) patients have addiction of Mishri
Control group - It was found that maximum ie 27 (7941) patients have
no addiction 4(1176) patients have addiction of smoking 2 (588)
patients have addiction of Tobacco 1 (294) patients have addiction of
Mishri and 0 (0) patients have addiction of alcohol
Very few patients were addicted to Alcohol Smoking Tobacco and Mishri
These factors can be taken as provoking factors for Otomycosis
Page | 131
Discussion based on probable Mode of action of Karnadhoopana
In Ayurveda classics Karna Dhoopana is therapeutic procedure explain for
Karnasrava Dhoopana is administration of Dhooma (Fumes) with the help of
Dhoopan Dravya References indicates that analgesic and disinfectant effect
of Dhoopana karma and mention for Dushta Vrana Chikitsa It reduces
Vedana Srava amp also does Vrana Ropana action
Various Dhoopanas and Dhoopan Dravas for different element in various
Samhitas of Ayurveda but there is a lacuna of availability of reference
regarding how to do it and method of procedure Matra Kala Contraindication
etc
Currently simple modified way of Karnadhoopana according to Yukti Praman
and experience but there is lac of standardization
Karnadhoopana is one among the topical Bahiparimajan type of treatment
Karna Parmarjana is procedure of cleaning ear with the help of cotton or gauze
piece soaked in honey
Page | 132
Dhoopan
The fumes coming out on burning Agaruwadi Varti
Administrated directly into external ear canal
Causes vasodilation
Due to this increase blood supply in external ear canal
It helps in absorption of drug
Fumes dries up Srava and bring the analgesic effect
Karnagata Kapha amp Avrut Vata Dosha Shaman
Decrease in signs and symptoms like karnasrava Karnshool Karnabadhirya amp
Karnandu
Page | 133
3 Discussion based on probable mode of action of Agaruwadi
Dhoopana
Agaru ndash
I Agaru is a fragrant tree aroma is a result of fungal pathogenesis when the
wood of tree is contaminated by fungi at wounds it develops scrap filled
with resin and turn out to be aroma Medicinal use of Agaru have been
recorded in ancient medicinal science in in inflammatory disease and some
infective disease
II Acharya Charaka has referred to Agaru as an Ushna dravya despite having
Tikta Rasa Ashtang Samgraha used Agaru as Dhupana Dravya along with
Madan and Yawa in Karnasrava Nighantu recommended is use as a
Dhoopana
III In various Samhitas and Nighantus Agaru described as Tikta Snighdha
Sheetaprashamana Vranaprasadana Tvachya Due to these properties
Agaru is used in the treatment of Karna-Akashi Roga and Dushta Vrana
Shodhaka
IV Agaru is reported to have Antimicrobial Analgesic Antioxidants
Antihistaminic and anxiolytic properties Its Antihistaminic property gives
relief from itching which is cardinal feature of Otomycosis Due to Katu
Ushna Tikta Guna improves blood circulation Bheda stage develop It is
Niram Awastha of Dosha Karnagata kapha and vata get decrease and
symptoms like karnashoolakarnasrava get decrease Agaru also have a
Antioxidant properties
V Chemically Agaru Contain 2-(2-Phenylethyl) Chromones Terpenoids
Flavonoids
VI Natural Agarwood had inhibitive activities towards Staphylococcus Aures
The chloroform extract of Agarwood prolongs the pain threshold[108]
Page | 134
Madan
I Madanphala have therapeutic properties like Anti-inflammatory
Antiallergic Analgesic and Wound healing
II It is Useful in treatment of disease like Shotha (inflammation) Vidradhi
(Abscess) Pratishaya (Common cold) Kushta(Skin disease)
III Extract of Madanphala mainly contain Glcosides Tritorpenct
Glycosides Saponin
IV Saponin glycosides are act as fire extinguisher This property is helpful
for vartiIt also act as a detergent which clean the surface of fungus
V Tritorpenct act as a anti-inflammatory antimicrobial and
immunomodulator compound Interaction of glycosides with sterol
causes disturbance of selective permeability in plasmic membraneso
exudates and discharge get decrease
VI Pharmacological activity [109]
Antibacterial Activity The preliminary antibacterial activity of Methanolic
extract of Randia D lam was done on some standard and wild pathogenic
strains The inhibition of the bacterial growth was more pronounced on E coli
as compared to the other tested organism This shows the antibacterial action
of Randia D secondary infection can prevent
Anti-Allergic Activity In Ayurveda Randia D Extract and its fraction of milk
induced leukocytosis and eosinophilia in mice
Anti-Inflammatory Activity The crude methanol extract of fruit of Randia D
effectively reduced the carrageenin induced oedema in hind paw of the rats
significant reduction in granular tissue formation was recorded This activity
seems to be significant at various acute phases of inflammation and om
formation of granular tissue This proves action of Madanaphala in shopa
(inflammation)
Page | 135
Analgesic Activity Analgesic activity was tested in mice weighing between 20-
250 with six number of animals in each group Methanlic extract of fruit Randia
d give analgesic activity in both models This proves its Shoolanashaka (pain
killer) action
Immunomodulatory Activity Randia D has immunostimulant activity and
chloroform fraction which strongly affected immune system seems to be
bioactive fraction of this plant
The overall effect of Agaru Mandanphala Yawa having Anti-inflammatory
Antiseptic Antimicrobial Property Active ingredient shows these properties
Agaru Yawa Madanphala
Vatakaphaghna
Act as
Vranashodhak
Vedanasthapaka
Sheetaprashamana
Shothara
Avarana of Vata get decrease so helps to Shaman of Vata dosha
Karnakandu Karnashoola Karnasrava
Prashamana
Page | 136
This fact can be taken into consideration and probably acknowledge that
Karnadhoopana with Agaruwadi Varti had not leave any residue in the ear
Removal of fibrin keratinocyte migration and in growth of epithelial tissue
plays a major role in healing It is technique of fumigation of ear with the
smoke of anti-infective drug In Karnadhoopana Sthanik Swedana increase the
blood supply and helps in absorption of the drug reduce Karnakandu amp
Karnshoola associated with infection
Page | 137
SUMMARY AND CONCLUSION
Page | 138
The dissertation entitled randomize comparative clinical trial to study the
effect of Agaruwadi Karnadhoopan and Guggula Karnadhoopan In Karnasrava
wsr to Otomycosis
The dissertation is divided into fallowing parts
Introduction
Review of literature
Ayurvedic review
Modern Review
Drug review
Procedure review
Material and Method
Observation and result
Discussion
Summary and conclusion
bull INTRODUCTION
It includes importance of Shalakyatantra in Sushrut Samhita Charka
Samhita And Ashtang Samgraha
Common and specific causes of Karnasrava
Karnasrava is a clinical entity which can be corelate with Otomycosis
In Ashtang Samgraha stated the procedure like Karnadhoopana with
Agaru Yawa Madanphala in Karnasrava
Page | 139
bull REVIEW OF LITERATURE
1 Ayurvedic review
2 Modern review
3 Drug review
Ayurvedic review-
It includes Rachana-Sharir and Kriya-Sharir of Karna detail description of
Karnaroga and its types Karnaroga Samanya hetu Poorvaroopa Rupa
Samprapti Upadrava Pathya-Apathya of Karnasrava Vishesh Nidan and
Chikitsa of Karnasrava Detail description of Karnadhoopana according to
various Acharays have been mentioned
Modern review-
It includes anatomy and physiology of Ear brief anatomy of ear anatomy of
External middle and Internal ear Detail description of the disease
Otomycosis mechanism of fungal infection in external canal pathophysiology
investigations diagnosis and management
Drug review-
Detail description of Agaru Yawa Madan Guggula and its synonyms
Ayurvedic properties Karma uses Pharmacological action and their
pharmacodynamic properties
Page | 140
MATERIAL AND METHOD
It includes description regarding materials required for the study Preparation
of Agaruwadi Varti its Standardization Sterilization and packaging
Plan of study
1 Total 68 patients completed the treatment Age criteria was kept
between 18-60 years Patient selection was done by done by simple
random sampling method and divided into two groups A (Trial) and
Group B (Control) 34 patients in each group
2 Patients in Group A were treated with Karnadhoopana with Agaruwadi
Varti for 7 days two times in a day while patients in Group B were treated
with Karnadhoopana with Guggula for 7 days two times in a day
3 Clinical examination done during each follow up ie 0th 4rd 7th and
observation were recorded
Page | 141
OBSERVATIONS AND RESULTS
Page | 142
1 It was observed that higher incidence of disease Karnasrava ie
Otomycosis found in age group 25-35 years
2 Disease otomycosis was equal in both male and female
3 The trial group there was significant relief in Karnakandu (8906)
Karnasrava(9333) Karnashoola(7667) and karnabadhirya(100)
4 In control group there was significant relief in Karnakandu (7414)
Karnasrava(9524) Karnashoola(8438) and
karnabadhirya(8750)
Page | 143
REFERANCES
Page | 144
1 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published byChaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 17 page no
5
2 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 19 page no
6
3 DRNarayan Vidwas Shero-Karna-Nasa and MukhrogaAnand publication
edition 4th 2014 Page no-52
4 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-205
page no 111
5 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 111
6 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Shlok no2012
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 112
8 Dr KBBhargavaDr SK BhargavaDr TMShahaA Short book of ENT
diseases Usha publication edition 10th
9 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 8 Page no -52
Page | 145
10 Research and Review Journal of Ayurvedic science yoga and
Naturopathy 2017 4(3) 1-5 pA Critical review of Otomycosis in cortex to
Karnaroga described in Ayurvedic classic by amisha patel D B Vaghala
Chandani goswami Vol4 no3 (2017)
11 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogpratished Adhaya Shlok no-213
page no127
12 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedh Adhaya Shlok no-
2140 page no 131
13 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyant shirasiya adhaya Shlok no 1712 page no-
258
14 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
15 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
16 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Aupadravik Adhaya Shlok no-15 page no
2
17 Vaidya Jaymini panday Harit Samhita hindi commentaryChaukhamba
vidhyabhartiVaranasiedition 2010 Shlok no- 13-14page no-10
18 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 146
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-20345
page no 112
19 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Karnarogavigyniyam Shlok
no 21 Page no-731
20 Charak
21 Pandit Harigovind Shashtri Namalinganusasana Amarkosha of
Amarsimha hindi commentary published by Chaukhamba Sanskrit
Sansthan page no- 463
22 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
23 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 37
24 Shree Taranath-Trkavachspati-Bhattacharyen Vchaspatym published
by Rashtriya Samskrit Sansthandelhi Volume 4 page no- 5149
25 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
26 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
27 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
28 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Page | 147
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
29 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Indriyaopakramaniya Adhaya Shlok no 811
page no- 125
30 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243
31 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-510 page no56
32 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no3108 page no- 385
33 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no33 page no- 366
34 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sarvabhutachintasharir Adhaya
Shlok no-126 page no9
35 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-522 page no60
36 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-532 page no61
37 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Page | 148
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-521page no58
38 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-527 page no61
39 VdBramhand Tripathi Ashtanghradaya Sharirsthansthan Published by
Chaukhamba prakashana 2005 Shlok no331 page no-372
40 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Siravarnavibhaktisharir Adhaya
Shlok no-725 page no83
41 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Sharirsankhyavykaransharir Adhaya Shlok
no-512
42 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Pratekmarmanirdeshsharir
Adhaya Shlok no-628 page no75
43 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
44 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Marmasharirsthan Shlok no429 page
no- 393
45 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243244
Page | 149
46 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
47 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan pu blished by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711
48 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
49 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
50 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Shlok no 711 page no- 847
51 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Adhaya Shlok no-628 page no- 75
52 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Gandushavidhiadhaya Shlok no2232
page no- 261
53 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Karnavydhbandhvidhi Adhaya Shlok no-
1611 page no- 86
54 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Nidansthan Published by Chaukhamba
Page | 150
Sanskrit SansthanVaranasi Vatvydhinidansa Adhaya Shlok no183 page
no- 304
55 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavaykaransharir
Adhaya Shlok no-532 page no61
56 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Tristaisniya adhaya Shlok no 1120 page no-
163
57 P Hazarika Dr Nayaka R Balkrishnan Textbook of EarNoseThroat and
Head-Neck Surgery CBS Publication Anatomy of Ear
58 DrKB Bhargava DrSKBhargava DrTMShaha A short book of ENT
Diseases Published by Usha Publication 10th edition page no10
59 MrSalah Mansour MrJacques MagnanMr Hassan Haidar MrKaren
Nicolas MRStephan Louryan Comprehensive and clinical anatomy of the
Middle Ear Published by Springer publication Chapter -Middle Ear cavity
Page no 19 to 121
60 DrPLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 7
61 James OPickles An introduction to Physiology of Hearing Published by
Emerald publication 4th edition page no- 1 to 265
62 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
63 VdBramhand Tripathi Ashtanghradaya Uttarsthan Published by
Chaukhamba prakashana 2005 Karnaroga vigyniyam adhaya Shlok
no1713 page no- 998
Page | 151
64 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Shlok no- 212 page no-
730
65 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no
1-2 page no- 309
66 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana
67 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyantshirasiya Adhaya Shlok no 1713 page no-
258
68 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no-
6 page no- 310
69 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Karnarogavigyniym Shlok no- 1725-26 Page no-
1003
70 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2140 page
no 131
71 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Adhyay 18 shlok 35
72 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt
Karnarogapratishedhoadhya Shlok no-2211 Page no- 735
73 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 152
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2141 page
no 131
74 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2142 page
no 131
75 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2144 page
no 131
76 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 34 page no- 649
77 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2145page
no 131
78 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 37 page no- 649
79 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2146page
no
80 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
81 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 153
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2143page
no
82 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publication Krnarogadhikara adhaya page no-
318
83 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary
Madhyamkhand Vatkalpana shlok no- 782-83 page no- 137
84 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 72-77 page no- 651
85 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
86 Vd Shree Laxmipatishastri Yogratnakara
87 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
Karnarogadhikara Shlok no- 808182 page no- 652
88 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 83 page no- 652
89 (PDF) Otomycosis A Comprehensive Review (researchgatenet)
90 httpswwwncbinlmnihgovpubmed24948980
91 A Simon Carney Scott-Browns Otorhinolaryngology Head and Neck
Surgery CRC press 8th publication Otitis externa and otomycosis
92 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no Page no -
93 wwwguggulipidcomtradhtm
Page | 154
94 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
95 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-28 page no-
43
96 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009Agaru page
no726-728
97 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishra chapter Karpuradi varga Shlok no-31-
43 Page no- 116
98 httpswwwthiemeinimagecatlogsample_chapter_GOMPpdf
99 (PDF) Chemical Constituents and Pharmacological Activity of Agarwood
and Aquilaria Plants (researchgatenet)
100 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 4 chapter no-2 page no-4
101 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 chapter no-152 Madanpage
no376-379
102 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
103 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-54 page no-
84
104 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 page no697-699
patol-yawa
Page | 155
105 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
106 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
Dhoompanvidhi page no- 252-254
107 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012Chikitasasthan Shlok
no- 151page no-406
108 httpswwwmdpicom1420-3049232342pdf
109 httpswwwijamcoinindexphpijamarticledownload0610201530
0
Page | 156
BIBILOGRAPHY
Page | 157
1 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
2 Scott-Brown WG Diseases of the EarNose and Throat Landon
Botterworth and co(publishers) Ltd1952 Volume 2
3 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012
4 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009
5 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi commantry
Purvakhand and Madhyamkhand
6 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Published by Chaukhamba Sanskrit
SansthanVaranasi
8 The Ayurvedic Pharmacopeia of India Ministry of Health and family welfare
department of Ayush Part 1 and part 4
9 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005
10 Acharya Trivedi Raguveer Prasad Ashtang sangrah published by
Vaidyanath Ayurveda bhavan pvt
11 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition
12 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary published by Chaukhamba
Orientalia
Page | 158
ANNEXURE
Page | 159
ANNEXURE- 1
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
CASE RECORD FORM
RESEARCH PROFORMA FOR MS (AYU) DESSERTATION
DEPARTMENT OF SHALAKYATANTRA
NAME -
ADDRESS -
GENDER - AGE - OCCUPATION-
RELIGION - EDUCATION - MARITAL STATUS-
OPD IPD NO-
DATE OF ADMISSIONCOMMESEMENT-
DATE OF DISCHARGECOMPLITION-
DATE OF COUNSELLING-
TEL NO-
CHIEF COMPLAINTS-
PAST MEDICAL AND SURGICAL HISTORY-
TREATMENT HISTORY-
FAMILY HISTORY-
Page | 160
PERSONAL HISTORY-
a) Ahar(Diet)
b) Vihar
c) History of addiction
GENERAL EXAMINATION
PULSE - MIN BP - mm of hg
TEMP - 0F RR - MIN
ASHATAVIDHA PARIKSHANA
Nadi- Mutra- Mala-
Jivha- Shabda- Sparsha-
Drik- Aakruti-
SYSTEMIC EXAMINATION
RS ndash
CNS-
CVS ndash
Page | 161
LOCAL EXAMINATION (KARNA PARIKSHAN)
OBSERVATION TABLE FOR SUBJECTIVE CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching )
RIGHT EAR LEFT EAR
KARNASHASHUKULI
KARNAPUTRAK
KARNAPALI
KARNAKUHARA -
SRAVA
GANDH
VARNA
SWARUPA
KARNAPATALA (TM)
Page | 162
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
Hearing Test
1Renne Test ndash
2 Weber Test -
Examination of Ear-
Pathological Investigation-
Other Examination-
Nidan Panchak-
1Hetu-
2Purvarup-
3Rupa-
4Upashayanupashaya-
5Samprapti
Signature of Guide Signature of Doctor(Researcher)
Page | 163
ANNEXURE 12
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Dhoopana Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization were done as recommended in pharmacy procedure
The raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 were mixed together
in equal quantity to make Agaruwadi churn
STEP 4 - Agaruwadi churn were triturated with appropriate quantity of water
and prepared Varti in GMP Certified Ayurvedic pharmacy Standard aseptic
precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Dhoopana Varti was packed in sterile air packed
container
STEP 6 - Agaruwadi Dhoopan was given with the help of Dhoopan yantra
TREATMENT DETAIL-
Purvakarma -
1 The patient is asked to sit comfortably on chair having sufficient light and
less amount of dust
2 The EAC is cleaned thoroughly by Pichu Varti (cotton swab) to remove the
discharge and other debris
Pradhankarma -
1 The patient is asked to relax completely on the chair
Page | 164
2 Fumes are passed to the ear with Dhoopana Yantra
3 Dhoopana yantra is funnel shaped and its one end will keep the ear covered
for the passage of Dhooma into the ear canal and other end where Agaruwadi
Dhoopana Varti were placed which produces fumes
4 This Dhoopana was given for 5 min
Pashchat karma -
1 The patient were advised to avoid cold refrigerated food drinks cold water
bath cold wind fog and prevent water from entering the ear
(A) Agaruwadi Dhoopana Varti
B) Guggula Dhoopana Varti SOP of it is same as above Agaruwadi Dhoopana
Varti
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Page | 165
ANNEXURE 21
INFORMED CONSENT DOCUMENT
Study Title
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
Introduction
- You are invited to take part in a research study RANDOMSIED COMPARATIVE
CLINICAL TRIAL TO STUDY THE EFFECT OF AGARUWADI DHOOPANA AND
GUGGULA DHOOPANA IN KARNASRAVA
- Before you decide it is important for you to understand why the
research is being done and what it will involve
- Please take time to read the following information carefully and discuss
it with friends relatives and your doctor if you wish
- Ask us if there is anything that is not clear or if you would like more
information
Purpose amp Nature of Study
- In this research project by examine you and ldquoKarnasravardquo (Otomycosis)
disease were treated
- In the part of treatment Agaruwadi Dhoopana or Guggula Dhoopan were
given
- Dhoopana means medicated drug fumes were given in ear with the help of
Dhoopan Yantra
Page | 166
- Treatment was given for 7 days
Study Duration
7days
Participation
- Your participation is entirely voluntary
- If you do decide to take part you were given this information sheet to keep
and be asked to sign a informed consent form
- If you decide to take part you are still free to withdraw at any time and
without giving a reason This will not affect the standard of current or future
medical care you may receive
Confidentiality
- All information which is collected about you during the research were
kept strictly confidential
- Any information about you which is collected from the center will have
your identity in the form of a code number so that it will remain confidential
Benefits Of Study
- The results obtained from this study would be helpful for providing better
quality of treatment amp other essential facilities for Karnasrava (Discharge)
patients
- You will get clinical benefit from the study
Page | 167
Risks Of Study
- In this treatment there are few chances of Irritation of Ear Nose and
congestion at EAC if any of these happens then treatment were given
Results Of Study
- If the Results obtained are profitable then they may get published
without disclosing your details
Signature of patient
Date
Time
Phone no of Researcher
Page | 168
रण मादहती पतरक
सशोिनाच शीषवक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE
EFFECT OF AGARUWADI DHOOPANA AND GUGGULA DHOOPANA
IN KARNASRAVA
परसतताना
- आपणास या सशोिनातपमक अभयासात सहिागी होणय़ाच आाहन करणयात यत आह
- सशोिनातील सहिाग तननदशचत करणयापी सशोिनाच उददश समजन घया
- खालील मादहती काळजीपवक ाचा आणण आशयक ािलयास आपलया डॉकिराशी कका
दहतशरचतकाशी चचाव करा
- काही सददिता असलयास कका आणखी मादहती ही असलयास आमछयाशी चचाव करा
सशोिनाच उददीटि सतरप
- सदर सशोिन परकलपामरधय आपलयाला तपासणी करन कणवसरा या वयाशरिची शरचककतपसा दणयात
यणार आह
- सदर वयाशरिची शरचककतपसा महणन आपणास अगरादी िपन कका गगल िपन
दणयात यणार आह
- सदर औषि आपणास 7 ददस घयायाच आह
Page | 169
कालािी
- 7 ददस
सहिाग
- आपला सहिाग हा पणवपण ऎनदछिक आह
- आपला सहिाग तननदशचत असलयास आपणास ही मादहती पतरतरका दणयात यईल आपणास यातील
समती पतरकार सही कराी लागल
- सहिाग तननदशचत असनही आपण कोणतपयाही ळस कोणतही कारण न दता माघार घ शकता
याचा आपलया दयकीय सविर कोणताही पररणाम होणार नाही
गोपनीयता
- सशोिना दरमयान गोळा कलली आपलया वषयाची सव मादहती गोपनीय ठणयात यईल
- आपली यनदकतक मादहती साकततक सतरपात गोपनीय ठणयात यईल
सशोिनाच फ़ायद
- सशोिनाच तनटकषव कणवसरा बाशरित रणाछया दयकीय इतर सविाचा दजाव सिारणयास
फायदशीर ठरतील
सशोिनातील जोणखम
- य़ा शरचककतपसमरधय कान दखण डॊळय़ातन नाकातन पाणी य़ण नाकात जळजळण डोक जड
होण ही लिण ददस शकतात यापकी लिण तनमावण झालयास तपयाची शरचककतपसा कली जाईल
Page | 170
सशोिनाच तनटकषव
सशोिनाच तनटकषव फ़ायदशीर ठरलयास आपली मादहती गोपनीय ठन परकाशशत करणय़ात यईल
रण सतािरी-
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
Page | 171
ANNEXURE 31
INFORMED CONSENT FORM
Patient OPD no __________
Subjectrsquos Identifier
Date of Birth Age Gender
I _____________________________________ age___________ years
exercising my free power of choice hereby give my consent to be included
as a participant in the clinical study entitled
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
1 I confirm that I have read have been read and understood the information
sheet for the above study and can ask questions
2 I understand that my participation in the study is voluntary and that I am
free to withdraw at any time without giving any reason without affecting my
medical care or legal rights
3 I understand that the Ethics Committee members investigators and study
doctors will not need my permission to look at my health records both in
respect of the current study and any further research that may be conducted
in relation to it even if I withdraw from the trial I agree to his access
However I understand that my identity will not be revealed in information
released to third parties or published
4I agree not to restrict the use of any data or results that arisefrom this study
provided such a use only for scientific purpose
5 I agree to take part in the above study
Page | 172
signature with Date-
Left hand thumb impression
Name amp signature of the witness ndash
Name amp signature of the student ndash
Page | 173
ANNEXURE 32
समतीपतरक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
वयकतीच य
ददनाक जरमददनाक
1) मी ह तननदशचत कररत आह ककसदर सशोिन परकलपाबाबतची सपणव मदहती मी ाचली असनमला ती
समजली आहतपयाबददल मला परशन वचारणयाची पणव मिा आह सदर मादहतीन माझ समािान झाल
आह
2) मी सदर सशोिनातन माझया मजीनसार किीही बाहर पड शकतो या माझया अशरिकाराची मला कलपना
आह
3) माझी दयककय मादहती तपासणयाची कागदपतर कळ सशोिनाकररता ापरली जाणार आहत याची
मला मादहती आहसदर सशोिन परकलपातील सबशरित घिकाना माझी दयककय मादहती पाहणयाची मी
समती दत आहतरावप या सदिावतील माझी ओळख दशववणारी मादहती कोणासही ददली जाणार नाहीयाची
मला कलपना दणयात आली आह
4) सदर अभयासातन शमळणारी मादहती अरा तनटकषव कळ शासततरीय हतसाठी ापरल जाणयासाठी माझी
समती आह
5) रील अभयासात सहिागी होणयास माझी समती आह
रण सतािरी-
Page | 174
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
ASSESSMENT CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching)
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
a) कणवशल ( pain )- 0 - Absent
1 ndash Present
Page | 175
b) कणवकणड (Itching)- 0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
c) कणवसततरा ( Discharge )
0- Absent
1-Mild- Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाशरियव ( conductive Loss of hearing )
0 - Present
1 - Absent
Page | 176
Page | 177
Page | 178
Page | 179
Page | 180
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
Page | 181
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 182
AUTHENTIFICATION CERTIFICATE
Page | 3
Ayurveda is ancient science of life a system of health and medicine
which aims to assist people in living a healthy life It is a person-centered
medicine which deals with healthy lifestyle systemic diseases prevention
diagnosis and treatment Ayurveda is divided into eight branches[1] It has
a separate branch of clinical and surgical specialization concerning ENT and
ophthalmology known as Shalakyatantra One out of the eight branches of
Ayurveda Shalakyatantra deal with the etiology diagnosis prognosis
prevention treatment and complication of diseases which are located at
Urdhwang Pradesh[2]
Karna is one among the Panchendriya (sense organ) situated at
Urdhwang Pradesha [3] It is originated from Akash Mahabhuta Aachary
Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga Vigyniyam
Aadhaya[4] He mentioned Karnasrava as separate diseases[5] Aacharya
Charaka explain 4 Karnaroga He had not described Karnasrava as
independent diseases but explain Karnasrava as a symptom under four
Karnaroga Acharya Vagbhata mentioned Karnasrava as a symptom in
Karnashoola according to Dosha He included this into Kaphaj Karnashoola
itself[6] Karnasrava means discharge through ear The Samanya Hetu of
Karnaroga are Avashaya or Pratishaya that is common cold Sheeta Vihara
or exposure to cold environment Karnakandu or self-inflicted trauma by
use of ear bud or pine to clean itching in ear Shabda Shashtra Mithyayoga
that is misuse of instrument or listening to high sound frequencies[7] The
other predisposing factors are such as abuse of nonspecific broad-spectrum
antibiotics steroids and immune suppressed disorders
Classical features of Karnasrava can be compared with otomycosis
Otomycosis is acute sub-acute or chronic fungal infection in external ear
which rarely involves the middle ear[8] Otomycosis is characterized by pain
itching discharge conductive deafness of mild to moderate in nature
Fungal spores invade in the epithelial layer of EAC In response to that
inflammatory process starts which will reflect as pain Itching is due to
immune reaction of body during inflammatory process As a result of
Page | 4
inflammatory process exudates were produced which will mix up with
fungal colonies and appear as discharge In initial stage of disease ear
discharge is watery but if there is secondary bacterial infection occur it
becomes mucopurulent Ear blockage and conductive type of hearing loss
are due to accumulation of fungal mass in external auditory canal
Fungal mass appears white or black or brown and is like a wet piece
of filter paper Examination with otoscope Aspergillus Niger appears black
headed filaments growth Aspergillus fumigates as a pale blue or green and
candida as a white or creamy deposit[9]
Otomycosis is a common condition and it mostly occurs in humid
area According to American academy of otolaryngology prevalence of
otomycosis is 52 all over a world and 09 in India 5-25 otitis externa
cases are due to otomycosis Nearly 61 types of fungal species being involve
in otitis externa 90 of fungal infection cases involve Aspergillus species
and the rest candida species[10]
In Ayurveda The common treatment Principle for all is Ghritapana
Rasayana Bhramacharaya Avyayama (Excessive exercise)
Ashirasnana(Head bath) Atibhashashya(Excessive speaking) This can be
used for the prevention and management of Karnaroga[11] Acharya
Sushruta explain specific treatment modality for Karnasrava is
Karnaprakshalana Karnapoorana Karnadhoopana Shirovirechana
Karnadhavana[12]These therapeutic procedure can be updated according to
different stages of these condition
In routine OPD it is observed that patient of otomycosis respond
more frequently to topical therapy than to systemic therapy Among all the
treatment modality Karnadhoopana is an effective and simple procedure
In this regard Karnadhoopana with Agaruwadi Varti or uggula had explain
in Ashtang Samgraha Agaruwadi Varti contain Agaru Yawa Madanphala
All these contains of Agaruwadi Varti and Guggula acts as Ruksha Ushna
Teekshana Laghu Guna acts as effective Shodhaka keeps ear dry reduce
Page | 5
pain discharge foul smell and thus control the infection Dhoopana is also
useful as Adhidaivika Chikitsa to protect the patient from external attack of
visible and invisible organism The principal treatment modality adopted in
Allopathic system of medicine is oral antibiotics and topical antibiotic drop
Long term use of oral antibiotic causes adverse effect like gastric irritation
reduce immunity and resistance to drug Long term use of topical antibiotic
drops cause Ph change in external canal which become prone to fungal
infection
Hence the therapeutic procedure with Guggula or Agaruwadi Varti
Karnadhoopana are cost effective safe and easy procedure and it can be
used more effectively
Page | 6
AIM OF STUDY
To evaluate the effect of Agaruwadi Varti Dhoopana and Guggula Varti
Dhoopana in management of Karnasrava
OBJECTIVE
To compare the efficacy of Agaruwadi Dhoopana and Guggula Dhoopana in
Karnasrava
HYPOTHESIS
NULL HYPOTHESIS -
H0- Agaruwadi Dhoopana is not effective than Guggula Dhoopana in
Karnasrava
ALTERNATE HYPOTHESIS -
H1- Agaruwadi Dhoopana is more or equally effective than Guggula
Dhoopana in Karnasrava
RESEARCH QUESTION
Whether there is significant difference between Agaruwadi Dhoopana and
Guggula Dhoopana in Karnasrava
Page | 7
PREVIOUS WORK DONE -
1 Anupama Patra B Effect Of Arka Taila In The Management Of
Karnasrava With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2007
2 Palmer Komalben K Further Study On Role Of Arka Taila In The
Management Of Karnasrava With Special Reference To
Otomycosis Shalakya Tantra Institute for Post Graduate Teaching amp
Research in Ayurveda Gujarat Ayurved University Jamnagar 2010
3 Sathisha Shankar B Management Of Karnasrava With Sthanika
Guggulu Dhoopana And Rasnaadi Guggulu-A Comparitive Study Shalakya
Tantra Government Ayurvedic Medical College Bangalore 2011
4 Shashikala DK Comparative Study On The Efficacy Of Vacha
Lashunaadi Taila Karna Pichu And Nimba Patraadi Dhoopana In The
Management Of Karna Srava Shalakya Tantra Government Ayurvedic
Medical College Bangalore 2014
5 Javale Anant A Clinical Study On The Efficacy Of Arka Taila In The
Management Of Karna-Srava Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2005
6 Pournima V Koti Management Of Karnasrava With Priyangvadi Taila
Pichu With And Without Saarivadi Vati Shalakya Tantra Sri Jagadguru
Gavisiddeswar Ayurvedic Medical College Koppal 2015
7 Amisha Patel A Clinical Evaluation Of Honey In The Management Of
Karna Shoola With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching and Research in Ayurveda
Gujarat Ayurved University Jamnagar 2016
Page | 8
REVIEW OF LITRATURE
Page | 9
Ayurvedic literature Ayurveda is a science of life practice since
thousands of years The ancient Indian system of medicine and surgery is
commonly known as Ayurveda This was given the status of Upaveda or
fifth Veda in the next stage of growth Among the available literature three
Samhita that is Charaka Samhita Sushrut Samhita Ashtang Hrudayam and
Ashtang Samgraha are the chief source of knowledge of Ayurveda
Ayurveda consist of eight branches Shalakyatantra is one among them
Shalakyatantra is one of its specialized branch deals with science of
ophthalmology otorhinolaryngology Oro dental surgery and head Acharya
Sushruta himself a practical surgeon was the first to advocate dissection of
dead bodies is indispensable for a successful student of surgery He had
described gross anatomy in the first chapter of Uttartantra Shalakyatantra
define by different Acharys as follows
शालाकय नामोरधवजतरगताना रोगाणा शरणनयनदनघराणाददसशरशरताना वयाशरिनामपशमनारव
स स ११०
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत [13]
चस १७१२
Shalakya Tantra Nirukti and Parichaya
शलाकायााः कमव शालाकय ततपपरिान शलाकयम डलहण [14]
The term Shalakyatantra is derived from Shalakya and Tantra
The word Shalakya means A probe and Tantra denotes teaching and
practices found in scripturesThe compendium in which application of
Shalaka in various surgical procedures is principally described is called as
Shalakya tantra
दनदटिवशारदााः शालाककनाः डलहण ( सउ ११३)[15]
An eye specialist is termed as Shalaki by Dalhana
Page | 10
Synonyms of Shalakya Tantra
Uttamanga Chikitsa Jatrurdhwa Chikitsa Urdhwang Chikitsa Shalakya
Chikitsa
Importance of Shalakyatantra-
Life of living being and all the Indriyas are situated in the head hence it is
known as Uttamanga
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत
चस १७१२
The treatment given to this part of the body is described specially in
Shalakya tantra While describing the importance of Shiras Vagbhata
correlates it to the root of tree (Urdhwa Mula) and body to the trunk of tree
(Adha Shaka)
Sushruta has deal with Mukha Roga in Nidan Shan and its treatment in
Chikitsasthan The description regarding the disease of eye ear nose and
head are found only in UttaraSthan Sushruta specially describes the
disease of Shalakyatantra as told by Videha in the beginning of Uttartantra
itself[16]
Shalakyatantra Itihas-
India Exhibits traditional of more than thousands of years in art literature
language logic and philosophy etc The convention was in its sophisticated
and advanced attire throughout the Vedic period
Vedic period ndash
1 Natush was treated for deafness by Ashwinikumars (Rigveda)
2 Rujaswa and Kanva were treated for blindness by Ashwani Kumaras
(Rigvedas)
Page | 11
3 There are several prayers mentioned for normal functioning of sense
organs (Yajurveda)
4 Structures and functions of Mastishka are described (Atharveda)
5 Mantras having reference to disease of Eye Ear Oral cavity etc are
found (Atharvaveda)
Upanishada Period ndash
1 Samhita Period
a) Sushrut Samhita ndash
bull Explanation regarding Netra Nasa and Shirorogas (Uttartantra 1-
26th chapter)
bull Details regarding Mukha and Karna Roga Nidan and
Chikitsa(Nidansthan 16th and Chikitsasthan 22nd chapter)
bull Description regarding Karna Chedana Sandhana Nasa
Ostasandhana Sutra Sthan 16th chapter
b) Charaka Samhita -
bull Explanation regarding Shirorogas (Sutrasthan 17th chapter)
bull Explanation of Gala rogas like Upajivika Galshundi and Rohini
bull Nasa Shiro Mukha Karna and Netra Chikitsa (Chikitsa sthan 26th
chapter)
bull Description regarding Lakshana and Chikitsa of Shankhaka
Ardhavbhedaka Shirovirechana and Shiro basti (siddhi sthan 9th
chapter)
c)Ashtnga Sangraha ndash
bull Detailed description regarding Shalakyatantara (Uttartantra 11-28
chapter)
bull Description of Kriyakalpa (Sutrasthan 32nd and 33rd)
Page | 12
d)Ashtang Hrudayam
bull Detailed description on Shalakya Tantra (Uttar tantra 8-24 chapters)
bull Kriyakalpas (Sutrasthan 23rd and 24th chapter)
e) Bhela Samhita
bull Chakshushya Vaisheshik and Buddhi Vaisheshik Alochaka pitta
f) Harita Samhita- Branch of Medical science offering elaborating
information about the procedure like Nasya Anjan Gandusha etc
comprehended with their applications in disease of Head Eyes Ears
Eyebrows Throat Temporal region and cervical spine is known as
Shalakyatantara
शशरोरोगा नतररोगा कणवरोगा वशषताः भरकरठशङकमरयास य रोगा समिनदरत दह १३
तषा परततकारकम व नसतयतपयवणजनातन च अभयङगमखगणडषकियााः शालकयसशमतााः १४
इतत शालाकयनाम [17]
Documentation of different ancient literature gives various references
regarding all aspects of Karnasrava in various periods It is very much
important to know the history of Karnasrava from Vedic Pauranic Samhita
and Samgraha period
Vedic period ndash The Vedas being the oldest source of knowledge have no
direct mentioning of Karnasrava
Page | 13
Samhita and Samgraha period ndash
Aacharya Sushruta described about Karnaroga Karnasrava Nidan
Roopa and Chikitsa The detail description is available in Sushrut
Samhita Uttartantra 20 and 21st chapters
Aacharya Charaka did not specify Karnasrava but mentioned 4 types
of Karnarogas that is Vataj Pittaj Kaphaja and Sannipataja and their
treatment in 26th chapter of Chikitsasthan
In Ashtang Hrudaya karnasrava is not explained as a separate disease
but Chikitsa is mentioned in 18th chapter of Astanga Hrudaya
uttartantra
In Ashtang Samgraha Chikitsa is mentioned in 22nd chapter of Astang
Samgraha Uttartantra
The details about Karnasrava are explained in Bhavprakasha
Madhyamakhanda 64th chapter
Madhavakara has explained about Karnasrava in 57th chapter of
Madhymakhanda
Karnasrava is also explained in Sharangadara Samhita Uttarkhand 11th
chapter
The reference for treatment of Karnasrava is available in
Yogaratnakara
In Gadhnigraha Karnasrava and its treatment is mentioned in
Karnarogadhikara Adhaya
Vangasena had mentioned about the disease and treatment in 69th
chapter
Chakradatta explained Karnasrava in 57th chapter
Dalhana has given commentary on Sushrut Samhita Uttartantra 20th
and 21st chapter
Sankhya Samprapti of Karnasrava ndash
Aachary Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga
Vigyniyam Aadhaya Aacharya charaka explain 4 Karnaroga in
Page | 14
Karnarohvigyniyam Adhaya based on doshas Acharya Vagabhata in
Ashtang Hrudaya explain 25 Karnaroga in Adhyaya
कणवशल परणादशरच बाशरियव कषड ए च
कणवसरााः कणवकणडाः कणव चवसतततर च
कशमकणवपरततनाहौ विशरिदवविसततरा
कणवपाकाः पततकणवसततराशवशरचतवविम
कणावबवद सपतवि शोफशरचावप चतवविाः
ऎत कणवगता रोगा अटिावशततरीररतााः
स उ २०- ३ त ५[18]
ातकणवरोग वपततकणवरोग कफकणवरोग
रकतकणवरोग सनदरनपातकणवरोग कणवनाद
बशरिरतप परततनाह कणडाः शोफ पततकणवक
किशमकणवक उियरपविरधयअशो अबवद
कशरचकणवक वपपपली वदाररका पाळीशोष
ततिका पररपोिो उतपपातो उरमरर दाःखिवन
शलहाखयााः परचवशनदरतकणवरोगा उकतााः
इदिीका अ स उ २१ [19]
चतपाराः कणवरोगााः
च स [20]
Page | 15
KARNA
Karna ndash करोतत शबद गरहण [21]
The organ of hearing
Karnasrava- कणवसतय कणवयोाव ससराा [22]
Discharge from the ear is referred as Karnasrava
KARNA SHAREERA
bull Nirukti
कणयवत अकणयवत अनन इती [23]
It means reception and conduction of sound waves
These are the functions of external and middle ear
bull Nirukti of Sravanam
शरयत अनन इती शरणम[24]
It means perception of sound
It can be attributed to the internal ear function
bull Karna Utpatti-
Karna is an organ formed by Akash Mahabhuta[25]
The fundamental characteristic is as follows
Indriya ndash Srotram [26]
Indriya Adhisthan ndash Karna [27]
Indriya Dravy ndash Akasha [28]
Indriya Arth ndashShabdha [29]
Indriya buddhi ndash Srotobyddhi
Page | 16
bull Paryaya of Karna- Shabdapatha Srotrapatha Sravanam shruti
Kuhuram Dwanigraham etc
bull Definition of Karna-
कणवशटकलयनदछिरनमिटिोपगरदहत शरोतरमछयत [30]
मा तन ५७१
The definition of Karna is stated in Madhav Nidanam Indriya which is not
seen with naked eye along with Shashkuli is called Shrotra that is Karna
Indriya is so minute that it is not perceived with any sense organ
In Charak Samhita the word Karna explain as the Indriya Adhisthan of
Shabdha Karna is described as one of the Prathyangas of the body He
emphasizes that all Indriyas manifest during the 3rd month of gestation
period
Acharya Sushruta while describing formation of Purusha from Prakriti or
Avyakta narrated that all Indriyas are developing from the Vikarika and
Taijas Ahankara Both Vagabhata and Sushruta stated that Karna as one of
the Bahirsrotas
शरण नयन दन घराण गदमढराणण न सततरोताशसराणा बदहमवखातन [31]
स शा ५-१०
In Ashtang Hradaya Vagbhata has states that all Indriyas are Atmaja
According to him lower lobule elevated helix projected posterior portion
fleshy and adherent ear are indications of long span of life[32]
ततरखातखातन दह अनदसतमन शरोतर शबद ववकतता [33]
ा शा ३-३
शबदाः शबदनदरिय सवनदछििसमहो ववकतता [34]
स शा १-२६
Page | 17
Ear has the prominence of Akash Mahabhuta The prominent dosha of ear
is Vata It is important seat of Vata The prominent Dhatus are Asthi and
Mamsa Karna is one of the Panchgnanendriyas and it meant for hearing
Sushruta narrated that Karnasthita Asthi and Sandhi
घराणकणवगरीाकषिकोषष तरणातन [35]
सशा ५-२२
शरोतरशरगािकष शखाताव [36]
सशा ५-३२
गडकणवशखटककम [37]
स शा ५-२२
One Sandhi and one Tarunasthi in ear
Sandhi ndash Karna contain two Sandhi one in each ear Type of Sandhi is
Shankhavartha which is present in Shringataka
Mansapeshi ndash 2[38]
Siras ndash 10 [39]
Vataj Sira - 4
Pittaj sira - 2
Kaphaj sira - 2
Raktaj Sira - 2
Avedhya sira-
कणवयोदवश तासा शबदादहनीनामकका पररहरत
सशा ७-२५[40]
Amongst above mentioned ten Siras each Karna lodges one Shabdavaha
Sira It is Avedhya
Page | 18
Dhamani -2
Length of ear is 4 Angula
Karna moola ndash 2 Angula
कणाविरतर चतदवशअगलम
स शा ३५-१४[41]
The distance between two ears through the back of the neck is 14 Angula
bull Marmas of Karna-
1 Vidhuras-
कणवपटठतो अिाःसशरशरत विर ततर बशरियवम
सशा ६-३७[42]
कणतपयादद सतनायममवणी ककनदचचनदरनममनाकर कलयकररणणच
डलहणाचयव[43]
अिसततात कणवयोतनवमन विर शरततहाररणण
ा शा ४-२९[44]
Sankhya-2
Vistara- frac12 Angula
Type- Snayumarma (Susha)
- Dhamanimarma(AH)
- Vaikalykar
Sthana- It is situated in the depressed portion in the back of the ear
Injury to them causes loss of hearing
Page | 19
2 Shringataka marma-
नदजवहाकषिनाशसकाशरोतरखचतटियसरमम
तालरयासतयातन चतपारर सरोतसा तष ममवस
वदि शरगातकाखयष सददसततपयजतत जीवतम
मा तन ५७१ [45]
Sankhya- 4
Type- Siramarma
Sthana- It is in head that is amidst Siras (blood vessels) nursing sense
organ
A palm size area near Talu
Injury to this Marma causes death
In modern anatomy ear divides into Bhayakarna or External ear Mdhyakarn
or Middle ear Antahkarna or Internal ear This is extremely appropriate
Even though the ear is divided into three divisions in the point of modern
anatomy Ayurveda denotes ear organ is one Ayurveda treats disease by
way of assessing Dosha and Dushya Here Dushya is one that is Karnendria
Dosha difference will call for different treatment for different disease Hence
treating the vitiated Dosha will cure the disease irrespective whether it is in
external middle or internal ear The thought is based on different
fundamental principle from Ayurveda
bull Parts of Karna
In Ayurveda classics detailed description about anatomy of ear is not
available But the various parts are mentioned as follows
Bhayakarna- External ear
Mdhyakarna ndash Middle ear
Antahkarna- Internal ear
Page | 20
द कणवशटकशलक दॊ कणवपतरकौ
च शा 7-11[46]
कणवशटकशलक कणवगतातवकौ कणवपतरकौ त बाहयकणा
चिदतत च शा 7-11[47]
शटकली बाहयपालयाशरिटिानम
डलहन- स शरच 25-1 12[48]
Karna Shashkulika ndash It is also called as Karna Shashakuli Charaka has
mentioned this term while describing different Pratyngas of the body
Acharaya Gananatha sen has given the clarification for it as a pinna or
auricle[49]
Karnapali ndash It is popularly known as lobule of the ear Daivakrita Chidra is
present in it
Karnaputrika- Ayurvedic scholars accepted two terms in this cortex They
are Karnaputrika and Karnaputrika The former is considered as Tragus and
antitragus[50]
Karna Prushtha- It can be taken as the cranial surface of mastoid or
auricle[51]
Karnapeetha- Aacharaya Sushruta firstly mention the term Karnapeetha
It is mentioned first by Sushruta while describing the procedure of
Karnavyadana Vagbhata has mentioned that it is Adhobhaga of Karna
Dalhana has clarified that it is the region above the Karnaputrika that is the
region which is at the bottom of the concha
Karnamoola ndash It can be considered as parotid region[52]
Karna lathika ndashAcharaya Dalhana mentioned lobule as a Karna Lathika
Page | 21
Karnaavatu ndashThis term is used by Sushruta while describing the
measurements of different Angapratyangas where he has mentioned that
the distance between the Karnaavatu is 14 Angul Dalhana has comments
that it can be taken as the distance between two ears from behind[53]
Shabdhavahasrotas ndash It also called as Shabdapatha or Srotapatha The
whole passage through which the sound waves pass can be taken as
Shabdavahasrotas[54]
Shrotashringataka ndash It can be taken as the labyrinth of ear[55]
bull Dosha in context to Karna-
Karna is principal location of Vayu
1 Prana Vayu- Prana Vayu circulating in oral cavity is responsible for
Dehadhruka that is keeping all body parts active Indriyadruka that is
keeping all Dnyanendriya healthy by proper nourishment (Purana) helps in
deglutition of food material and convey the stimulation of Indriyabuddhi
and atma
2 Udana Vayu- Bala(strength) Varna speech singing are its function It
is responsible for facial expressions due to pleasure sorrow anger love
frustration etc in general its circulation and actions are just opposite to
Pranavayu
3 Vyana Vayu- Its principal functions are circulation of Rasa and Rakta
through body and various movements Its main location is Hrudaya Five
types of movements for which it is responsible are expansion contraction
upward downward and oblique other activities are opening closure of
eyelid yawning perspiration During circulation if it gets obstructed due
to Srotodushti it generates disease of that Srotas Vyana Vayu gets vitiated
by disease of Rasa Rakta Oja and Chetanadhatu
Page | 22
4 Samana Vayu- It is circulating in the vicinity of stomach and intestine
and helps in keeping the Jatharagni (digestive juices and enzymes) in
equilibrium Disturbance in Jatharagni precipitates disease
5 Tarpaka Kapha- Entire body functions movements are controlled and
executed by various centers in the brain Sensation perceived by sense
organs is conveyed to Mann and Aatma residing in Hrudaya The motor
signals from them are then conveyed to the functioning
organsKarmendriya through Prana Vayu Shira head is therefore a
location of continuous activities motions of Vata All these centers are in
unctuous Majjadhatu in the Shira For stabilizing this ever-active Vata and
to nourish the Majja dhatu very unctuous Tarpaka Kapha situated in Shira
plays an important role
bull Ayurvedic aspect of sound perception [56]
According to Ayurveda Pratyaksha Dnyan or Perception of any sensation
including Shabda occurs due to interaction of the Karnendriya and the
Indriya- Arth -Karma resulting in Sravana
External Environmental acquaintance with living body is executed by five
sense organs namely Netra Karna Nasa Jivha and Twaka All
Dnyanendriya that is sense organ are Panchmahabhautic combination
Despite this fact every Indrya sense organ perceives object Tanmatra of
that Mahabhuta only from which it is originated from Akash Mahabhuta and
hence perceives Shabd only that is audio perception Shrotrendriya is one
of the principal locations of Vata and its function is to perceive Shabda that
is sound waves This sensation is conveyed through Shabdavahi Dhamanis
to Mana and Atma through Pranavayu and the sequence is responsible for
perception of sound in this way external sound is perceived and interpreted
when Atma is linked with Mann Mann is linked with Indriyabuddhi that is
minute virtual Dnyanendriya located in brain Indriyabuddhi is linked with
Adhishthana with prominent Mahabhuta and lastly with Indriya
ArthShabdatanmatra that is sense object Once this sequence is completed
Page | 23
the meaning of a particular sound is interpreted and understood In this
entire process of perception and interpretation of sound waves Pranavayu
and Tarpaka Kapha located in Shira play extremely important role Hence
the healthy status of all the sense organ depends upon the normal
physiologically homeostatic condition of Pranavayu and Tarpaka Kapha
MANAS
ATAMA
BUDDHI
AHANKARA
ARTHA
Page | 24
EAR ANATOMY
bull Embryology of the Ear [57]
1 The sound conducting apparatus develops from the branchial apparatus
whereas the sound perceptive apparatus from the ectodermal otocyst
2 The pinna develops from the six hillocks around the 1st branchial cleft
3 External auditory canal develops from 1st branchial cleft
4 The outpouching of the 1st pharyngeal pouch gives rise to a proximal
narrow part that forms the eustachian tube and distal dilated part that
forms the middle ear cavity
5 Prussakrsquos space is a potential space lateral to the Shrapnellrsquos membrane
and medically by the neck of malleus that can be involved during the
extension of cholesteatoma
6 Development starts in the 3rd week of the intrauterine life and is
completed by 16th week of intrauterine life Membranous and boney
labyrinth develops from the otic capsule
The Ear is divided into
1 External Ear
2 Middle Ear
3 Internal Ear or the labyrinth
Page | 25
Fig 1 Ear Anatomy
EXTERNAL EAR [58]
The outside ear contains pinna and lobule
Pinna is the noticeable piece of outer ear made from single sheet of yellow
flexible ligament covered by subcutaneous tissue and skin It has two
surfaces average and parallel It is intently disciple to perichondrium on its
sidelong surface while it is somewhat free on average surface Pinna
incorporates tragus helix against helix fossa three-sided scaphoid fossa
incisura terminalis
External auditory Canal ndash It extends from the bottom of the conchea to
the tympanic membrane and measures about 24 mm along its posterior
wallit is S shaped
Parts 1 Cartilaginous part
2 Bony part
Page | 26
Cartilaginous part ndash The outer one third is cartilaginous consist of fibro
cartilage is directed first inward backward and upward It has Fissure of
Santorium The skin of this part of the canal contains hair follicles
sebaceous gland and cruminous gland
Bony part ndash The inner two third part is boney It goes forward downward
and medially skin lined in this part is very thin Isthmus is the narrowest
part of the canal lying medial to junction of bony and cartilaginous part
nearly 5 mm lateral to tympanic membrane
The roof and posterior wall of the external auditory canal shorter than floor
and anterior wall The skin lining the tympanic membrane and boney canal
has a self-cleansing property due to migration of keratin layer of epithelium
from drum towards the cartilaginous portion
Relations- Anteriorly- Temporomandibular joint and parotid gland
Superiorly- Middle cranial fossa
Inferiorly- parotid gland
Posterior- Mastoid antrum mastoid air cells and facial nerve
Nerve supply ndashSensory nerve supply of the external ear The auricle
supplied by fibers of the great auricular nerve (C2 and C3) and lesser
occipital nerve (C2) Auriculo temporal branch of the 5th cranial nerve and
auricle branch of the vagus (Arnoldrsquos nerve) supply external canal Facial
nerve has small sensory contribution on posterior-inferior wall
Tympanic Membrane -It is the partition between EAC and middle ear It
is a thin semitranslucent membrane pearly white in colored lying obliquely
in the medial end of EAC with the angle of 55 It is forming major part of
lateral wall of middle ear Annulus tympanicus is attached at its
circumference to the sulcus The TM is oval shape It measures
approximately 10 mm in vertical diameter and 90 mm in horizontal
diameter
Page | 27
Layers ndash Tympanic membrane consist of three layers
1 Outer Epithelium or cuticular layer which is continuous with skin of
external ear
2 Middle fibrous layer has both circular and radial fibers middle layer
missing in upper part
3 Inner layer- Inner mucosal layer which is continuous with middle ear
mucosa
Parts ndash Tympanic membrane consist of two parts
1 Pars tensa -It is largest part below the malleolar folds The inner
surface at the center attached to the handle of malleus Angle of cone
is most illuminated part in the pars tensa at anteroinferior part of pars
tensa
2 Pars flaccida Sharpnells membrane -it is triangular area above the
malleolar folds which are thin and devoid of fibrous tissue and
annulus It fits into notch of Rivinous
Nerve supply 1 Anterior half of lateral surface Auriculotemporal V3
2 Posterior half of lateral surface Auricular branch of vagus cn 10
3 Medial Surface Tympanic branch of CN 9 (Jacobsons nerve)
Fig 2 Tympanic membrane of ear
Page | 28
MIDDLE EAR [59]
The middle ear or tympanic cavity is an irregular laterally compressed
space within the temporal bone It is filled with air that is supplied to you
from the nasal part of the throat through the ear canal It contains a chain
of mobile bones that connect its side with the medial wall and serve to
transmit vibrations transmitted to the eardrum through the cavity to the
inner ear Including the parapet the vertical and anteroposterior diameters
of the cavity are each approximately 15 mm The transverse diameter
measures about 6mm at the top and 4mm at the bottom Compared to the
eardrum it is only about 2mm The eardrum is limited laterally by the
eardrum medially by the lateral wall of the inner ear It communicates
behind with the tympanic antrum and through it with the air cells of the
mastoid and in front with the auditory canal The middle ear together with
the Eustachian tube aditus antral and mastoid air cells is called the
middle ear cleft It is lined by mucus membrane and filled with air
It is divided into 3 parts
1 Mesotympanum (located in front of the pars tensa)
2 Epitympanum or attic (located above the pars tensa but medial to
Sharpnells membrane and the lateral bony wall of the attic)
3 Hypotympanum (located under pars tensa) The middle ear is like a
hexagonal box with a roof
Carotid or Anterior wall- It separates middle ear cavity from internal
carotid artery The various structure passing through anterior wall of
tympanic cavity
bull Canal of chorda tympani nerve
bull Canal of tensor tympani muscle
bull Eustachian tube
bull Anterior malleolar ligament
bull Anterior tympanic artery
Page | 29
Posterior or mastoid wall ndash The upper part of the back wall shows the
opening of the auditorium Below the auditory is a triangular bony
projection known as the pyramidalis processors The stapedial tendon is
transmitted through the apex of the pyramidalis processes The vertical
portion of the facial nerve descends along the posterior wall until it opens
into the stylomastoid foramen
Roof or Tegmental wall (Pars terminalis)- It is formed by a thin bone
plate called the tegman tympanum that separates the skull and tympanic
cavities It is located on the anterior surface of the rocky part of the
temporal bone near the junction with the temporal shell it extends back to
the roof in the tympanic membrane and anteriorly to cover the half canal
of the tensor tympanic muscle The lateral border corresponds to the
remains of the Petro scaly suture
Floor ndash It is formed by a thin plate of bone which separate middle ear from
the bulb of the internal jugular vein lodged in the jugular fossa
Lateral wall ndash It is formed by tympanic membrane and partly by a portion
of squamous part of the temporal bone It separates the middle ear from
external ear
Medial wall- It separates the middle ear from the inner ear
bull The promontory is the most prominent and convex part formed by the
basal rotation of the cochlea
bull The bony lateral semicircular canal is postero-superior to the promontory
above the oval window
bull The oval window is located between the middle ear and the vestibular
slope of the cochlea It is closed by the stirrup footrest and the annular
ligament
Page | 30
bull The round window is located under and behind the cape The round
window recess is directed to the rear It is closed by the secondary eardrum
and separates the middle ear of the Scala tympani from the cochlea
bull The facial nerve passes through the bony fallopian tube above the oval
window
Mastoid Antrum ndash It is a large space with air in the upper part of the
mastoid and communicates with the attic through the aditus The roof is
formed by the antri tegmen which extends and separates the tympani
tegmen from the middle cranial fossa The lateral wall of the antrum is
formed by a bony plate that is on average 15 cm thick in adults It is
marked externally on the surface of the mastoid by the suprameatal triangle
(MacEwen)
Aditus and Antrum- Aditus is a gap through which the attic communicates
with the antrum The boney prominence of the horizontal canal lies on its
medial aspect even as the fossa incudes to thats attaches the quick system
of incus lies laterally Facial nerve publications simply underneath the
aditus
The mastoid and its air cell system-
The mastoid consists of bone cortex with a honeycomb of air cell
underneath Depending on development of air cell three types of mastoids
have been described
1Well-pneumatized or cellular- Mastoid cells are well developed and
intervening septa are thin
2Diploetic- Mastoid consist of marrow spaces and a few air cells
3Sclerotic or acellular ndash There are no cells or marrow spaces
With any type of mastoid pneumatization antrum is always present In
sclerotic mastoids antrum is usually small and the sigmoid sinus is
anteposed
Page | 31
Depending on the location mastoid air cells are divided into
1 Zygomatic cells (In the root of zygoma)
2 Tegman cell (Extending into tegmen tympani)
3 Perisinus cells (overlying the sinus plate)
4 Retrofecial cells (round the facial nerve)
5 Peri labyrinthine cells (located above below and behind the
labyrinthine some of them pass through the arch of superior
semicircular canal These cells may communicate with the petrous
apex)
6 Peritubal (around the Eustachian tube Along with hypotymoanic
cells they also communicate with the petrous apex)
7 Tip cells (which are quite large and lie medial and lateral to the
digastric ridge in the tip of mastoid)
8 Marginal cells (Lying behind the sinus plate and may extend into
the occipital bone)
9 Squamosal cells (Lying in the squamous part of temporal bone)
Development of Mastoid ndash
The mastoid develops from the scaly petrous bone The petrosquamosal
suture may persist in the form of a bone plate - Korners septum which
separates the superficial squamosal cells from the deep rock cells Korners
septum is surgically important because it can cause problems locating the
antrum and deeper cells and thus lead to incomplete removal of the disease
during mastoidectomy The mastoid antrum can only be reached if Korners
septum is removed
Page | 32
Fig 3 Cross section of Mastoid
Contents of the middle ear
Ossicles ndash Three tiny bones which conduct the sound from eardrum to oval
window
Malleus ndash It is the largest and most lateral ossicle measuring 8 mm in
length It has head neck handle anterior and lateral processes The head
is situated in the epitympanum A lateral process project laterally from the
neck while the handle is firmly fixed to the pars tensa of the ear drum
Incus- It has a body short process and long process The body short
process and long process The body articulate with the head of mallelus in
the attic and the short process project into the attic The long process
projects downwards behind the handle of malleus running parallel to it and
articulate with the head of the stapes via the lenticular process
Stapes ndash It is the smallest ossicle measuring about 35 mm and consist of
head neck footplate and anterior and posterior curcura The footplate of
stapes is held to the oval window by the annular ligament
Page | 33
Muscles ndash
1Tensor tympani ndash It is inserted is a branch of the facial nerve which carries
the sense of taste It is first arch muscle supplied by branch of mandibular
nerve V3
2 Stapedious muscles ndash It is inserted to the neck of stapes It is the second
arch muscle supplied by branch of facial nerve that is nerve to stapedius
Fig 4 Contents of the middle ear
Blood supply of Middle Ear
bull Anterior tympanic branch of maxillary artery which supplies tympanic
membrane
bull Stylomastoid branch of posterior auricular artery which supplies middle
ear and mastoid air cells
Page | 34
Four minor vessels are
bull Petrosal branch of middle meningeal artery runs along greater petrosal
nerve
bull Superior tympanic branch of middle meningeal srtery traversing along
the canal for tensor tympanic muscle
bull Branch of artery of pterygoid carotid
bull Tympanic branch of internal carotid
Lymphatic Drainage of Ear
Lymphatics from the middle ear drain into retropharyngeal and parotid
nodes while those of the Surgical Importance ndash Eustachian tube drain into
retropharyngeal group
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 middle is likely to pass to
middle ear
2 Moreover middle ear suppurative disease may spread to adjacent organs
and produce complication eg Labyrinthitis meningitis facial nerve palsy
etc
3 Lenticular process is vulnerable in suppurative ear diseases and causes
ocular disruption
4 Prussac space is the site of primary acquired cholesteatoma
Page | 35
INNER EAR [60]
Inner ear is divided into two parts
1 Bony Labyrinth
2 Membranous labyrinth
Anatomy of bony labyrinth
It is divided into two parts
1 Vestibule
2 Cochlea
3 Semicircular canal
The vestibule is located between the medial wall of the middle ear and the
lateral to internal acoustic meatus anterior to the semicircular canal and
posterior to the cochlea The vestibule is the central part of the inner ear
On its side is the oval window opening which is closed by the bracket foot
plate The bony cochlea is located in front of the vestibule It has 275 turns
wound around a bony axis called a modiolus The cochlea is about 30 mm
long The hollow center of the modiolus is a spiral canal that contains the
fibers and ganglion cells of the cochlear nerve A thin bony sheet the bony
lamina winda around the modiolus This divides the cochlear duct into two
galleries the Scala vestibuli above and the scala tympani below
There are three semicircular canals superior posterior and lateral They
are semicircular in shape and open into the vestibule One end of the
semicircle is enlarged and is known as the sphere
The membranous labyrinth is in the bony labyrinth It is connected to the
bony labyrinth by fibrous trabeculae and is surrounded by perilymph The
endolymph is located in the membranous labyrinth
Page | 36
The utricle is in the upper part of the vestibule while the saccule is found
below Both the utricle and saccule contain a single sensory patch called
the macula Each macula is covered with a neuroepithelium made up of
neuroepithelium made up of sensory hair cells and support cells these cells
are separated by a basement membrane Fibers of the vestibulo-cochlear
nerve enter the macula and pierce the basement membrane to terminate
at the base of the hair cell or cell bodies The utricle and the saccule with
their macula are called otolith organs Membrane semicircular canals are
the membrane canals of the corresponding bony semicircular canals They
open into the utricle through five openings One end of the opening of each
channel is dilated called the sphere in which the sensory organ of each
channel is located The cross section of the Scala standard looks like a right
angle The base is formed by the basilar membrane Sensory cells are
arranged on the surface of the basilar membrane These sensory cells with
their supporting cells form a complex neuroepithelium called the basilar
papilla or the cortical organ named after an Italian microscopist The
organs of the corti have a gelatinous membrane called the tectorial
membrane and they are supported by the pillar of the corti The cortical
pillars enclose a space called the corti tunnel which contains a fluid called
cortical lymph Vestibule is lies between the medial wall of the middle ear
and lateral to internal acoustic meatus anterior to semicircular canal and
posterior to the cochlea 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 Boney cochlea lies in front of the vestibule It has 275 turns
coiling around boney axis called modiolus Cochlea is approximately 30 mm
in length The hollow center of the modiolus is a spiral canal containing the
fibers and ganglion cells of cochlear nerve A thin boney sheet the osseous
lamina winda around the modiolus This divides the cochlear canal into two
galleries the Scala vestibuli above and the scala tympani below
Page | 37
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 boney labyrinth It is connected
to the bony labyrinth by fibrous trabeculae and is surrounded by perilymph
Endolymph 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 single sensory patch called macula Each
macula is covered by neuroepithelium consist of Neuroepithelium consists
of sensory hair cells and supporting cells these cells are separated by
basement membrane Fibers 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 are referred
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 corti lymph
Page | 38
Fig 5 Inner Ear
Blood supply of labyrinth
Labyrinthine artery
Common cochlear Anterior vestibular Artery
Vestibulocochlear artery Main cochlear artery
Cochlear branch posterior vestibular artery
Page | 39
PHYSIOLOGY OF HEARING [61]
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
bull Mechanical conduction of sound (conductive apparatus)
bull Transduction of mechanical energy to electrical impulses (sensory
system of cochlea)
bull Conduction of electrical impulses to brain (neural
Fig 6 PHYSIOLOGY OF HEARING
Page | 40
Conduction of sound
Under the surface of water we cannot hear the sound made in air because
9995 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 must 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 13 times longer than long process of incus providing
a mechanical advantage of 13
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 beings 211 As the effective
vibratory area of the tympanic membrane is only two- thirds the effective
areal ratio is reduced to 141 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
Page | 41
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 lobe
Page | 42
DISEASES REVIEW
करणसराव
Nirukti - करणसय कणवयोाव ससराा [62]
Nidana- Acharya Sushruta and Vagbhata describe the common etiological
factors for the Karnaroga
अशयाय जलिीडा कणवकणडयन मरत
शमथययोगन शसततरसतय कवपतो अरय च कोपन ||
सउ २० १२
1 Avashaya or Pratishaya
(Excessive exposure to cold)
2 Jalakrida
(Excessive swimming)
3 Karnakandunyanum
(Excessive scracing due to itching)
4 Mithyayogena Shatrasya
(Improper instrumentation during wax removal or foreign body removal)
5Shabdasya
(Louder sound for long durationperverted contact of sound)
6 Abhighata (Trauma)
7 Vitiation of Tridoshas
Page | 43
Samanya Nidana according to different Samhita
Vishesh Nidan of Karnasrava
Acharya Charaka has not mentioned any kind of Nidana regarding Karnaroga
but has described Utapati of Karnaroga from Siroroga in Karnasirasym
Adhyaya[67]
शशरोअशिघातादरा तनमजजतो जल परपकादरा अवप विि
सरतत पय शरणॊ अतनलात स कणवससरा इतत परककतीत
सउ २० १०
असस ३७२५ [68]
1 Shiroabhighatat - Head Injury-Fracture of middle cranial fossa
2 Jala nimajjana - CSF otorrhoea fracture of middle cranial fossa
3 Karnaprapaka
4 Karna Vidhradhi -Puyasrava
Sr
no
Samanya Nidana SU AH[63] AS[64] YR[65] MN[66]
1 Avashaya + + +
2 Pratishaya + +
3 Shabdha
mithyayoga
+
4 Shashtra
mithyayoga
+ + +
5 Karnakandooyan + + + + +
6 Jalkrida + + + + +
7 Abhighata + + +
Page | 44
Samanya samprapti
परापय शरोतरशसरा कयावत शल शरोतशस गान
त कणवगता रोगा अटिावशततरीता
सउ २० १२
Due to common and specific etiology factors the vitiated Doshas gets
Sthanasamshraya in Karna and causes Karnasrava It is the stages of
Samprapti were Doshas gets lodged in Srotas and start processes of Dosh
Dushya Sammurchsna Due to Shiroabhighata Jalanimmajana Karna Paka
Karna Vidhradi vitiated Vata Dosha and Karna becomes Avruta by Vata and
results in Karnasrava Normal physiology of Dosha Dhatus and Malas entirely
depends on the normality of Srotas Dosh Dushya Sammurchana or
manifestation of diseases will not take place if only vitiation of Doshas take
place without deformity of Srotas Here in Karnasrava vitiation of Srotas are
Atipravritti Sanga and Vimargagamana take place Atipravritti is being excess
production of fungus Sanga is obstruction in external acoustic canal
Vimargagamana is the propagation of discharge through ear
Vishesh Samprapti
Karnasrava occurs due to Nij nidana is Pratishaya while Agantuja nidanas are
Avashya Jalkrida and Karnakanduyan Due to etiological factors which are
Vata-Kapha provocative in nature gradual vitiation of Doshas will occur After
vitiation they get accumulated (Sthan samshraya) in external auditory canal
In other hand when patient does Sevana of Agantuj Nidan like water enter in
external ear scratching of ear unsterile instrumentation leads to Dosh
Prakopa These cause Twak and Mamsa Dhatu Dushti which leads to
discontinuity of epithelium of ear canal which creates suitable atmosphere for
fungal pathogen to grow The vitiated Vata will produce symptoms such as
Page | 45
pain hearing impairment and vitiated Kapha causes symptoms like itching
discharge ear blockage By assessing the symptoms it can be said that Kapha
Avrita Vata Dosha is responsible for the manifestation of clinical features like
pain itching discharge Which are seen in Karnasrava that is otomycosis
Acharya Charaka has mentioned while explaining Samanya Chikitsa of
Karnaroga that it should be treated like Vrana when Paka and Srava is present
as a symptom Fungal spores invade in the epithelial layer of EAC In response
to infection inflammatory process is start This is a Paka Avastha After
removing the fungal mass ulceration in external acoustic canal is commonly
seen As a result of infection process exudates was produced which will mix
up- with fungal colonies and appear as discharge As per Dosha involvement
in Vrana Shoola Srava can be differ According to Acharya Sushruta Ruk is
the Samanya Lakshana of Vrana and Vishesha Lakshana of Vrana includes
pain discharge discoloration itching etc according to Dosha involvement
which are also seen in otomycosis In otomycosis mainly watery and purulent
type of discharge is present which indicates Paka avastha If there is Dosha
involve in Vrana is called Dushta Vrana Acharya Sushruta and Acharya
Vagabhata have mentioned verity of Srava in Twak and Mamsa Vranavastu
which is found in otomycosis Based on this description otomycosis can be
correlated with Karnasrava
Page | 46
Representing the Samprapti of Karnasrava
Vishesh Nidana ndash Shiroabhighatat
Jala nimajjana
Prapaka Vidhradhi
Vitited vata
Avarana by kapha
Vimargagamana of Vata
Karnasrava
Samprapti Ghataka
Dosha ndash Kapha and Vata
Dushya ndash Rasa Rakta and Mansa
Strotodushti ndash Vimargagamana and Sang
Adhishthana ndash Karna (Bhayakarna)
Rogmarga ndash Madhyama
Page | 47
Purvarupa
The Purvarupa of Karnasrava are not mentioned separately in any ayurvedic
classics In routine practice cretin Purvarupa are noted
1 Karnakandu
2 Karnagurutwa
3 Alpa karnashoola
4 Discomfort in ear
Rupa
1 Karnashoola
2 Karnakandu
3 Karnasrava
4 karnabadhirya
5 Cotton wool like or wet newspaper like grayish brown or black colored mass
is seen
6 External auditory canal skin appears edematous and red
Upashaya and Anupashaya
Appropriate application of Aushadhi Ahara and Vihara when produces relief in
the symptom is called as Upashaya and when aggravates the symptoms is
called Anaupashaya There is not any reference available in the classics about
the Upashaya and Anupashaya of karnasrava
Sadhyasadhyata
Sushruta has not mentioned specially the Sadhyasadhyata of Karnarogas But
Vagbhata has mentioned Karnasrava as a Sadhyavyadhi[69]
Sadhysadhyatagives the clear picture of prognosis of the disease It depends
on many factors like nature of disease severity of disease Vaya Prakriti Bala
of the patient etc
Page | 48
Upadrava of Karnasrava
In Samhita there is no reference available regarding the Upadrava of
Karnasrava
Samanya Chikitsa ndash
The common treatment principle for all Karnaroga is Ghritapana Use of
Rasayana Bhrahmacharya Avyayama Shirasnana and Atibhashaya
सामरय कणवरोगष घतपान रसयनम
अवयायमो शशराःसतनान बरमहचयवम कतपरनम
स उ२१३
Ghratapana - Ghrita is a Yogavahi and follow Sanskara in addition to these
acquired properties and capable of retaining its own properties So Ghritapana
is effective in Karnasrava
Rasayana - Rasayana represent the basic approach of Ayurveda which
comprise preventive promotive and curative aspect of health
Brahmacharyaapalana -It is like Sadvrittapalana and is equals to Rasayana
effect
Vyayama - It leads to vitiation if Vatas a Karna is a Sthana of vata and
exercise causes Kshayaj Samprapti hence it is important to avoid exercise in
Karnasrava
Shirasnana- In Shirasnana water enters in external acoustic canal it changes
the PH of meatus skin from acid to alkali which favors the growth of pathogens
Atibhashya - Excessive speaking causes Vata Prakopa and Vatapraokopa is
basic Samprapti for Karnasrava as the preventive aspect avoidance of
excessive speaking is necessary
Page | 49
Ghritapana Rasayana and Brahmacharyapalana should be followed for
preservation of dhatu Samyata and restriction of vitiation of Vata Vayayama
Shirasnana and Atibhashaya should be avoided in Karnasrava to protect the
Siras from the affliction of Vata and Kapha
Vishesha Chikitsa ndash
The general treatment principle of Karnasrava described in classics is closely
related to Dushtavrana Chikitsa
शशरोवरचन च ए िपन परण तरा
परमाजवन िान च ीकषय ीकषय़ाचारत [70]
स उ २१४०
कणवसततरा ोददत कयावत पततकशमकणवयो [71]
ाउ १८३५
उपददि च सततरोत साय परात वपचततवशि परमजय
य अगर मदन सघत गगलना ा िपतयतपा मिना परयत [72]
असउ २२४२४३
In addition to that Shirovirechana Karnadhoopana Karnapurana
karnapramarjana Karnadhavana are also indicated
Page | 50
Treatment is also mentioned for Karnasrava
1 Karnaprakshalana Yoga - with Aargawadadi Gana Kashaya and Surasadi
Gana Kashaya [73]
2 Avachurnana Yoga ndash with Aargawadadi Gana Churna and Surasadi Gana
Churna[74]
3 Karnapoorna Yoga ndash
bull Rasanjana Laksha with Sarjachoorna[75]
bull Panchkashaya with Kapittha swarasa and Madhu[76]
bull Jambu AmrapallavShivalaKshuodra Mahavriksha and Madhuki 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 done[77]
bull Sarjatwak Choorna with Karpashiphalarasa and Madhu[78]
bull Abhaya LodraTindukaSamanga(Manjista) Kwatha of this Dravyas mixed
with Madhu and Kapittha Rasa[79]
bull Yogratnakara mention the following drugs for Karnapoorana-
a Samudraphena Churna[80]
b Jambwambpatra Yoga
4 Karnadhoopana Yoga ndash
bull Dhoopana with Churna of Bilvapatra Haridra Palandu[81]
bull Vartak Dhoopana [82]
5 Internal Medications-
bull Rasnadi Guggula [83]
bull Triphala Guggula [84]
bull Sarivadi Vati [85]
bull Gandhaka Rasayana [86]
Page | 51
According to Vagbhata-
Ear should be cleaned with the Pichu and Varti followed by Guggula Dhoopana
and then Karnapoorana with Madhu Followed by Avachurnanana with
Sukshmachootana of Surasadigana
Pathyaapathya ndash Pathya and Apathy mentioned for Samanya Karnaroga is
recommended in Karnasrava also
पथय[87]
सतदो वरको मन नसतय िमाः शशरावयिाः
गोिमाः शालयो मदगााः याशच परतन हवाः 80
लाो मयरो हररणानदसततततरो नकककिाः
पिोल शशगर ातावक सतनषराण कदठललकम
रसायनातन सवणण बरमहचयवमिाषणाम |
उपयकत यरादोषशमद कणावमय दहतम ||81||
िापर २१
Aharaja Upacharaja
bull Godhuma bull Vamana
bull Shala bull Virechana
bull Mudga bull Nasya
bull Yava bull Dhoomapana
bull Puranagitra bull Kavala
bull Lava Harina Tittiramamsa
Page | 52
अपथय[88]
दरत काटठ शशरसतनान वययाम शलटमल गर
कणडयन तषारशच कणवरोगी पररतपयजत
िापर २१
Viharaja
bull Patola ShigruVartaka bull Bhramacharaya
bull Sunishannaka bull Avyayama
bull Katthlika bull Aakthanam
bull All types of Rasayana bull Upacharaja
bull Vamana
Apathyas
bull Abhishyandakara Aharas
bull Shirasnana
bull Karna kandooyana
bull Tushara sevana
bull Guru Kaphakaraka Aaharas
bull Dantdhavana
Page | 53
OTOMYCOSIS
Definition-
Otomycosis is a superficial acute sub-acute or chronic infection of external
ear canal It is mostly unilateral It is characterized by inflammation purities
and scaling Otomycosis is a common condition encountered in ENT practice
more in chronic and persistent ear infection
The Fungal infections are not communicable in the usual sense but the
humans become an accidental host by their introduction into tissue trauma
The virulence factors favoring colonization of fungus in human host are yet to
be identified Ability of the fungus to grow at 37 C and elaboration of a variety
of enzymes and toxins are speculated to contribute to virulence Only 100 to
150 species are generally recognized as a cause of disease in humans[89]
Prevalence-
Otomycosis is a word wide in distribution and in various record stated that 5
to 20 of all cases of infective otitis externa Otomycosis prevalent is more in
warm and humid climates It is one of the commonest manifestations in India
during rainy season It occurs mostly in humid atmosphere otitis externa due
to fungal infection may resembles the desquamative form of diffuse infective
otitis externa The incidence in temperature climates has increased in
proportion to the use of topical antibiotics which have a medium sterilized of
other organism in which the fungus may flourish
Page | 54
Predisposing factors- [90]
1 Environmental factors such as climate contagious and polluting hygiene
more frequently during rainy season as the humidity increases
2 Individual susceptibility ndashGeneral Immunological status of the Individual
eg HIV infection Radiotherapy chemotherapy Diabetes mellitus
3 Self-inflicted trauma that is use of pins to clean the itching ear or use of ear
bud to clean the wax
4 Wide spread of topical antibiotics steroid preparations which have medium
sterilized of other organism in which the fungus may grow
5 Failure of defense mechanism in External auditory canal
6 During swimming or head bath water enters in External acoustic canal
causes quantitative and qualitative change in ear wax It causes change in pH
7 Long term use of hearing aids
Pathophysiology ndash
The life cycle of the average mold encountered in the ear may be reckoned
as two weeks and flare ups may be anticipated at such intervals Swimming is
held responsible for infection in many cases The sequence sequence of
pathogenic changes produced by molds in the external ear is as follows ndash
1 Implantation of the organism in external ear
2 Growth of organism follows the rate depending on condition of temperature
moisture or preexisting irritation
3 Invasion of epithelium occurs with attendant itching and discomfort which
may be quite severe
Page | 55
4 Exfoliation of epithelium occurs as nature attempts to overcome the
infection by casting off upper most cells
5 Denudation occurs from exfoliation as the top layers of epithelium are cast
off and the canal becomes filled with debris
6 Superficial ulceration and lizematoid dermatitis results if the pathologic
process goes for enough The changes do not always proceed through the
entire sequence sometimes the molds produce changes of the mildest
imaginable character which may be overlooked[91]
Clinical features -
Symptoms-
1 Irritation and itching ndash Irritation is mostly found when the infective
organism is aspergillus niger There is sensation of discomfort which is more
diffuse in the ear canal then localized in the deeper part Candida infection
causes marked itching In external ear it is intense and worse at night
2 Discharge through ear- Intermittent scanty colorless discharge through
ear Mucus being a fungal metabolic product appears as discharge Excessive
discharge is associated with mixed infection
3 Pain and discomfort ndash Mild to severe pain in the ear occasionally Mostly
seen in cases where ear is infected with Aspergillus flavus mixed infection
with gram negative organism or mixed infection with candida and aspergillus
Headache is sometimes associated with pain
4 Deafness- Varying degree of mild to moderate conductive deafness
5 A sensation of fullness in ear
6 Tinnitus 7 Vertigo
Page | 56
Signs ndash
1 The external acoustic meatus may contain a mass formed of epithelial
debris exudates cerumen and fungus
2 Erythematous external canal
Fungal appearance
A Niger - The color of the mass which is usually grey or black is mainly
determined by the type of fungus concerned Its appearance is like wet
newspaper or blotting paper or a cotton wool It has a peculiar musty odor In
this infection fruiting heads may be seen as black specks in the debris
Occasionally as inactive form occurs in which the canal is lined by mold giving
a fluffy appearance due to the presence of tiny mycelia
Candida ndash Candida infections generally show as white deposits on magenta
colored skin when the debris is removed it rapidly recovers in 24 hrs
The underlying canal skin is often inflamed and granular due to invasion by
fungal mycelia and be seen in all cases In rare cases excoriation and
ulceration with marked extensive shedding of the epithelium and deep
ulceration can be seen usually associated with a flavus and with pathogenic
bacteria[92]
Otoscope Appearance
1 Aspergillus Niger ndash Black headed
2 Aspergillus Fumigators ndash pale blue or green
3 Candida Albicans ndash White- or cream-colored deposits
Page | 57
4 Auricle is normal in most cases In severe cases small ulceration with crust
formation may be present on lateral surface
5 Tympanic Membrane
In most cases it is normal with normal mobility and normal hearing In a few
cases the surface of the tympanic membrane is congested and scaly There is
erosion or ulceration of the external epithelial layer and the membrane itself
may be edematous
Diagnosis
1 Above mentioned symptoms and signs
2 In the stage at which patient with otitis externa usually first present
themselves mycelia threads conidiophors not visible to naked eye may
sometimes be identified with the microscope
3 Confirmed by culture
Page | 58
Fig7 Aspergillus Niger Fig8 Candida Albicans
Fig9 Aspergillus Fumigators Fig 10 Wet Paper like appearance
Page | 59
Treatment
1 Antibiotic or steroid drops should be discontinued if they are being instilled
since long time
2 Removal of fungal mass epithelial debris and discharge from the external
canal or mastoid cavity repeatedly and thoroughly by forcepa or suction or
syringing or cautiously blow a stream of air into the canal through a fine
cannula and dry thoroughly by swabbing liquid petroleum on swab used in
cleaning the ear lessens the burning sensation when metacresy acetate is to
be employed in the subsequent treatment
Furuncle is developed as a complication if there is no gentleness in cleaning
Cleansing may have to be delayed until local sensitiveness is lessened which
can usually be accomplished within twenty-four hours If there is excessive
epithelial debris along with otomycosis then metacresyl acetate which is a
keratolytic in introduction into the external auditory canal on cotton wick and
is allowed to remain for twenty-four hours After twenty-four hours the cotton
wick is removed at which time the canal can usually be cleansed with little
discomfort as the medication is also anesthetic The epithelium of the canal
was white from contact with the drug The top layer was detached and this
epithelial debris can be easily wiped away The wick is reinserted and wet with
metacresyl acetate
The treatment is employed for three to four days in succession and then a
bland application is substituted Icthyol iodine is of value at this stage Iodine
ointment 2 in combination with Tannic acid 2 is also an excellent local
application following cresatin treatment
Next one of the fungicides may be applied
Page | 60
1 Nystin Effective for candida infection but less active against aspergillus
group Nystatin in boric powder consisting of 100000units of nystatingm of
powder 3 times week for 3 weeks
2 Clotrimazole Available as 11 cream or drops or lotions Phenyl
(zchlorophenyl) 1 ndash imidazole ndash methane is a chlorinated trityl imidazol 1
effective against candida and dermatophytes and for aspergilli infection
3 Amphotericin B Available as cream and as 3 solution and 015 drops
for topical application Very effective for candida infection can be fungistatic
or fungicidal
4 Econazole Available as solution (Econazole nitrate) and as cream (1)
Broad spectrum ndash more effective for Aspergillus Also active against some
gram-positive bacteria (Staphylococci and Streptococci and Dermatophytes)
5 Miconazole Highly effective against dermatophytes and candida infections
used as a 21 cream applied once or twice a day for 10 days
6 Gentian violet 21 Available as drops (recently some evidence of
carcinogenicity) Discolors the ear canal and this interfere with clinical
examination
Other topical antifungal agents are ketoconazole Natamycin Tolciclat Bifonas
zole Fenticonzole Oxiconazole Tioconazole ciclopiroxolomine Tolnafate
Haloprogin Flucytosine Acetic acid Whit field ointment selenium sulfide
undcyclenic acid triacetin etc
Page | 61
Minimal length of treatment
A month of drug treatment is usually required because the antifungal agents
used are not sporicidal and it is necessary that the period of treatment covers
germination time It may be advisable to give short gaps in the period of
treatment to ensure all spores have germinated before deciding to terminate
therapy
Prevention
Accomplished by strict attention to the predisposing causes
1 Water should be prevented from entering the ear
2 Avoidance of external ear trauma
3 Use of alcohol medicated or plain in the ears after swimming mercuric
cyanide (15000) in ethyl alcohol (70) is a satisfactory liquid to use
Ear stoppers do no good unless their use is followed by some antiseptic in the
canal Divers exposed to water for long periods of time may also use acidic
alcohol
4 During Summer months with their high humidity special efforts are needed
to maintain ear dry 5 Indiscriminate use of topical antibiotics steroid
preparations should be avoided
Page | 62
DRUG REVIEW
1 GUGGULA
Fig11 - Guggula
Historical review of Guggula [93]
bull Atharvaveda one of the well-known Vedas of Hindus The earliest
reference given by Atharvaveda medicinal and therapeutic properties of
Guggula Guggula has long history of use in Ayurveda
bull Acharya Charaka Sushruta and Vagbhata describe detail regarding the
actions uses and indication as well as the variety of Guggula
Page | 63
bull Various Nighantus (Medical lexicons) were written between 12th and 14th
centuries AD was based on the Ayurvedic literature also describes
Guggula
bull The explanation of word Guggula is that Gunjo Vyadhegurdti Rakshati
which means to relief against different diseases
bull Guggula is the best medicine because it develops through the rays of
hot sun on specific circumstances
bull Guggula has an aromatic odor
गगलो कणवदौगवररधय िपन शरटठमछयत[94]
स उ २२११२
Latin name- Commiphora mukul
Family ndash Burseraceae
Rasa- Tikta Katu
Guna ndash Laghu Rukshasukshma vishada sara
Veerya ndash Ushna
Vipaka ndash Katu
Action- Rasayana Lekhana
Doshaghanta - Tridoshhara
Page | 64
Chemical composition [95]
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Oleoresin-Z-Guggulsterone E-Guggulsterone
Gum- guggulignans 1 and 2 guggula Tetrols mukulol allylcembrol c
27
Guggulusterol 1 2 ans 3 Z and E ndash guggulusterol
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Parts Used ndash Gum oleoresin
Guggula purity test
1 Yellowish brown emulsion is obtained when Guggula is triturated with
water
2 An ethereal solution of the drug attains reddish colour when treated
with br2 vapors and purple colour when moistened with nitric acid
Biochemical action ndash Antiseptic Anti-inflammatory Disinfectant Diuretic
Immunostimulant stimulating expectorant Ant suppurative Antipyretic
Enhance phagocytosis
Karma- Rasayana cardiovascular disease
Page | 65
2 AGARU-
Fig 12 Agaru
Historical review of Agaru [96]
bull The word Agaru literally means the one which is the heaviest and no
aromatic wood is heavier than it Since thousands of years Agaru lsquoThe
wood of Godrsquo has been used for multiple purpose like commercial
medicinal spiritual aromatic historical
bull The medicinal use of Agaru have been recorded in many pieces of India
Greek Roman Chinese Middle eastern and European since ancient times
bull Acharya Charaka used Agaru and pest of Rasna to counteract the effect of
cold in Agraya Dravyas
bull Acharya Sushruta used Agaru as a Dhoopana Dravya along with Guggula
Ral and Shoma in the treatment of Karnasweda and Vrana
Page | 66
Types-
bull Dhanwantsri Nighantu describes Kaleyaka as a type of Agaru
bull Sodhala Nighantu describes three types of Agaru ndash Agaru Krishna
Agaru Kakatunda Agaru
bull Raj Nighantu describes five types of Agaru ndash Krishna Agaru Kasht
Agaru Daha Agaru Mangalya Agaru and Agurusaar
bull Arthashasstra describes three Agaru wood product
1 Jongaka ndash Black or variegated black in colour and having variegated
spots
2 Dongaka ndash Black in color
3 Parasamudraka- Black in colour and smells like Navamallika
अगर उटण कि तपछय ततकत ततकषण च वपततलम
लघ कणाविरोगघन शीत ात कफपरणत
िापर २१ [97]
Family- Thymelaccensis
Latin name- Aquilaria agallocha
Guna- Laghu Ruksha Tikshan
Rasa- Katu Tikta
Vipaka ndash Katu
Virya ndash Ushna
Karma- Sheetaprasasmana Vranaorasadan Tvachya Pittavardhaka
Shirovirechana Mangalya Sugandhik and Rochaka in properties [100]
Krishna Agaru karma- Katu Tikta rasa Ushna Sheeta when applied externally
and Pittahara when taken orally
Page | 67
Chemical Constituents -
Agaru hardwood is rich in essential oil resins alkaloids saponins Steroids
terpenoids tannins flavonoids and phenolic compound Agaru wood
predominantly contains 2-[-2-phenylethy]-4H-chromen-4-one derivatives and
sesquiterpenes Agaru oil contains selinene dihydroselinene agarnol b-
agarofuran vetispira-2(11)valerianol dihydrokaranone and tetradecanoic
acids[99]
Part Used ndash
Heartwood- Dark resinous wood which is formed when the plant becomes
infected with a type of fungus (ascomycetous mold) Species of Aspergillus
fusarium and penicillium are reported to be associated with the development
of infection Prior to infection the heartwood is odorless relatively light and
pale colored however as the infection progresses the tree produces a dark
aromatic resin in the heartwood The infected resin in response to the attack
which results in accumulation of a very dense dark resin in the heartwood
The infected resin embedded wood is known as Agarwood Infection is more
common on the trunk roots and the area when branches divide The formation
of Agarwood starts when the tree attains the age of 20 years On an average
approximately 30 ml oil is extracted from 100 kg of infected Agarwood[98]
Qualities of best Agaru-
It should be black in color
It should be extremely heavy and aromatic
It should be oily in appearance and test
It should be sink in water
It should burn easily with bright flame with a bright flame giving off a pleasant
smell
Page | 68
3 MADANA
Fig 13 MADANA
Madana consist of dried fruit of Xeromphis spinosa It is a deciduous thorny
shrub or a small tree reaching a high up to 9 m and girth about a meter
branches numerous thick and horizontal found in sub-Himalayan tracts[101]
मदनो मिरनदसततकतो ीयोटणो लखनो लघ
ानदरतिदवििीहर परततशयायवरणारतक
रि कटठकफ़ानाहशोथगलमवरणापह[102]
िा पर १६० १६1
Page | 69
Latin name-Randia dumetorum
Familly ndash Rubiaceae
Rasa - Madhura Tikta
Guna-Laghu Ruksha
Virya- Ushna
Vipaka ndash Katu
Karma- Vamana and Lekhana
Chemical Composition-
Essential Oil Valerianic acid Saponin tannin resin [103]
Page | 70
YAWA [104]
Fig 14 Yawa
1 In Samhitakala Aacharya Charaka Acharya Sushruta explain detail about
medicinal properties of Yawa
2The use of Yawa in Aaharya Dravya mainly described by Dhanwantari
Nighantu Raj Nighantu Bhavprakash Nighantu[105]
Macroscopic Description-
Fruit a caryopsis elliptical oblong Ovoid and tapering at both ends smooth
about 1cm long and 02- 03cm wide dorsally compressed and flattened on
the sides with a shallow longitudinal furrow 3-5 ridges having shallow
depression between them grains tightly enclosed and adhering the lemma
and palea pale greenish yellow odor not distinct taste sweetish acrid
Page | 71
Latin Name ndash Hordenum vulgare
Family- Poaceae
Rasa- Kashaya Madhura
Virya- Sita
Vipaka- Katu
Karma- Vatakrt Pittahara Kaphahara Medahara Balya Visrya
SthairyakaraLekhana
Page | 72
PROCEDURE REVIEW [105]
In Ayurvedic classics there are many references regarding Dhoopana Dravya
Dhoopana is administering Dhuma with the help of Dhoopana Dravya
In Kashyapa Samhita there are 40 types of Dhoopana advised for children
Anesthesia (Mohajananam Dhoopa) is also mentioned For this Dhoopana the
drug used were herbs hairs of animals legs horns old cloths of Buddhist
monks
From the references available regarding Dhoopana we can understand that
Karna can be protected from maggots (krimi) Bactria (Rakshogna) lice etc
References clearly indicate the analgesic and disinfectant effect of Dhoopana
Karma Dhoopana is mentioned for Dushta Vrana Chikitsa It reduces Vedana
Srava Pootigandha of Dushtavrana It also helps in Vranaropana
Dushtavrana Chikitsa is mentioned in the treatment of Karnasrava[106]
Origin of Dhoopana-
In ancient period children of sages were constantly harassed by the
Rakshasas Hence the sages approached lord Agni for shelter Agni in turn
gave them Dhoopana Dravya and asked sages to use the Dhoopana for
protection against Rakshasas bhutas pishachas
Classification of Dhoopana
1 It is classified into Dhupa Anudhupa Pratidhupa
2 On the basis of Origin it is classified into Jangama and Sthavara
Selection of Guggula for Dhoopana
Page | 73
bull Guggul is a best Vatahara
bull It is Krimighana
bull It contains Oleoresin
bull In Ashtang Hrudaya Guggula Dhoopana mentioned for Karnasrava
Selection of Agaru for Dhoopana
bull Agaru is Laghu Ruksha Katu Tikshna
bull Vranaorasadan Tvachya
bull It should burn easily with bright flame with a bright flame giving off a
pleasant smell
Karna Dhoopana Indication
1 Karnaarava
2 Putikarna
3 Krimikarna
4Vataj Karnashula
Contraindications
Especially for Karnadhoopan contraindication is not mentioned in classic texts
But Dhoopana is contraindicated in Pittaj vaydhi Sharad and Grishma Rutu
Page | 74
MATERIAL AND METHOD
Page | 75
For randomize comparative clinical trial to study the effect of Agaruwadi
Karnadhoopana and Guggula Karnadhoopana in Karnasrava following material
and method were required
Source of data
Patient irrespective of gender occupation religion social economic status
signs and symptoms of classical features of Karnasrava (Otomycosis) selected
from the OPD of Shalakyatantra department
Materials ndash
1Patients
2 Drugs-Agaruwadi Dhoopana
Guggula Dhoopana
3Torch
4Otoscope
5 Tuning fork
6Jobson horn probe
7Cotton
8Case record form
DRUG
Group A Trial Group
1Churana of Agaru Yawa Madan
2Ghrita
3Jala
Group B Control Group
1Googula Churna
Page | 76
Properties of Drug
Table no 1 Properties of Drug
Drug
Family
Rasa Veerya Vipaka Effect
on
Dosha
Guna Karma
Agaru
(Aquilegria
Agallocha)
Thymelaca
ceae
Katu
Tikta
Ushna Katu KV Laghu
Ruksha
Tikshna
Shitaprashamana
Shothahara
Vedanasthapak
Durghandhihara
Madan
(Randia
spinosa)
Rubiaceace
Kashaya
Madhur
Tikat
Katu
Ushna Katu KV Ruksha
Laghu
Vatakaphaghana
Shothahara
Vedanasthapak
Vranashodhak
Yawa
Poaceae
Hordeum
Vulgare
Kashaya
Madhur
Sheeta Madhur KP Ruksha
Laghu
Vataghana
Vernashodhana
Raktshodhaka
Guggula
Commiphora
Mukul
Burseracea
e
Tikta
Kashaya
Anushna Katu VPK Laghu
Ruksha
Shothahara
Vedanasthapaka
Kandughna
Ghrita Madhura Sheet Madhur VK Snigdha Vataghana
Shothahara
Vedanasthapaka
Page | 77
METHODOLOGY
SELECTION CRITERIA
1)INCLUSION CRITERIA
1 Patients having signs and symptoms of Karnasrava (Otomycosis) ie करणशल
( pain ) करणकणड ( Itching ) करणसतराव ( Discharge )बाधिरण ( conductive Loss of
hearing )
2 Patient from age group 19 to 70 years
3 Any Gender
2)EXCLUSION CRITERIA
1 Patients suffering from any systemic disease like DM TB HTN
2 Chronic suppurative otitis media (CSOM)
3 Acute supportive otitis media (ASOM)
3 Perforation of Tympanic membrane
4 Chronic otitis media
3)WITHDRAWAL CRITERIA
1If patient develops any adverse effect such as irritation pain burning
sensation in ear loss of hearing and such patients was withdrawn from trial
and receive prompt appropriate medical attention
2If patient shows aggravation in symptoms
3If patient refuses to continue with the treatment
Page | 78
STUDY SETTING
Types of study - Randomized Clinical comparative Trial
Place of work - OPD of Shalakyatantra
Duration of study - 18 months
Study Population - Patients of Karnasrava in Shalakyatantra OPD
SAMPLE SIZE CALCULATION
Sampling Method ndash Purposive sampling followed by random allocation in two
groups
Sample size calculation-
n = z2 p (1-p)
d2
Were
n = sample size
P = prevalence of disease=10
z = standard normal variable ie 196
d = error ie005
desired Sample Size would be
n = Z2 P(1-P)d2
= (196)2x (0021) x(0979)(005)2
= 34
Visiting ENT OPD (ShalakyaTantra) and IPD (ShalakyaTantra) 21 = 34
n raquo34
So one group includes 34patients
Page | 79
Sampling Method
Total 68 patient of Karnasrava are selected by Purposive sampling followed by
random allocation in two groups Written informed consent is taken prior to
commencement of trial They are divided in 2 groups
Group A (Trial Group) 34 patients treated with Agaruwadi Dhoopana for 7
days
Dose 5 minutes twice in a day
Group B (Control Group) 34 patients treated with Guggula Dhoopana for 7
days
Dose 5 minutes twice in a day
STUDY DESIGN ndash
Open labeled Randomized Comparative Clinical trial
STUDY DESIGN
Screening of patient
Inclusion criteria satisfied Exclusion criteria
Initial assessment Excluded
Counseling of patient Treated accordingly
Patient selection by Simple Random Sampling Method
Page | 80
68 Patients were divided in two groups lsquoArsquo and lsquoBrsquo
Trial group A-34 patients were given
Agaruwadi Dhoopana
Control group B- 34 patients were
given Guggul Dhoopana
Informed written consent
Treatment was given for 7 days
Assessment on 1st 4th and 7th day
Post assessments follow up on 15th day
Observation
Data Collection
Statistical analysis of data
Conclusion
Page | 81
(A) Agaruwadi Varti for group A (Trial group)
Table no 2
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
B) Guggula Varti for group B (Control group)
SOP of it is same as above Agaruwadi Varti
Table no 3
Drug Guggula Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
FOLLOW UP
For both groups follow ups were done on 1st 4th and 7th and post
assessment follow up15th day
EXAMINATIONS
Torch for Local examination of ear
Otoscope examination
Tuning fork Test
Page | 82
OBSERVATION TABLE
Table no 4
Sr no Subjective criteria Day 1 Day 4 Day 7 Day 15
1 करणशल
(pain)
2 करणकणड
(Itching)
3 करणसतराव (Discharge )
4 बाधिरण (Conductive Deafness)
OBSERVATIONS
a) करणशल (Pain) -
0 - Absent
1 ndash Present
b) करणकणड (Itching) -
0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
Page | 83
c) करणसतराव (Discharge)
0- Absent
1- Mild -Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाधिरण (conductive Loss of hearing)
0 - Absent
1- Present
Observations were carried out before and after completion of treatment and
during each follow up After observations the data collected and presented in
the form of graphs charts and table
Page | 84
TRIAL DRUG
Authentication and standardization of raw drug material done After
authentication and standardizing of raw drug material Agaruwadi Varti was
prepared by Varti as explained in Ayurvedic classics
Method of Varti preparations
Panchavidh Kashaya Kalpana that is five method of pharmaceutical
preparation constitutes the fundamental process of Ayurvedic pharmaceutics
which is well explained in Sushrut Samhita Varti Kalpana is one among them
which can be included in Kalka Kalpana
तीररसतरपतपतीनामपरककव तीत [106]
स डलहण शरच 151
Medicines are powered triturated and given the Varti shape that is like wick
of lamp so it is called as Varti Kalpana
Drug content Agaru Madan Yawa
Route of Administration Local
Dose Two times a day
Duration 7 days
Page | 85
Methodology
Standard operating procedure (SOP) of Agaruwadi Varti
Agaruwadi Varti is prepared according to the classical text
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization was done as recommended in pharmacy procedure The
raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 mixed together in
equal quantity to make Agaruwadi churn
Quantity of each churn is 4 grams all are mixed when the Varti get dry total
weight of Varti was 10gram
STEP 4 - Agaruwadi churn triturated with appropriate quantity of water or
Ghrita and prepared Varti in GMP Certified Ayurvedic pharmacy Standard
aseptic precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Varti was packed in sterile air packed container
STEP 6 - Agaruwadi Dhoopana was given with the help of Dhoopana yantra
Authentication and Standardization of raw drug of Agaruwadi Varti was done
Sterilization was done as recommended in pharmacy procedure Sterile
preparation packed in sterile container of suitable size Under all aseptic
precaution Karnadhoopana given to infected ear
Page | 86
Containers for packaging and their sterilization-
Sterilization of the containers for storing Varties was done by Ethylene Oxide
(Eto) method
Ethylene Oxide (Eto) procedure-
It includes exposure of materials to ethylene oxide gas under vacuum in a
sealed chamber It consists of four primary variables
1Gas Concentration
2Humidity
3Temperature
4 Time
EtO gas is an alkylating agent which disturbs the DNA of microorganism
preventing them from reproducing It penetrates the breathable packaging
and sterilizes all the accessible surface of the product to render products
sterility by alkylation of essentials proteins for cell reproduction
Most Eto sterilization methods involves three different stages These can be
separated into three different on the size or number of devices to treat
1Preconditioning stage-
First products are passed through a preconditioning phase to make
microorganism grow The batch load goes through a well time under a
controlled environment of temperature and humidity
2Sterilizer stage-
Performed using process phase specially designed to provide the required level
of EtO exposure to assure sterility for a device or family of devices
3Degasser Aerration stage-
Finally products need to go through a degassing phase to remove any residual
particles of Eto The batch load goes over well time under a temperature-
controlled environment
The sterile containers were then used to store Agaruwadi Varti and handed to
patients included in the study
Page | 87
Packing of Agaruwadi Varti
The ETO sterilize plastic container were used for packing of Agaruwadi Varti
Varti was filled into these sterilize containers (7 in each) In an aseptic
environment plugging and capping was done under aseptic precautions In this
way packing of Agaruwadi Varti done These Varti were given to patient and
advise to take two times a day under all hygienic precautions
History and Examination
bull Proper history and presenting complains was recorded on case record form
bull Ear examination with otoscope was done during initial assessment and each
follow up
bull Otoscopic examination was done during initial assessment and each follow
up
bull Systemic Examination that is Blood Pressure Temperature Respiration
rate Pulse was recorded on case record form
Page | 88
Raw material
Fig14 यव चरण Fig15 मदनफळ चरण
Fig16 अगर चरण Fig17 गगगळ चरण
Page | 89
Preparation of Agaruwadi Varti
Fig18 Preparation of Agaruwadi Varti
Fig19 अगरवादी वरती
Page | 90
Fig20 Instruments used for examination of Karnasrava
Fig19 Karnadhoopana Yantra
Page | 91
Karnadhoopana Procedure
Fig 22 Karnadhoopana Procedure
Page | 92
OBSERVATIONS AND RESULTS
Page | 93
BASED ON DRUGS
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 94
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
AUTHENTICATION CERTIFICATE
Page | 95
BASED ON STASTICIAL ANALYSIS OF DEMOGRAPHIC DATA
68 patients of Karnasrava ndash Otomycosis
Table no 5
No of Patients Total
Group A Group B
Registered 38 37 75
Completed 34 34 68
Discontinue 04 03 07
Total 68 patients were enrolled in study 38 patients registered in group A
amongst them 34 patients completed the treatment and04 patients
discontinued the treatment However in group B 37 patients completed the
treatment and 03 patients discontinued the treatment out of 37 registered
patients
Hence the total number of patients registered in the present study was 75
and out of which 68 patients were discontinued the treatment So they
dropped out from the study While 68 patients were successfully completed
the treatment So observations and result of 68 patients were given below
Here we are going to discuss the statistical analysis of the data obtained in
the form of master chart that was prepared in accordance with the data
collected from the patients that had been included in the study The purpose
of statistical analysis was to analyzed the relation between age gender
occupation diet addiction and education
Page | 96
1 Age wise distribution of patients
Table no 6
In trial group 10 (29412) patients were from age group 18-25 years 14
(41176) patients were from age group 25-35 years 8 (23529) patients
were from age group 35-45 years and 2 (58824) patients were from age
group 45-60 yearsIn control group 6 (17647) patients were from age group
18-25 years 14 (41176) patients were from age group 25-35 years 7
(20588) patients were from age group 35-45 years and 7 (20588)
patients were from age group 45-60 years
Fig 23 Age wise distribution of patients
0
2
4
6
8
10
12
14
15 -25 25-35 35-45 45-60
10
14
8
2
6
14
7 7
Age Distribution
Trial Group N Control Group N
Age Distribution
Trial Group Control Group
N N
18 -25 10 29412 6 17647
25-35 14 41176 14 41176
35-45 8 23529 7 20588
45-60 2 58824 7 20588
Total 34 100 34 100
Page | 97
1 Gender wise distribution of patients
Table no 7
Sex
Trial Group Control Group
N N
Female 23 67647 15 44118
Male 11 32353 19 55882
Total 34 100 34 100
In trial group 23 (67647) patients were female and 11 (32353) patients
were male
In Control group 15 (44118) patients were female and 19 (55882)
patients were male
Fig 24 Gender wise distribution of patients
0
5
10
15
20
25
N N
TRIAL GROUP CONTROL GROUP
23
15
11
19
Gender
Female Male
Page | 98
2 Education wise distribution of patients
Table no 8
Education
Trial Group Control Group
N N
Illiterate 4 11765 3 88235
SSC 4 11765 3 88235
HSC 8 23529 9 26471
Graduation 16 47059 10 29412
Primary 1 29412 3 88235
Post-Graduation 1 29412 6 17647
Total 34 100 34 100
In trial group 4 (11765) patients were illiterate 4 (11765) patients were
SSC educated 8 (23529) patients were HSC educated 16 (47059)
patients were graduated 1 (29412) patients were primary educated and
1(29412) patients were post graduated
In control grou 3 (88235) patients were illiterate 3 (88235) patients
were SSC educated 9 (26471) patients were HSC educated 10 (29412)
patients were graduated 3 (88235) patients were primary educated and
6 (17647) patients were post graduated
Page | 99
Fig 25 Education wise distribution of patients
0
2
4
6
8
10
12
14
16
ILLITERATE SSC HSC GRADUATION PRIMARY POST GRADUATION
4 4
8
16
1 1
3 3
910
3
6
Education
Trial Group N Control Group N
Page | 100
3 Occupation wise distribution of patients
Table no 9
Occupation
Trial Group Control Group
N N
Accountant 1 294 2 588
Housewife 11 3235 8 2353
Engineer 1 294 1 294
Job 1 294 4 1176
Labor 1 294 3 882
Mess 1 294 0 000
Naturotherapyst 1 294 0 000
Pharma 1 294 0 000
Shopkeeper 4 1176 2 588
Singer 1 294 0 000
Student 8 2353 4 1176
Tailor 1 294 1 294
Teacher 1 294 1 294
Worker 1 294 3 882
Farmer 0 000 1 294
Lab Tech 0 000 1 294
Page | 101
Daily Collection 0 000 1 294
Fruit seller 0 000 1 294
Bus Driver 0 000 1 294
Total 34 10000 34 10000
In trial group 11 (3235 ) were housewife 8(2353) were students
4(1176) were shopkeeper 1(294) was accountant 1(294) was
engineer 1(294) was doing job 1(294)was labour 1(294) was
catering 1(294) was Naturotherapyst 1(294) was Pharma 1(294)
was Singer 1(294) was Tailor 1(294) was Teacher and 1(294) was
worker
In Control group 8 (2353)were housewife 4(1176) were students
2(588) were shopkeeper 2(588) was accountant 1(294) was
engineer 4( 1176) was doing job 3(882)was labor 1(294) was
Farmer 1(294) was Lab tech 1(294) was Daily collection 1(294)
was Tailor 1(294) was Teacher and 3(882) was worker 1(294) was
Fruit seller and 1(294) Bus driver
Fig 26 Education wise distribution of patients
0
2
4
6
8
10
12
1
11
1 1 1 1 1 1
4
1
8
1 1 10 0 0 0 0
2
8
1
43
0 0 02
0
4
1 13
1 1 1 1 1
Occupation
Trial Group N Control Group N
Page | 102
4 Religion wise distribution of patients
Table no 10
Religion
Trial Group Control Group
N N
Hindu 31 9118 33 9706
Muslim 3 882 1 294
Total 34 10000 34 10000
In trial group 31 (9118) patients were Hindu and 3 (882) patients were
Muslim
In control group 33 (9706) patients were Hindu and 1 (294) patient
were Muslim
Fig 27 Religion wise distribution of patients
0
5
10
15
20
25
30
35
N N
TRIAL GROUP CONTROL GROUP
3133
31
Religion
Hindu Muslim
Page | 103
5 Diet wise distribution of patients
Table no 11
Diet
Trial Group Control Group
N N
Veg 14 4118 20 5882
Non-Veg 20 5882 14 4118
Total 34 10000 34 10000
In trial group 14 (4118) patients were vegetarian and 20 (5882)
patients were Non vegetarian
In control group 20 (5882) patients were vegetarian and 14 (4118)
patients were Non-Veg
Fig 28 Diet wise distribution of patients
0
5
10
15
20
N N
TRIAL GROUP CONTROL GROUP
14
2020
14
Diet
Veg Non Veg
Page | 104
6 Addiction wise distribution of patients
Table no 12
Addiction
Trial Group Control Group
N N
None 30 8824 27 7941
Alcohol 2 588 0 000
Tobacco 1 294 2 588
Mishri 0 000 1 294
Smoking 1 294 4 1176
Total 34 10000 34 10000
In trial group 30 (8824) patients have no addiction 2 (588) patients
have addiction of alcohol 1 (294) patients have addiction of Tobacco 0
(0) patients have addiction of Mishri and 1 (294) patients have addiction
of smoking
In control group 27 (7941) patients have no addiction 0 (0) patients
have addiction of alcohol 2 (588) patients have addiction of Tobacco 1
(294) patients have addiction of Mishri and 11 (1176) patients have
addiction of smoking
Page | 105
Fig 29 Addiction wise distribution of patients
0
5
10
15
20
25
30
NONE ALCOHOL TOBACCO MISHRI SMOKING
30
21
01
27
0
21
4
Addiction
Trial Group N Control Group N
Page | 106
Statistical Analysis and Results
Effect of study on Karnashoola-
Table no 13
Karnashoola
Group A Group B
BT AT BT AT
N N N N
Grade 2 0 000 0 000 0 000 0 000
Grade 1 30 10000 7 2333 32 10667 5 1667
Grade 0 4 1333 27 9000 2 667 29 9667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 30 Effect of study on Karnashoola
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
30
7
32
54
27
2
29
Karnashoola
Grade 2 Grade 1 Grade 0
Page | 107
Table no 14
Karnashoola Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 088 100 033 006
969 2829E-
08 7667 HS
AT 021 000 041 007
Group
B
BT 094 100 024 004
1037 7103E-
11 8438 HS
AT 015 000 036 007
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 31
000010020030040050060070080090100
BT AT BT AT
GROUP A GROUP B
088
021
094
015
Karnashoola
Mean
Page | 108
Table no 15
Karnashoola
Mean SD Effect
Group
A
Group
B Trial Control Trial Control
Day 1 088 094 033 024 000 000
Day 3 065 071 049 046 2667 2500
Day 5 024 038 043 049 7333 5938
Day 14 021 015 041 036 7667 8438
000
010
020
030
040
050
060
070
080
090
100
Day 1 Day 3 Day 5 Day 14
Karnashoola
Mean Group A Mean Group B
Page | 109
Table no 16
Karnashoola N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3250 110500
510000 275 Control group 34 3650 124100
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 110
Effect of study on Karnakandu
Table no 17
Karnakandu
Group A Group B
BT AT BT AT
N N N N
Grade 3 7 2333 0 000 4 1333 0 000
Grade 2 18 6000 0 000 18 6000 0 000
Grade 1 7 2333 7 2333 10 3333 15 5000
Grade 0 2 667 27 9000 2 667 19 6333
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 32 Effect of study on Karnakandu
0
5
10
15
20
25
30
N N N N
BT AT BT AT
GROUP A GROUP B
7
0
4
0
18
0
18
0
7 7
10
15
2
27
2
19
karnakandu
Grade 3 Grade 2 Grade 1 Grade 0
Page | 111
Table no 18
Karnakandu Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 188 200 081 015
1091 3119E-
10 8906 HS
AT 021 000 041 007
Group
B
BT 171 200 076 014
1032 4746E-
09 7414 HS
AT 044 000 050 009
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Page | 112
Fig 33
Table no 19
Karnakandu
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 188 171 081 076 000 000
Day 3 126 118 057 058 3281 3103
Day 5 071 074 046 051 6250 5690
Day 14 021 044 041 050 8906 7414
000
020
040
060
080
100
120
140
160
180
200
BT AT BT AT
GROUP A GROUP B
188
021
171
044
Karnakandu
Mean
Page | 113
Table no 20
Karnakandu N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 4051 137750
373500 006 Control group 34 2849 96850
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is less than
005 Hence we conclude that there is significant difference between Trial
Group and Control Group
000
020
040
060
080
100
120
140
160
180
200
Day 1 Day 3 Day 5 Day 14
Karnakandu
Mean Group A Mean Group B
Page | 114
Effect of study on Karnasrava
Table no 21
Karnasrava
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 11 3667 0 000 8 2667 0 000
Grade 1 23 7667 3 1000 26 8667 2 667
Grade 0 0 000 31 10333 0 000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 34
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
11
0
8
0
23
3
26
20
31
0
32
Karnasrava
Grade 3 Grade 2 Grade 1 Grade 0
Page | 115
Table no 22
Karnasrava Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 132 100 047 009
1122 4356E-
13 9333 HS
AT 009 000 029 005
Group
B
BT 124 100 043 008
1130 9364E-
14 9524 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 35
000
020
040
060
080
100
120
140
BT AT BT AT
GROUP A GROUP B
132
009
124
006
Karnasrava
Mean
Page | 116
Table no 23
Karnasrava
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 132 124 047 043 000 000
Day 3 100 100 025 025 2444 1905
Day 5 047 038 051 049 6444 6905
Day 14 009 006 029 024 9333 9524
000
020
040
060
080
100
120
140
Day 1 Day 3 Day 5 Day 14
Karnasrava
Mean Group A Mean Group B
Page | 117
Table no 24
Karnasrava N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3535 120200
549000 655 Control
group 34 3365 114400
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 118
Effect of study on Karnabadhirya
Table no 25
Karn
Badhirya
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 0 000 0 000 0 000 0 000
Grade 1 13 4333 0 000 16 5333 2 667
Grade 0 21 7000 34 11333 18 6000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 36
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 00 0 0 0
13
0
16
2
21
34
18
32
Karnabadhirya
Grade 3 Grade 2 Grade 1 Grade 0
Page | 119
Table no 26
Karn
Badhirya Mean Median SD SE
Wilcoxon
W P-Value
Effect Result
Group
A
BT 038 000 049 009
799 7173E-
05 10000 HS
AT 000 000 000 000
Group
B
BT 047 000 051 009
816 0000138 8750 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 38
000
005
010
015
020
025
030
035
040
045
050
BT AT BT AT
GROUP A GROUP B
038
000
047
006
Karnbadhirya
Mean
Page | 120
Table no 27
Karn
Badhirya
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 038 047 049 051 000 000
Day 3 009 006 029 024 7692 8750
Day 5 003 006 017 024 9231 8750
Day 14 000 006 000 024 10000 8750
000
005
010
015
020
025
030
035
040
045
050
Day 1 Day 3 Day 5 Day 14
Karn Badhirya
Mean Group A Mean Group B
Page | 121
Table no 28
Karn
Badhirya N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3400 115600
561000 806 Control
group 34 3500 119000
Total 68
Page | 122
COMPARISION BETWEEN GROUP A AND GROUP B
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Table no 29
Overall Effect
Trial Group Control Group
N N
Marked Improvement 21 6176 16 4706
Moderate Improvement 8 2353 13 3824
Mild Improvement 4 1176 5 1471
No Change 1 2941 0 0
TOTAL 34 100 34 100
Fig 39
0
5
10
15
20
25
MARKED IMPROVEMENT
MODERATE IMPROVEMENT
MILD IMPROVEMENT NO CHANGE
21
8
41
1613
5
0
Overall Effect
Trial Group N Control Group N
Page | 123
DISCUSSION
Page | 124
Discussion is nothing but the logical reasoning of observations In
every research work discussion part is very important because it brings into
light about the logical analysis which are helpful in filling the research gap in
the scientific world
The discussion is categorized into following ways for the ease of
understanding
1 Discussion on selection of topic
2 Discussion on review of literature
3 Discussion on drugs their mode of action on the disease mode of action
of Karnadhoopana
4 Discussion on observation and results
1 Discussion on selection of topic
Otomycosis is commonly encountered in day-to-day practice Majority
of Indian people affected with this pathology This disease commonly
manifests in developing countries low socio-economic standard and lack
of hygiene Now a days due to busy lifestyle people are not able to follow
the proper instruction of care of ear which may be responsible for the
recurrent nature of disease So for the management of this we use
Karnadhoopana with the help of Agaruwadi Varti Dhoopana is simple
easy cost-effective procedure which can be done even at OPD levelso
for the disease Karnasrava we selected Karna Dhoopana as therapeutic
procedure Karnadhoopana was done with Agaruwadi Varti and Guggula
Varti which was very effective for treatment
Page | 125
2 Discussion on review of literature
Karnasrava is one such disease among 28 Karnarogas mentioned by
Acharya Sushruta in the chapter named Karna Roga Vigyana Acharya
Charaka included Karnasrava as symptom under the four types of
Karnarogas due to vitiation of different doshas Acharya Vagbhata has
not described Karnasrava separately It is a fact that systemic
description of Karnarogas is available in all the ancients of pus from a
Vata afflicted ear may results from head injury or immersion in water
Karnasrava is a clinical entity which can be correlated with Otomycosis
Karnasrava is explained as symptom as well as a disease in Ayurveda
Nidana- Karnasrava occur due to Samanya Nidana and Vishesh Nidana
Vishesh Nidana like Shirobhighata Nimmajato jale Mithyayoga of Shashtra
The exact pathology behind Karnasrava is not understood clearly
Purvarupa ndash No specific Purvarupa are found for Karnasrava in classical
literature Acharya Madhukara describe Purvarupa as expression of
Rupa(lakshana) with less intensity that is less intensity itching sound in ear
may considered as Purvarupa of Lakshana
Samprapti- Aacharya Sushruta not explained the Samprapti of Karnasrava
separately and we must consider the general Samprapti of Karnaroga Due to
various aetiologias as cited above ear afflicted by Vata dosha causes Twak
Rakta Mamsa dushti results in Karnasrava According to Acharya Sushruta
Vata-Kapha dose is dominance in Karnasrava
Page | 126
Nidan
Nija Agantuja
Vata ndash kapha prakopak nidana Shirobhighata Nimmajato-jale
Mithya yoga of Shastra
Vata- kapha Prakopaka(Chaya prakopak) Vata-kapha prakopaka
( Achay prakopak)
Twak Rakta Mamsa dushti
Karnasrava
Page | 127
Chikitsa
The curative aspect and this must be done simultaneously giving due
importance to Nidan Parivarjana that is preventive measures So Nidan
Parivarjana that is avoidance of causative factors like Jalkrida Mithyayogen
shashtrasya Karnakandu Shirasnan Pratishaya is the first step in combating
the disease and form the part of line of treatment
Above Samprapti helps us to proceed towards the treatment of Karnasrava
The main protocol of treatment is removal of fungus and wound management
which include various measures to keep area day clean clear of microbes and
providing ideal condition for healing
Samany Chikitsa- Acharya Sushruta described general treatment for
Karnaroga as Snehapana (Drinking ghee) Rasayana (Rejuvenation therapy)
Bhramacharya Avoid excessive speaking Avoidance of physical exercise and
head bath
Vishesha Chikitsa ndash Acharya Sushruta mentioned some procedures in the
treatment of Karnasrava which is Shirovirechana Karnadhoopana
Karnapurana Karanpramarjana Dhavan Avachurnana Karnapurana Above
various procedures described in Ayurveda for management of fungus growth
in ear discharging ear fulfill these requirements of wound management
Page | 128
Discussion on observation and Result
Out of 68 patients 34 patients included for the trial The incidence of
Karnasrava is observed in trial and control groups
The statistical analysis provided the following data
AGE
Trial group- Maximum no of patients that is 14 (41176) patients were from
age group 25-35 years followed by 29412 patients were from age group
18-25 years 23529patients were from age group 35-45 years and
58824 patients were from age group 45-60 years
Control group - Maximum no of patients that is 14 (41176) patients were
from age group 25-35 years followed by 20588 patients were from age
group 35-45 years and 20588 patients were from age group 45-60 years
17647 patients were from age group 15-25 years
The maximum no of cases of Karnasrava found in age group between 25 to
35 years The reason behind this is repeated use of ear bud or emersed water
in ear More use of earphone or working more in cold environment
GENDER
Trial group ndash A higher prevalence seen in females 6764 and 3235 in
males
Control group - A higher prevalence seen in males 5588 and 4411 in
females
Females and males both are prone to disease
Page | 129
EDUCATION
Trial group-It is observed that amongst 34 patients maximum ie16
(47059) patients were graduated 8 (23529) patients were HSC
educated 4 (11765) patients were SSC educated 4 (11765) patients
were illiterate 1 (29412) patient were primary educated and 1(29412)
patient were post graduated
Control group- It is observed that 10 (29412) patients were graduated 9
(26471) patients were HSC educated 6 (17647) patients were post
graduated 3 (88235) patients were SSC educated 3 (88235) patients
were primary educated3 (88235) patients were illiterate
There is no direct relation between education and Otomycosis
RELIGION
Trial group- The incidence of patients of Hindu religion are 9118 and Muslim
religion are 882
Control group- The incidence of patients of Hindu religion are 9706 and
Muslim religion are 294
There is no probable explanation for this maximum number of patients in
Hindu religion it depends upon the patients attend the hospital and
community residing there
Page | 130
DIET
Trial group It was found that maximum ie5882 patients were taking
mixed diet while 4118 were taking vegetarian diet
Control group It was found that maximum ie5882 were taking
vegetarian diet while 4118 patients were taking mixed diet
The dietary habit of person is based on choice availability and religious
customs of the person
ADDICTION-
Trial group- It was found that maximum ie 30 (8824) patients have no
addiction 2 (588) patients have addiction of alcohol 1 (294) patients
have addiction of Tobacco 1 (294) patients have addiction of smoking and
0 (0) patients have addiction of Mishri
Control group - It was found that maximum ie 27 (7941) patients have
no addiction 4(1176) patients have addiction of smoking 2 (588)
patients have addiction of Tobacco 1 (294) patients have addiction of
Mishri and 0 (0) patients have addiction of alcohol
Very few patients were addicted to Alcohol Smoking Tobacco and Mishri
These factors can be taken as provoking factors for Otomycosis
Page | 131
Discussion based on probable Mode of action of Karnadhoopana
In Ayurveda classics Karna Dhoopana is therapeutic procedure explain for
Karnasrava Dhoopana is administration of Dhooma (Fumes) with the help of
Dhoopan Dravya References indicates that analgesic and disinfectant effect
of Dhoopana karma and mention for Dushta Vrana Chikitsa It reduces
Vedana Srava amp also does Vrana Ropana action
Various Dhoopanas and Dhoopan Dravas for different element in various
Samhitas of Ayurveda but there is a lacuna of availability of reference
regarding how to do it and method of procedure Matra Kala Contraindication
etc
Currently simple modified way of Karnadhoopana according to Yukti Praman
and experience but there is lac of standardization
Karnadhoopana is one among the topical Bahiparimajan type of treatment
Karna Parmarjana is procedure of cleaning ear with the help of cotton or gauze
piece soaked in honey
Page | 132
Dhoopan
The fumes coming out on burning Agaruwadi Varti
Administrated directly into external ear canal
Causes vasodilation
Due to this increase blood supply in external ear canal
It helps in absorption of drug
Fumes dries up Srava and bring the analgesic effect
Karnagata Kapha amp Avrut Vata Dosha Shaman
Decrease in signs and symptoms like karnasrava Karnshool Karnabadhirya amp
Karnandu
Page | 133
3 Discussion based on probable mode of action of Agaruwadi
Dhoopana
Agaru ndash
I Agaru is a fragrant tree aroma is a result of fungal pathogenesis when the
wood of tree is contaminated by fungi at wounds it develops scrap filled
with resin and turn out to be aroma Medicinal use of Agaru have been
recorded in ancient medicinal science in in inflammatory disease and some
infective disease
II Acharya Charaka has referred to Agaru as an Ushna dravya despite having
Tikta Rasa Ashtang Samgraha used Agaru as Dhupana Dravya along with
Madan and Yawa in Karnasrava Nighantu recommended is use as a
Dhoopana
III In various Samhitas and Nighantus Agaru described as Tikta Snighdha
Sheetaprashamana Vranaprasadana Tvachya Due to these properties
Agaru is used in the treatment of Karna-Akashi Roga and Dushta Vrana
Shodhaka
IV Agaru is reported to have Antimicrobial Analgesic Antioxidants
Antihistaminic and anxiolytic properties Its Antihistaminic property gives
relief from itching which is cardinal feature of Otomycosis Due to Katu
Ushna Tikta Guna improves blood circulation Bheda stage develop It is
Niram Awastha of Dosha Karnagata kapha and vata get decrease and
symptoms like karnashoolakarnasrava get decrease Agaru also have a
Antioxidant properties
V Chemically Agaru Contain 2-(2-Phenylethyl) Chromones Terpenoids
Flavonoids
VI Natural Agarwood had inhibitive activities towards Staphylococcus Aures
The chloroform extract of Agarwood prolongs the pain threshold[108]
Page | 134
Madan
I Madanphala have therapeutic properties like Anti-inflammatory
Antiallergic Analgesic and Wound healing
II It is Useful in treatment of disease like Shotha (inflammation) Vidradhi
(Abscess) Pratishaya (Common cold) Kushta(Skin disease)
III Extract of Madanphala mainly contain Glcosides Tritorpenct
Glycosides Saponin
IV Saponin glycosides are act as fire extinguisher This property is helpful
for vartiIt also act as a detergent which clean the surface of fungus
V Tritorpenct act as a anti-inflammatory antimicrobial and
immunomodulator compound Interaction of glycosides with sterol
causes disturbance of selective permeability in plasmic membraneso
exudates and discharge get decrease
VI Pharmacological activity [109]
Antibacterial Activity The preliminary antibacterial activity of Methanolic
extract of Randia D lam was done on some standard and wild pathogenic
strains The inhibition of the bacterial growth was more pronounced on E coli
as compared to the other tested organism This shows the antibacterial action
of Randia D secondary infection can prevent
Anti-Allergic Activity In Ayurveda Randia D Extract and its fraction of milk
induced leukocytosis and eosinophilia in mice
Anti-Inflammatory Activity The crude methanol extract of fruit of Randia D
effectively reduced the carrageenin induced oedema in hind paw of the rats
significant reduction in granular tissue formation was recorded This activity
seems to be significant at various acute phases of inflammation and om
formation of granular tissue This proves action of Madanaphala in shopa
(inflammation)
Page | 135
Analgesic Activity Analgesic activity was tested in mice weighing between 20-
250 with six number of animals in each group Methanlic extract of fruit Randia
d give analgesic activity in both models This proves its Shoolanashaka (pain
killer) action
Immunomodulatory Activity Randia D has immunostimulant activity and
chloroform fraction which strongly affected immune system seems to be
bioactive fraction of this plant
The overall effect of Agaru Mandanphala Yawa having Anti-inflammatory
Antiseptic Antimicrobial Property Active ingredient shows these properties
Agaru Yawa Madanphala
Vatakaphaghna
Act as
Vranashodhak
Vedanasthapaka
Sheetaprashamana
Shothara
Avarana of Vata get decrease so helps to Shaman of Vata dosha
Karnakandu Karnashoola Karnasrava
Prashamana
Page | 136
This fact can be taken into consideration and probably acknowledge that
Karnadhoopana with Agaruwadi Varti had not leave any residue in the ear
Removal of fibrin keratinocyte migration and in growth of epithelial tissue
plays a major role in healing It is technique of fumigation of ear with the
smoke of anti-infective drug In Karnadhoopana Sthanik Swedana increase the
blood supply and helps in absorption of the drug reduce Karnakandu amp
Karnshoola associated with infection
Page | 137
SUMMARY AND CONCLUSION
Page | 138
The dissertation entitled randomize comparative clinical trial to study the
effect of Agaruwadi Karnadhoopan and Guggula Karnadhoopan In Karnasrava
wsr to Otomycosis
The dissertation is divided into fallowing parts
Introduction
Review of literature
Ayurvedic review
Modern Review
Drug review
Procedure review
Material and Method
Observation and result
Discussion
Summary and conclusion
bull INTRODUCTION
It includes importance of Shalakyatantra in Sushrut Samhita Charka
Samhita And Ashtang Samgraha
Common and specific causes of Karnasrava
Karnasrava is a clinical entity which can be corelate with Otomycosis
In Ashtang Samgraha stated the procedure like Karnadhoopana with
Agaru Yawa Madanphala in Karnasrava
Page | 139
bull REVIEW OF LITERATURE
1 Ayurvedic review
2 Modern review
3 Drug review
Ayurvedic review-
It includes Rachana-Sharir and Kriya-Sharir of Karna detail description of
Karnaroga and its types Karnaroga Samanya hetu Poorvaroopa Rupa
Samprapti Upadrava Pathya-Apathya of Karnasrava Vishesh Nidan and
Chikitsa of Karnasrava Detail description of Karnadhoopana according to
various Acharays have been mentioned
Modern review-
It includes anatomy and physiology of Ear brief anatomy of ear anatomy of
External middle and Internal ear Detail description of the disease
Otomycosis mechanism of fungal infection in external canal pathophysiology
investigations diagnosis and management
Drug review-
Detail description of Agaru Yawa Madan Guggula and its synonyms
Ayurvedic properties Karma uses Pharmacological action and their
pharmacodynamic properties
Page | 140
MATERIAL AND METHOD
It includes description regarding materials required for the study Preparation
of Agaruwadi Varti its Standardization Sterilization and packaging
Plan of study
1 Total 68 patients completed the treatment Age criteria was kept
between 18-60 years Patient selection was done by done by simple
random sampling method and divided into two groups A (Trial) and
Group B (Control) 34 patients in each group
2 Patients in Group A were treated with Karnadhoopana with Agaruwadi
Varti for 7 days two times in a day while patients in Group B were treated
with Karnadhoopana with Guggula for 7 days two times in a day
3 Clinical examination done during each follow up ie 0th 4rd 7th and
observation were recorded
Page | 141
OBSERVATIONS AND RESULTS
Page | 142
1 It was observed that higher incidence of disease Karnasrava ie
Otomycosis found in age group 25-35 years
2 Disease otomycosis was equal in both male and female
3 The trial group there was significant relief in Karnakandu (8906)
Karnasrava(9333) Karnashoola(7667) and karnabadhirya(100)
4 In control group there was significant relief in Karnakandu (7414)
Karnasrava(9524) Karnashoola(8438) and
karnabadhirya(8750)
Page | 143
REFERANCES
Page | 144
1 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published byChaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 17 page no
5
2 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 19 page no
6
3 DRNarayan Vidwas Shero-Karna-Nasa and MukhrogaAnand publication
edition 4th 2014 Page no-52
4 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-205
page no 111
5 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 111
6 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Shlok no2012
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 112
8 Dr KBBhargavaDr SK BhargavaDr TMShahaA Short book of ENT
diseases Usha publication edition 10th
9 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 8 Page no -52
Page | 145
10 Research and Review Journal of Ayurvedic science yoga and
Naturopathy 2017 4(3) 1-5 pA Critical review of Otomycosis in cortex to
Karnaroga described in Ayurvedic classic by amisha patel D B Vaghala
Chandani goswami Vol4 no3 (2017)
11 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogpratished Adhaya Shlok no-213
page no127
12 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedh Adhaya Shlok no-
2140 page no 131
13 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyant shirasiya adhaya Shlok no 1712 page no-
258
14 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
15 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
16 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Aupadravik Adhaya Shlok no-15 page no
2
17 Vaidya Jaymini panday Harit Samhita hindi commentaryChaukhamba
vidhyabhartiVaranasiedition 2010 Shlok no- 13-14page no-10
18 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 146
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-20345
page no 112
19 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Karnarogavigyniyam Shlok
no 21 Page no-731
20 Charak
21 Pandit Harigovind Shashtri Namalinganusasana Amarkosha of
Amarsimha hindi commentary published by Chaukhamba Sanskrit
Sansthan page no- 463
22 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
23 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 37
24 Shree Taranath-Trkavachspati-Bhattacharyen Vchaspatym published
by Rashtriya Samskrit Sansthandelhi Volume 4 page no- 5149
25 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
26 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
27 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
28 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Page | 147
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
29 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Indriyaopakramaniya Adhaya Shlok no 811
page no- 125
30 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243
31 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-510 page no56
32 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no3108 page no- 385
33 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no33 page no- 366
34 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sarvabhutachintasharir Adhaya
Shlok no-126 page no9
35 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-522 page no60
36 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-532 page no61
37 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Page | 148
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-521page no58
38 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-527 page no61
39 VdBramhand Tripathi Ashtanghradaya Sharirsthansthan Published by
Chaukhamba prakashana 2005 Shlok no331 page no-372
40 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Siravarnavibhaktisharir Adhaya
Shlok no-725 page no83
41 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Sharirsankhyavykaransharir Adhaya Shlok
no-512
42 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Pratekmarmanirdeshsharir
Adhaya Shlok no-628 page no75
43 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
44 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Marmasharirsthan Shlok no429 page
no- 393
45 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243244
Page | 149
46 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
47 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan pu blished by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711
48 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
49 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
50 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Shlok no 711 page no- 847
51 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Adhaya Shlok no-628 page no- 75
52 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Gandushavidhiadhaya Shlok no2232
page no- 261
53 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Karnavydhbandhvidhi Adhaya Shlok no-
1611 page no- 86
54 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Nidansthan Published by Chaukhamba
Page | 150
Sanskrit SansthanVaranasi Vatvydhinidansa Adhaya Shlok no183 page
no- 304
55 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavaykaransharir
Adhaya Shlok no-532 page no61
56 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Tristaisniya adhaya Shlok no 1120 page no-
163
57 P Hazarika Dr Nayaka R Balkrishnan Textbook of EarNoseThroat and
Head-Neck Surgery CBS Publication Anatomy of Ear
58 DrKB Bhargava DrSKBhargava DrTMShaha A short book of ENT
Diseases Published by Usha Publication 10th edition page no10
59 MrSalah Mansour MrJacques MagnanMr Hassan Haidar MrKaren
Nicolas MRStephan Louryan Comprehensive and clinical anatomy of the
Middle Ear Published by Springer publication Chapter -Middle Ear cavity
Page no 19 to 121
60 DrPLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 7
61 James OPickles An introduction to Physiology of Hearing Published by
Emerald publication 4th edition page no- 1 to 265
62 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
63 VdBramhand Tripathi Ashtanghradaya Uttarsthan Published by
Chaukhamba prakashana 2005 Karnaroga vigyniyam adhaya Shlok
no1713 page no- 998
Page | 151
64 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Shlok no- 212 page no-
730
65 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no
1-2 page no- 309
66 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana
67 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyantshirasiya Adhaya Shlok no 1713 page no-
258
68 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no-
6 page no- 310
69 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Karnarogavigyniym Shlok no- 1725-26 Page no-
1003
70 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2140 page
no 131
71 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Adhyay 18 shlok 35
72 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt
Karnarogapratishedhoadhya Shlok no-2211 Page no- 735
73 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 152
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2141 page
no 131
74 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2142 page
no 131
75 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2144 page
no 131
76 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 34 page no- 649
77 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2145page
no 131
78 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 37 page no- 649
79 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2146page
no
80 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
81 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 153
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2143page
no
82 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publication Krnarogadhikara adhaya page no-
318
83 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary
Madhyamkhand Vatkalpana shlok no- 782-83 page no- 137
84 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 72-77 page no- 651
85 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
86 Vd Shree Laxmipatishastri Yogratnakara
87 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
Karnarogadhikara Shlok no- 808182 page no- 652
88 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 83 page no- 652
89 (PDF) Otomycosis A Comprehensive Review (researchgatenet)
90 httpswwwncbinlmnihgovpubmed24948980
91 A Simon Carney Scott-Browns Otorhinolaryngology Head and Neck
Surgery CRC press 8th publication Otitis externa and otomycosis
92 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no Page no -
93 wwwguggulipidcomtradhtm
Page | 154
94 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
95 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-28 page no-
43
96 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009Agaru page
no726-728
97 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishra chapter Karpuradi varga Shlok no-31-
43 Page no- 116
98 httpswwwthiemeinimagecatlogsample_chapter_GOMPpdf
99 (PDF) Chemical Constituents and Pharmacological Activity of Agarwood
and Aquilaria Plants (researchgatenet)
100 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 4 chapter no-2 page no-4
101 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 chapter no-152 Madanpage
no376-379
102 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
103 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-54 page no-
84
104 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 page no697-699
patol-yawa
Page | 155
105 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
106 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
Dhoompanvidhi page no- 252-254
107 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012Chikitasasthan Shlok
no- 151page no-406
108 httpswwwmdpicom1420-3049232342pdf
109 httpswwwijamcoinindexphpijamarticledownload0610201530
0
Page | 156
BIBILOGRAPHY
Page | 157
1 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
2 Scott-Brown WG Diseases of the EarNose and Throat Landon
Botterworth and co(publishers) Ltd1952 Volume 2
3 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012
4 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009
5 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi commantry
Purvakhand and Madhyamkhand
6 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Published by Chaukhamba Sanskrit
SansthanVaranasi
8 The Ayurvedic Pharmacopeia of India Ministry of Health and family welfare
department of Ayush Part 1 and part 4
9 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005
10 Acharya Trivedi Raguveer Prasad Ashtang sangrah published by
Vaidyanath Ayurveda bhavan pvt
11 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition
12 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary published by Chaukhamba
Orientalia
Page | 158
ANNEXURE
Page | 159
ANNEXURE- 1
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
CASE RECORD FORM
RESEARCH PROFORMA FOR MS (AYU) DESSERTATION
DEPARTMENT OF SHALAKYATANTRA
NAME -
ADDRESS -
GENDER - AGE - OCCUPATION-
RELIGION - EDUCATION - MARITAL STATUS-
OPD IPD NO-
DATE OF ADMISSIONCOMMESEMENT-
DATE OF DISCHARGECOMPLITION-
DATE OF COUNSELLING-
TEL NO-
CHIEF COMPLAINTS-
PAST MEDICAL AND SURGICAL HISTORY-
TREATMENT HISTORY-
FAMILY HISTORY-
Page | 160
PERSONAL HISTORY-
a) Ahar(Diet)
b) Vihar
c) History of addiction
GENERAL EXAMINATION
PULSE - MIN BP - mm of hg
TEMP - 0F RR - MIN
ASHATAVIDHA PARIKSHANA
Nadi- Mutra- Mala-
Jivha- Shabda- Sparsha-
Drik- Aakruti-
SYSTEMIC EXAMINATION
RS ndash
CNS-
CVS ndash
Page | 161
LOCAL EXAMINATION (KARNA PARIKSHAN)
OBSERVATION TABLE FOR SUBJECTIVE CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching )
RIGHT EAR LEFT EAR
KARNASHASHUKULI
KARNAPUTRAK
KARNAPALI
KARNAKUHARA -
SRAVA
GANDH
VARNA
SWARUPA
KARNAPATALA (TM)
Page | 162
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
Hearing Test
1Renne Test ndash
2 Weber Test -
Examination of Ear-
Pathological Investigation-
Other Examination-
Nidan Panchak-
1Hetu-
2Purvarup-
3Rupa-
4Upashayanupashaya-
5Samprapti
Signature of Guide Signature of Doctor(Researcher)
Page | 163
ANNEXURE 12
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Dhoopana Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization were done as recommended in pharmacy procedure
The raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 were mixed together
in equal quantity to make Agaruwadi churn
STEP 4 - Agaruwadi churn were triturated with appropriate quantity of water
and prepared Varti in GMP Certified Ayurvedic pharmacy Standard aseptic
precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Dhoopana Varti was packed in sterile air packed
container
STEP 6 - Agaruwadi Dhoopan was given with the help of Dhoopan yantra
TREATMENT DETAIL-
Purvakarma -
1 The patient is asked to sit comfortably on chair having sufficient light and
less amount of dust
2 The EAC is cleaned thoroughly by Pichu Varti (cotton swab) to remove the
discharge and other debris
Pradhankarma -
1 The patient is asked to relax completely on the chair
Page | 164
2 Fumes are passed to the ear with Dhoopana Yantra
3 Dhoopana yantra is funnel shaped and its one end will keep the ear covered
for the passage of Dhooma into the ear canal and other end where Agaruwadi
Dhoopana Varti were placed which produces fumes
4 This Dhoopana was given for 5 min
Pashchat karma -
1 The patient were advised to avoid cold refrigerated food drinks cold water
bath cold wind fog and prevent water from entering the ear
(A) Agaruwadi Dhoopana Varti
B) Guggula Dhoopana Varti SOP of it is same as above Agaruwadi Dhoopana
Varti
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Page | 165
ANNEXURE 21
INFORMED CONSENT DOCUMENT
Study Title
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
Introduction
- You are invited to take part in a research study RANDOMSIED COMPARATIVE
CLINICAL TRIAL TO STUDY THE EFFECT OF AGARUWADI DHOOPANA AND
GUGGULA DHOOPANA IN KARNASRAVA
- Before you decide it is important for you to understand why the
research is being done and what it will involve
- Please take time to read the following information carefully and discuss
it with friends relatives and your doctor if you wish
- Ask us if there is anything that is not clear or if you would like more
information
Purpose amp Nature of Study
- In this research project by examine you and ldquoKarnasravardquo (Otomycosis)
disease were treated
- In the part of treatment Agaruwadi Dhoopana or Guggula Dhoopan were
given
- Dhoopana means medicated drug fumes were given in ear with the help of
Dhoopan Yantra
Page | 166
- Treatment was given for 7 days
Study Duration
7days
Participation
- Your participation is entirely voluntary
- If you do decide to take part you were given this information sheet to keep
and be asked to sign a informed consent form
- If you decide to take part you are still free to withdraw at any time and
without giving a reason This will not affect the standard of current or future
medical care you may receive
Confidentiality
- All information which is collected about you during the research were
kept strictly confidential
- Any information about you which is collected from the center will have
your identity in the form of a code number so that it will remain confidential
Benefits Of Study
- The results obtained from this study would be helpful for providing better
quality of treatment amp other essential facilities for Karnasrava (Discharge)
patients
- You will get clinical benefit from the study
Page | 167
Risks Of Study
- In this treatment there are few chances of Irritation of Ear Nose and
congestion at EAC if any of these happens then treatment were given
Results Of Study
- If the Results obtained are profitable then they may get published
without disclosing your details
Signature of patient
Date
Time
Phone no of Researcher
Page | 168
रण मादहती पतरक
सशोिनाच शीषवक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE
EFFECT OF AGARUWADI DHOOPANA AND GUGGULA DHOOPANA
IN KARNASRAVA
परसतताना
- आपणास या सशोिनातपमक अभयासात सहिागी होणय़ाच आाहन करणयात यत आह
- सशोिनातील सहिाग तननदशचत करणयापी सशोिनाच उददश समजन घया
- खालील मादहती काळजीपवक ाचा आणण आशयक ािलयास आपलया डॉकिराशी कका
दहतशरचतकाशी चचाव करा
- काही सददिता असलयास कका आणखी मादहती ही असलयास आमछयाशी चचाव करा
सशोिनाच उददीटि सतरप
- सदर सशोिन परकलपामरधय आपलयाला तपासणी करन कणवसरा या वयाशरिची शरचककतपसा दणयात
यणार आह
- सदर वयाशरिची शरचककतपसा महणन आपणास अगरादी िपन कका गगल िपन
दणयात यणार आह
- सदर औषि आपणास 7 ददस घयायाच आह
Page | 169
कालािी
- 7 ददस
सहिाग
- आपला सहिाग हा पणवपण ऎनदछिक आह
- आपला सहिाग तननदशचत असलयास आपणास ही मादहती पतरतरका दणयात यईल आपणास यातील
समती पतरकार सही कराी लागल
- सहिाग तननदशचत असनही आपण कोणतपयाही ळस कोणतही कारण न दता माघार घ शकता
याचा आपलया दयकीय सविर कोणताही पररणाम होणार नाही
गोपनीयता
- सशोिना दरमयान गोळा कलली आपलया वषयाची सव मादहती गोपनीय ठणयात यईल
- आपली यनदकतक मादहती साकततक सतरपात गोपनीय ठणयात यईल
सशोिनाच फ़ायद
- सशोिनाच तनटकषव कणवसरा बाशरित रणाछया दयकीय इतर सविाचा दजाव सिारणयास
फायदशीर ठरतील
सशोिनातील जोणखम
- य़ा शरचककतपसमरधय कान दखण डॊळय़ातन नाकातन पाणी य़ण नाकात जळजळण डोक जड
होण ही लिण ददस शकतात यापकी लिण तनमावण झालयास तपयाची शरचककतपसा कली जाईल
Page | 170
सशोिनाच तनटकषव
सशोिनाच तनटकषव फ़ायदशीर ठरलयास आपली मादहती गोपनीय ठन परकाशशत करणय़ात यईल
रण सतािरी-
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
Page | 171
ANNEXURE 31
INFORMED CONSENT FORM
Patient OPD no __________
Subjectrsquos Identifier
Date of Birth Age Gender
I _____________________________________ age___________ years
exercising my free power of choice hereby give my consent to be included
as a participant in the clinical study entitled
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
1 I confirm that I have read have been read and understood the information
sheet for the above study and can ask questions
2 I understand that my participation in the study is voluntary and that I am
free to withdraw at any time without giving any reason without affecting my
medical care or legal rights
3 I understand that the Ethics Committee members investigators and study
doctors will not need my permission to look at my health records both in
respect of the current study and any further research that may be conducted
in relation to it even if I withdraw from the trial I agree to his access
However I understand that my identity will not be revealed in information
released to third parties or published
4I agree not to restrict the use of any data or results that arisefrom this study
provided such a use only for scientific purpose
5 I agree to take part in the above study
Page | 172
signature with Date-
Left hand thumb impression
Name amp signature of the witness ndash
Name amp signature of the student ndash
Page | 173
ANNEXURE 32
समतीपतरक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
वयकतीच य
ददनाक जरमददनाक
1) मी ह तननदशचत कररत आह ककसदर सशोिन परकलपाबाबतची सपणव मदहती मी ाचली असनमला ती
समजली आहतपयाबददल मला परशन वचारणयाची पणव मिा आह सदर मादहतीन माझ समािान झाल
आह
2) मी सदर सशोिनातन माझया मजीनसार किीही बाहर पड शकतो या माझया अशरिकाराची मला कलपना
आह
3) माझी दयककय मादहती तपासणयाची कागदपतर कळ सशोिनाकररता ापरली जाणार आहत याची
मला मादहती आहसदर सशोिन परकलपातील सबशरित घिकाना माझी दयककय मादहती पाहणयाची मी
समती दत आहतरावप या सदिावतील माझी ओळख दशववणारी मादहती कोणासही ददली जाणार नाहीयाची
मला कलपना दणयात आली आह
4) सदर अभयासातन शमळणारी मादहती अरा तनटकषव कळ शासततरीय हतसाठी ापरल जाणयासाठी माझी
समती आह
5) रील अभयासात सहिागी होणयास माझी समती आह
रण सतािरी-
Page | 174
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
ASSESSMENT CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching)
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
a) कणवशल ( pain )- 0 - Absent
1 ndash Present
Page | 175
b) कणवकणड (Itching)- 0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
c) कणवसततरा ( Discharge )
0- Absent
1-Mild- Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाशरियव ( conductive Loss of hearing )
0 - Present
1 - Absent
Page | 176
Page | 177
Page | 178
Page | 179
Page | 180
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
Page | 181
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 182
AUTHENTIFICATION CERTIFICATE
Page | 4
inflammatory process exudates were produced which will mix up with
fungal colonies and appear as discharge In initial stage of disease ear
discharge is watery but if there is secondary bacterial infection occur it
becomes mucopurulent Ear blockage and conductive type of hearing loss
are due to accumulation of fungal mass in external auditory canal
Fungal mass appears white or black or brown and is like a wet piece
of filter paper Examination with otoscope Aspergillus Niger appears black
headed filaments growth Aspergillus fumigates as a pale blue or green and
candida as a white or creamy deposit[9]
Otomycosis is a common condition and it mostly occurs in humid
area According to American academy of otolaryngology prevalence of
otomycosis is 52 all over a world and 09 in India 5-25 otitis externa
cases are due to otomycosis Nearly 61 types of fungal species being involve
in otitis externa 90 of fungal infection cases involve Aspergillus species
and the rest candida species[10]
In Ayurveda The common treatment Principle for all is Ghritapana
Rasayana Bhramacharaya Avyayama (Excessive exercise)
Ashirasnana(Head bath) Atibhashashya(Excessive speaking) This can be
used for the prevention and management of Karnaroga[11] Acharya
Sushruta explain specific treatment modality for Karnasrava is
Karnaprakshalana Karnapoorana Karnadhoopana Shirovirechana
Karnadhavana[12]These therapeutic procedure can be updated according to
different stages of these condition
In routine OPD it is observed that patient of otomycosis respond
more frequently to topical therapy than to systemic therapy Among all the
treatment modality Karnadhoopana is an effective and simple procedure
In this regard Karnadhoopana with Agaruwadi Varti or uggula had explain
in Ashtang Samgraha Agaruwadi Varti contain Agaru Yawa Madanphala
All these contains of Agaruwadi Varti and Guggula acts as Ruksha Ushna
Teekshana Laghu Guna acts as effective Shodhaka keeps ear dry reduce
Page | 5
pain discharge foul smell and thus control the infection Dhoopana is also
useful as Adhidaivika Chikitsa to protect the patient from external attack of
visible and invisible organism The principal treatment modality adopted in
Allopathic system of medicine is oral antibiotics and topical antibiotic drop
Long term use of oral antibiotic causes adverse effect like gastric irritation
reduce immunity and resistance to drug Long term use of topical antibiotic
drops cause Ph change in external canal which become prone to fungal
infection
Hence the therapeutic procedure with Guggula or Agaruwadi Varti
Karnadhoopana are cost effective safe and easy procedure and it can be
used more effectively
Page | 6
AIM OF STUDY
To evaluate the effect of Agaruwadi Varti Dhoopana and Guggula Varti
Dhoopana in management of Karnasrava
OBJECTIVE
To compare the efficacy of Agaruwadi Dhoopana and Guggula Dhoopana in
Karnasrava
HYPOTHESIS
NULL HYPOTHESIS -
H0- Agaruwadi Dhoopana is not effective than Guggula Dhoopana in
Karnasrava
ALTERNATE HYPOTHESIS -
H1- Agaruwadi Dhoopana is more or equally effective than Guggula
Dhoopana in Karnasrava
RESEARCH QUESTION
Whether there is significant difference between Agaruwadi Dhoopana and
Guggula Dhoopana in Karnasrava
Page | 7
PREVIOUS WORK DONE -
1 Anupama Patra B Effect Of Arka Taila In The Management Of
Karnasrava With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2007
2 Palmer Komalben K Further Study On Role Of Arka Taila In The
Management Of Karnasrava With Special Reference To
Otomycosis Shalakya Tantra Institute for Post Graduate Teaching amp
Research in Ayurveda Gujarat Ayurved University Jamnagar 2010
3 Sathisha Shankar B Management Of Karnasrava With Sthanika
Guggulu Dhoopana And Rasnaadi Guggulu-A Comparitive Study Shalakya
Tantra Government Ayurvedic Medical College Bangalore 2011
4 Shashikala DK Comparative Study On The Efficacy Of Vacha
Lashunaadi Taila Karna Pichu And Nimba Patraadi Dhoopana In The
Management Of Karna Srava Shalakya Tantra Government Ayurvedic
Medical College Bangalore 2014
5 Javale Anant A Clinical Study On The Efficacy Of Arka Taila In The
Management Of Karna-Srava Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2005
6 Pournima V Koti Management Of Karnasrava With Priyangvadi Taila
Pichu With And Without Saarivadi Vati Shalakya Tantra Sri Jagadguru
Gavisiddeswar Ayurvedic Medical College Koppal 2015
7 Amisha Patel A Clinical Evaluation Of Honey In The Management Of
Karna Shoola With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching and Research in Ayurveda
Gujarat Ayurved University Jamnagar 2016
Page | 8
REVIEW OF LITRATURE
Page | 9
Ayurvedic literature Ayurveda is a science of life practice since
thousands of years The ancient Indian system of medicine and surgery is
commonly known as Ayurveda This was given the status of Upaveda or
fifth Veda in the next stage of growth Among the available literature three
Samhita that is Charaka Samhita Sushrut Samhita Ashtang Hrudayam and
Ashtang Samgraha are the chief source of knowledge of Ayurveda
Ayurveda consist of eight branches Shalakyatantra is one among them
Shalakyatantra is one of its specialized branch deals with science of
ophthalmology otorhinolaryngology Oro dental surgery and head Acharya
Sushruta himself a practical surgeon was the first to advocate dissection of
dead bodies is indispensable for a successful student of surgery He had
described gross anatomy in the first chapter of Uttartantra Shalakyatantra
define by different Acharys as follows
शालाकय नामोरधवजतरगताना रोगाणा शरणनयनदनघराणाददसशरशरताना वयाशरिनामपशमनारव
स स ११०
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत [13]
चस १७१२
Shalakya Tantra Nirukti and Parichaya
शलाकायााः कमव शालाकय ततपपरिान शलाकयम डलहण [14]
The term Shalakyatantra is derived from Shalakya and Tantra
The word Shalakya means A probe and Tantra denotes teaching and
practices found in scripturesThe compendium in which application of
Shalaka in various surgical procedures is principally described is called as
Shalakya tantra
दनदटिवशारदााः शालाककनाः डलहण ( सउ ११३)[15]
An eye specialist is termed as Shalaki by Dalhana
Page | 10
Synonyms of Shalakya Tantra
Uttamanga Chikitsa Jatrurdhwa Chikitsa Urdhwang Chikitsa Shalakya
Chikitsa
Importance of Shalakyatantra-
Life of living being and all the Indriyas are situated in the head hence it is
known as Uttamanga
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत
चस १७१२
The treatment given to this part of the body is described specially in
Shalakya tantra While describing the importance of Shiras Vagbhata
correlates it to the root of tree (Urdhwa Mula) and body to the trunk of tree
(Adha Shaka)
Sushruta has deal with Mukha Roga in Nidan Shan and its treatment in
Chikitsasthan The description regarding the disease of eye ear nose and
head are found only in UttaraSthan Sushruta specially describes the
disease of Shalakyatantra as told by Videha in the beginning of Uttartantra
itself[16]
Shalakyatantra Itihas-
India Exhibits traditional of more than thousands of years in art literature
language logic and philosophy etc The convention was in its sophisticated
and advanced attire throughout the Vedic period
Vedic period ndash
1 Natush was treated for deafness by Ashwinikumars (Rigveda)
2 Rujaswa and Kanva were treated for blindness by Ashwani Kumaras
(Rigvedas)
Page | 11
3 There are several prayers mentioned for normal functioning of sense
organs (Yajurveda)
4 Structures and functions of Mastishka are described (Atharveda)
5 Mantras having reference to disease of Eye Ear Oral cavity etc are
found (Atharvaveda)
Upanishada Period ndash
1 Samhita Period
a) Sushrut Samhita ndash
bull Explanation regarding Netra Nasa and Shirorogas (Uttartantra 1-
26th chapter)
bull Details regarding Mukha and Karna Roga Nidan and
Chikitsa(Nidansthan 16th and Chikitsasthan 22nd chapter)
bull Description regarding Karna Chedana Sandhana Nasa
Ostasandhana Sutra Sthan 16th chapter
b) Charaka Samhita -
bull Explanation regarding Shirorogas (Sutrasthan 17th chapter)
bull Explanation of Gala rogas like Upajivika Galshundi and Rohini
bull Nasa Shiro Mukha Karna and Netra Chikitsa (Chikitsa sthan 26th
chapter)
bull Description regarding Lakshana and Chikitsa of Shankhaka
Ardhavbhedaka Shirovirechana and Shiro basti (siddhi sthan 9th
chapter)
c)Ashtnga Sangraha ndash
bull Detailed description regarding Shalakyatantara (Uttartantra 11-28
chapter)
bull Description of Kriyakalpa (Sutrasthan 32nd and 33rd)
Page | 12
d)Ashtang Hrudayam
bull Detailed description on Shalakya Tantra (Uttar tantra 8-24 chapters)
bull Kriyakalpas (Sutrasthan 23rd and 24th chapter)
e) Bhela Samhita
bull Chakshushya Vaisheshik and Buddhi Vaisheshik Alochaka pitta
f) Harita Samhita- Branch of Medical science offering elaborating
information about the procedure like Nasya Anjan Gandusha etc
comprehended with their applications in disease of Head Eyes Ears
Eyebrows Throat Temporal region and cervical spine is known as
Shalakyatantara
शशरोरोगा नतररोगा कणवरोगा वशषताः भरकरठशङकमरयास य रोगा समिनदरत दह १३
तषा परततकारकम व नसतयतपयवणजनातन च अभयङगमखगणडषकियााः शालकयसशमतााः १४
इतत शालाकयनाम [17]
Documentation of different ancient literature gives various references
regarding all aspects of Karnasrava in various periods It is very much
important to know the history of Karnasrava from Vedic Pauranic Samhita
and Samgraha period
Vedic period ndash The Vedas being the oldest source of knowledge have no
direct mentioning of Karnasrava
Page | 13
Samhita and Samgraha period ndash
Aacharya Sushruta described about Karnaroga Karnasrava Nidan
Roopa and Chikitsa The detail description is available in Sushrut
Samhita Uttartantra 20 and 21st chapters
Aacharya Charaka did not specify Karnasrava but mentioned 4 types
of Karnarogas that is Vataj Pittaj Kaphaja and Sannipataja and their
treatment in 26th chapter of Chikitsasthan
In Ashtang Hrudaya karnasrava is not explained as a separate disease
but Chikitsa is mentioned in 18th chapter of Astanga Hrudaya
uttartantra
In Ashtang Samgraha Chikitsa is mentioned in 22nd chapter of Astang
Samgraha Uttartantra
The details about Karnasrava are explained in Bhavprakasha
Madhyamakhanda 64th chapter
Madhavakara has explained about Karnasrava in 57th chapter of
Madhymakhanda
Karnasrava is also explained in Sharangadara Samhita Uttarkhand 11th
chapter
The reference for treatment of Karnasrava is available in
Yogaratnakara
In Gadhnigraha Karnasrava and its treatment is mentioned in
Karnarogadhikara Adhaya
Vangasena had mentioned about the disease and treatment in 69th
chapter
Chakradatta explained Karnasrava in 57th chapter
Dalhana has given commentary on Sushrut Samhita Uttartantra 20th
and 21st chapter
Sankhya Samprapti of Karnasrava ndash
Aachary Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga
Vigyniyam Aadhaya Aacharya charaka explain 4 Karnaroga in
Page | 14
Karnarohvigyniyam Adhaya based on doshas Acharya Vagabhata in
Ashtang Hrudaya explain 25 Karnaroga in Adhyaya
कणवशल परणादशरच बाशरियव कषड ए च
कणवसरााः कणवकणडाः कणव चवसतततर च
कशमकणवपरततनाहौ विशरिदवविसततरा
कणवपाकाः पततकणवसततराशवशरचतवविम
कणावबवद सपतवि शोफशरचावप चतवविाः
ऎत कणवगता रोगा अटिावशततरीररतााः
स उ २०- ३ त ५[18]
ातकणवरोग वपततकणवरोग कफकणवरोग
रकतकणवरोग सनदरनपातकणवरोग कणवनाद
बशरिरतप परततनाह कणडाः शोफ पततकणवक
किशमकणवक उियरपविरधयअशो अबवद
कशरचकणवक वपपपली वदाररका पाळीशोष
ततिका पररपोिो उतपपातो उरमरर दाःखिवन
शलहाखयााः परचवशनदरतकणवरोगा उकतााः
इदिीका अ स उ २१ [19]
चतपाराः कणवरोगााः
च स [20]
Page | 15
KARNA
Karna ndash करोतत शबद गरहण [21]
The organ of hearing
Karnasrava- कणवसतय कणवयोाव ससराा [22]
Discharge from the ear is referred as Karnasrava
KARNA SHAREERA
bull Nirukti
कणयवत अकणयवत अनन इती [23]
It means reception and conduction of sound waves
These are the functions of external and middle ear
bull Nirukti of Sravanam
शरयत अनन इती शरणम[24]
It means perception of sound
It can be attributed to the internal ear function
bull Karna Utpatti-
Karna is an organ formed by Akash Mahabhuta[25]
The fundamental characteristic is as follows
Indriya ndash Srotram [26]
Indriya Adhisthan ndash Karna [27]
Indriya Dravy ndash Akasha [28]
Indriya Arth ndashShabdha [29]
Indriya buddhi ndash Srotobyddhi
Page | 16
bull Paryaya of Karna- Shabdapatha Srotrapatha Sravanam shruti
Kuhuram Dwanigraham etc
bull Definition of Karna-
कणवशटकलयनदछिरनमिटिोपगरदहत शरोतरमछयत [30]
मा तन ५७१
The definition of Karna is stated in Madhav Nidanam Indriya which is not
seen with naked eye along with Shashkuli is called Shrotra that is Karna
Indriya is so minute that it is not perceived with any sense organ
In Charak Samhita the word Karna explain as the Indriya Adhisthan of
Shabdha Karna is described as one of the Prathyangas of the body He
emphasizes that all Indriyas manifest during the 3rd month of gestation
period
Acharya Sushruta while describing formation of Purusha from Prakriti or
Avyakta narrated that all Indriyas are developing from the Vikarika and
Taijas Ahankara Both Vagabhata and Sushruta stated that Karna as one of
the Bahirsrotas
शरण नयन दन घराण गदमढराणण न सततरोताशसराणा बदहमवखातन [31]
स शा ५-१०
In Ashtang Hradaya Vagbhata has states that all Indriyas are Atmaja
According to him lower lobule elevated helix projected posterior portion
fleshy and adherent ear are indications of long span of life[32]
ततरखातखातन दह अनदसतमन शरोतर शबद ववकतता [33]
ा शा ३-३
शबदाः शबदनदरिय सवनदछििसमहो ववकतता [34]
स शा १-२६
Page | 17
Ear has the prominence of Akash Mahabhuta The prominent dosha of ear
is Vata It is important seat of Vata The prominent Dhatus are Asthi and
Mamsa Karna is one of the Panchgnanendriyas and it meant for hearing
Sushruta narrated that Karnasthita Asthi and Sandhi
घराणकणवगरीाकषिकोषष तरणातन [35]
सशा ५-२२
शरोतरशरगािकष शखाताव [36]
सशा ५-३२
गडकणवशखटककम [37]
स शा ५-२२
One Sandhi and one Tarunasthi in ear
Sandhi ndash Karna contain two Sandhi one in each ear Type of Sandhi is
Shankhavartha which is present in Shringataka
Mansapeshi ndash 2[38]
Siras ndash 10 [39]
Vataj Sira - 4
Pittaj sira - 2
Kaphaj sira - 2
Raktaj Sira - 2
Avedhya sira-
कणवयोदवश तासा शबदादहनीनामकका पररहरत
सशा ७-२५[40]
Amongst above mentioned ten Siras each Karna lodges one Shabdavaha
Sira It is Avedhya
Page | 18
Dhamani -2
Length of ear is 4 Angula
Karna moola ndash 2 Angula
कणाविरतर चतदवशअगलम
स शा ३५-१४[41]
The distance between two ears through the back of the neck is 14 Angula
bull Marmas of Karna-
1 Vidhuras-
कणवपटठतो अिाःसशरशरत विर ततर बशरियवम
सशा ६-३७[42]
कणतपयादद सतनायममवणी ककनदचचनदरनममनाकर कलयकररणणच
डलहणाचयव[43]
अिसततात कणवयोतनवमन विर शरततहाररणण
ा शा ४-२९[44]
Sankhya-2
Vistara- frac12 Angula
Type- Snayumarma (Susha)
- Dhamanimarma(AH)
- Vaikalykar
Sthana- It is situated in the depressed portion in the back of the ear
Injury to them causes loss of hearing
Page | 19
2 Shringataka marma-
नदजवहाकषिनाशसकाशरोतरखचतटियसरमम
तालरयासतयातन चतपारर सरोतसा तष ममवस
वदि शरगातकाखयष सददसततपयजतत जीवतम
मा तन ५७१ [45]
Sankhya- 4
Type- Siramarma
Sthana- It is in head that is amidst Siras (blood vessels) nursing sense
organ
A palm size area near Talu
Injury to this Marma causes death
In modern anatomy ear divides into Bhayakarna or External ear Mdhyakarn
or Middle ear Antahkarna or Internal ear This is extremely appropriate
Even though the ear is divided into three divisions in the point of modern
anatomy Ayurveda denotes ear organ is one Ayurveda treats disease by
way of assessing Dosha and Dushya Here Dushya is one that is Karnendria
Dosha difference will call for different treatment for different disease Hence
treating the vitiated Dosha will cure the disease irrespective whether it is in
external middle or internal ear The thought is based on different
fundamental principle from Ayurveda
bull Parts of Karna
In Ayurveda classics detailed description about anatomy of ear is not
available But the various parts are mentioned as follows
Bhayakarna- External ear
Mdhyakarna ndash Middle ear
Antahkarna- Internal ear
Page | 20
द कणवशटकशलक दॊ कणवपतरकौ
च शा 7-11[46]
कणवशटकशलक कणवगतातवकौ कणवपतरकौ त बाहयकणा
चिदतत च शा 7-11[47]
शटकली बाहयपालयाशरिटिानम
डलहन- स शरच 25-1 12[48]
Karna Shashkulika ndash It is also called as Karna Shashakuli Charaka has
mentioned this term while describing different Pratyngas of the body
Acharaya Gananatha sen has given the clarification for it as a pinna or
auricle[49]
Karnapali ndash It is popularly known as lobule of the ear Daivakrita Chidra is
present in it
Karnaputrika- Ayurvedic scholars accepted two terms in this cortex They
are Karnaputrika and Karnaputrika The former is considered as Tragus and
antitragus[50]
Karna Prushtha- It can be taken as the cranial surface of mastoid or
auricle[51]
Karnapeetha- Aacharaya Sushruta firstly mention the term Karnapeetha
It is mentioned first by Sushruta while describing the procedure of
Karnavyadana Vagbhata has mentioned that it is Adhobhaga of Karna
Dalhana has clarified that it is the region above the Karnaputrika that is the
region which is at the bottom of the concha
Karnamoola ndash It can be considered as parotid region[52]
Karna lathika ndashAcharaya Dalhana mentioned lobule as a Karna Lathika
Page | 21
Karnaavatu ndashThis term is used by Sushruta while describing the
measurements of different Angapratyangas where he has mentioned that
the distance between the Karnaavatu is 14 Angul Dalhana has comments
that it can be taken as the distance between two ears from behind[53]
Shabdhavahasrotas ndash It also called as Shabdapatha or Srotapatha The
whole passage through which the sound waves pass can be taken as
Shabdavahasrotas[54]
Shrotashringataka ndash It can be taken as the labyrinth of ear[55]
bull Dosha in context to Karna-
Karna is principal location of Vayu
1 Prana Vayu- Prana Vayu circulating in oral cavity is responsible for
Dehadhruka that is keeping all body parts active Indriyadruka that is
keeping all Dnyanendriya healthy by proper nourishment (Purana) helps in
deglutition of food material and convey the stimulation of Indriyabuddhi
and atma
2 Udana Vayu- Bala(strength) Varna speech singing are its function It
is responsible for facial expressions due to pleasure sorrow anger love
frustration etc in general its circulation and actions are just opposite to
Pranavayu
3 Vyana Vayu- Its principal functions are circulation of Rasa and Rakta
through body and various movements Its main location is Hrudaya Five
types of movements for which it is responsible are expansion contraction
upward downward and oblique other activities are opening closure of
eyelid yawning perspiration During circulation if it gets obstructed due
to Srotodushti it generates disease of that Srotas Vyana Vayu gets vitiated
by disease of Rasa Rakta Oja and Chetanadhatu
Page | 22
4 Samana Vayu- It is circulating in the vicinity of stomach and intestine
and helps in keeping the Jatharagni (digestive juices and enzymes) in
equilibrium Disturbance in Jatharagni precipitates disease
5 Tarpaka Kapha- Entire body functions movements are controlled and
executed by various centers in the brain Sensation perceived by sense
organs is conveyed to Mann and Aatma residing in Hrudaya The motor
signals from them are then conveyed to the functioning
organsKarmendriya through Prana Vayu Shira head is therefore a
location of continuous activities motions of Vata All these centers are in
unctuous Majjadhatu in the Shira For stabilizing this ever-active Vata and
to nourish the Majja dhatu very unctuous Tarpaka Kapha situated in Shira
plays an important role
bull Ayurvedic aspect of sound perception [56]
According to Ayurveda Pratyaksha Dnyan or Perception of any sensation
including Shabda occurs due to interaction of the Karnendriya and the
Indriya- Arth -Karma resulting in Sravana
External Environmental acquaintance with living body is executed by five
sense organs namely Netra Karna Nasa Jivha and Twaka All
Dnyanendriya that is sense organ are Panchmahabhautic combination
Despite this fact every Indrya sense organ perceives object Tanmatra of
that Mahabhuta only from which it is originated from Akash Mahabhuta and
hence perceives Shabd only that is audio perception Shrotrendriya is one
of the principal locations of Vata and its function is to perceive Shabda that
is sound waves This sensation is conveyed through Shabdavahi Dhamanis
to Mana and Atma through Pranavayu and the sequence is responsible for
perception of sound in this way external sound is perceived and interpreted
when Atma is linked with Mann Mann is linked with Indriyabuddhi that is
minute virtual Dnyanendriya located in brain Indriyabuddhi is linked with
Adhishthana with prominent Mahabhuta and lastly with Indriya
ArthShabdatanmatra that is sense object Once this sequence is completed
Page | 23
the meaning of a particular sound is interpreted and understood In this
entire process of perception and interpretation of sound waves Pranavayu
and Tarpaka Kapha located in Shira play extremely important role Hence
the healthy status of all the sense organ depends upon the normal
physiologically homeostatic condition of Pranavayu and Tarpaka Kapha
MANAS
ATAMA
BUDDHI
AHANKARA
ARTHA
Page | 24
EAR ANATOMY
bull Embryology of the Ear [57]
1 The sound conducting apparatus develops from the branchial apparatus
whereas the sound perceptive apparatus from the ectodermal otocyst
2 The pinna develops from the six hillocks around the 1st branchial cleft
3 External auditory canal develops from 1st branchial cleft
4 The outpouching of the 1st pharyngeal pouch gives rise to a proximal
narrow part that forms the eustachian tube and distal dilated part that
forms the middle ear cavity
5 Prussakrsquos space is a potential space lateral to the Shrapnellrsquos membrane
and medically by the neck of malleus that can be involved during the
extension of cholesteatoma
6 Development starts in the 3rd week of the intrauterine life and is
completed by 16th week of intrauterine life Membranous and boney
labyrinth develops from the otic capsule
The Ear is divided into
1 External Ear
2 Middle Ear
3 Internal Ear or the labyrinth
Page | 25
Fig 1 Ear Anatomy
EXTERNAL EAR [58]
The outside ear contains pinna and lobule
Pinna is the noticeable piece of outer ear made from single sheet of yellow
flexible ligament covered by subcutaneous tissue and skin It has two
surfaces average and parallel It is intently disciple to perichondrium on its
sidelong surface while it is somewhat free on average surface Pinna
incorporates tragus helix against helix fossa three-sided scaphoid fossa
incisura terminalis
External auditory Canal ndash It extends from the bottom of the conchea to
the tympanic membrane and measures about 24 mm along its posterior
wallit is S shaped
Parts 1 Cartilaginous part
2 Bony part
Page | 26
Cartilaginous part ndash The outer one third is cartilaginous consist of fibro
cartilage is directed first inward backward and upward It has Fissure of
Santorium The skin of this part of the canal contains hair follicles
sebaceous gland and cruminous gland
Bony part ndash The inner two third part is boney It goes forward downward
and medially skin lined in this part is very thin Isthmus is the narrowest
part of the canal lying medial to junction of bony and cartilaginous part
nearly 5 mm lateral to tympanic membrane
The roof and posterior wall of the external auditory canal shorter than floor
and anterior wall The skin lining the tympanic membrane and boney canal
has a self-cleansing property due to migration of keratin layer of epithelium
from drum towards the cartilaginous portion
Relations- Anteriorly- Temporomandibular joint and parotid gland
Superiorly- Middle cranial fossa
Inferiorly- parotid gland
Posterior- Mastoid antrum mastoid air cells and facial nerve
Nerve supply ndashSensory nerve supply of the external ear The auricle
supplied by fibers of the great auricular nerve (C2 and C3) and lesser
occipital nerve (C2) Auriculo temporal branch of the 5th cranial nerve and
auricle branch of the vagus (Arnoldrsquos nerve) supply external canal Facial
nerve has small sensory contribution on posterior-inferior wall
Tympanic Membrane -It is the partition between EAC and middle ear It
is a thin semitranslucent membrane pearly white in colored lying obliquely
in the medial end of EAC with the angle of 55 It is forming major part of
lateral wall of middle ear Annulus tympanicus is attached at its
circumference to the sulcus The TM is oval shape It measures
approximately 10 mm in vertical diameter and 90 mm in horizontal
diameter
Page | 27
Layers ndash Tympanic membrane consist of three layers
1 Outer Epithelium or cuticular layer which is continuous with skin of
external ear
2 Middle fibrous layer has both circular and radial fibers middle layer
missing in upper part
3 Inner layer- Inner mucosal layer which is continuous with middle ear
mucosa
Parts ndash Tympanic membrane consist of two parts
1 Pars tensa -It is largest part below the malleolar folds The inner
surface at the center attached to the handle of malleus Angle of cone
is most illuminated part in the pars tensa at anteroinferior part of pars
tensa
2 Pars flaccida Sharpnells membrane -it is triangular area above the
malleolar folds which are thin and devoid of fibrous tissue and
annulus It fits into notch of Rivinous
Nerve supply 1 Anterior half of lateral surface Auriculotemporal V3
2 Posterior half of lateral surface Auricular branch of vagus cn 10
3 Medial Surface Tympanic branch of CN 9 (Jacobsons nerve)
Fig 2 Tympanic membrane of ear
Page | 28
MIDDLE EAR [59]
The middle ear or tympanic cavity is an irregular laterally compressed
space within the temporal bone It is filled with air that is supplied to you
from the nasal part of the throat through the ear canal It contains a chain
of mobile bones that connect its side with the medial wall and serve to
transmit vibrations transmitted to the eardrum through the cavity to the
inner ear Including the parapet the vertical and anteroposterior diameters
of the cavity are each approximately 15 mm The transverse diameter
measures about 6mm at the top and 4mm at the bottom Compared to the
eardrum it is only about 2mm The eardrum is limited laterally by the
eardrum medially by the lateral wall of the inner ear It communicates
behind with the tympanic antrum and through it with the air cells of the
mastoid and in front with the auditory canal The middle ear together with
the Eustachian tube aditus antral and mastoid air cells is called the
middle ear cleft It is lined by mucus membrane and filled with air
It is divided into 3 parts
1 Mesotympanum (located in front of the pars tensa)
2 Epitympanum or attic (located above the pars tensa but medial to
Sharpnells membrane and the lateral bony wall of the attic)
3 Hypotympanum (located under pars tensa) The middle ear is like a
hexagonal box with a roof
Carotid or Anterior wall- It separates middle ear cavity from internal
carotid artery The various structure passing through anterior wall of
tympanic cavity
bull Canal of chorda tympani nerve
bull Canal of tensor tympani muscle
bull Eustachian tube
bull Anterior malleolar ligament
bull Anterior tympanic artery
Page | 29
Posterior or mastoid wall ndash The upper part of the back wall shows the
opening of the auditorium Below the auditory is a triangular bony
projection known as the pyramidalis processors The stapedial tendon is
transmitted through the apex of the pyramidalis processes The vertical
portion of the facial nerve descends along the posterior wall until it opens
into the stylomastoid foramen
Roof or Tegmental wall (Pars terminalis)- It is formed by a thin bone
plate called the tegman tympanum that separates the skull and tympanic
cavities It is located on the anterior surface of the rocky part of the
temporal bone near the junction with the temporal shell it extends back to
the roof in the tympanic membrane and anteriorly to cover the half canal
of the tensor tympanic muscle The lateral border corresponds to the
remains of the Petro scaly suture
Floor ndash It is formed by a thin plate of bone which separate middle ear from
the bulb of the internal jugular vein lodged in the jugular fossa
Lateral wall ndash It is formed by tympanic membrane and partly by a portion
of squamous part of the temporal bone It separates the middle ear from
external ear
Medial wall- It separates the middle ear from the inner ear
bull The promontory is the most prominent and convex part formed by the
basal rotation of the cochlea
bull The bony lateral semicircular canal is postero-superior to the promontory
above the oval window
bull The oval window is located between the middle ear and the vestibular
slope of the cochlea It is closed by the stirrup footrest and the annular
ligament
Page | 30
bull The round window is located under and behind the cape The round
window recess is directed to the rear It is closed by the secondary eardrum
and separates the middle ear of the Scala tympani from the cochlea
bull The facial nerve passes through the bony fallopian tube above the oval
window
Mastoid Antrum ndash It is a large space with air in the upper part of the
mastoid and communicates with the attic through the aditus The roof is
formed by the antri tegmen which extends and separates the tympani
tegmen from the middle cranial fossa The lateral wall of the antrum is
formed by a bony plate that is on average 15 cm thick in adults It is
marked externally on the surface of the mastoid by the suprameatal triangle
(MacEwen)
Aditus and Antrum- Aditus is a gap through which the attic communicates
with the antrum The boney prominence of the horizontal canal lies on its
medial aspect even as the fossa incudes to thats attaches the quick system
of incus lies laterally Facial nerve publications simply underneath the
aditus
The mastoid and its air cell system-
The mastoid consists of bone cortex with a honeycomb of air cell
underneath Depending on development of air cell three types of mastoids
have been described
1Well-pneumatized or cellular- Mastoid cells are well developed and
intervening septa are thin
2Diploetic- Mastoid consist of marrow spaces and a few air cells
3Sclerotic or acellular ndash There are no cells or marrow spaces
With any type of mastoid pneumatization antrum is always present In
sclerotic mastoids antrum is usually small and the sigmoid sinus is
anteposed
Page | 31
Depending on the location mastoid air cells are divided into
1 Zygomatic cells (In the root of zygoma)
2 Tegman cell (Extending into tegmen tympani)
3 Perisinus cells (overlying the sinus plate)
4 Retrofecial cells (round the facial nerve)
5 Peri labyrinthine cells (located above below and behind the
labyrinthine some of them pass through the arch of superior
semicircular canal These cells may communicate with the petrous
apex)
6 Peritubal (around the Eustachian tube Along with hypotymoanic
cells they also communicate with the petrous apex)
7 Tip cells (which are quite large and lie medial and lateral to the
digastric ridge in the tip of mastoid)
8 Marginal cells (Lying behind the sinus plate and may extend into
the occipital bone)
9 Squamosal cells (Lying in the squamous part of temporal bone)
Development of Mastoid ndash
The mastoid develops from the scaly petrous bone The petrosquamosal
suture may persist in the form of a bone plate - Korners septum which
separates the superficial squamosal cells from the deep rock cells Korners
septum is surgically important because it can cause problems locating the
antrum and deeper cells and thus lead to incomplete removal of the disease
during mastoidectomy The mastoid antrum can only be reached if Korners
septum is removed
Page | 32
Fig 3 Cross section of Mastoid
Contents of the middle ear
Ossicles ndash Three tiny bones which conduct the sound from eardrum to oval
window
Malleus ndash It is the largest and most lateral ossicle measuring 8 mm in
length It has head neck handle anterior and lateral processes The head
is situated in the epitympanum A lateral process project laterally from the
neck while the handle is firmly fixed to the pars tensa of the ear drum
Incus- It has a body short process and long process The body short
process and long process The body articulate with the head of mallelus in
the attic and the short process project into the attic The long process
projects downwards behind the handle of malleus running parallel to it and
articulate with the head of the stapes via the lenticular process
Stapes ndash It is the smallest ossicle measuring about 35 mm and consist of
head neck footplate and anterior and posterior curcura The footplate of
stapes is held to the oval window by the annular ligament
Page | 33
Muscles ndash
1Tensor tympani ndash It is inserted is a branch of the facial nerve which carries
the sense of taste It is first arch muscle supplied by branch of mandibular
nerve V3
2 Stapedious muscles ndash It is inserted to the neck of stapes It is the second
arch muscle supplied by branch of facial nerve that is nerve to stapedius
Fig 4 Contents of the middle ear
Blood supply of Middle Ear
bull Anterior tympanic branch of maxillary artery which supplies tympanic
membrane
bull Stylomastoid branch of posterior auricular artery which supplies middle
ear and mastoid air cells
Page | 34
Four minor vessels are
bull Petrosal branch of middle meningeal artery runs along greater petrosal
nerve
bull Superior tympanic branch of middle meningeal srtery traversing along
the canal for tensor tympanic muscle
bull Branch of artery of pterygoid carotid
bull Tympanic branch of internal carotid
Lymphatic Drainage of Ear
Lymphatics from the middle ear drain into retropharyngeal and parotid
nodes while those of the Surgical Importance ndash Eustachian tube drain into
retropharyngeal group
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 middle is likely to pass to
middle ear
2 Moreover middle ear suppurative disease may spread to adjacent organs
and produce complication eg Labyrinthitis meningitis facial nerve palsy
etc
3 Lenticular process is vulnerable in suppurative ear diseases and causes
ocular disruption
4 Prussac space is the site of primary acquired cholesteatoma
Page | 35
INNER EAR [60]
Inner ear is divided into two parts
1 Bony Labyrinth
2 Membranous labyrinth
Anatomy of bony labyrinth
It is divided into two parts
1 Vestibule
2 Cochlea
3 Semicircular canal
The vestibule is located between the medial wall of the middle ear and the
lateral to internal acoustic meatus anterior to the semicircular canal and
posterior to the cochlea The vestibule is the central part of the inner ear
On its side is the oval window opening which is closed by the bracket foot
plate The bony cochlea is located in front of the vestibule It has 275 turns
wound around a bony axis called a modiolus The cochlea is about 30 mm
long The hollow center of the modiolus is a spiral canal that contains the
fibers and ganglion cells of the cochlear nerve A thin bony sheet the bony
lamina winda around the modiolus This divides the cochlear duct into two
galleries the Scala vestibuli above and the scala tympani below
There are three semicircular canals superior posterior and lateral They
are semicircular in shape and open into the vestibule One end of the
semicircle is enlarged and is known as the sphere
The membranous labyrinth is in the bony labyrinth It is connected to the
bony labyrinth by fibrous trabeculae and is surrounded by perilymph The
endolymph is located in the membranous labyrinth
Page | 36
The utricle is in the upper part of the vestibule while the saccule is found
below Both the utricle and saccule contain a single sensory patch called
the macula Each macula is covered with a neuroepithelium made up of
neuroepithelium made up of sensory hair cells and support cells these cells
are separated by a basement membrane Fibers of the vestibulo-cochlear
nerve enter the macula and pierce the basement membrane to terminate
at the base of the hair cell or cell bodies The utricle and the saccule with
their macula are called otolith organs Membrane semicircular canals are
the membrane canals of the corresponding bony semicircular canals They
open into the utricle through five openings One end of the opening of each
channel is dilated called the sphere in which the sensory organ of each
channel is located The cross section of the Scala standard looks like a right
angle The base is formed by the basilar membrane Sensory cells are
arranged on the surface of the basilar membrane These sensory cells with
their supporting cells form a complex neuroepithelium called the basilar
papilla or the cortical organ named after an Italian microscopist The
organs of the corti have a gelatinous membrane called the tectorial
membrane and they are supported by the pillar of the corti The cortical
pillars enclose a space called the corti tunnel which contains a fluid called
cortical lymph Vestibule is lies between the medial wall of the middle ear
and lateral to internal acoustic meatus anterior to semicircular canal and
posterior to the cochlea 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 Boney cochlea lies in front of the vestibule It has 275 turns
coiling around boney axis called modiolus Cochlea is approximately 30 mm
in length The hollow center of the modiolus is a spiral canal containing the
fibers and ganglion cells of cochlear nerve A thin boney sheet the osseous
lamina winda around the modiolus This divides the cochlear canal into two
galleries the Scala vestibuli above and the scala tympani below
Page | 37
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 boney labyrinth It is connected
to the bony labyrinth by fibrous trabeculae and is surrounded by perilymph
Endolymph 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 single sensory patch called macula Each
macula is covered by neuroepithelium consist of Neuroepithelium consists
of sensory hair cells and supporting cells these cells are separated by
basement membrane Fibers 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 are referred
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 corti lymph
Page | 38
Fig 5 Inner Ear
Blood supply of labyrinth
Labyrinthine artery
Common cochlear Anterior vestibular Artery
Vestibulocochlear artery Main cochlear artery
Cochlear branch posterior vestibular artery
Page | 39
PHYSIOLOGY OF HEARING [61]
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
bull Mechanical conduction of sound (conductive apparatus)
bull Transduction of mechanical energy to electrical impulses (sensory
system of cochlea)
bull Conduction of electrical impulses to brain (neural
Fig 6 PHYSIOLOGY OF HEARING
Page | 40
Conduction of sound
Under the surface of water we cannot hear the sound made in air because
9995 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 must 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 13 times longer than long process of incus providing
a mechanical advantage of 13
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 beings 211 As the effective
vibratory area of the tympanic membrane is only two- thirds the effective
areal ratio is reduced to 141 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
Page | 41
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 lobe
Page | 42
DISEASES REVIEW
करणसराव
Nirukti - करणसय कणवयोाव ससराा [62]
Nidana- Acharya Sushruta and Vagbhata describe the common etiological
factors for the Karnaroga
अशयाय जलिीडा कणवकणडयन मरत
शमथययोगन शसततरसतय कवपतो अरय च कोपन ||
सउ २० १२
1 Avashaya or Pratishaya
(Excessive exposure to cold)
2 Jalakrida
(Excessive swimming)
3 Karnakandunyanum
(Excessive scracing due to itching)
4 Mithyayogena Shatrasya
(Improper instrumentation during wax removal or foreign body removal)
5Shabdasya
(Louder sound for long durationperverted contact of sound)
6 Abhighata (Trauma)
7 Vitiation of Tridoshas
Page | 43
Samanya Nidana according to different Samhita
Vishesh Nidan of Karnasrava
Acharya Charaka has not mentioned any kind of Nidana regarding Karnaroga
but has described Utapati of Karnaroga from Siroroga in Karnasirasym
Adhyaya[67]
शशरोअशिघातादरा तनमजजतो जल परपकादरा अवप विि
सरतत पय शरणॊ अतनलात स कणवससरा इतत परककतीत
सउ २० १०
असस ३७२५ [68]
1 Shiroabhighatat - Head Injury-Fracture of middle cranial fossa
2 Jala nimajjana - CSF otorrhoea fracture of middle cranial fossa
3 Karnaprapaka
4 Karna Vidhradhi -Puyasrava
Sr
no
Samanya Nidana SU AH[63] AS[64] YR[65] MN[66]
1 Avashaya + + +
2 Pratishaya + +
3 Shabdha
mithyayoga
+
4 Shashtra
mithyayoga
+ + +
5 Karnakandooyan + + + + +
6 Jalkrida + + + + +
7 Abhighata + + +
Page | 44
Samanya samprapti
परापय शरोतरशसरा कयावत शल शरोतशस गान
त कणवगता रोगा अटिावशततरीता
सउ २० १२
Due to common and specific etiology factors the vitiated Doshas gets
Sthanasamshraya in Karna and causes Karnasrava It is the stages of
Samprapti were Doshas gets lodged in Srotas and start processes of Dosh
Dushya Sammurchsna Due to Shiroabhighata Jalanimmajana Karna Paka
Karna Vidhradi vitiated Vata Dosha and Karna becomes Avruta by Vata and
results in Karnasrava Normal physiology of Dosha Dhatus and Malas entirely
depends on the normality of Srotas Dosh Dushya Sammurchana or
manifestation of diseases will not take place if only vitiation of Doshas take
place without deformity of Srotas Here in Karnasrava vitiation of Srotas are
Atipravritti Sanga and Vimargagamana take place Atipravritti is being excess
production of fungus Sanga is obstruction in external acoustic canal
Vimargagamana is the propagation of discharge through ear
Vishesh Samprapti
Karnasrava occurs due to Nij nidana is Pratishaya while Agantuja nidanas are
Avashya Jalkrida and Karnakanduyan Due to etiological factors which are
Vata-Kapha provocative in nature gradual vitiation of Doshas will occur After
vitiation they get accumulated (Sthan samshraya) in external auditory canal
In other hand when patient does Sevana of Agantuj Nidan like water enter in
external ear scratching of ear unsterile instrumentation leads to Dosh
Prakopa These cause Twak and Mamsa Dhatu Dushti which leads to
discontinuity of epithelium of ear canal which creates suitable atmosphere for
fungal pathogen to grow The vitiated Vata will produce symptoms such as
Page | 45
pain hearing impairment and vitiated Kapha causes symptoms like itching
discharge ear blockage By assessing the symptoms it can be said that Kapha
Avrita Vata Dosha is responsible for the manifestation of clinical features like
pain itching discharge Which are seen in Karnasrava that is otomycosis
Acharya Charaka has mentioned while explaining Samanya Chikitsa of
Karnaroga that it should be treated like Vrana when Paka and Srava is present
as a symptom Fungal spores invade in the epithelial layer of EAC In response
to infection inflammatory process is start This is a Paka Avastha After
removing the fungal mass ulceration in external acoustic canal is commonly
seen As a result of infection process exudates was produced which will mix
up- with fungal colonies and appear as discharge As per Dosha involvement
in Vrana Shoola Srava can be differ According to Acharya Sushruta Ruk is
the Samanya Lakshana of Vrana and Vishesha Lakshana of Vrana includes
pain discharge discoloration itching etc according to Dosha involvement
which are also seen in otomycosis In otomycosis mainly watery and purulent
type of discharge is present which indicates Paka avastha If there is Dosha
involve in Vrana is called Dushta Vrana Acharya Sushruta and Acharya
Vagabhata have mentioned verity of Srava in Twak and Mamsa Vranavastu
which is found in otomycosis Based on this description otomycosis can be
correlated with Karnasrava
Page | 46
Representing the Samprapti of Karnasrava
Vishesh Nidana ndash Shiroabhighatat
Jala nimajjana
Prapaka Vidhradhi
Vitited vata
Avarana by kapha
Vimargagamana of Vata
Karnasrava
Samprapti Ghataka
Dosha ndash Kapha and Vata
Dushya ndash Rasa Rakta and Mansa
Strotodushti ndash Vimargagamana and Sang
Adhishthana ndash Karna (Bhayakarna)
Rogmarga ndash Madhyama
Page | 47
Purvarupa
The Purvarupa of Karnasrava are not mentioned separately in any ayurvedic
classics In routine practice cretin Purvarupa are noted
1 Karnakandu
2 Karnagurutwa
3 Alpa karnashoola
4 Discomfort in ear
Rupa
1 Karnashoola
2 Karnakandu
3 Karnasrava
4 karnabadhirya
5 Cotton wool like or wet newspaper like grayish brown or black colored mass
is seen
6 External auditory canal skin appears edematous and red
Upashaya and Anupashaya
Appropriate application of Aushadhi Ahara and Vihara when produces relief in
the symptom is called as Upashaya and when aggravates the symptoms is
called Anaupashaya There is not any reference available in the classics about
the Upashaya and Anupashaya of karnasrava
Sadhyasadhyata
Sushruta has not mentioned specially the Sadhyasadhyata of Karnarogas But
Vagbhata has mentioned Karnasrava as a Sadhyavyadhi[69]
Sadhysadhyatagives the clear picture of prognosis of the disease It depends
on many factors like nature of disease severity of disease Vaya Prakriti Bala
of the patient etc
Page | 48
Upadrava of Karnasrava
In Samhita there is no reference available regarding the Upadrava of
Karnasrava
Samanya Chikitsa ndash
The common treatment principle for all Karnaroga is Ghritapana Use of
Rasayana Bhrahmacharya Avyayama Shirasnana and Atibhashaya
सामरय कणवरोगष घतपान रसयनम
अवयायमो शशराःसतनान बरमहचयवम कतपरनम
स उ२१३
Ghratapana - Ghrita is a Yogavahi and follow Sanskara in addition to these
acquired properties and capable of retaining its own properties So Ghritapana
is effective in Karnasrava
Rasayana - Rasayana represent the basic approach of Ayurveda which
comprise preventive promotive and curative aspect of health
Brahmacharyaapalana -It is like Sadvrittapalana and is equals to Rasayana
effect
Vyayama - It leads to vitiation if Vatas a Karna is a Sthana of vata and
exercise causes Kshayaj Samprapti hence it is important to avoid exercise in
Karnasrava
Shirasnana- In Shirasnana water enters in external acoustic canal it changes
the PH of meatus skin from acid to alkali which favors the growth of pathogens
Atibhashya - Excessive speaking causes Vata Prakopa and Vatapraokopa is
basic Samprapti for Karnasrava as the preventive aspect avoidance of
excessive speaking is necessary
Page | 49
Ghritapana Rasayana and Brahmacharyapalana should be followed for
preservation of dhatu Samyata and restriction of vitiation of Vata Vayayama
Shirasnana and Atibhashaya should be avoided in Karnasrava to protect the
Siras from the affliction of Vata and Kapha
Vishesha Chikitsa ndash
The general treatment principle of Karnasrava described in classics is closely
related to Dushtavrana Chikitsa
शशरोवरचन च ए िपन परण तरा
परमाजवन िान च ीकषय ीकषय़ाचारत [70]
स उ २१४०
कणवसततरा ोददत कयावत पततकशमकणवयो [71]
ाउ १८३५
उपददि च सततरोत साय परात वपचततवशि परमजय
य अगर मदन सघत गगलना ा िपतयतपा मिना परयत [72]
असउ २२४२४३
In addition to that Shirovirechana Karnadhoopana Karnapurana
karnapramarjana Karnadhavana are also indicated
Page | 50
Treatment is also mentioned for Karnasrava
1 Karnaprakshalana Yoga - with Aargawadadi Gana Kashaya and Surasadi
Gana Kashaya [73]
2 Avachurnana Yoga ndash with Aargawadadi Gana Churna and Surasadi Gana
Churna[74]
3 Karnapoorna Yoga ndash
bull Rasanjana Laksha with Sarjachoorna[75]
bull Panchkashaya with Kapittha swarasa and Madhu[76]
bull Jambu AmrapallavShivalaKshuodra Mahavriksha and Madhuki 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 done[77]
bull Sarjatwak Choorna with Karpashiphalarasa and Madhu[78]
bull Abhaya LodraTindukaSamanga(Manjista) Kwatha of this Dravyas mixed
with Madhu and Kapittha Rasa[79]
bull Yogratnakara mention the following drugs for Karnapoorana-
a Samudraphena Churna[80]
b Jambwambpatra Yoga
4 Karnadhoopana Yoga ndash
bull Dhoopana with Churna of Bilvapatra Haridra Palandu[81]
bull Vartak Dhoopana [82]
5 Internal Medications-
bull Rasnadi Guggula [83]
bull Triphala Guggula [84]
bull Sarivadi Vati [85]
bull Gandhaka Rasayana [86]
Page | 51
According to Vagbhata-
Ear should be cleaned with the Pichu and Varti followed by Guggula Dhoopana
and then Karnapoorana with Madhu Followed by Avachurnanana with
Sukshmachootana of Surasadigana
Pathyaapathya ndash Pathya and Apathy mentioned for Samanya Karnaroga is
recommended in Karnasrava also
पथय[87]
सतदो वरको मन नसतय िमाः शशरावयिाः
गोिमाः शालयो मदगााः याशच परतन हवाः 80
लाो मयरो हररणानदसततततरो नकककिाः
पिोल शशगर ातावक सतनषराण कदठललकम
रसायनातन सवणण बरमहचयवमिाषणाम |
उपयकत यरादोषशमद कणावमय दहतम ||81||
िापर २१
Aharaja Upacharaja
bull Godhuma bull Vamana
bull Shala bull Virechana
bull Mudga bull Nasya
bull Yava bull Dhoomapana
bull Puranagitra bull Kavala
bull Lava Harina Tittiramamsa
Page | 52
अपथय[88]
दरत काटठ शशरसतनान वययाम शलटमल गर
कणडयन तषारशच कणवरोगी पररतपयजत
िापर २१
Viharaja
bull Patola ShigruVartaka bull Bhramacharaya
bull Sunishannaka bull Avyayama
bull Katthlika bull Aakthanam
bull All types of Rasayana bull Upacharaja
bull Vamana
Apathyas
bull Abhishyandakara Aharas
bull Shirasnana
bull Karna kandooyana
bull Tushara sevana
bull Guru Kaphakaraka Aaharas
bull Dantdhavana
Page | 53
OTOMYCOSIS
Definition-
Otomycosis is a superficial acute sub-acute or chronic infection of external
ear canal It is mostly unilateral It is characterized by inflammation purities
and scaling Otomycosis is a common condition encountered in ENT practice
more in chronic and persistent ear infection
The Fungal infections are not communicable in the usual sense but the
humans become an accidental host by their introduction into tissue trauma
The virulence factors favoring colonization of fungus in human host are yet to
be identified Ability of the fungus to grow at 37 C and elaboration of a variety
of enzymes and toxins are speculated to contribute to virulence Only 100 to
150 species are generally recognized as a cause of disease in humans[89]
Prevalence-
Otomycosis is a word wide in distribution and in various record stated that 5
to 20 of all cases of infective otitis externa Otomycosis prevalent is more in
warm and humid climates It is one of the commonest manifestations in India
during rainy season It occurs mostly in humid atmosphere otitis externa due
to fungal infection may resembles the desquamative form of diffuse infective
otitis externa The incidence in temperature climates has increased in
proportion to the use of topical antibiotics which have a medium sterilized of
other organism in which the fungus may flourish
Page | 54
Predisposing factors- [90]
1 Environmental factors such as climate contagious and polluting hygiene
more frequently during rainy season as the humidity increases
2 Individual susceptibility ndashGeneral Immunological status of the Individual
eg HIV infection Radiotherapy chemotherapy Diabetes mellitus
3 Self-inflicted trauma that is use of pins to clean the itching ear or use of ear
bud to clean the wax
4 Wide spread of topical antibiotics steroid preparations which have medium
sterilized of other organism in which the fungus may grow
5 Failure of defense mechanism in External auditory canal
6 During swimming or head bath water enters in External acoustic canal
causes quantitative and qualitative change in ear wax It causes change in pH
7 Long term use of hearing aids
Pathophysiology ndash
The life cycle of the average mold encountered in the ear may be reckoned
as two weeks and flare ups may be anticipated at such intervals Swimming is
held responsible for infection in many cases The sequence sequence of
pathogenic changes produced by molds in the external ear is as follows ndash
1 Implantation of the organism in external ear
2 Growth of organism follows the rate depending on condition of temperature
moisture or preexisting irritation
3 Invasion of epithelium occurs with attendant itching and discomfort which
may be quite severe
Page | 55
4 Exfoliation of epithelium occurs as nature attempts to overcome the
infection by casting off upper most cells
5 Denudation occurs from exfoliation as the top layers of epithelium are cast
off and the canal becomes filled with debris
6 Superficial ulceration and lizematoid dermatitis results if the pathologic
process goes for enough The changes do not always proceed through the
entire sequence sometimes the molds produce changes of the mildest
imaginable character which may be overlooked[91]
Clinical features -
Symptoms-
1 Irritation and itching ndash Irritation is mostly found when the infective
organism is aspergillus niger There is sensation of discomfort which is more
diffuse in the ear canal then localized in the deeper part Candida infection
causes marked itching In external ear it is intense and worse at night
2 Discharge through ear- Intermittent scanty colorless discharge through
ear Mucus being a fungal metabolic product appears as discharge Excessive
discharge is associated with mixed infection
3 Pain and discomfort ndash Mild to severe pain in the ear occasionally Mostly
seen in cases where ear is infected with Aspergillus flavus mixed infection
with gram negative organism or mixed infection with candida and aspergillus
Headache is sometimes associated with pain
4 Deafness- Varying degree of mild to moderate conductive deafness
5 A sensation of fullness in ear
6 Tinnitus 7 Vertigo
Page | 56
Signs ndash
1 The external acoustic meatus may contain a mass formed of epithelial
debris exudates cerumen and fungus
2 Erythematous external canal
Fungal appearance
A Niger - The color of the mass which is usually grey or black is mainly
determined by the type of fungus concerned Its appearance is like wet
newspaper or blotting paper or a cotton wool It has a peculiar musty odor In
this infection fruiting heads may be seen as black specks in the debris
Occasionally as inactive form occurs in which the canal is lined by mold giving
a fluffy appearance due to the presence of tiny mycelia
Candida ndash Candida infections generally show as white deposits on magenta
colored skin when the debris is removed it rapidly recovers in 24 hrs
The underlying canal skin is often inflamed and granular due to invasion by
fungal mycelia and be seen in all cases In rare cases excoriation and
ulceration with marked extensive shedding of the epithelium and deep
ulceration can be seen usually associated with a flavus and with pathogenic
bacteria[92]
Otoscope Appearance
1 Aspergillus Niger ndash Black headed
2 Aspergillus Fumigators ndash pale blue or green
3 Candida Albicans ndash White- or cream-colored deposits
Page | 57
4 Auricle is normal in most cases In severe cases small ulceration with crust
formation may be present on lateral surface
5 Tympanic Membrane
In most cases it is normal with normal mobility and normal hearing In a few
cases the surface of the tympanic membrane is congested and scaly There is
erosion or ulceration of the external epithelial layer and the membrane itself
may be edematous
Diagnosis
1 Above mentioned symptoms and signs
2 In the stage at which patient with otitis externa usually first present
themselves mycelia threads conidiophors not visible to naked eye may
sometimes be identified with the microscope
3 Confirmed by culture
Page | 58
Fig7 Aspergillus Niger Fig8 Candida Albicans
Fig9 Aspergillus Fumigators Fig 10 Wet Paper like appearance
Page | 59
Treatment
1 Antibiotic or steroid drops should be discontinued if they are being instilled
since long time
2 Removal of fungal mass epithelial debris and discharge from the external
canal or mastoid cavity repeatedly and thoroughly by forcepa or suction or
syringing or cautiously blow a stream of air into the canal through a fine
cannula and dry thoroughly by swabbing liquid petroleum on swab used in
cleaning the ear lessens the burning sensation when metacresy acetate is to
be employed in the subsequent treatment
Furuncle is developed as a complication if there is no gentleness in cleaning
Cleansing may have to be delayed until local sensitiveness is lessened which
can usually be accomplished within twenty-four hours If there is excessive
epithelial debris along with otomycosis then metacresyl acetate which is a
keratolytic in introduction into the external auditory canal on cotton wick and
is allowed to remain for twenty-four hours After twenty-four hours the cotton
wick is removed at which time the canal can usually be cleansed with little
discomfort as the medication is also anesthetic The epithelium of the canal
was white from contact with the drug The top layer was detached and this
epithelial debris can be easily wiped away The wick is reinserted and wet with
metacresyl acetate
The treatment is employed for three to four days in succession and then a
bland application is substituted Icthyol iodine is of value at this stage Iodine
ointment 2 in combination with Tannic acid 2 is also an excellent local
application following cresatin treatment
Next one of the fungicides may be applied
Page | 60
1 Nystin Effective for candida infection but less active against aspergillus
group Nystatin in boric powder consisting of 100000units of nystatingm of
powder 3 times week for 3 weeks
2 Clotrimazole Available as 11 cream or drops or lotions Phenyl
(zchlorophenyl) 1 ndash imidazole ndash methane is a chlorinated trityl imidazol 1
effective against candida and dermatophytes and for aspergilli infection
3 Amphotericin B Available as cream and as 3 solution and 015 drops
for topical application Very effective for candida infection can be fungistatic
or fungicidal
4 Econazole Available as solution (Econazole nitrate) and as cream (1)
Broad spectrum ndash more effective for Aspergillus Also active against some
gram-positive bacteria (Staphylococci and Streptococci and Dermatophytes)
5 Miconazole Highly effective against dermatophytes and candida infections
used as a 21 cream applied once or twice a day for 10 days
6 Gentian violet 21 Available as drops (recently some evidence of
carcinogenicity) Discolors the ear canal and this interfere with clinical
examination
Other topical antifungal agents are ketoconazole Natamycin Tolciclat Bifonas
zole Fenticonzole Oxiconazole Tioconazole ciclopiroxolomine Tolnafate
Haloprogin Flucytosine Acetic acid Whit field ointment selenium sulfide
undcyclenic acid triacetin etc
Page | 61
Minimal length of treatment
A month of drug treatment is usually required because the antifungal agents
used are not sporicidal and it is necessary that the period of treatment covers
germination time It may be advisable to give short gaps in the period of
treatment to ensure all spores have germinated before deciding to terminate
therapy
Prevention
Accomplished by strict attention to the predisposing causes
1 Water should be prevented from entering the ear
2 Avoidance of external ear trauma
3 Use of alcohol medicated or plain in the ears after swimming mercuric
cyanide (15000) in ethyl alcohol (70) is a satisfactory liquid to use
Ear stoppers do no good unless their use is followed by some antiseptic in the
canal Divers exposed to water for long periods of time may also use acidic
alcohol
4 During Summer months with their high humidity special efforts are needed
to maintain ear dry 5 Indiscriminate use of topical antibiotics steroid
preparations should be avoided
Page | 62
DRUG REVIEW
1 GUGGULA
Fig11 - Guggula
Historical review of Guggula [93]
bull Atharvaveda one of the well-known Vedas of Hindus The earliest
reference given by Atharvaveda medicinal and therapeutic properties of
Guggula Guggula has long history of use in Ayurveda
bull Acharya Charaka Sushruta and Vagbhata describe detail regarding the
actions uses and indication as well as the variety of Guggula
Page | 63
bull Various Nighantus (Medical lexicons) were written between 12th and 14th
centuries AD was based on the Ayurvedic literature also describes
Guggula
bull The explanation of word Guggula is that Gunjo Vyadhegurdti Rakshati
which means to relief against different diseases
bull Guggula is the best medicine because it develops through the rays of
hot sun on specific circumstances
bull Guggula has an aromatic odor
गगलो कणवदौगवररधय िपन शरटठमछयत[94]
स उ २२११२
Latin name- Commiphora mukul
Family ndash Burseraceae
Rasa- Tikta Katu
Guna ndash Laghu Rukshasukshma vishada sara
Veerya ndash Ushna
Vipaka ndash Katu
Action- Rasayana Lekhana
Doshaghanta - Tridoshhara
Page | 64
Chemical composition [95]
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Oleoresin-Z-Guggulsterone E-Guggulsterone
Gum- guggulignans 1 and 2 guggula Tetrols mukulol allylcembrol c
27
Guggulusterol 1 2 ans 3 Z and E ndash guggulusterol
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Parts Used ndash Gum oleoresin
Guggula purity test
1 Yellowish brown emulsion is obtained when Guggula is triturated with
water
2 An ethereal solution of the drug attains reddish colour when treated
with br2 vapors and purple colour when moistened with nitric acid
Biochemical action ndash Antiseptic Anti-inflammatory Disinfectant Diuretic
Immunostimulant stimulating expectorant Ant suppurative Antipyretic
Enhance phagocytosis
Karma- Rasayana cardiovascular disease
Page | 65
2 AGARU-
Fig 12 Agaru
Historical review of Agaru [96]
bull The word Agaru literally means the one which is the heaviest and no
aromatic wood is heavier than it Since thousands of years Agaru lsquoThe
wood of Godrsquo has been used for multiple purpose like commercial
medicinal spiritual aromatic historical
bull The medicinal use of Agaru have been recorded in many pieces of India
Greek Roman Chinese Middle eastern and European since ancient times
bull Acharya Charaka used Agaru and pest of Rasna to counteract the effect of
cold in Agraya Dravyas
bull Acharya Sushruta used Agaru as a Dhoopana Dravya along with Guggula
Ral and Shoma in the treatment of Karnasweda and Vrana
Page | 66
Types-
bull Dhanwantsri Nighantu describes Kaleyaka as a type of Agaru
bull Sodhala Nighantu describes three types of Agaru ndash Agaru Krishna
Agaru Kakatunda Agaru
bull Raj Nighantu describes five types of Agaru ndash Krishna Agaru Kasht
Agaru Daha Agaru Mangalya Agaru and Agurusaar
bull Arthashasstra describes three Agaru wood product
1 Jongaka ndash Black or variegated black in colour and having variegated
spots
2 Dongaka ndash Black in color
3 Parasamudraka- Black in colour and smells like Navamallika
अगर उटण कि तपछय ततकत ततकषण च वपततलम
लघ कणाविरोगघन शीत ात कफपरणत
िापर २१ [97]
Family- Thymelaccensis
Latin name- Aquilaria agallocha
Guna- Laghu Ruksha Tikshan
Rasa- Katu Tikta
Vipaka ndash Katu
Virya ndash Ushna
Karma- Sheetaprasasmana Vranaorasadan Tvachya Pittavardhaka
Shirovirechana Mangalya Sugandhik and Rochaka in properties [100]
Krishna Agaru karma- Katu Tikta rasa Ushna Sheeta when applied externally
and Pittahara when taken orally
Page | 67
Chemical Constituents -
Agaru hardwood is rich in essential oil resins alkaloids saponins Steroids
terpenoids tannins flavonoids and phenolic compound Agaru wood
predominantly contains 2-[-2-phenylethy]-4H-chromen-4-one derivatives and
sesquiterpenes Agaru oil contains selinene dihydroselinene agarnol b-
agarofuran vetispira-2(11)valerianol dihydrokaranone and tetradecanoic
acids[99]
Part Used ndash
Heartwood- Dark resinous wood which is formed when the plant becomes
infected with a type of fungus (ascomycetous mold) Species of Aspergillus
fusarium and penicillium are reported to be associated with the development
of infection Prior to infection the heartwood is odorless relatively light and
pale colored however as the infection progresses the tree produces a dark
aromatic resin in the heartwood The infected resin in response to the attack
which results in accumulation of a very dense dark resin in the heartwood
The infected resin embedded wood is known as Agarwood Infection is more
common on the trunk roots and the area when branches divide The formation
of Agarwood starts when the tree attains the age of 20 years On an average
approximately 30 ml oil is extracted from 100 kg of infected Agarwood[98]
Qualities of best Agaru-
It should be black in color
It should be extremely heavy and aromatic
It should be oily in appearance and test
It should be sink in water
It should burn easily with bright flame with a bright flame giving off a pleasant
smell
Page | 68
3 MADANA
Fig 13 MADANA
Madana consist of dried fruit of Xeromphis spinosa It is a deciduous thorny
shrub or a small tree reaching a high up to 9 m and girth about a meter
branches numerous thick and horizontal found in sub-Himalayan tracts[101]
मदनो मिरनदसततकतो ीयोटणो लखनो लघ
ानदरतिदवििीहर परततशयायवरणारतक
रि कटठकफ़ानाहशोथगलमवरणापह[102]
िा पर १६० १६1
Page | 69
Latin name-Randia dumetorum
Familly ndash Rubiaceae
Rasa - Madhura Tikta
Guna-Laghu Ruksha
Virya- Ushna
Vipaka ndash Katu
Karma- Vamana and Lekhana
Chemical Composition-
Essential Oil Valerianic acid Saponin tannin resin [103]
Page | 70
YAWA [104]
Fig 14 Yawa
1 In Samhitakala Aacharya Charaka Acharya Sushruta explain detail about
medicinal properties of Yawa
2The use of Yawa in Aaharya Dravya mainly described by Dhanwantari
Nighantu Raj Nighantu Bhavprakash Nighantu[105]
Macroscopic Description-
Fruit a caryopsis elliptical oblong Ovoid and tapering at both ends smooth
about 1cm long and 02- 03cm wide dorsally compressed and flattened on
the sides with a shallow longitudinal furrow 3-5 ridges having shallow
depression between them grains tightly enclosed and adhering the lemma
and palea pale greenish yellow odor not distinct taste sweetish acrid
Page | 71
Latin Name ndash Hordenum vulgare
Family- Poaceae
Rasa- Kashaya Madhura
Virya- Sita
Vipaka- Katu
Karma- Vatakrt Pittahara Kaphahara Medahara Balya Visrya
SthairyakaraLekhana
Page | 72
PROCEDURE REVIEW [105]
In Ayurvedic classics there are many references regarding Dhoopana Dravya
Dhoopana is administering Dhuma with the help of Dhoopana Dravya
In Kashyapa Samhita there are 40 types of Dhoopana advised for children
Anesthesia (Mohajananam Dhoopa) is also mentioned For this Dhoopana the
drug used were herbs hairs of animals legs horns old cloths of Buddhist
monks
From the references available regarding Dhoopana we can understand that
Karna can be protected from maggots (krimi) Bactria (Rakshogna) lice etc
References clearly indicate the analgesic and disinfectant effect of Dhoopana
Karma Dhoopana is mentioned for Dushta Vrana Chikitsa It reduces Vedana
Srava Pootigandha of Dushtavrana It also helps in Vranaropana
Dushtavrana Chikitsa is mentioned in the treatment of Karnasrava[106]
Origin of Dhoopana-
In ancient period children of sages were constantly harassed by the
Rakshasas Hence the sages approached lord Agni for shelter Agni in turn
gave them Dhoopana Dravya and asked sages to use the Dhoopana for
protection against Rakshasas bhutas pishachas
Classification of Dhoopana
1 It is classified into Dhupa Anudhupa Pratidhupa
2 On the basis of Origin it is classified into Jangama and Sthavara
Selection of Guggula for Dhoopana
Page | 73
bull Guggul is a best Vatahara
bull It is Krimighana
bull It contains Oleoresin
bull In Ashtang Hrudaya Guggula Dhoopana mentioned for Karnasrava
Selection of Agaru for Dhoopana
bull Agaru is Laghu Ruksha Katu Tikshna
bull Vranaorasadan Tvachya
bull It should burn easily with bright flame with a bright flame giving off a
pleasant smell
Karna Dhoopana Indication
1 Karnaarava
2 Putikarna
3 Krimikarna
4Vataj Karnashula
Contraindications
Especially for Karnadhoopan contraindication is not mentioned in classic texts
But Dhoopana is contraindicated in Pittaj vaydhi Sharad and Grishma Rutu
Page | 74
MATERIAL AND METHOD
Page | 75
For randomize comparative clinical trial to study the effect of Agaruwadi
Karnadhoopana and Guggula Karnadhoopana in Karnasrava following material
and method were required
Source of data
Patient irrespective of gender occupation religion social economic status
signs and symptoms of classical features of Karnasrava (Otomycosis) selected
from the OPD of Shalakyatantra department
Materials ndash
1Patients
2 Drugs-Agaruwadi Dhoopana
Guggula Dhoopana
3Torch
4Otoscope
5 Tuning fork
6Jobson horn probe
7Cotton
8Case record form
DRUG
Group A Trial Group
1Churana of Agaru Yawa Madan
2Ghrita
3Jala
Group B Control Group
1Googula Churna
Page | 76
Properties of Drug
Table no 1 Properties of Drug
Drug
Family
Rasa Veerya Vipaka Effect
on
Dosha
Guna Karma
Agaru
(Aquilegria
Agallocha)
Thymelaca
ceae
Katu
Tikta
Ushna Katu KV Laghu
Ruksha
Tikshna
Shitaprashamana
Shothahara
Vedanasthapak
Durghandhihara
Madan
(Randia
spinosa)
Rubiaceace
Kashaya
Madhur
Tikat
Katu
Ushna Katu KV Ruksha
Laghu
Vatakaphaghana
Shothahara
Vedanasthapak
Vranashodhak
Yawa
Poaceae
Hordeum
Vulgare
Kashaya
Madhur
Sheeta Madhur KP Ruksha
Laghu
Vataghana
Vernashodhana
Raktshodhaka
Guggula
Commiphora
Mukul
Burseracea
e
Tikta
Kashaya
Anushna Katu VPK Laghu
Ruksha
Shothahara
Vedanasthapaka
Kandughna
Ghrita Madhura Sheet Madhur VK Snigdha Vataghana
Shothahara
Vedanasthapaka
Page | 77
METHODOLOGY
SELECTION CRITERIA
1)INCLUSION CRITERIA
1 Patients having signs and symptoms of Karnasrava (Otomycosis) ie करणशल
( pain ) करणकणड ( Itching ) करणसतराव ( Discharge )बाधिरण ( conductive Loss of
hearing )
2 Patient from age group 19 to 70 years
3 Any Gender
2)EXCLUSION CRITERIA
1 Patients suffering from any systemic disease like DM TB HTN
2 Chronic suppurative otitis media (CSOM)
3 Acute supportive otitis media (ASOM)
3 Perforation of Tympanic membrane
4 Chronic otitis media
3)WITHDRAWAL CRITERIA
1If patient develops any adverse effect such as irritation pain burning
sensation in ear loss of hearing and such patients was withdrawn from trial
and receive prompt appropriate medical attention
2If patient shows aggravation in symptoms
3If patient refuses to continue with the treatment
Page | 78
STUDY SETTING
Types of study - Randomized Clinical comparative Trial
Place of work - OPD of Shalakyatantra
Duration of study - 18 months
Study Population - Patients of Karnasrava in Shalakyatantra OPD
SAMPLE SIZE CALCULATION
Sampling Method ndash Purposive sampling followed by random allocation in two
groups
Sample size calculation-
n = z2 p (1-p)
d2
Were
n = sample size
P = prevalence of disease=10
z = standard normal variable ie 196
d = error ie005
desired Sample Size would be
n = Z2 P(1-P)d2
= (196)2x (0021) x(0979)(005)2
= 34
Visiting ENT OPD (ShalakyaTantra) and IPD (ShalakyaTantra) 21 = 34
n raquo34
So one group includes 34patients
Page | 79
Sampling Method
Total 68 patient of Karnasrava are selected by Purposive sampling followed by
random allocation in two groups Written informed consent is taken prior to
commencement of trial They are divided in 2 groups
Group A (Trial Group) 34 patients treated with Agaruwadi Dhoopana for 7
days
Dose 5 minutes twice in a day
Group B (Control Group) 34 patients treated with Guggula Dhoopana for 7
days
Dose 5 minutes twice in a day
STUDY DESIGN ndash
Open labeled Randomized Comparative Clinical trial
STUDY DESIGN
Screening of patient
Inclusion criteria satisfied Exclusion criteria
Initial assessment Excluded
Counseling of patient Treated accordingly
Patient selection by Simple Random Sampling Method
Page | 80
68 Patients were divided in two groups lsquoArsquo and lsquoBrsquo
Trial group A-34 patients were given
Agaruwadi Dhoopana
Control group B- 34 patients were
given Guggul Dhoopana
Informed written consent
Treatment was given for 7 days
Assessment on 1st 4th and 7th day
Post assessments follow up on 15th day
Observation
Data Collection
Statistical analysis of data
Conclusion
Page | 81
(A) Agaruwadi Varti for group A (Trial group)
Table no 2
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
B) Guggula Varti for group B (Control group)
SOP of it is same as above Agaruwadi Varti
Table no 3
Drug Guggula Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
FOLLOW UP
For both groups follow ups were done on 1st 4th and 7th and post
assessment follow up15th day
EXAMINATIONS
Torch for Local examination of ear
Otoscope examination
Tuning fork Test
Page | 82
OBSERVATION TABLE
Table no 4
Sr no Subjective criteria Day 1 Day 4 Day 7 Day 15
1 करणशल
(pain)
2 करणकणड
(Itching)
3 करणसतराव (Discharge )
4 बाधिरण (Conductive Deafness)
OBSERVATIONS
a) करणशल (Pain) -
0 - Absent
1 ndash Present
b) करणकणड (Itching) -
0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
Page | 83
c) करणसतराव (Discharge)
0- Absent
1- Mild -Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाधिरण (conductive Loss of hearing)
0 - Absent
1- Present
Observations were carried out before and after completion of treatment and
during each follow up After observations the data collected and presented in
the form of graphs charts and table
Page | 84
TRIAL DRUG
Authentication and standardization of raw drug material done After
authentication and standardizing of raw drug material Agaruwadi Varti was
prepared by Varti as explained in Ayurvedic classics
Method of Varti preparations
Panchavidh Kashaya Kalpana that is five method of pharmaceutical
preparation constitutes the fundamental process of Ayurvedic pharmaceutics
which is well explained in Sushrut Samhita Varti Kalpana is one among them
which can be included in Kalka Kalpana
तीररसतरपतपतीनामपरककव तीत [106]
स डलहण शरच 151
Medicines are powered triturated and given the Varti shape that is like wick
of lamp so it is called as Varti Kalpana
Drug content Agaru Madan Yawa
Route of Administration Local
Dose Two times a day
Duration 7 days
Page | 85
Methodology
Standard operating procedure (SOP) of Agaruwadi Varti
Agaruwadi Varti is prepared according to the classical text
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization was done as recommended in pharmacy procedure The
raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 mixed together in
equal quantity to make Agaruwadi churn
Quantity of each churn is 4 grams all are mixed when the Varti get dry total
weight of Varti was 10gram
STEP 4 - Agaruwadi churn triturated with appropriate quantity of water or
Ghrita and prepared Varti in GMP Certified Ayurvedic pharmacy Standard
aseptic precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Varti was packed in sterile air packed container
STEP 6 - Agaruwadi Dhoopana was given with the help of Dhoopana yantra
Authentication and Standardization of raw drug of Agaruwadi Varti was done
Sterilization was done as recommended in pharmacy procedure Sterile
preparation packed in sterile container of suitable size Under all aseptic
precaution Karnadhoopana given to infected ear
Page | 86
Containers for packaging and their sterilization-
Sterilization of the containers for storing Varties was done by Ethylene Oxide
(Eto) method
Ethylene Oxide (Eto) procedure-
It includes exposure of materials to ethylene oxide gas under vacuum in a
sealed chamber It consists of four primary variables
1Gas Concentration
2Humidity
3Temperature
4 Time
EtO gas is an alkylating agent which disturbs the DNA of microorganism
preventing them from reproducing It penetrates the breathable packaging
and sterilizes all the accessible surface of the product to render products
sterility by alkylation of essentials proteins for cell reproduction
Most Eto sterilization methods involves three different stages These can be
separated into three different on the size or number of devices to treat
1Preconditioning stage-
First products are passed through a preconditioning phase to make
microorganism grow The batch load goes through a well time under a
controlled environment of temperature and humidity
2Sterilizer stage-
Performed using process phase specially designed to provide the required level
of EtO exposure to assure sterility for a device or family of devices
3Degasser Aerration stage-
Finally products need to go through a degassing phase to remove any residual
particles of Eto The batch load goes over well time under a temperature-
controlled environment
The sterile containers were then used to store Agaruwadi Varti and handed to
patients included in the study
Page | 87
Packing of Agaruwadi Varti
The ETO sterilize plastic container were used for packing of Agaruwadi Varti
Varti was filled into these sterilize containers (7 in each) In an aseptic
environment plugging and capping was done under aseptic precautions In this
way packing of Agaruwadi Varti done These Varti were given to patient and
advise to take two times a day under all hygienic precautions
History and Examination
bull Proper history and presenting complains was recorded on case record form
bull Ear examination with otoscope was done during initial assessment and each
follow up
bull Otoscopic examination was done during initial assessment and each follow
up
bull Systemic Examination that is Blood Pressure Temperature Respiration
rate Pulse was recorded on case record form
Page | 88
Raw material
Fig14 यव चरण Fig15 मदनफळ चरण
Fig16 अगर चरण Fig17 गगगळ चरण
Page | 89
Preparation of Agaruwadi Varti
Fig18 Preparation of Agaruwadi Varti
Fig19 अगरवादी वरती
Page | 90
Fig20 Instruments used for examination of Karnasrava
Fig19 Karnadhoopana Yantra
Page | 91
Karnadhoopana Procedure
Fig 22 Karnadhoopana Procedure
Page | 92
OBSERVATIONS AND RESULTS
Page | 93
BASED ON DRUGS
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 94
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
AUTHENTICATION CERTIFICATE
Page | 95
BASED ON STASTICIAL ANALYSIS OF DEMOGRAPHIC DATA
68 patients of Karnasrava ndash Otomycosis
Table no 5
No of Patients Total
Group A Group B
Registered 38 37 75
Completed 34 34 68
Discontinue 04 03 07
Total 68 patients were enrolled in study 38 patients registered in group A
amongst them 34 patients completed the treatment and04 patients
discontinued the treatment However in group B 37 patients completed the
treatment and 03 patients discontinued the treatment out of 37 registered
patients
Hence the total number of patients registered in the present study was 75
and out of which 68 patients were discontinued the treatment So they
dropped out from the study While 68 patients were successfully completed
the treatment So observations and result of 68 patients were given below
Here we are going to discuss the statistical analysis of the data obtained in
the form of master chart that was prepared in accordance with the data
collected from the patients that had been included in the study The purpose
of statistical analysis was to analyzed the relation between age gender
occupation diet addiction and education
Page | 96
1 Age wise distribution of patients
Table no 6
In trial group 10 (29412) patients were from age group 18-25 years 14
(41176) patients were from age group 25-35 years 8 (23529) patients
were from age group 35-45 years and 2 (58824) patients were from age
group 45-60 yearsIn control group 6 (17647) patients were from age group
18-25 years 14 (41176) patients were from age group 25-35 years 7
(20588) patients were from age group 35-45 years and 7 (20588)
patients were from age group 45-60 years
Fig 23 Age wise distribution of patients
0
2
4
6
8
10
12
14
15 -25 25-35 35-45 45-60
10
14
8
2
6
14
7 7
Age Distribution
Trial Group N Control Group N
Age Distribution
Trial Group Control Group
N N
18 -25 10 29412 6 17647
25-35 14 41176 14 41176
35-45 8 23529 7 20588
45-60 2 58824 7 20588
Total 34 100 34 100
Page | 97
1 Gender wise distribution of patients
Table no 7
Sex
Trial Group Control Group
N N
Female 23 67647 15 44118
Male 11 32353 19 55882
Total 34 100 34 100
In trial group 23 (67647) patients were female and 11 (32353) patients
were male
In Control group 15 (44118) patients were female and 19 (55882)
patients were male
Fig 24 Gender wise distribution of patients
0
5
10
15
20
25
N N
TRIAL GROUP CONTROL GROUP
23
15
11
19
Gender
Female Male
Page | 98
2 Education wise distribution of patients
Table no 8
Education
Trial Group Control Group
N N
Illiterate 4 11765 3 88235
SSC 4 11765 3 88235
HSC 8 23529 9 26471
Graduation 16 47059 10 29412
Primary 1 29412 3 88235
Post-Graduation 1 29412 6 17647
Total 34 100 34 100
In trial group 4 (11765) patients were illiterate 4 (11765) patients were
SSC educated 8 (23529) patients were HSC educated 16 (47059)
patients were graduated 1 (29412) patients were primary educated and
1(29412) patients were post graduated
In control grou 3 (88235) patients were illiterate 3 (88235) patients
were SSC educated 9 (26471) patients were HSC educated 10 (29412)
patients were graduated 3 (88235) patients were primary educated and
6 (17647) patients were post graduated
Page | 99
Fig 25 Education wise distribution of patients
0
2
4
6
8
10
12
14
16
ILLITERATE SSC HSC GRADUATION PRIMARY POST GRADUATION
4 4
8
16
1 1
3 3
910
3
6
Education
Trial Group N Control Group N
Page | 100
3 Occupation wise distribution of patients
Table no 9
Occupation
Trial Group Control Group
N N
Accountant 1 294 2 588
Housewife 11 3235 8 2353
Engineer 1 294 1 294
Job 1 294 4 1176
Labor 1 294 3 882
Mess 1 294 0 000
Naturotherapyst 1 294 0 000
Pharma 1 294 0 000
Shopkeeper 4 1176 2 588
Singer 1 294 0 000
Student 8 2353 4 1176
Tailor 1 294 1 294
Teacher 1 294 1 294
Worker 1 294 3 882
Farmer 0 000 1 294
Lab Tech 0 000 1 294
Page | 101
Daily Collection 0 000 1 294
Fruit seller 0 000 1 294
Bus Driver 0 000 1 294
Total 34 10000 34 10000
In trial group 11 (3235 ) were housewife 8(2353) were students
4(1176) were shopkeeper 1(294) was accountant 1(294) was
engineer 1(294) was doing job 1(294)was labour 1(294) was
catering 1(294) was Naturotherapyst 1(294) was Pharma 1(294)
was Singer 1(294) was Tailor 1(294) was Teacher and 1(294) was
worker
In Control group 8 (2353)were housewife 4(1176) were students
2(588) were shopkeeper 2(588) was accountant 1(294) was
engineer 4( 1176) was doing job 3(882)was labor 1(294) was
Farmer 1(294) was Lab tech 1(294) was Daily collection 1(294)
was Tailor 1(294) was Teacher and 3(882) was worker 1(294) was
Fruit seller and 1(294) Bus driver
Fig 26 Education wise distribution of patients
0
2
4
6
8
10
12
1
11
1 1 1 1 1 1
4
1
8
1 1 10 0 0 0 0
2
8
1
43
0 0 02
0
4
1 13
1 1 1 1 1
Occupation
Trial Group N Control Group N
Page | 102
4 Religion wise distribution of patients
Table no 10
Religion
Trial Group Control Group
N N
Hindu 31 9118 33 9706
Muslim 3 882 1 294
Total 34 10000 34 10000
In trial group 31 (9118) patients were Hindu and 3 (882) patients were
Muslim
In control group 33 (9706) patients were Hindu and 1 (294) patient
were Muslim
Fig 27 Religion wise distribution of patients
0
5
10
15
20
25
30
35
N N
TRIAL GROUP CONTROL GROUP
3133
31
Religion
Hindu Muslim
Page | 103
5 Diet wise distribution of patients
Table no 11
Diet
Trial Group Control Group
N N
Veg 14 4118 20 5882
Non-Veg 20 5882 14 4118
Total 34 10000 34 10000
In trial group 14 (4118) patients were vegetarian and 20 (5882)
patients were Non vegetarian
In control group 20 (5882) patients were vegetarian and 14 (4118)
patients were Non-Veg
Fig 28 Diet wise distribution of patients
0
5
10
15
20
N N
TRIAL GROUP CONTROL GROUP
14
2020
14
Diet
Veg Non Veg
Page | 104
6 Addiction wise distribution of patients
Table no 12
Addiction
Trial Group Control Group
N N
None 30 8824 27 7941
Alcohol 2 588 0 000
Tobacco 1 294 2 588
Mishri 0 000 1 294
Smoking 1 294 4 1176
Total 34 10000 34 10000
In trial group 30 (8824) patients have no addiction 2 (588) patients
have addiction of alcohol 1 (294) patients have addiction of Tobacco 0
(0) patients have addiction of Mishri and 1 (294) patients have addiction
of smoking
In control group 27 (7941) patients have no addiction 0 (0) patients
have addiction of alcohol 2 (588) patients have addiction of Tobacco 1
(294) patients have addiction of Mishri and 11 (1176) patients have
addiction of smoking
Page | 105
Fig 29 Addiction wise distribution of patients
0
5
10
15
20
25
30
NONE ALCOHOL TOBACCO MISHRI SMOKING
30
21
01
27
0
21
4
Addiction
Trial Group N Control Group N
Page | 106
Statistical Analysis and Results
Effect of study on Karnashoola-
Table no 13
Karnashoola
Group A Group B
BT AT BT AT
N N N N
Grade 2 0 000 0 000 0 000 0 000
Grade 1 30 10000 7 2333 32 10667 5 1667
Grade 0 4 1333 27 9000 2 667 29 9667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 30 Effect of study on Karnashoola
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
30
7
32
54
27
2
29
Karnashoola
Grade 2 Grade 1 Grade 0
Page | 107
Table no 14
Karnashoola Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 088 100 033 006
969 2829E-
08 7667 HS
AT 021 000 041 007
Group
B
BT 094 100 024 004
1037 7103E-
11 8438 HS
AT 015 000 036 007
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 31
000010020030040050060070080090100
BT AT BT AT
GROUP A GROUP B
088
021
094
015
Karnashoola
Mean
Page | 108
Table no 15
Karnashoola
Mean SD Effect
Group
A
Group
B Trial Control Trial Control
Day 1 088 094 033 024 000 000
Day 3 065 071 049 046 2667 2500
Day 5 024 038 043 049 7333 5938
Day 14 021 015 041 036 7667 8438
000
010
020
030
040
050
060
070
080
090
100
Day 1 Day 3 Day 5 Day 14
Karnashoola
Mean Group A Mean Group B
Page | 109
Table no 16
Karnashoola N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3250 110500
510000 275 Control group 34 3650 124100
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 110
Effect of study on Karnakandu
Table no 17
Karnakandu
Group A Group B
BT AT BT AT
N N N N
Grade 3 7 2333 0 000 4 1333 0 000
Grade 2 18 6000 0 000 18 6000 0 000
Grade 1 7 2333 7 2333 10 3333 15 5000
Grade 0 2 667 27 9000 2 667 19 6333
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 32 Effect of study on Karnakandu
0
5
10
15
20
25
30
N N N N
BT AT BT AT
GROUP A GROUP B
7
0
4
0
18
0
18
0
7 7
10
15
2
27
2
19
karnakandu
Grade 3 Grade 2 Grade 1 Grade 0
Page | 111
Table no 18
Karnakandu Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 188 200 081 015
1091 3119E-
10 8906 HS
AT 021 000 041 007
Group
B
BT 171 200 076 014
1032 4746E-
09 7414 HS
AT 044 000 050 009
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Page | 112
Fig 33
Table no 19
Karnakandu
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 188 171 081 076 000 000
Day 3 126 118 057 058 3281 3103
Day 5 071 074 046 051 6250 5690
Day 14 021 044 041 050 8906 7414
000
020
040
060
080
100
120
140
160
180
200
BT AT BT AT
GROUP A GROUP B
188
021
171
044
Karnakandu
Mean
Page | 113
Table no 20
Karnakandu N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 4051 137750
373500 006 Control group 34 2849 96850
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is less than
005 Hence we conclude that there is significant difference between Trial
Group and Control Group
000
020
040
060
080
100
120
140
160
180
200
Day 1 Day 3 Day 5 Day 14
Karnakandu
Mean Group A Mean Group B
Page | 114
Effect of study on Karnasrava
Table no 21
Karnasrava
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 11 3667 0 000 8 2667 0 000
Grade 1 23 7667 3 1000 26 8667 2 667
Grade 0 0 000 31 10333 0 000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 34
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
11
0
8
0
23
3
26
20
31
0
32
Karnasrava
Grade 3 Grade 2 Grade 1 Grade 0
Page | 115
Table no 22
Karnasrava Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 132 100 047 009
1122 4356E-
13 9333 HS
AT 009 000 029 005
Group
B
BT 124 100 043 008
1130 9364E-
14 9524 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 35
000
020
040
060
080
100
120
140
BT AT BT AT
GROUP A GROUP B
132
009
124
006
Karnasrava
Mean
Page | 116
Table no 23
Karnasrava
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 132 124 047 043 000 000
Day 3 100 100 025 025 2444 1905
Day 5 047 038 051 049 6444 6905
Day 14 009 006 029 024 9333 9524
000
020
040
060
080
100
120
140
Day 1 Day 3 Day 5 Day 14
Karnasrava
Mean Group A Mean Group B
Page | 117
Table no 24
Karnasrava N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3535 120200
549000 655 Control
group 34 3365 114400
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 118
Effect of study on Karnabadhirya
Table no 25
Karn
Badhirya
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 0 000 0 000 0 000 0 000
Grade 1 13 4333 0 000 16 5333 2 667
Grade 0 21 7000 34 11333 18 6000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 36
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 00 0 0 0
13
0
16
2
21
34
18
32
Karnabadhirya
Grade 3 Grade 2 Grade 1 Grade 0
Page | 119
Table no 26
Karn
Badhirya Mean Median SD SE
Wilcoxon
W P-Value
Effect Result
Group
A
BT 038 000 049 009
799 7173E-
05 10000 HS
AT 000 000 000 000
Group
B
BT 047 000 051 009
816 0000138 8750 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 38
000
005
010
015
020
025
030
035
040
045
050
BT AT BT AT
GROUP A GROUP B
038
000
047
006
Karnbadhirya
Mean
Page | 120
Table no 27
Karn
Badhirya
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 038 047 049 051 000 000
Day 3 009 006 029 024 7692 8750
Day 5 003 006 017 024 9231 8750
Day 14 000 006 000 024 10000 8750
000
005
010
015
020
025
030
035
040
045
050
Day 1 Day 3 Day 5 Day 14
Karn Badhirya
Mean Group A Mean Group B
Page | 121
Table no 28
Karn
Badhirya N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3400 115600
561000 806 Control
group 34 3500 119000
Total 68
Page | 122
COMPARISION BETWEEN GROUP A AND GROUP B
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Table no 29
Overall Effect
Trial Group Control Group
N N
Marked Improvement 21 6176 16 4706
Moderate Improvement 8 2353 13 3824
Mild Improvement 4 1176 5 1471
No Change 1 2941 0 0
TOTAL 34 100 34 100
Fig 39
0
5
10
15
20
25
MARKED IMPROVEMENT
MODERATE IMPROVEMENT
MILD IMPROVEMENT NO CHANGE
21
8
41
1613
5
0
Overall Effect
Trial Group N Control Group N
Page | 123
DISCUSSION
Page | 124
Discussion is nothing but the logical reasoning of observations In
every research work discussion part is very important because it brings into
light about the logical analysis which are helpful in filling the research gap in
the scientific world
The discussion is categorized into following ways for the ease of
understanding
1 Discussion on selection of topic
2 Discussion on review of literature
3 Discussion on drugs their mode of action on the disease mode of action
of Karnadhoopana
4 Discussion on observation and results
1 Discussion on selection of topic
Otomycosis is commonly encountered in day-to-day practice Majority
of Indian people affected with this pathology This disease commonly
manifests in developing countries low socio-economic standard and lack
of hygiene Now a days due to busy lifestyle people are not able to follow
the proper instruction of care of ear which may be responsible for the
recurrent nature of disease So for the management of this we use
Karnadhoopana with the help of Agaruwadi Varti Dhoopana is simple
easy cost-effective procedure which can be done even at OPD levelso
for the disease Karnasrava we selected Karna Dhoopana as therapeutic
procedure Karnadhoopana was done with Agaruwadi Varti and Guggula
Varti which was very effective for treatment
Page | 125
2 Discussion on review of literature
Karnasrava is one such disease among 28 Karnarogas mentioned by
Acharya Sushruta in the chapter named Karna Roga Vigyana Acharya
Charaka included Karnasrava as symptom under the four types of
Karnarogas due to vitiation of different doshas Acharya Vagbhata has
not described Karnasrava separately It is a fact that systemic
description of Karnarogas is available in all the ancients of pus from a
Vata afflicted ear may results from head injury or immersion in water
Karnasrava is a clinical entity which can be correlated with Otomycosis
Karnasrava is explained as symptom as well as a disease in Ayurveda
Nidana- Karnasrava occur due to Samanya Nidana and Vishesh Nidana
Vishesh Nidana like Shirobhighata Nimmajato jale Mithyayoga of Shashtra
The exact pathology behind Karnasrava is not understood clearly
Purvarupa ndash No specific Purvarupa are found for Karnasrava in classical
literature Acharya Madhukara describe Purvarupa as expression of
Rupa(lakshana) with less intensity that is less intensity itching sound in ear
may considered as Purvarupa of Lakshana
Samprapti- Aacharya Sushruta not explained the Samprapti of Karnasrava
separately and we must consider the general Samprapti of Karnaroga Due to
various aetiologias as cited above ear afflicted by Vata dosha causes Twak
Rakta Mamsa dushti results in Karnasrava According to Acharya Sushruta
Vata-Kapha dose is dominance in Karnasrava
Page | 126
Nidan
Nija Agantuja
Vata ndash kapha prakopak nidana Shirobhighata Nimmajato-jale
Mithya yoga of Shastra
Vata- kapha Prakopaka(Chaya prakopak) Vata-kapha prakopaka
( Achay prakopak)
Twak Rakta Mamsa dushti
Karnasrava
Page | 127
Chikitsa
The curative aspect and this must be done simultaneously giving due
importance to Nidan Parivarjana that is preventive measures So Nidan
Parivarjana that is avoidance of causative factors like Jalkrida Mithyayogen
shashtrasya Karnakandu Shirasnan Pratishaya is the first step in combating
the disease and form the part of line of treatment
Above Samprapti helps us to proceed towards the treatment of Karnasrava
The main protocol of treatment is removal of fungus and wound management
which include various measures to keep area day clean clear of microbes and
providing ideal condition for healing
Samany Chikitsa- Acharya Sushruta described general treatment for
Karnaroga as Snehapana (Drinking ghee) Rasayana (Rejuvenation therapy)
Bhramacharya Avoid excessive speaking Avoidance of physical exercise and
head bath
Vishesha Chikitsa ndash Acharya Sushruta mentioned some procedures in the
treatment of Karnasrava which is Shirovirechana Karnadhoopana
Karnapurana Karanpramarjana Dhavan Avachurnana Karnapurana Above
various procedures described in Ayurveda for management of fungus growth
in ear discharging ear fulfill these requirements of wound management
Page | 128
Discussion on observation and Result
Out of 68 patients 34 patients included for the trial The incidence of
Karnasrava is observed in trial and control groups
The statistical analysis provided the following data
AGE
Trial group- Maximum no of patients that is 14 (41176) patients were from
age group 25-35 years followed by 29412 patients were from age group
18-25 years 23529patients were from age group 35-45 years and
58824 patients were from age group 45-60 years
Control group - Maximum no of patients that is 14 (41176) patients were
from age group 25-35 years followed by 20588 patients were from age
group 35-45 years and 20588 patients were from age group 45-60 years
17647 patients were from age group 15-25 years
The maximum no of cases of Karnasrava found in age group between 25 to
35 years The reason behind this is repeated use of ear bud or emersed water
in ear More use of earphone or working more in cold environment
GENDER
Trial group ndash A higher prevalence seen in females 6764 and 3235 in
males
Control group - A higher prevalence seen in males 5588 and 4411 in
females
Females and males both are prone to disease
Page | 129
EDUCATION
Trial group-It is observed that amongst 34 patients maximum ie16
(47059) patients were graduated 8 (23529) patients were HSC
educated 4 (11765) patients were SSC educated 4 (11765) patients
were illiterate 1 (29412) patient were primary educated and 1(29412)
patient were post graduated
Control group- It is observed that 10 (29412) patients were graduated 9
(26471) patients were HSC educated 6 (17647) patients were post
graduated 3 (88235) patients were SSC educated 3 (88235) patients
were primary educated3 (88235) patients were illiterate
There is no direct relation between education and Otomycosis
RELIGION
Trial group- The incidence of patients of Hindu religion are 9118 and Muslim
religion are 882
Control group- The incidence of patients of Hindu religion are 9706 and
Muslim religion are 294
There is no probable explanation for this maximum number of patients in
Hindu religion it depends upon the patients attend the hospital and
community residing there
Page | 130
DIET
Trial group It was found that maximum ie5882 patients were taking
mixed diet while 4118 were taking vegetarian diet
Control group It was found that maximum ie5882 were taking
vegetarian diet while 4118 patients were taking mixed diet
The dietary habit of person is based on choice availability and religious
customs of the person
ADDICTION-
Trial group- It was found that maximum ie 30 (8824) patients have no
addiction 2 (588) patients have addiction of alcohol 1 (294) patients
have addiction of Tobacco 1 (294) patients have addiction of smoking and
0 (0) patients have addiction of Mishri
Control group - It was found that maximum ie 27 (7941) patients have
no addiction 4(1176) patients have addiction of smoking 2 (588)
patients have addiction of Tobacco 1 (294) patients have addiction of
Mishri and 0 (0) patients have addiction of alcohol
Very few patients were addicted to Alcohol Smoking Tobacco and Mishri
These factors can be taken as provoking factors for Otomycosis
Page | 131
Discussion based on probable Mode of action of Karnadhoopana
In Ayurveda classics Karna Dhoopana is therapeutic procedure explain for
Karnasrava Dhoopana is administration of Dhooma (Fumes) with the help of
Dhoopan Dravya References indicates that analgesic and disinfectant effect
of Dhoopana karma and mention for Dushta Vrana Chikitsa It reduces
Vedana Srava amp also does Vrana Ropana action
Various Dhoopanas and Dhoopan Dravas for different element in various
Samhitas of Ayurveda but there is a lacuna of availability of reference
regarding how to do it and method of procedure Matra Kala Contraindication
etc
Currently simple modified way of Karnadhoopana according to Yukti Praman
and experience but there is lac of standardization
Karnadhoopana is one among the topical Bahiparimajan type of treatment
Karna Parmarjana is procedure of cleaning ear with the help of cotton or gauze
piece soaked in honey
Page | 132
Dhoopan
The fumes coming out on burning Agaruwadi Varti
Administrated directly into external ear canal
Causes vasodilation
Due to this increase blood supply in external ear canal
It helps in absorption of drug
Fumes dries up Srava and bring the analgesic effect
Karnagata Kapha amp Avrut Vata Dosha Shaman
Decrease in signs and symptoms like karnasrava Karnshool Karnabadhirya amp
Karnandu
Page | 133
3 Discussion based on probable mode of action of Agaruwadi
Dhoopana
Agaru ndash
I Agaru is a fragrant tree aroma is a result of fungal pathogenesis when the
wood of tree is contaminated by fungi at wounds it develops scrap filled
with resin and turn out to be aroma Medicinal use of Agaru have been
recorded in ancient medicinal science in in inflammatory disease and some
infective disease
II Acharya Charaka has referred to Agaru as an Ushna dravya despite having
Tikta Rasa Ashtang Samgraha used Agaru as Dhupana Dravya along with
Madan and Yawa in Karnasrava Nighantu recommended is use as a
Dhoopana
III In various Samhitas and Nighantus Agaru described as Tikta Snighdha
Sheetaprashamana Vranaprasadana Tvachya Due to these properties
Agaru is used in the treatment of Karna-Akashi Roga and Dushta Vrana
Shodhaka
IV Agaru is reported to have Antimicrobial Analgesic Antioxidants
Antihistaminic and anxiolytic properties Its Antihistaminic property gives
relief from itching which is cardinal feature of Otomycosis Due to Katu
Ushna Tikta Guna improves blood circulation Bheda stage develop It is
Niram Awastha of Dosha Karnagata kapha and vata get decrease and
symptoms like karnashoolakarnasrava get decrease Agaru also have a
Antioxidant properties
V Chemically Agaru Contain 2-(2-Phenylethyl) Chromones Terpenoids
Flavonoids
VI Natural Agarwood had inhibitive activities towards Staphylococcus Aures
The chloroform extract of Agarwood prolongs the pain threshold[108]
Page | 134
Madan
I Madanphala have therapeutic properties like Anti-inflammatory
Antiallergic Analgesic and Wound healing
II It is Useful in treatment of disease like Shotha (inflammation) Vidradhi
(Abscess) Pratishaya (Common cold) Kushta(Skin disease)
III Extract of Madanphala mainly contain Glcosides Tritorpenct
Glycosides Saponin
IV Saponin glycosides are act as fire extinguisher This property is helpful
for vartiIt also act as a detergent which clean the surface of fungus
V Tritorpenct act as a anti-inflammatory antimicrobial and
immunomodulator compound Interaction of glycosides with sterol
causes disturbance of selective permeability in plasmic membraneso
exudates and discharge get decrease
VI Pharmacological activity [109]
Antibacterial Activity The preliminary antibacterial activity of Methanolic
extract of Randia D lam was done on some standard and wild pathogenic
strains The inhibition of the bacterial growth was more pronounced on E coli
as compared to the other tested organism This shows the antibacterial action
of Randia D secondary infection can prevent
Anti-Allergic Activity In Ayurveda Randia D Extract and its fraction of milk
induced leukocytosis and eosinophilia in mice
Anti-Inflammatory Activity The crude methanol extract of fruit of Randia D
effectively reduced the carrageenin induced oedema in hind paw of the rats
significant reduction in granular tissue formation was recorded This activity
seems to be significant at various acute phases of inflammation and om
formation of granular tissue This proves action of Madanaphala in shopa
(inflammation)
Page | 135
Analgesic Activity Analgesic activity was tested in mice weighing between 20-
250 with six number of animals in each group Methanlic extract of fruit Randia
d give analgesic activity in both models This proves its Shoolanashaka (pain
killer) action
Immunomodulatory Activity Randia D has immunostimulant activity and
chloroform fraction which strongly affected immune system seems to be
bioactive fraction of this plant
The overall effect of Agaru Mandanphala Yawa having Anti-inflammatory
Antiseptic Antimicrobial Property Active ingredient shows these properties
Agaru Yawa Madanphala
Vatakaphaghna
Act as
Vranashodhak
Vedanasthapaka
Sheetaprashamana
Shothara
Avarana of Vata get decrease so helps to Shaman of Vata dosha
Karnakandu Karnashoola Karnasrava
Prashamana
Page | 136
This fact can be taken into consideration and probably acknowledge that
Karnadhoopana with Agaruwadi Varti had not leave any residue in the ear
Removal of fibrin keratinocyte migration and in growth of epithelial tissue
plays a major role in healing It is technique of fumigation of ear with the
smoke of anti-infective drug In Karnadhoopana Sthanik Swedana increase the
blood supply and helps in absorption of the drug reduce Karnakandu amp
Karnshoola associated with infection
Page | 137
SUMMARY AND CONCLUSION
Page | 138
The dissertation entitled randomize comparative clinical trial to study the
effect of Agaruwadi Karnadhoopan and Guggula Karnadhoopan In Karnasrava
wsr to Otomycosis
The dissertation is divided into fallowing parts
Introduction
Review of literature
Ayurvedic review
Modern Review
Drug review
Procedure review
Material and Method
Observation and result
Discussion
Summary and conclusion
bull INTRODUCTION
It includes importance of Shalakyatantra in Sushrut Samhita Charka
Samhita And Ashtang Samgraha
Common and specific causes of Karnasrava
Karnasrava is a clinical entity which can be corelate with Otomycosis
In Ashtang Samgraha stated the procedure like Karnadhoopana with
Agaru Yawa Madanphala in Karnasrava
Page | 139
bull REVIEW OF LITERATURE
1 Ayurvedic review
2 Modern review
3 Drug review
Ayurvedic review-
It includes Rachana-Sharir and Kriya-Sharir of Karna detail description of
Karnaroga and its types Karnaroga Samanya hetu Poorvaroopa Rupa
Samprapti Upadrava Pathya-Apathya of Karnasrava Vishesh Nidan and
Chikitsa of Karnasrava Detail description of Karnadhoopana according to
various Acharays have been mentioned
Modern review-
It includes anatomy and physiology of Ear brief anatomy of ear anatomy of
External middle and Internal ear Detail description of the disease
Otomycosis mechanism of fungal infection in external canal pathophysiology
investigations diagnosis and management
Drug review-
Detail description of Agaru Yawa Madan Guggula and its synonyms
Ayurvedic properties Karma uses Pharmacological action and their
pharmacodynamic properties
Page | 140
MATERIAL AND METHOD
It includes description regarding materials required for the study Preparation
of Agaruwadi Varti its Standardization Sterilization and packaging
Plan of study
1 Total 68 patients completed the treatment Age criteria was kept
between 18-60 years Patient selection was done by done by simple
random sampling method and divided into two groups A (Trial) and
Group B (Control) 34 patients in each group
2 Patients in Group A were treated with Karnadhoopana with Agaruwadi
Varti for 7 days two times in a day while patients in Group B were treated
with Karnadhoopana with Guggula for 7 days two times in a day
3 Clinical examination done during each follow up ie 0th 4rd 7th and
observation were recorded
Page | 141
OBSERVATIONS AND RESULTS
Page | 142
1 It was observed that higher incidence of disease Karnasrava ie
Otomycosis found in age group 25-35 years
2 Disease otomycosis was equal in both male and female
3 The trial group there was significant relief in Karnakandu (8906)
Karnasrava(9333) Karnashoola(7667) and karnabadhirya(100)
4 In control group there was significant relief in Karnakandu (7414)
Karnasrava(9524) Karnashoola(8438) and
karnabadhirya(8750)
Page | 143
REFERANCES
Page | 144
1 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published byChaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 17 page no
5
2 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 19 page no
6
3 DRNarayan Vidwas Shero-Karna-Nasa and MukhrogaAnand publication
edition 4th 2014 Page no-52
4 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-205
page no 111
5 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 111
6 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Shlok no2012
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 112
8 Dr KBBhargavaDr SK BhargavaDr TMShahaA Short book of ENT
diseases Usha publication edition 10th
9 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 8 Page no -52
Page | 145
10 Research and Review Journal of Ayurvedic science yoga and
Naturopathy 2017 4(3) 1-5 pA Critical review of Otomycosis in cortex to
Karnaroga described in Ayurvedic classic by amisha patel D B Vaghala
Chandani goswami Vol4 no3 (2017)
11 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogpratished Adhaya Shlok no-213
page no127
12 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedh Adhaya Shlok no-
2140 page no 131
13 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyant shirasiya adhaya Shlok no 1712 page no-
258
14 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
15 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
16 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Aupadravik Adhaya Shlok no-15 page no
2
17 Vaidya Jaymini panday Harit Samhita hindi commentaryChaukhamba
vidhyabhartiVaranasiedition 2010 Shlok no- 13-14page no-10
18 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 146
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-20345
page no 112
19 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Karnarogavigyniyam Shlok
no 21 Page no-731
20 Charak
21 Pandit Harigovind Shashtri Namalinganusasana Amarkosha of
Amarsimha hindi commentary published by Chaukhamba Sanskrit
Sansthan page no- 463
22 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
23 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 37
24 Shree Taranath-Trkavachspati-Bhattacharyen Vchaspatym published
by Rashtriya Samskrit Sansthandelhi Volume 4 page no- 5149
25 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
26 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
27 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
28 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Page | 147
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
29 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Indriyaopakramaniya Adhaya Shlok no 811
page no- 125
30 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243
31 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-510 page no56
32 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no3108 page no- 385
33 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no33 page no- 366
34 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sarvabhutachintasharir Adhaya
Shlok no-126 page no9
35 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-522 page no60
36 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-532 page no61
37 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Page | 148
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-521page no58
38 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-527 page no61
39 VdBramhand Tripathi Ashtanghradaya Sharirsthansthan Published by
Chaukhamba prakashana 2005 Shlok no331 page no-372
40 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Siravarnavibhaktisharir Adhaya
Shlok no-725 page no83
41 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Sharirsankhyavykaransharir Adhaya Shlok
no-512
42 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Pratekmarmanirdeshsharir
Adhaya Shlok no-628 page no75
43 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
44 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Marmasharirsthan Shlok no429 page
no- 393
45 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243244
Page | 149
46 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
47 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan pu blished by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711
48 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
49 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
50 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Shlok no 711 page no- 847
51 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Adhaya Shlok no-628 page no- 75
52 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Gandushavidhiadhaya Shlok no2232
page no- 261
53 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Karnavydhbandhvidhi Adhaya Shlok no-
1611 page no- 86
54 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Nidansthan Published by Chaukhamba
Page | 150
Sanskrit SansthanVaranasi Vatvydhinidansa Adhaya Shlok no183 page
no- 304
55 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavaykaransharir
Adhaya Shlok no-532 page no61
56 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Tristaisniya adhaya Shlok no 1120 page no-
163
57 P Hazarika Dr Nayaka R Balkrishnan Textbook of EarNoseThroat and
Head-Neck Surgery CBS Publication Anatomy of Ear
58 DrKB Bhargava DrSKBhargava DrTMShaha A short book of ENT
Diseases Published by Usha Publication 10th edition page no10
59 MrSalah Mansour MrJacques MagnanMr Hassan Haidar MrKaren
Nicolas MRStephan Louryan Comprehensive and clinical anatomy of the
Middle Ear Published by Springer publication Chapter -Middle Ear cavity
Page no 19 to 121
60 DrPLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 7
61 James OPickles An introduction to Physiology of Hearing Published by
Emerald publication 4th edition page no- 1 to 265
62 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
63 VdBramhand Tripathi Ashtanghradaya Uttarsthan Published by
Chaukhamba prakashana 2005 Karnaroga vigyniyam adhaya Shlok
no1713 page no- 998
Page | 151
64 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Shlok no- 212 page no-
730
65 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no
1-2 page no- 309
66 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana
67 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyantshirasiya Adhaya Shlok no 1713 page no-
258
68 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no-
6 page no- 310
69 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Karnarogavigyniym Shlok no- 1725-26 Page no-
1003
70 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2140 page
no 131
71 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Adhyay 18 shlok 35
72 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt
Karnarogapratishedhoadhya Shlok no-2211 Page no- 735
73 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 152
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2141 page
no 131
74 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2142 page
no 131
75 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2144 page
no 131
76 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 34 page no- 649
77 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2145page
no 131
78 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 37 page no- 649
79 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2146page
no
80 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
81 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 153
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2143page
no
82 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publication Krnarogadhikara adhaya page no-
318
83 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary
Madhyamkhand Vatkalpana shlok no- 782-83 page no- 137
84 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 72-77 page no- 651
85 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
86 Vd Shree Laxmipatishastri Yogratnakara
87 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
Karnarogadhikara Shlok no- 808182 page no- 652
88 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 83 page no- 652
89 (PDF) Otomycosis A Comprehensive Review (researchgatenet)
90 httpswwwncbinlmnihgovpubmed24948980
91 A Simon Carney Scott-Browns Otorhinolaryngology Head and Neck
Surgery CRC press 8th publication Otitis externa and otomycosis
92 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no Page no -
93 wwwguggulipidcomtradhtm
Page | 154
94 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
95 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-28 page no-
43
96 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009Agaru page
no726-728
97 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishra chapter Karpuradi varga Shlok no-31-
43 Page no- 116
98 httpswwwthiemeinimagecatlogsample_chapter_GOMPpdf
99 (PDF) Chemical Constituents and Pharmacological Activity of Agarwood
and Aquilaria Plants (researchgatenet)
100 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 4 chapter no-2 page no-4
101 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 chapter no-152 Madanpage
no376-379
102 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
103 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-54 page no-
84
104 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 page no697-699
patol-yawa
Page | 155
105 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
106 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
Dhoompanvidhi page no- 252-254
107 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012Chikitasasthan Shlok
no- 151page no-406
108 httpswwwmdpicom1420-3049232342pdf
109 httpswwwijamcoinindexphpijamarticledownload0610201530
0
Page | 156
BIBILOGRAPHY
Page | 157
1 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
2 Scott-Brown WG Diseases of the EarNose and Throat Landon
Botterworth and co(publishers) Ltd1952 Volume 2
3 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012
4 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009
5 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi commantry
Purvakhand and Madhyamkhand
6 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Published by Chaukhamba Sanskrit
SansthanVaranasi
8 The Ayurvedic Pharmacopeia of India Ministry of Health and family welfare
department of Ayush Part 1 and part 4
9 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005
10 Acharya Trivedi Raguveer Prasad Ashtang sangrah published by
Vaidyanath Ayurveda bhavan pvt
11 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition
12 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary published by Chaukhamba
Orientalia
Page | 158
ANNEXURE
Page | 159
ANNEXURE- 1
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
CASE RECORD FORM
RESEARCH PROFORMA FOR MS (AYU) DESSERTATION
DEPARTMENT OF SHALAKYATANTRA
NAME -
ADDRESS -
GENDER - AGE - OCCUPATION-
RELIGION - EDUCATION - MARITAL STATUS-
OPD IPD NO-
DATE OF ADMISSIONCOMMESEMENT-
DATE OF DISCHARGECOMPLITION-
DATE OF COUNSELLING-
TEL NO-
CHIEF COMPLAINTS-
PAST MEDICAL AND SURGICAL HISTORY-
TREATMENT HISTORY-
FAMILY HISTORY-
Page | 160
PERSONAL HISTORY-
a) Ahar(Diet)
b) Vihar
c) History of addiction
GENERAL EXAMINATION
PULSE - MIN BP - mm of hg
TEMP - 0F RR - MIN
ASHATAVIDHA PARIKSHANA
Nadi- Mutra- Mala-
Jivha- Shabda- Sparsha-
Drik- Aakruti-
SYSTEMIC EXAMINATION
RS ndash
CNS-
CVS ndash
Page | 161
LOCAL EXAMINATION (KARNA PARIKSHAN)
OBSERVATION TABLE FOR SUBJECTIVE CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching )
RIGHT EAR LEFT EAR
KARNASHASHUKULI
KARNAPUTRAK
KARNAPALI
KARNAKUHARA -
SRAVA
GANDH
VARNA
SWARUPA
KARNAPATALA (TM)
Page | 162
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
Hearing Test
1Renne Test ndash
2 Weber Test -
Examination of Ear-
Pathological Investigation-
Other Examination-
Nidan Panchak-
1Hetu-
2Purvarup-
3Rupa-
4Upashayanupashaya-
5Samprapti
Signature of Guide Signature of Doctor(Researcher)
Page | 163
ANNEXURE 12
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Dhoopana Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization were done as recommended in pharmacy procedure
The raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 were mixed together
in equal quantity to make Agaruwadi churn
STEP 4 - Agaruwadi churn were triturated with appropriate quantity of water
and prepared Varti in GMP Certified Ayurvedic pharmacy Standard aseptic
precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Dhoopana Varti was packed in sterile air packed
container
STEP 6 - Agaruwadi Dhoopan was given with the help of Dhoopan yantra
TREATMENT DETAIL-
Purvakarma -
1 The patient is asked to sit comfortably on chair having sufficient light and
less amount of dust
2 The EAC is cleaned thoroughly by Pichu Varti (cotton swab) to remove the
discharge and other debris
Pradhankarma -
1 The patient is asked to relax completely on the chair
Page | 164
2 Fumes are passed to the ear with Dhoopana Yantra
3 Dhoopana yantra is funnel shaped and its one end will keep the ear covered
for the passage of Dhooma into the ear canal and other end where Agaruwadi
Dhoopana Varti were placed which produces fumes
4 This Dhoopana was given for 5 min
Pashchat karma -
1 The patient were advised to avoid cold refrigerated food drinks cold water
bath cold wind fog and prevent water from entering the ear
(A) Agaruwadi Dhoopana Varti
B) Guggula Dhoopana Varti SOP of it is same as above Agaruwadi Dhoopana
Varti
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Page | 165
ANNEXURE 21
INFORMED CONSENT DOCUMENT
Study Title
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
Introduction
- You are invited to take part in a research study RANDOMSIED COMPARATIVE
CLINICAL TRIAL TO STUDY THE EFFECT OF AGARUWADI DHOOPANA AND
GUGGULA DHOOPANA IN KARNASRAVA
- Before you decide it is important for you to understand why the
research is being done and what it will involve
- Please take time to read the following information carefully and discuss
it with friends relatives and your doctor if you wish
- Ask us if there is anything that is not clear or if you would like more
information
Purpose amp Nature of Study
- In this research project by examine you and ldquoKarnasravardquo (Otomycosis)
disease were treated
- In the part of treatment Agaruwadi Dhoopana or Guggula Dhoopan were
given
- Dhoopana means medicated drug fumes were given in ear with the help of
Dhoopan Yantra
Page | 166
- Treatment was given for 7 days
Study Duration
7days
Participation
- Your participation is entirely voluntary
- If you do decide to take part you were given this information sheet to keep
and be asked to sign a informed consent form
- If you decide to take part you are still free to withdraw at any time and
without giving a reason This will not affect the standard of current or future
medical care you may receive
Confidentiality
- All information which is collected about you during the research were
kept strictly confidential
- Any information about you which is collected from the center will have
your identity in the form of a code number so that it will remain confidential
Benefits Of Study
- The results obtained from this study would be helpful for providing better
quality of treatment amp other essential facilities for Karnasrava (Discharge)
patients
- You will get clinical benefit from the study
Page | 167
Risks Of Study
- In this treatment there are few chances of Irritation of Ear Nose and
congestion at EAC if any of these happens then treatment were given
Results Of Study
- If the Results obtained are profitable then they may get published
without disclosing your details
Signature of patient
Date
Time
Phone no of Researcher
Page | 168
रण मादहती पतरक
सशोिनाच शीषवक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE
EFFECT OF AGARUWADI DHOOPANA AND GUGGULA DHOOPANA
IN KARNASRAVA
परसतताना
- आपणास या सशोिनातपमक अभयासात सहिागी होणय़ाच आाहन करणयात यत आह
- सशोिनातील सहिाग तननदशचत करणयापी सशोिनाच उददश समजन घया
- खालील मादहती काळजीपवक ाचा आणण आशयक ािलयास आपलया डॉकिराशी कका
दहतशरचतकाशी चचाव करा
- काही सददिता असलयास कका आणखी मादहती ही असलयास आमछयाशी चचाव करा
सशोिनाच उददीटि सतरप
- सदर सशोिन परकलपामरधय आपलयाला तपासणी करन कणवसरा या वयाशरिची शरचककतपसा दणयात
यणार आह
- सदर वयाशरिची शरचककतपसा महणन आपणास अगरादी िपन कका गगल िपन
दणयात यणार आह
- सदर औषि आपणास 7 ददस घयायाच आह
Page | 169
कालािी
- 7 ददस
सहिाग
- आपला सहिाग हा पणवपण ऎनदछिक आह
- आपला सहिाग तननदशचत असलयास आपणास ही मादहती पतरतरका दणयात यईल आपणास यातील
समती पतरकार सही कराी लागल
- सहिाग तननदशचत असनही आपण कोणतपयाही ळस कोणतही कारण न दता माघार घ शकता
याचा आपलया दयकीय सविर कोणताही पररणाम होणार नाही
गोपनीयता
- सशोिना दरमयान गोळा कलली आपलया वषयाची सव मादहती गोपनीय ठणयात यईल
- आपली यनदकतक मादहती साकततक सतरपात गोपनीय ठणयात यईल
सशोिनाच फ़ायद
- सशोिनाच तनटकषव कणवसरा बाशरित रणाछया दयकीय इतर सविाचा दजाव सिारणयास
फायदशीर ठरतील
सशोिनातील जोणखम
- य़ा शरचककतपसमरधय कान दखण डॊळय़ातन नाकातन पाणी य़ण नाकात जळजळण डोक जड
होण ही लिण ददस शकतात यापकी लिण तनमावण झालयास तपयाची शरचककतपसा कली जाईल
Page | 170
सशोिनाच तनटकषव
सशोिनाच तनटकषव फ़ायदशीर ठरलयास आपली मादहती गोपनीय ठन परकाशशत करणय़ात यईल
रण सतािरी-
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
Page | 171
ANNEXURE 31
INFORMED CONSENT FORM
Patient OPD no __________
Subjectrsquos Identifier
Date of Birth Age Gender
I _____________________________________ age___________ years
exercising my free power of choice hereby give my consent to be included
as a participant in the clinical study entitled
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
1 I confirm that I have read have been read and understood the information
sheet for the above study and can ask questions
2 I understand that my participation in the study is voluntary and that I am
free to withdraw at any time without giving any reason without affecting my
medical care or legal rights
3 I understand that the Ethics Committee members investigators and study
doctors will not need my permission to look at my health records both in
respect of the current study and any further research that may be conducted
in relation to it even if I withdraw from the trial I agree to his access
However I understand that my identity will not be revealed in information
released to third parties or published
4I agree not to restrict the use of any data or results that arisefrom this study
provided such a use only for scientific purpose
5 I agree to take part in the above study
Page | 172
signature with Date-
Left hand thumb impression
Name amp signature of the witness ndash
Name amp signature of the student ndash
Page | 173
ANNEXURE 32
समतीपतरक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
वयकतीच य
ददनाक जरमददनाक
1) मी ह तननदशचत कररत आह ककसदर सशोिन परकलपाबाबतची सपणव मदहती मी ाचली असनमला ती
समजली आहतपयाबददल मला परशन वचारणयाची पणव मिा आह सदर मादहतीन माझ समािान झाल
आह
2) मी सदर सशोिनातन माझया मजीनसार किीही बाहर पड शकतो या माझया अशरिकाराची मला कलपना
आह
3) माझी दयककय मादहती तपासणयाची कागदपतर कळ सशोिनाकररता ापरली जाणार आहत याची
मला मादहती आहसदर सशोिन परकलपातील सबशरित घिकाना माझी दयककय मादहती पाहणयाची मी
समती दत आहतरावप या सदिावतील माझी ओळख दशववणारी मादहती कोणासही ददली जाणार नाहीयाची
मला कलपना दणयात आली आह
4) सदर अभयासातन शमळणारी मादहती अरा तनटकषव कळ शासततरीय हतसाठी ापरल जाणयासाठी माझी
समती आह
5) रील अभयासात सहिागी होणयास माझी समती आह
रण सतािरी-
Page | 174
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
ASSESSMENT CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching)
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
a) कणवशल ( pain )- 0 - Absent
1 ndash Present
Page | 175
b) कणवकणड (Itching)- 0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
c) कणवसततरा ( Discharge )
0- Absent
1-Mild- Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाशरियव ( conductive Loss of hearing )
0 - Present
1 - Absent
Page | 176
Page | 177
Page | 178
Page | 179
Page | 180
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
Page | 181
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 182
AUTHENTIFICATION CERTIFICATE
Page | 5
pain discharge foul smell and thus control the infection Dhoopana is also
useful as Adhidaivika Chikitsa to protect the patient from external attack of
visible and invisible organism The principal treatment modality adopted in
Allopathic system of medicine is oral antibiotics and topical antibiotic drop
Long term use of oral antibiotic causes adverse effect like gastric irritation
reduce immunity and resistance to drug Long term use of topical antibiotic
drops cause Ph change in external canal which become prone to fungal
infection
Hence the therapeutic procedure with Guggula or Agaruwadi Varti
Karnadhoopana are cost effective safe and easy procedure and it can be
used more effectively
Page | 6
AIM OF STUDY
To evaluate the effect of Agaruwadi Varti Dhoopana and Guggula Varti
Dhoopana in management of Karnasrava
OBJECTIVE
To compare the efficacy of Agaruwadi Dhoopana and Guggula Dhoopana in
Karnasrava
HYPOTHESIS
NULL HYPOTHESIS -
H0- Agaruwadi Dhoopana is not effective than Guggula Dhoopana in
Karnasrava
ALTERNATE HYPOTHESIS -
H1- Agaruwadi Dhoopana is more or equally effective than Guggula
Dhoopana in Karnasrava
RESEARCH QUESTION
Whether there is significant difference between Agaruwadi Dhoopana and
Guggula Dhoopana in Karnasrava
Page | 7
PREVIOUS WORK DONE -
1 Anupama Patra B Effect Of Arka Taila In The Management Of
Karnasrava With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2007
2 Palmer Komalben K Further Study On Role Of Arka Taila In The
Management Of Karnasrava With Special Reference To
Otomycosis Shalakya Tantra Institute for Post Graduate Teaching amp
Research in Ayurveda Gujarat Ayurved University Jamnagar 2010
3 Sathisha Shankar B Management Of Karnasrava With Sthanika
Guggulu Dhoopana And Rasnaadi Guggulu-A Comparitive Study Shalakya
Tantra Government Ayurvedic Medical College Bangalore 2011
4 Shashikala DK Comparative Study On The Efficacy Of Vacha
Lashunaadi Taila Karna Pichu And Nimba Patraadi Dhoopana In The
Management Of Karna Srava Shalakya Tantra Government Ayurvedic
Medical College Bangalore 2014
5 Javale Anant A Clinical Study On The Efficacy Of Arka Taila In The
Management Of Karna-Srava Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2005
6 Pournima V Koti Management Of Karnasrava With Priyangvadi Taila
Pichu With And Without Saarivadi Vati Shalakya Tantra Sri Jagadguru
Gavisiddeswar Ayurvedic Medical College Koppal 2015
7 Amisha Patel A Clinical Evaluation Of Honey In The Management Of
Karna Shoola With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching and Research in Ayurveda
Gujarat Ayurved University Jamnagar 2016
Page | 8
REVIEW OF LITRATURE
Page | 9
Ayurvedic literature Ayurveda is a science of life practice since
thousands of years The ancient Indian system of medicine and surgery is
commonly known as Ayurveda This was given the status of Upaveda or
fifth Veda in the next stage of growth Among the available literature three
Samhita that is Charaka Samhita Sushrut Samhita Ashtang Hrudayam and
Ashtang Samgraha are the chief source of knowledge of Ayurveda
Ayurveda consist of eight branches Shalakyatantra is one among them
Shalakyatantra is one of its specialized branch deals with science of
ophthalmology otorhinolaryngology Oro dental surgery and head Acharya
Sushruta himself a practical surgeon was the first to advocate dissection of
dead bodies is indispensable for a successful student of surgery He had
described gross anatomy in the first chapter of Uttartantra Shalakyatantra
define by different Acharys as follows
शालाकय नामोरधवजतरगताना रोगाणा शरणनयनदनघराणाददसशरशरताना वयाशरिनामपशमनारव
स स ११०
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत [13]
चस १७१२
Shalakya Tantra Nirukti and Parichaya
शलाकायााः कमव शालाकय ततपपरिान शलाकयम डलहण [14]
The term Shalakyatantra is derived from Shalakya and Tantra
The word Shalakya means A probe and Tantra denotes teaching and
practices found in scripturesThe compendium in which application of
Shalaka in various surgical procedures is principally described is called as
Shalakya tantra
दनदटिवशारदााः शालाककनाः डलहण ( सउ ११३)[15]
An eye specialist is termed as Shalaki by Dalhana
Page | 10
Synonyms of Shalakya Tantra
Uttamanga Chikitsa Jatrurdhwa Chikitsa Urdhwang Chikitsa Shalakya
Chikitsa
Importance of Shalakyatantra-
Life of living being and all the Indriyas are situated in the head hence it is
known as Uttamanga
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत
चस १७१२
The treatment given to this part of the body is described specially in
Shalakya tantra While describing the importance of Shiras Vagbhata
correlates it to the root of tree (Urdhwa Mula) and body to the trunk of tree
(Adha Shaka)
Sushruta has deal with Mukha Roga in Nidan Shan and its treatment in
Chikitsasthan The description regarding the disease of eye ear nose and
head are found only in UttaraSthan Sushruta specially describes the
disease of Shalakyatantra as told by Videha in the beginning of Uttartantra
itself[16]
Shalakyatantra Itihas-
India Exhibits traditional of more than thousands of years in art literature
language logic and philosophy etc The convention was in its sophisticated
and advanced attire throughout the Vedic period
Vedic period ndash
1 Natush was treated for deafness by Ashwinikumars (Rigveda)
2 Rujaswa and Kanva were treated for blindness by Ashwani Kumaras
(Rigvedas)
Page | 11
3 There are several prayers mentioned for normal functioning of sense
organs (Yajurveda)
4 Structures and functions of Mastishka are described (Atharveda)
5 Mantras having reference to disease of Eye Ear Oral cavity etc are
found (Atharvaveda)
Upanishada Period ndash
1 Samhita Period
a) Sushrut Samhita ndash
bull Explanation regarding Netra Nasa and Shirorogas (Uttartantra 1-
26th chapter)
bull Details regarding Mukha and Karna Roga Nidan and
Chikitsa(Nidansthan 16th and Chikitsasthan 22nd chapter)
bull Description regarding Karna Chedana Sandhana Nasa
Ostasandhana Sutra Sthan 16th chapter
b) Charaka Samhita -
bull Explanation regarding Shirorogas (Sutrasthan 17th chapter)
bull Explanation of Gala rogas like Upajivika Galshundi and Rohini
bull Nasa Shiro Mukha Karna and Netra Chikitsa (Chikitsa sthan 26th
chapter)
bull Description regarding Lakshana and Chikitsa of Shankhaka
Ardhavbhedaka Shirovirechana and Shiro basti (siddhi sthan 9th
chapter)
c)Ashtnga Sangraha ndash
bull Detailed description regarding Shalakyatantara (Uttartantra 11-28
chapter)
bull Description of Kriyakalpa (Sutrasthan 32nd and 33rd)
Page | 12
d)Ashtang Hrudayam
bull Detailed description on Shalakya Tantra (Uttar tantra 8-24 chapters)
bull Kriyakalpas (Sutrasthan 23rd and 24th chapter)
e) Bhela Samhita
bull Chakshushya Vaisheshik and Buddhi Vaisheshik Alochaka pitta
f) Harita Samhita- Branch of Medical science offering elaborating
information about the procedure like Nasya Anjan Gandusha etc
comprehended with their applications in disease of Head Eyes Ears
Eyebrows Throat Temporal region and cervical spine is known as
Shalakyatantara
शशरोरोगा नतररोगा कणवरोगा वशषताः भरकरठशङकमरयास य रोगा समिनदरत दह १३
तषा परततकारकम व नसतयतपयवणजनातन च अभयङगमखगणडषकियााः शालकयसशमतााः १४
इतत शालाकयनाम [17]
Documentation of different ancient literature gives various references
regarding all aspects of Karnasrava in various periods It is very much
important to know the history of Karnasrava from Vedic Pauranic Samhita
and Samgraha period
Vedic period ndash The Vedas being the oldest source of knowledge have no
direct mentioning of Karnasrava
Page | 13
Samhita and Samgraha period ndash
Aacharya Sushruta described about Karnaroga Karnasrava Nidan
Roopa and Chikitsa The detail description is available in Sushrut
Samhita Uttartantra 20 and 21st chapters
Aacharya Charaka did not specify Karnasrava but mentioned 4 types
of Karnarogas that is Vataj Pittaj Kaphaja and Sannipataja and their
treatment in 26th chapter of Chikitsasthan
In Ashtang Hrudaya karnasrava is not explained as a separate disease
but Chikitsa is mentioned in 18th chapter of Astanga Hrudaya
uttartantra
In Ashtang Samgraha Chikitsa is mentioned in 22nd chapter of Astang
Samgraha Uttartantra
The details about Karnasrava are explained in Bhavprakasha
Madhyamakhanda 64th chapter
Madhavakara has explained about Karnasrava in 57th chapter of
Madhymakhanda
Karnasrava is also explained in Sharangadara Samhita Uttarkhand 11th
chapter
The reference for treatment of Karnasrava is available in
Yogaratnakara
In Gadhnigraha Karnasrava and its treatment is mentioned in
Karnarogadhikara Adhaya
Vangasena had mentioned about the disease and treatment in 69th
chapter
Chakradatta explained Karnasrava in 57th chapter
Dalhana has given commentary on Sushrut Samhita Uttartantra 20th
and 21st chapter
Sankhya Samprapti of Karnasrava ndash
Aachary Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga
Vigyniyam Aadhaya Aacharya charaka explain 4 Karnaroga in
Page | 14
Karnarohvigyniyam Adhaya based on doshas Acharya Vagabhata in
Ashtang Hrudaya explain 25 Karnaroga in Adhyaya
कणवशल परणादशरच बाशरियव कषड ए च
कणवसरााः कणवकणडाः कणव चवसतततर च
कशमकणवपरततनाहौ विशरिदवविसततरा
कणवपाकाः पततकणवसततराशवशरचतवविम
कणावबवद सपतवि शोफशरचावप चतवविाः
ऎत कणवगता रोगा अटिावशततरीररतााः
स उ २०- ३ त ५[18]
ातकणवरोग वपततकणवरोग कफकणवरोग
रकतकणवरोग सनदरनपातकणवरोग कणवनाद
बशरिरतप परततनाह कणडाः शोफ पततकणवक
किशमकणवक उियरपविरधयअशो अबवद
कशरचकणवक वपपपली वदाररका पाळीशोष
ततिका पररपोिो उतपपातो उरमरर दाःखिवन
शलहाखयााः परचवशनदरतकणवरोगा उकतााः
इदिीका अ स उ २१ [19]
चतपाराः कणवरोगााः
च स [20]
Page | 15
KARNA
Karna ndash करोतत शबद गरहण [21]
The organ of hearing
Karnasrava- कणवसतय कणवयोाव ससराा [22]
Discharge from the ear is referred as Karnasrava
KARNA SHAREERA
bull Nirukti
कणयवत अकणयवत अनन इती [23]
It means reception and conduction of sound waves
These are the functions of external and middle ear
bull Nirukti of Sravanam
शरयत अनन इती शरणम[24]
It means perception of sound
It can be attributed to the internal ear function
bull Karna Utpatti-
Karna is an organ formed by Akash Mahabhuta[25]
The fundamental characteristic is as follows
Indriya ndash Srotram [26]
Indriya Adhisthan ndash Karna [27]
Indriya Dravy ndash Akasha [28]
Indriya Arth ndashShabdha [29]
Indriya buddhi ndash Srotobyddhi
Page | 16
bull Paryaya of Karna- Shabdapatha Srotrapatha Sravanam shruti
Kuhuram Dwanigraham etc
bull Definition of Karna-
कणवशटकलयनदछिरनमिटिोपगरदहत शरोतरमछयत [30]
मा तन ५७१
The definition of Karna is stated in Madhav Nidanam Indriya which is not
seen with naked eye along with Shashkuli is called Shrotra that is Karna
Indriya is so minute that it is not perceived with any sense organ
In Charak Samhita the word Karna explain as the Indriya Adhisthan of
Shabdha Karna is described as one of the Prathyangas of the body He
emphasizes that all Indriyas manifest during the 3rd month of gestation
period
Acharya Sushruta while describing formation of Purusha from Prakriti or
Avyakta narrated that all Indriyas are developing from the Vikarika and
Taijas Ahankara Both Vagabhata and Sushruta stated that Karna as one of
the Bahirsrotas
शरण नयन दन घराण गदमढराणण न सततरोताशसराणा बदहमवखातन [31]
स शा ५-१०
In Ashtang Hradaya Vagbhata has states that all Indriyas are Atmaja
According to him lower lobule elevated helix projected posterior portion
fleshy and adherent ear are indications of long span of life[32]
ततरखातखातन दह अनदसतमन शरोतर शबद ववकतता [33]
ा शा ३-३
शबदाः शबदनदरिय सवनदछििसमहो ववकतता [34]
स शा १-२६
Page | 17
Ear has the prominence of Akash Mahabhuta The prominent dosha of ear
is Vata It is important seat of Vata The prominent Dhatus are Asthi and
Mamsa Karna is one of the Panchgnanendriyas and it meant for hearing
Sushruta narrated that Karnasthita Asthi and Sandhi
घराणकणवगरीाकषिकोषष तरणातन [35]
सशा ५-२२
शरोतरशरगािकष शखाताव [36]
सशा ५-३२
गडकणवशखटककम [37]
स शा ५-२२
One Sandhi and one Tarunasthi in ear
Sandhi ndash Karna contain two Sandhi one in each ear Type of Sandhi is
Shankhavartha which is present in Shringataka
Mansapeshi ndash 2[38]
Siras ndash 10 [39]
Vataj Sira - 4
Pittaj sira - 2
Kaphaj sira - 2
Raktaj Sira - 2
Avedhya sira-
कणवयोदवश तासा शबदादहनीनामकका पररहरत
सशा ७-२५[40]
Amongst above mentioned ten Siras each Karna lodges one Shabdavaha
Sira It is Avedhya
Page | 18
Dhamani -2
Length of ear is 4 Angula
Karna moola ndash 2 Angula
कणाविरतर चतदवशअगलम
स शा ३५-१४[41]
The distance between two ears through the back of the neck is 14 Angula
bull Marmas of Karna-
1 Vidhuras-
कणवपटठतो अिाःसशरशरत विर ततर बशरियवम
सशा ६-३७[42]
कणतपयादद सतनायममवणी ककनदचचनदरनममनाकर कलयकररणणच
डलहणाचयव[43]
अिसततात कणवयोतनवमन विर शरततहाररणण
ा शा ४-२९[44]
Sankhya-2
Vistara- frac12 Angula
Type- Snayumarma (Susha)
- Dhamanimarma(AH)
- Vaikalykar
Sthana- It is situated in the depressed portion in the back of the ear
Injury to them causes loss of hearing
Page | 19
2 Shringataka marma-
नदजवहाकषिनाशसकाशरोतरखचतटियसरमम
तालरयासतयातन चतपारर सरोतसा तष ममवस
वदि शरगातकाखयष सददसततपयजतत जीवतम
मा तन ५७१ [45]
Sankhya- 4
Type- Siramarma
Sthana- It is in head that is amidst Siras (blood vessels) nursing sense
organ
A palm size area near Talu
Injury to this Marma causes death
In modern anatomy ear divides into Bhayakarna or External ear Mdhyakarn
or Middle ear Antahkarna or Internal ear This is extremely appropriate
Even though the ear is divided into three divisions in the point of modern
anatomy Ayurveda denotes ear organ is one Ayurveda treats disease by
way of assessing Dosha and Dushya Here Dushya is one that is Karnendria
Dosha difference will call for different treatment for different disease Hence
treating the vitiated Dosha will cure the disease irrespective whether it is in
external middle or internal ear The thought is based on different
fundamental principle from Ayurveda
bull Parts of Karna
In Ayurveda classics detailed description about anatomy of ear is not
available But the various parts are mentioned as follows
Bhayakarna- External ear
Mdhyakarna ndash Middle ear
Antahkarna- Internal ear
Page | 20
द कणवशटकशलक दॊ कणवपतरकौ
च शा 7-11[46]
कणवशटकशलक कणवगतातवकौ कणवपतरकौ त बाहयकणा
चिदतत च शा 7-11[47]
शटकली बाहयपालयाशरिटिानम
डलहन- स शरच 25-1 12[48]
Karna Shashkulika ndash It is also called as Karna Shashakuli Charaka has
mentioned this term while describing different Pratyngas of the body
Acharaya Gananatha sen has given the clarification for it as a pinna or
auricle[49]
Karnapali ndash It is popularly known as lobule of the ear Daivakrita Chidra is
present in it
Karnaputrika- Ayurvedic scholars accepted two terms in this cortex They
are Karnaputrika and Karnaputrika The former is considered as Tragus and
antitragus[50]
Karna Prushtha- It can be taken as the cranial surface of mastoid or
auricle[51]
Karnapeetha- Aacharaya Sushruta firstly mention the term Karnapeetha
It is mentioned first by Sushruta while describing the procedure of
Karnavyadana Vagbhata has mentioned that it is Adhobhaga of Karna
Dalhana has clarified that it is the region above the Karnaputrika that is the
region which is at the bottom of the concha
Karnamoola ndash It can be considered as parotid region[52]
Karna lathika ndashAcharaya Dalhana mentioned lobule as a Karna Lathika
Page | 21
Karnaavatu ndashThis term is used by Sushruta while describing the
measurements of different Angapratyangas where he has mentioned that
the distance between the Karnaavatu is 14 Angul Dalhana has comments
that it can be taken as the distance between two ears from behind[53]
Shabdhavahasrotas ndash It also called as Shabdapatha or Srotapatha The
whole passage through which the sound waves pass can be taken as
Shabdavahasrotas[54]
Shrotashringataka ndash It can be taken as the labyrinth of ear[55]
bull Dosha in context to Karna-
Karna is principal location of Vayu
1 Prana Vayu- Prana Vayu circulating in oral cavity is responsible for
Dehadhruka that is keeping all body parts active Indriyadruka that is
keeping all Dnyanendriya healthy by proper nourishment (Purana) helps in
deglutition of food material and convey the stimulation of Indriyabuddhi
and atma
2 Udana Vayu- Bala(strength) Varna speech singing are its function It
is responsible for facial expressions due to pleasure sorrow anger love
frustration etc in general its circulation and actions are just opposite to
Pranavayu
3 Vyana Vayu- Its principal functions are circulation of Rasa and Rakta
through body and various movements Its main location is Hrudaya Five
types of movements for which it is responsible are expansion contraction
upward downward and oblique other activities are opening closure of
eyelid yawning perspiration During circulation if it gets obstructed due
to Srotodushti it generates disease of that Srotas Vyana Vayu gets vitiated
by disease of Rasa Rakta Oja and Chetanadhatu
Page | 22
4 Samana Vayu- It is circulating in the vicinity of stomach and intestine
and helps in keeping the Jatharagni (digestive juices and enzymes) in
equilibrium Disturbance in Jatharagni precipitates disease
5 Tarpaka Kapha- Entire body functions movements are controlled and
executed by various centers in the brain Sensation perceived by sense
organs is conveyed to Mann and Aatma residing in Hrudaya The motor
signals from them are then conveyed to the functioning
organsKarmendriya through Prana Vayu Shira head is therefore a
location of continuous activities motions of Vata All these centers are in
unctuous Majjadhatu in the Shira For stabilizing this ever-active Vata and
to nourish the Majja dhatu very unctuous Tarpaka Kapha situated in Shira
plays an important role
bull Ayurvedic aspect of sound perception [56]
According to Ayurveda Pratyaksha Dnyan or Perception of any sensation
including Shabda occurs due to interaction of the Karnendriya and the
Indriya- Arth -Karma resulting in Sravana
External Environmental acquaintance with living body is executed by five
sense organs namely Netra Karna Nasa Jivha and Twaka All
Dnyanendriya that is sense organ are Panchmahabhautic combination
Despite this fact every Indrya sense organ perceives object Tanmatra of
that Mahabhuta only from which it is originated from Akash Mahabhuta and
hence perceives Shabd only that is audio perception Shrotrendriya is one
of the principal locations of Vata and its function is to perceive Shabda that
is sound waves This sensation is conveyed through Shabdavahi Dhamanis
to Mana and Atma through Pranavayu and the sequence is responsible for
perception of sound in this way external sound is perceived and interpreted
when Atma is linked with Mann Mann is linked with Indriyabuddhi that is
minute virtual Dnyanendriya located in brain Indriyabuddhi is linked with
Adhishthana with prominent Mahabhuta and lastly with Indriya
ArthShabdatanmatra that is sense object Once this sequence is completed
Page | 23
the meaning of a particular sound is interpreted and understood In this
entire process of perception and interpretation of sound waves Pranavayu
and Tarpaka Kapha located in Shira play extremely important role Hence
the healthy status of all the sense organ depends upon the normal
physiologically homeostatic condition of Pranavayu and Tarpaka Kapha
MANAS
ATAMA
BUDDHI
AHANKARA
ARTHA
Page | 24
EAR ANATOMY
bull Embryology of the Ear [57]
1 The sound conducting apparatus develops from the branchial apparatus
whereas the sound perceptive apparatus from the ectodermal otocyst
2 The pinna develops from the six hillocks around the 1st branchial cleft
3 External auditory canal develops from 1st branchial cleft
4 The outpouching of the 1st pharyngeal pouch gives rise to a proximal
narrow part that forms the eustachian tube and distal dilated part that
forms the middle ear cavity
5 Prussakrsquos space is a potential space lateral to the Shrapnellrsquos membrane
and medically by the neck of malleus that can be involved during the
extension of cholesteatoma
6 Development starts in the 3rd week of the intrauterine life and is
completed by 16th week of intrauterine life Membranous and boney
labyrinth develops from the otic capsule
The Ear is divided into
1 External Ear
2 Middle Ear
3 Internal Ear or the labyrinth
Page | 25
Fig 1 Ear Anatomy
EXTERNAL EAR [58]
The outside ear contains pinna and lobule
Pinna is the noticeable piece of outer ear made from single sheet of yellow
flexible ligament covered by subcutaneous tissue and skin It has two
surfaces average and parallel It is intently disciple to perichondrium on its
sidelong surface while it is somewhat free on average surface Pinna
incorporates tragus helix against helix fossa three-sided scaphoid fossa
incisura terminalis
External auditory Canal ndash It extends from the bottom of the conchea to
the tympanic membrane and measures about 24 mm along its posterior
wallit is S shaped
Parts 1 Cartilaginous part
2 Bony part
Page | 26
Cartilaginous part ndash The outer one third is cartilaginous consist of fibro
cartilage is directed first inward backward and upward It has Fissure of
Santorium The skin of this part of the canal contains hair follicles
sebaceous gland and cruminous gland
Bony part ndash The inner two third part is boney It goes forward downward
and medially skin lined in this part is very thin Isthmus is the narrowest
part of the canal lying medial to junction of bony and cartilaginous part
nearly 5 mm lateral to tympanic membrane
The roof and posterior wall of the external auditory canal shorter than floor
and anterior wall The skin lining the tympanic membrane and boney canal
has a self-cleansing property due to migration of keratin layer of epithelium
from drum towards the cartilaginous portion
Relations- Anteriorly- Temporomandibular joint and parotid gland
Superiorly- Middle cranial fossa
Inferiorly- parotid gland
Posterior- Mastoid antrum mastoid air cells and facial nerve
Nerve supply ndashSensory nerve supply of the external ear The auricle
supplied by fibers of the great auricular nerve (C2 and C3) and lesser
occipital nerve (C2) Auriculo temporal branch of the 5th cranial nerve and
auricle branch of the vagus (Arnoldrsquos nerve) supply external canal Facial
nerve has small sensory contribution on posterior-inferior wall
Tympanic Membrane -It is the partition between EAC and middle ear It
is a thin semitranslucent membrane pearly white in colored lying obliquely
in the medial end of EAC with the angle of 55 It is forming major part of
lateral wall of middle ear Annulus tympanicus is attached at its
circumference to the sulcus The TM is oval shape It measures
approximately 10 mm in vertical diameter and 90 mm in horizontal
diameter
Page | 27
Layers ndash Tympanic membrane consist of three layers
1 Outer Epithelium or cuticular layer which is continuous with skin of
external ear
2 Middle fibrous layer has both circular and radial fibers middle layer
missing in upper part
3 Inner layer- Inner mucosal layer which is continuous with middle ear
mucosa
Parts ndash Tympanic membrane consist of two parts
1 Pars tensa -It is largest part below the malleolar folds The inner
surface at the center attached to the handle of malleus Angle of cone
is most illuminated part in the pars tensa at anteroinferior part of pars
tensa
2 Pars flaccida Sharpnells membrane -it is triangular area above the
malleolar folds which are thin and devoid of fibrous tissue and
annulus It fits into notch of Rivinous
Nerve supply 1 Anterior half of lateral surface Auriculotemporal V3
2 Posterior half of lateral surface Auricular branch of vagus cn 10
3 Medial Surface Tympanic branch of CN 9 (Jacobsons nerve)
Fig 2 Tympanic membrane of ear
Page | 28
MIDDLE EAR [59]
The middle ear or tympanic cavity is an irregular laterally compressed
space within the temporal bone It is filled with air that is supplied to you
from the nasal part of the throat through the ear canal It contains a chain
of mobile bones that connect its side with the medial wall and serve to
transmit vibrations transmitted to the eardrum through the cavity to the
inner ear Including the parapet the vertical and anteroposterior diameters
of the cavity are each approximately 15 mm The transverse diameter
measures about 6mm at the top and 4mm at the bottom Compared to the
eardrum it is only about 2mm The eardrum is limited laterally by the
eardrum medially by the lateral wall of the inner ear It communicates
behind with the tympanic antrum and through it with the air cells of the
mastoid and in front with the auditory canal The middle ear together with
the Eustachian tube aditus antral and mastoid air cells is called the
middle ear cleft It is lined by mucus membrane and filled with air
It is divided into 3 parts
1 Mesotympanum (located in front of the pars tensa)
2 Epitympanum or attic (located above the pars tensa but medial to
Sharpnells membrane and the lateral bony wall of the attic)
3 Hypotympanum (located under pars tensa) The middle ear is like a
hexagonal box with a roof
Carotid or Anterior wall- It separates middle ear cavity from internal
carotid artery The various structure passing through anterior wall of
tympanic cavity
bull Canal of chorda tympani nerve
bull Canal of tensor tympani muscle
bull Eustachian tube
bull Anterior malleolar ligament
bull Anterior tympanic artery
Page | 29
Posterior or mastoid wall ndash The upper part of the back wall shows the
opening of the auditorium Below the auditory is a triangular bony
projection known as the pyramidalis processors The stapedial tendon is
transmitted through the apex of the pyramidalis processes The vertical
portion of the facial nerve descends along the posterior wall until it opens
into the stylomastoid foramen
Roof or Tegmental wall (Pars terminalis)- It is formed by a thin bone
plate called the tegman tympanum that separates the skull and tympanic
cavities It is located on the anterior surface of the rocky part of the
temporal bone near the junction with the temporal shell it extends back to
the roof in the tympanic membrane and anteriorly to cover the half canal
of the tensor tympanic muscle The lateral border corresponds to the
remains of the Petro scaly suture
Floor ndash It is formed by a thin plate of bone which separate middle ear from
the bulb of the internal jugular vein lodged in the jugular fossa
Lateral wall ndash It is formed by tympanic membrane and partly by a portion
of squamous part of the temporal bone It separates the middle ear from
external ear
Medial wall- It separates the middle ear from the inner ear
bull The promontory is the most prominent and convex part formed by the
basal rotation of the cochlea
bull The bony lateral semicircular canal is postero-superior to the promontory
above the oval window
bull The oval window is located between the middle ear and the vestibular
slope of the cochlea It is closed by the stirrup footrest and the annular
ligament
Page | 30
bull The round window is located under and behind the cape The round
window recess is directed to the rear It is closed by the secondary eardrum
and separates the middle ear of the Scala tympani from the cochlea
bull The facial nerve passes through the bony fallopian tube above the oval
window
Mastoid Antrum ndash It is a large space with air in the upper part of the
mastoid and communicates with the attic through the aditus The roof is
formed by the antri tegmen which extends and separates the tympani
tegmen from the middle cranial fossa The lateral wall of the antrum is
formed by a bony plate that is on average 15 cm thick in adults It is
marked externally on the surface of the mastoid by the suprameatal triangle
(MacEwen)
Aditus and Antrum- Aditus is a gap through which the attic communicates
with the antrum The boney prominence of the horizontal canal lies on its
medial aspect even as the fossa incudes to thats attaches the quick system
of incus lies laterally Facial nerve publications simply underneath the
aditus
The mastoid and its air cell system-
The mastoid consists of bone cortex with a honeycomb of air cell
underneath Depending on development of air cell three types of mastoids
have been described
1Well-pneumatized or cellular- Mastoid cells are well developed and
intervening septa are thin
2Diploetic- Mastoid consist of marrow spaces and a few air cells
3Sclerotic or acellular ndash There are no cells or marrow spaces
With any type of mastoid pneumatization antrum is always present In
sclerotic mastoids antrum is usually small and the sigmoid sinus is
anteposed
Page | 31
Depending on the location mastoid air cells are divided into
1 Zygomatic cells (In the root of zygoma)
2 Tegman cell (Extending into tegmen tympani)
3 Perisinus cells (overlying the sinus plate)
4 Retrofecial cells (round the facial nerve)
5 Peri labyrinthine cells (located above below and behind the
labyrinthine some of them pass through the arch of superior
semicircular canal These cells may communicate with the petrous
apex)
6 Peritubal (around the Eustachian tube Along with hypotymoanic
cells they also communicate with the petrous apex)
7 Tip cells (which are quite large and lie medial and lateral to the
digastric ridge in the tip of mastoid)
8 Marginal cells (Lying behind the sinus plate and may extend into
the occipital bone)
9 Squamosal cells (Lying in the squamous part of temporal bone)
Development of Mastoid ndash
The mastoid develops from the scaly petrous bone The petrosquamosal
suture may persist in the form of a bone plate - Korners septum which
separates the superficial squamosal cells from the deep rock cells Korners
septum is surgically important because it can cause problems locating the
antrum and deeper cells and thus lead to incomplete removal of the disease
during mastoidectomy The mastoid antrum can only be reached if Korners
septum is removed
Page | 32
Fig 3 Cross section of Mastoid
Contents of the middle ear
Ossicles ndash Three tiny bones which conduct the sound from eardrum to oval
window
Malleus ndash It is the largest and most lateral ossicle measuring 8 mm in
length It has head neck handle anterior and lateral processes The head
is situated in the epitympanum A lateral process project laterally from the
neck while the handle is firmly fixed to the pars tensa of the ear drum
Incus- It has a body short process and long process The body short
process and long process The body articulate with the head of mallelus in
the attic and the short process project into the attic The long process
projects downwards behind the handle of malleus running parallel to it and
articulate with the head of the stapes via the lenticular process
Stapes ndash It is the smallest ossicle measuring about 35 mm and consist of
head neck footplate and anterior and posterior curcura The footplate of
stapes is held to the oval window by the annular ligament
Page | 33
Muscles ndash
1Tensor tympani ndash It is inserted is a branch of the facial nerve which carries
the sense of taste It is first arch muscle supplied by branch of mandibular
nerve V3
2 Stapedious muscles ndash It is inserted to the neck of stapes It is the second
arch muscle supplied by branch of facial nerve that is nerve to stapedius
Fig 4 Contents of the middle ear
Blood supply of Middle Ear
bull Anterior tympanic branch of maxillary artery which supplies tympanic
membrane
bull Stylomastoid branch of posterior auricular artery which supplies middle
ear and mastoid air cells
Page | 34
Four minor vessels are
bull Petrosal branch of middle meningeal artery runs along greater petrosal
nerve
bull Superior tympanic branch of middle meningeal srtery traversing along
the canal for tensor tympanic muscle
bull Branch of artery of pterygoid carotid
bull Tympanic branch of internal carotid
Lymphatic Drainage of Ear
Lymphatics from the middle ear drain into retropharyngeal and parotid
nodes while those of the Surgical Importance ndash Eustachian tube drain into
retropharyngeal group
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 middle is likely to pass to
middle ear
2 Moreover middle ear suppurative disease may spread to adjacent organs
and produce complication eg Labyrinthitis meningitis facial nerve palsy
etc
3 Lenticular process is vulnerable in suppurative ear diseases and causes
ocular disruption
4 Prussac space is the site of primary acquired cholesteatoma
Page | 35
INNER EAR [60]
Inner ear is divided into two parts
1 Bony Labyrinth
2 Membranous labyrinth
Anatomy of bony labyrinth
It is divided into two parts
1 Vestibule
2 Cochlea
3 Semicircular canal
The vestibule is located between the medial wall of the middle ear and the
lateral to internal acoustic meatus anterior to the semicircular canal and
posterior to the cochlea The vestibule is the central part of the inner ear
On its side is the oval window opening which is closed by the bracket foot
plate The bony cochlea is located in front of the vestibule It has 275 turns
wound around a bony axis called a modiolus The cochlea is about 30 mm
long The hollow center of the modiolus is a spiral canal that contains the
fibers and ganglion cells of the cochlear nerve A thin bony sheet the bony
lamina winda around the modiolus This divides the cochlear duct into two
galleries the Scala vestibuli above and the scala tympani below
There are three semicircular canals superior posterior and lateral They
are semicircular in shape and open into the vestibule One end of the
semicircle is enlarged and is known as the sphere
The membranous labyrinth is in the bony labyrinth It is connected to the
bony labyrinth by fibrous trabeculae and is surrounded by perilymph The
endolymph is located in the membranous labyrinth
Page | 36
The utricle is in the upper part of the vestibule while the saccule is found
below Both the utricle and saccule contain a single sensory patch called
the macula Each macula is covered with a neuroepithelium made up of
neuroepithelium made up of sensory hair cells and support cells these cells
are separated by a basement membrane Fibers of the vestibulo-cochlear
nerve enter the macula and pierce the basement membrane to terminate
at the base of the hair cell or cell bodies The utricle and the saccule with
their macula are called otolith organs Membrane semicircular canals are
the membrane canals of the corresponding bony semicircular canals They
open into the utricle through five openings One end of the opening of each
channel is dilated called the sphere in which the sensory organ of each
channel is located The cross section of the Scala standard looks like a right
angle The base is formed by the basilar membrane Sensory cells are
arranged on the surface of the basilar membrane These sensory cells with
their supporting cells form a complex neuroepithelium called the basilar
papilla or the cortical organ named after an Italian microscopist The
organs of the corti have a gelatinous membrane called the tectorial
membrane and they are supported by the pillar of the corti The cortical
pillars enclose a space called the corti tunnel which contains a fluid called
cortical lymph Vestibule is lies between the medial wall of the middle ear
and lateral to internal acoustic meatus anterior to semicircular canal and
posterior to the cochlea 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 Boney cochlea lies in front of the vestibule It has 275 turns
coiling around boney axis called modiolus Cochlea is approximately 30 mm
in length The hollow center of the modiolus is a spiral canal containing the
fibers and ganglion cells of cochlear nerve A thin boney sheet the osseous
lamina winda around the modiolus This divides the cochlear canal into two
galleries the Scala vestibuli above and the scala tympani below
Page | 37
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 boney labyrinth It is connected
to the bony labyrinth by fibrous trabeculae and is surrounded by perilymph
Endolymph 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 single sensory patch called macula Each
macula is covered by neuroepithelium consist of Neuroepithelium consists
of sensory hair cells and supporting cells these cells are separated by
basement membrane Fibers 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 are referred
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 corti lymph
Page | 38
Fig 5 Inner Ear
Blood supply of labyrinth
Labyrinthine artery
Common cochlear Anterior vestibular Artery
Vestibulocochlear artery Main cochlear artery
Cochlear branch posterior vestibular artery
Page | 39
PHYSIOLOGY OF HEARING [61]
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
bull Mechanical conduction of sound (conductive apparatus)
bull Transduction of mechanical energy to electrical impulses (sensory
system of cochlea)
bull Conduction of electrical impulses to brain (neural
Fig 6 PHYSIOLOGY OF HEARING
Page | 40
Conduction of sound
Under the surface of water we cannot hear the sound made in air because
9995 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 must 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 13 times longer than long process of incus providing
a mechanical advantage of 13
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 beings 211 As the effective
vibratory area of the tympanic membrane is only two- thirds the effective
areal ratio is reduced to 141 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
Page | 41
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 lobe
Page | 42
DISEASES REVIEW
करणसराव
Nirukti - करणसय कणवयोाव ससराा [62]
Nidana- Acharya Sushruta and Vagbhata describe the common etiological
factors for the Karnaroga
अशयाय जलिीडा कणवकणडयन मरत
शमथययोगन शसततरसतय कवपतो अरय च कोपन ||
सउ २० १२
1 Avashaya or Pratishaya
(Excessive exposure to cold)
2 Jalakrida
(Excessive swimming)
3 Karnakandunyanum
(Excessive scracing due to itching)
4 Mithyayogena Shatrasya
(Improper instrumentation during wax removal or foreign body removal)
5Shabdasya
(Louder sound for long durationperverted contact of sound)
6 Abhighata (Trauma)
7 Vitiation of Tridoshas
Page | 43
Samanya Nidana according to different Samhita
Vishesh Nidan of Karnasrava
Acharya Charaka has not mentioned any kind of Nidana regarding Karnaroga
but has described Utapati of Karnaroga from Siroroga in Karnasirasym
Adhyaya[67]
शशरोअशिघातादरा तनमजजतो जल परपकादरा अवप विि
सरतत पय शरणॊ अतनलात स कणवससरा इतत परककतीत
सउ २० १०
असस ३७२५ [68]
1 Shiroabhighatat - Head Injury-Fracture of middle cranial fossa
2 Jala nimajjana - CSF otorrhoea fracture of middle cranial fossa
3 Karnaprapaka
4 Karna Vidhradhi -Puyasrava
Sr
no
Samanya Nidana SU AH[63] AS[64] YR[65] MN[66]
1 Avashaya + + +
2 Pratishaya + +
3 Shabdha
mithyayoga
+
4 Shashtra
mithyayoga
+ + +
5 Karnakandooyan + + + + +
6 Jalkrida + + + + +
7 Abhighata + + +
Page | 44
Samanya samprapti
परापय शरोतरशसरा कयावत शल शरोतशस गान
त कणवगता रोगा अटिावशततरीता
सउ २० १२
Due to common and specific etiology factors the vitiated Doshas gets
Sthanasamshraya in Karna and causes Karnasrava It is the stages of
Samprapti were Doshas gets lodged in Srotas and start processes of Dosh
Dushya Sammurchsna Due to Shiroabhighata Jalanimmajana Karna Paka
Karna Vidhradi vitiated Vata Dosha and Karna becomes Avruta by Vata and
results in Karnasrava Normal physiology of Dosha Dhatus and Malas entirely
depends on the normality of Srotas Dosh Dushya Sammurchana or
manifestation of diseases will not take place if only vitiation of Doshas take
place without deformity of Srotas Here in Karnasrava vitiation of Srotas are
Atipravritti Sanga and Vimargagamana take place Atipravritti is being excess
production of fungus Sanga is obstruction in external acoustic canal
Vimargagamana is the propagation of discharge through ear
Vishesh Samprapti
Karnasrava occurs due to Nij nidana is Pratishaya while Agantuja nidanas are
Avashya Jalkrida and Karnakanduyan Due to etiological factors which are
Vata-Kapha provocative in nature gradual vitiation of Doshas will occur After
vitiation they get accumulated (Sthan samshraya) in external auditory canal
In other hand when patient does Sevana of Agantuj Nidan like water enter in
external ear scratching of ear unsterile instrumentation leads to Dosh
Prakopa These cause Twak and Mamsa Dhatu Dushti which leads to
discontinuity of epithelium of ear canal which creates suitable atmosphere for
fungal pathogen to grow The vitiated Vata will produce symptoms such as
Page | 45
pain hearing impairment and vitiated Kapha causes symptoms like itching
discharge ear blockage By assessing the symptoms it can be said that Kapha
Avrita Vata Dosha is responsible for the manifestation of clinical features like
pain itching discharge Which are seen in Karnasrava that is otomycosis
Acharya Charaka has mentioned while explaining Samanya Chikitsa of
Karnaroga that it should be treated like Vrana when Paka and Srava is present
as a symptom Fungal spores invade in the epithelial layer of EAC In response
to infection inflammatory process is start This is a Paka Avastha After
removing the fungal mass ulceration in external acoustic canal is commonly
seen As a result of infection process exudates was produced which will mix
up- with fungal colonies and appear as discharge As per Dosha involvement
in Vrana Shoola Srava can be differ According to Acharya Sushruta Ruk is
the Samanya Lakshana of Vrana and Vishesha Lakshana of Vrana includes
pain discharge discoloration itching etc according to Dosha involvement
which are also seen in otomycosis In otomycosis mainly watery and purulent
type of discharge is present which indicates Paka avastha If there is Dosha
involve in Vrana is called Dushta Vrana Acharya Sushruta and Acharya
Vagabhata have mentioned verity of Srava in Twak and Mamsa Vranavastu
which is found in otomycosis Based on this description otomycosis can be
correlated with Karnasrava
Page | 46
Representing the Samprapti of Karnasrava
Vishesh Nidana ndash Shiroabhighatat
Jala nimajjana
Prapaka Vidhradhi
Vitited vata
Avarana by kapha
Vimargagamana of Vata
Karnasrava
Samprapti Ghataka
Dosha ndash Kapha and Vata
Dushya ndash Rasa Rakta and Mansa
Strotodushti ndash Vimargagamana and Sang
Adhishthana ndash Karna (Bhayakarna)
Rogmarga ndash Madhyama
Page | 47
Purvarupa
The Purvarupa of Karnasrava are not mentioned separately in any ayurvedic
classics In routine practice cretin Purvarupa are noted
1 Karnakandu
2 Karnagurutwa
3 Alpa karnashoola
4 Discomfort in ear
Rupa
1 Karnashoola
2 Karnakandu
3 Karnasrava
4 karnabadhirya
5 Cotton wool like or wet newspaper like grayish brown or black colored mass
is seen
6 External auditory canal skin appears edematous and red
Upashaya and Anupashaya
Appropriate application of Aushadhi Ahara and Vihara when produces relief in
the symptom is called as Upashaya and when aggravates the symptoms is
called Anaupashaya There is not any reference available in the classics about
the Upashaya and Anupashaya of karnasrava
Sadhyasadhyata
Sushruta has not mentioned specially the Sadhyasadhyata of Karnarogas But
Vagbhata has mentioned Karnasrava as a Sadhyavyadhi[69]
Sadhysadhyatagives the clear picture of prognosis of the disease It depends
on many factors like nature of disease severity of disease Vaya Prakriti Bala
of the patient etc
Page | 48
Upadrava of Karnasrava
In Samhita there is no reference available regarding the Upadrava of
Karnasrava
Samanya Chikitsa ndash
The common treatment principle for all Karnaroga is Ghritapana Use of
Rasayana Bhrahmacharya Avyayama Shirasnana and Atibhashaya
सामरय कणवरोगष घतपान रसयनम
अवयायमो शशराःसतनान बरमहचयवम कतपरनम
स उ२१३
Ghratapana - Ghrita is a Yogavahi and follow Sanskara in addition to these
acquired properties and capable of retaining its own properties So Ghritapana
is effective in Karnasrava
Rasayana - Rasayana represent the basic approach of Ayurveda which
comprise preventive promotive and curative aspect of health
Brahmacharyaapalana -It is like Sadvrittapalana and is equals to Rasayana
effect
Vyayama - It leads to vitiation if Vatas a Karna is a Sthana of vata and
exercise causes Kshayaj Samprapti hence it is important to avoid exercise in
Karnasrava
Shirasnana- In Shirasnana water enters in external acoustic canal it changes
the PH of meatus skin from acid to alkali which favors the growth of pathogens
Atibhashya - Excessive speaking causes Vata Prakopa and Vatapraokopa is
basic Samprapti for Karnasrava as the preventive aspect avoidance of
excessive speaking is necessary
Page | 49
Ghritapana Rasayana and Brahmacharyapalana should be followed for
preservation of dhatu Samyata and restriction of vitiation of Vata Vayayama
Shirasnana and Atibhashaya should be avoided in Karnasrava to protect the
Siras from the affliction of Vata and Kapha
Vishesha Chikitsa ndash
The general treatment principle of Karnasrava described in classics is closely
related to Dushtavrana Chikitsa
शशरोवरचन च ए िपन परण तरा
परमाजवन िान च ीकषय ीकषय़ाचारत [70]
स उ २१४०
कणवसततरा ोददत कयावत पततकशमकणवयो [71]
ाउ १८३५
उपददि च सततरोत साय परात वपचततवशि परमजय
य अगर मदन सघत गगलना ा िपतयतपा मिना परयत [72]
असउ २२४२४३
In addition to that Shirovirechana Karnadhoopana Karnapurana
karnapramarjana Karnadhavana are also indicated
Page | 50
Treatment is also mentioned for Karnasrava
1 Karnaprakshalana Yoga - with Aargawadadi Gana Kashaya and Surasadi
Gana Kashaya [73]
2 Avachurnana Yoga ndash with Aargawadadi Gana Churna and Surasadi Gana
Churna[74]
3 Karnapoorna Yoga ndash
bull Rasanjana Laksha with Sarjachoorna[75]
bull Panchkashaya with Kapittha swarasa and Madhu[76]
bull Jambu AmrapallavShivalaKshuodra Mahavriksha and Madhuki 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 done[77]
bull Sarjatwak Choorna with Karpashiphalarasa and Madhu[78]
bull Abhaya LodraTindukaSamanga(Manjista) Kwatha of this Dravyas mixed
with Madhu and Kapittha Rasa[79]
bull Yogratnakara mention the following drugs for Karnapoorana-
a Samudraphena Churna[80]
b Jambwambpatra Yoga
4 Karnadhoopana Yoga ndash
bull Dhoopana with Churna of Bilvapatra Haridra Palandu[81]
bull Vartak Dhoopana [82]
5 Internal Medications-
bull Rasnadi Guggula [83]
bull Triphala Guggula [84]
bull Sarivadi Vati [85]
bull Gandhaka Rasayana [86]
Page | 51
According to Vagbhata-
Ear should be cleaned with the Pichu and Varti followed by Guggula Dhoopana
and then Karnapoorana with Madhu Followed by Avachurnanana with
Sukshmachootana of Surasadigana
Pathyaapathya ndash Pathya and Apathy mentioned for Samanya Karnaroga is
recommended in Karnasrava also
पथय[87]
सतदो वरको मन नसतय िमाः शशरावयिाः
गोिमाः शालयो मदगााः याशच परतन हवाः 80
लाो मयरो हररणानदसततततरो नकककिाः
पिोल शशगर ातावक सतनषराण कदठललकम
रसायनातन सवणण बरमहचयवमिाषणाम |
उपयकत यरादोषशमद कणावमय दहतम ||81||
िापर २१
Aharaja Upacharaja
bull Godhuma bull Vamana
bull Shala bull Virechana
bull Mudga bull Nasya
bull Yava bull Dhoomapana
bull Puranagitra bull Kavala
bull Lava Harina Tittiramamsa
Page | 52
अपथय[88]
दरत काटठ शशरसतनान वययाम शलटमल गर
कणडयन तषारशच कणवरोगी पररतपयजत
िापर २१
Viharaja
bull Patola ShigruVartaka bull Bhramacharaya
bull Sunishannaka bull Avyayama
bull Katthlika bull Aakthanam
bull All types of Rasayana bull Upacharaja
bull Vamana
Apathyas
bull Abhishyandakara Aharas
bull Shirasnana
bull Karna kandooyana
bull Tushara sevana
bull Guru Kaphakaraka Aaharas
bull Dantdhavana
Page | 53
OTOMYCOSIS
Definition-
Otomycosis is a superficial acute sub-acute or chronic infection of external
ear canal It is mostly unilateral It is characterized by inflammation purities
and scaling Otomycosis is a common condition encountered in ENT practice
more in chronic and persistent ear infection
The Fungal infections are not communicable in the usual sense but the
humans become an accidental host by their introduction into tissue trauma
The virulence factors favoring colonization of fungus in human host are yet to
be identified Ability of the fungus to grow at 37 C and elaboration of a variety
of enzymes and toxins are speculated to contribute to virulence Only 100 to
150 species are generally recognized as a cause of disease in humans[89]
Prevalence-
Otomycosis is a word wide in distribution and in various record stated that 5
to 20 of all cases of infective otitis externa Otomycosis prevalent is more in
warm and humid climates It is one of the commonest manifestations in India
during rainy season It occurs mostly in humid atmosphere otitis externa due
to fungal infection may resembles the desquamative form of diffuse infective
otitis externa The incidence in temperature climates has increased in
proportion to the use of topical antibiotics which have a medium sterilized of
other organism in which the fungus may flourish
Page | 54
Predisposing factors- [90]
1 Environmental factors such as climate contagious and polluting hygiene
more frequently during rainy season as the humidity increases
2 Individual susceptibility ndashGeneral Immunological status of the Individual
eg HIV infection Radiotherapy chemotherapy Diabetes mellitus
3 Self-inflicted trauma that is use of pins to clean the itching ear or use of ear
bud to clean the wax
4 Wide spread of topical antibiotics steroid preparations which have medium
sterilized of other organism in which the fungus may grow
5 Failure of defense mechanism in External auditory canal
6 During swimming or head bath water enters in External acoustic canal
causes quantitative and qualitative change in ear wax It causes change in pH
7 Long term use of hearing aids
Pathophysiology ndash
The life cycle of the average mold encountered in the ear may be reckoned
as two weeks and flare ups may be anticipated at such intervals Swimming is
held responsible for infection in many cases The sequence sequence of
pathogenic changes produced by molds in the external ear is as follows ndash
1 Implantation of the organism in external ear
2 Growth of organism follows the rate depending on condition of temperature
moisture or preexisting irritation
3 Invasion of epithelium occurs with attendant itching and discomfort which
may be quite severe
Page | 55
4 Exfoliation of epithelium occurs as nature attempts to overcome the
infection by casting off upper most cells
5 Denudation occurs from exfoliation as the top layers of epithelium are cast
off and the canal becomes filled with debris
6 Superficial ulceration and lizematoid dermatitis results if the pathologic
process goes for enough The changes do not always proceed through the
entire sequence sometimes the molds produce changes of the mildest
imaginable character which may be overlooked[91]
Clinical features -
Symptoms-
1 Irritation and itching ndash Irritation is mostly found when the infective
organism is aspergillus niger There is sensation of discomfort which is more
diffuse in the ear canal then localized in the deeper part Candida infection
causes marked itching In external ear it is intense and worse at night
2 Discharge through ear- Intermittent scanty colorless discharge through
ear Mucus being a fungal metabolic product appears as discharge Excessive
discharge is associated with mixed infection
3 Pain and discomfort ndash Mild to severe pain in the ear occasionally Mostly
seen in cases where ear is infected with Aspergillus flavus mixed infection
with gram negative organism or mixed infection with candida and aspergillus
Headache is sometimes associated with pain
4 Deafness- Varying degree of mild to moderate conductive deafness
5 A sensation of fullness in ear
6 Tinnitus 7 Vertigo
Page | 56
Signs ndash
1 The external acoustic meatus may contain a mass formed of epithelial
debris exudates cerumen and fungus
2 Erythematous external canal
Fungal appearance
A Niger - The color of the mass which is usually grey or black is mainly
determined by the type of fungus concerned Its appearance is like wet
newspaper or blotting paper or a cotton wool It has a peculiar musty odor In
this infection fruiting heads may be seen as black specks in the debris
Occasionally as inactive form occurs in which the canal is lined by mold giving
a fluffy appearance due to the presence of tiny mycelia
Candida ndash Candida infections generally show as white deposits on magenta
colored skin when the debris is removed it rapidly recovers in 24 hrs
The underlying canal skin is often inflamed and granular due to invasion by
fungal mycelia and be seen in all cases In rare cases excoriation and
ulceration with marked extensive shedding of the epithelium and deep
ulceration can be seen usually associated with a flavus and with pathogenic
bacteria[92]
Otoscope Appearance
1 Aspergillus Niger ndash Black headed
2 Aspergillus Fumigators ndash pale blue or green
3 Candida Albicans ndash White- or cream-colored deposits
Page | 57
4 Auricle is normal in most cases In severe cases small ulceration with crust
formation may be present on lateral surface
5 Tympanic Membrane
In most cases it is normal with normal mobility and normal hearing In a few
cases the surface of the tympanic membrane is congested and scaly There is
erosion or ulceration of the external epithelial layer and the membrane itself
may be edematous
Diagnosis
1 Above mentioned symptoms and signs
2 In the stage at which patient with otitis externa usually first present
themselves mycelia threads conidiophors not visible to naked eye may
sometimes be identified with the microscope
3 Confirmed by culture
Page | 58
Fig7 Aspergillus Niger Fig8 Candida Albicans
Fig9 Aspergillus Fumigators Fig 10 Wet Paper like appearance
Page | 59
Treatment
1 Antibiotic or steroid drops should be discontinued if they are being instilled
since long time
2 Removal of fungal mass epithelial debris and discharge from the external
canal or mastoid cavity repeatedly and thoroughly by forcepa or suction or
syringing or cautiously blow a stream of air into the canal through a fine
cannula and dry thoroughly by swabbing liquid petroleum on swab used in
cleaning the ear lessens the burning sensation when metacresy acetate is to
be employed in the subsequent treatment
Furuncle is developed as a complication if there is no gentleness in cleaning
Cleansing may have to be delayed until local sensitiveness is lessened which
can usually be accomplished within twenty-four hours If there is excessive
epithelial debris along with otomycosis then metacresyl acetate which is a
keratolytic in introduction into the external auditory canal on cotton wick and
is allowed to remain for twenty-four hours After twenty-four hours the cotton
wick is removed at which time the canal can usually be cleansed with little
discomfort as the medication is also anesthetic The epithelium of the canal
was white from contact with the drug The top layer was detached and this
epithelial debris can be easily wiped away The wick is reinserted and wet with
metacresyl acetate
The treatment is employed for three to four days in succession and then a
bland application is substituted Icthyol iodine is of value at this stage Iodine
ointment 2 in combination with Tannic acid 2 is also an excellent local
application following cresatin treatment
Next one of the fungicides may be applied
Page | 60
1 Nystin Effective for candida infection but less active against aspergillus
group Nystatin in boric powder consisting of 100000units of nystatingm of
powder 3 times week for 3 weeks
2 Clotrimazole Available as 11 cream or drops or lotions Phenyl
(zchlorophenyl) 1 ndash imidazole ndash methane is a chlorinated trityl imidazol 1
effective against candida and dermatophytes and for aspergilli infection
3 Amphotericin B Available as cream and as 3 solution and 015 drops
for topical application Very effective for candida infection can be fungistatic
or fungicidal
4 Econazole Available as solution (Econazole nitrate) and as cream (1)
Broad spectrum ndash more effective for Aspergillus Also active against some
gram-positive bacteria (Staphylococci and Streptococci and Dermatophytes)
5 Miconazole Highly effective against dermatophytes and candida infections
used as a 21 cream applied once or twice a day for 10 days
6 Gentian violet 21 Available as drops (recently some evidence of
carcinogenicity) Discolors the ear canal and this interfere with clinical
examination
Other topical antifungal agents are ketoconazole Natamycin Tolciclat Bifonas
zole Fenticonzole Oxiconazole Tioconazole ciclopiroxolomine Tolnafate
Haloprogin Flucytosine Acetic acid Whit field ointment selenium sulfide
undcyclenic acid triacetin etc
Page | 61
Minimal length of treatment
A month of drug treatment is usually required because the antifungal agents
used are not sporicidal and it is necessary that the period of treatment covers
germination time It may be advisable to give short gaps in the period of
treatment to ensure all spores have germinated before deciding to terminate
therapy
Prevention
Accomplished by strict attention to the predisposing causes
1 Water should be prevented from entering the ear
2 Avoidance of external ear trauma
3 Use of alcohol medicated or plain in the ears after swimming mercuric
cyanide (15000) in ethyl alcohol (70) is a satisfactory liquid to use
Ear stoppers do no good unless their use is followed by some antiseptic in the
canal Divers exposed to water for long periods of time may also use acidic
alcohol
4 During Summer months with their high humidity special efforts are needed
to maintain ear dry 5 Indiscriminate use of topical antibiotics steroid
preparations should be avoided
Page | 62
DRUG REVIEW
1 GUGGULA
Fig11 - Guggula
Historical review of Guggula [93]
bull Atharvaveda one of the well-known Vedas of Hindus The earliest
reference given by Atharvaveda medicinal and therapeutic properties of
Guggula Guggula has long history of use in Ayurveda
bull Acharya Charaka Sushruta and Vagbhata describe detail regarding the
actions uses and indication as well as the variety of Guggula
Page | 63
bull Various Nighantus (Medical lexicons) were written between 12th and 14th
centuries AD was based on the Ayurvedic literature also describes
Guggula
bull The explanation of word Guggula is that Gunjo Vyadhegurdti Rakshati
which means to relief against different diseases
bull Guggula is the best medicine because it develops through the rays of
hot sun on specific circumstances
bull Guggula has an aromatic odor
गगलो कणवदौगवररधय िपन शरटठमछयत[94]
स उ २२११२
Latin name- Commiphora mukul
Family ndash Burseraceae
Rasa- Tikta Katu
Guna ndash Laghu Rukshasukshma vishada sara
Veerya ndash Ushna
Vipaka ndash Katu
Action- Rasayana Lekhana
Doshaghanta - Tridoshhara
Page | 64
Chemical composition [95]
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Oleoresin-Z-Guggulsterone E-Guggulsterone
Gum- guggulignans 1 and 2 guggula Tetrols mukulol allylcembrol c
27
Guggulusterol 1 2 ans 3 Z and E ndash guggulusterol
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Parts Used ndash Gum oleoresin
Guggula purity test
1 Yellowish brown emulsion is obtained when Guggula is triturated with
water
2 An ethereal solution of the drug attains reddish colour when treated
with br2 vapors and purple colour when moistened with nitric acid
Biochemical action ndash Antiseptic Anti-inflammatory Disinfectant Diuretic
Immunostimulant stimulating expectorant Ant suppurative Antipyretic
Enhance phagocytosis
Karma- Rasayana cardiovascular disease
Page | 65
2 AGARU-
Fig 12 Agaru
Historical review of Agaru [96]
bull The word Agaru literally means the one which is the heaviest and no
aromatic wood is heavier than it Since thousands of years Agaru lsquoThe
wood of Godrsquo has been used for multiple purpose like commercial
medicinal spiritual aromatic historical
bull The medicinal use of Agaru have been recorded in many pieces of India
Greek Roman Chinese Middle eastern and European since ancient times
bull Acharya Charaka used Agaru and pest of Rasna to counteract the effect of
cold in Agraya Dravyas
bull Acharya Sushruta used Agaru as a Dhoopana Dravya along with Guggula
Ral and Shoma in the treatment of Karnasweda and Vrana
Page | 66
Types-
bull Dhanwantsri Nighantu describes Kaleyaka as a type of Agaru
bull Sodhala Nighantu describes three types of Agaru ndash Agaru Krishna
Agaru Kakatunda Agaru
bull Raj Nighantu describes five types of Agaru ndash Krishna Agaru Kasht
Agaru Daha Agaru Mangalya Agaru and Agurusaar
bull Arthashasstra describes three Agaru wood product
1 Jongaka ndash Black or variegated black in colour and having variegated
spots
2 Dongaka ndash Black in color
3 Parasamudraka- Black in colour and smells like Navamallika
अगर उटण कि तपछय ततकत ततकषण च वपततलम
लघ कणाविरोगघन शीत ात कफपरणत
िापर २१ [97]
Family- Thymelaccensis
Latin name- Aquilaria agallocha
Guna- Laghu Ruksha Tikshan
Rasa- Katu Tikta
Vipaka ndash Katu
Virya ndash Ushna
Karma- Sheetaprasasmana Vranaorasadan Tvachya Pittavardhaka
Shirovirechana Mangalya Sugandhik and Rochaka in properties [100]
Krishna Agaru karma- Katu Tikta rasa Ushna Sheeta when applied externally
and Pittahara when taken orally
Page | 67
Chemical Constituents -
Agaru hardwood is rich in essential oil resins alkaloids saponins Steroids
terpenoids tannins flavonoids and phenolic compound Agaru wood
predominantly contains 2-[-2-phenylethy]-4H-chromen-4-one derivatives and
sesquiterpenes Agaru oil contains selinene dihydroselinene agarnol b-
agarofuran vetispira-2(11)valerianol dihydrokaranone and tetradecanoic
acids[99]
Part Used ndash
Heartwood- Dark resinous wood which is formed when the plant becomes
infected with a type of fungus (ascomycetous mold) Species of Aspergillus
fusarium and penicillium are reported to be associated with the development
of infection Prior to infection the heartwood is odorless relatively light and
pale colored however as the infection progresses the tree produces a dark
aromatic resin in the heartwood The infected resin in response to the attack
which results in accumulation of a very dense dark resin in the heartwood
The infected resin embedded wood is known as Agarwood Infection is more
common on the trunk roots and the area when branches divide The formation
of Agarwood starts when the tree attains the age of 20 years On an average
approximately 30 ml oil is extracted from 100 kg of infected Agarwood[98]
Qualities of best Agaru-
It should be black in color
It should be extremely heavy and aromatic
It should be oily in appearance and test
It should be sink in water
It should burn easily with bright flame with a bright flame giving off a pleasant
smell
Page | 68
3 MADANA
Fig 13 MADANA
Madana consist of dried fruit of Xeromphis spinosa It is a deciduous thorny
shrub or a small tree reaching a high up to 9 m and girth about a meter
branches numerous thick and horizontal found in sub-Himalayan tracts[101]
मदनो मिरनदसततकतो ीयोटणो लखनो लघ
ानदरतिदवििीहर परततशयायवरणारतक
रि कटठकफ़ानाहशोथगलमवरणापह[102]
िा पर १६० १६1
Page | 69
Latin name-Randia dumetorum
Familly ndash Rubiaceae
Rasa - Madhura Tikta
Guna-Laghu Ruksha
Virya- Ushna
Vipaka ndash Katu
Karma- Vamana and Lekhana
Chemical Composition-
Essential Oil Valerianic acid Saponin tannin resin [103]
Page | 70
YAWA [104]
Fig 14 Yawa
1 In Samhitakala Aacharya Charaka Acharya Sushruta explain detail about
medicinal properties of Yawa
2The use of Yawa in Aaharya Dravya mainly described by Dhanwantari
Nighantu Raj Nighantu Bhavprakash Nighantu[105]
Macroscopic Description-
Fruit a caryopsis elliptical oblong Ovoid and tapering at both ends smooth
about 1cm long and 02- 03cm wide dorsally compressed and flattened on
the sides with a shallow longitudinal furrow 3-5 ridges having shallow
depression between them grains tightly enclosed and adhering the lemma
and palea pale greenish yellow odor not distinct taste sweetish acrid
Page | 71
Latin Name ndash Hordenum vulgare
Family- Poaceae
Rasa- Kashaya Madhura
Virya- Sita
Vipaka- Katu
Karma- Vatakrt Pittahara Kaphahara Medahara Balya Visrya
SthairyakaraLekhana
Page | 72
PROCEDURE REVIEW [105]
In Ayurvedic classics there are many references regarding Dhoopana Dravya
Dhoopana is administering Dhuma with the help of Dhoopana Dravya
In Kashyapa Samhita there are 40 types of Dhoopana advised for children
Anesthesia (Mohajananam Dhoopa) is also mentioned For this Dhoopana the
drug used were herbs hairs of animals legs horns old cloths of Buddhist
monks
From the references available regarding Dhoopana we can understand that
Karna can be protected from maggots (krimi) Bactria (Rakshogna) lice etc
References clearly indicate the analgesic and disinfectant effect of Dhoopana
Karma Dhoopana is mentioned for Dushta Vrana Chikitsa It reduces Vedana
Srava Pootigandha of Dushtavrana It also helps in Vranaropana
Dushtavrana Chikitsa is mentioned in the treatment of Karnasrava[106]
Origin of Dhoopana-
In ancient period children of sages were constantly harassed by the
Rakshasas Hence the sages approached lord Agni for shelter Agni in turn
gave them Dhoopana Dravya and asked sages to use the Dhoopana for
protection against Rakshasas bhutas pishachas
Classification of Dhoopana
1 It is classified into Dhupa Anudhupa Pratidhupa
2 On the basis of Origin it is classified into Jangama and Sthavara
Selection of Guggula for Dhoopana
Page | 73
bull Guggul is a best Vatahara
bull It is Krimighana
bull It contains Oleoresin
bull In Ashtang Hrudaya Guggula Dhoopana mentioned for Karnasrava
Selection of Agaru for Dhoopana
bull Agaru is Laghu Ruksha Katu Tikshna
bull Vranaorasadan Tvachya
bull It should burn easily with bright flame with a bright flame giving off a
pleasant smell
Karna Dhoopana Indication
1 Karnaarava
2 Putikarna
3 Krimikarna
4Vataj Karnashula
Contraindications
Especially for Karnadhoopan contraindication is not mentioned in classic texts
But Dhoopana is contraindicated in Pittaj vaydhi Sharad and Grishma Rutu
Page | 74
MATERIAL AND METHOD
Page | 75
For randomize comparative clinical trial to study the effect of Agaruwadi
Karnadhoopana and Guggula Karnadhoopana in Karnasrava following material
and method were required
Source of data
Patient irrespective of gender occupation religion social economic status
signs and symptoms of classical features of Karnasrava (Otomycosis) selected
from the OPD of Shalakyatantra department
Materials ndash
1Patients
2 Drugs-Agaruwadi Dhoopana
Guggula Dhoopana
3Torch
4Otoscope
5 Tuning fork
6Jobson horn probe
7Cotton
8Case record form
DRUG
Group A Trial Group
1Churana of Agaru Yawa Madan
2Ghrita
3Jala
Group B Control Group
1Googula Churna
Page | 76
Properties of Drug
Table no 1 Properties of Drug
Drug
Family
Rasa Veerya Vipaka Effect
on
Dosha
Guna Karma
Agaru
(Aquilegria
Agallocha)
Thymelaca
ceae
Katu
Tikta
Ushna Katu KV Laghu
Ruksha
Tikshna
Shitaprashamana
Shothahara
Vedanasthapak
Durghandhihara
Madan
(Randia
spinosa)
Rubiaceace
Kashaya
Madhur
Tikat
Katu
Ushna Katu KV Ruksha
Laghu
Vatakaphaghana
Shothahara
Vedanasthapak
Vranashodhak
Yawa
Poaceae
Hordeum
Vulgare
Kashaya
Madhur
Sheeta Madhur KP Ruksha
Laghu
Vataghana
Vernashodhana
Raktshodhaka
Guggula
Commiphora
Mukul
Burseracea
e
Tikta
Kashaya
Anushna Katu VPK Laghu
Ruksha
Shothahara
Vedanasthapaka
Kandughna
Ghrita Madhura Sheet Madhur VK Snigdha Vataghana
Shothahara
Vedanasthapaka
Page | 77
METHODOLOGY
SELECTION CRITERIA
1)INCLUSION CRITERIA
1 Patients having signs and symptoms of Karnasrava (Otomycosis) ie करणशल
( pain ) करणकणड ( Itching ) करणसतराव ( Discharge )बाधिरण ( conductive Loss of
hearing )
2 Patient from age group 19 to 70 years
3 Any Gender
2)EXCLUSION CRITERIA
1 Patients suffering from any systemic disease like DM TB HTN
2 Chronic suppurative otitis media (CSOM)
3 Acute supportive otitis media (ASOM)
3 Perforation of Tympanic membrane
4 Chronic otitis media
3)WITHDRAWAL CRITERIA
1If patient develops any adverse effect such as irritation pain burning
sensation in ear loss of hearing and such patients was withdrawn from trial
and receive prompt appropriate medical attention
2If patient shows aggravation in symptoms
3If patient refuses to continue with the treatment
Page | 78
STUDY SETTING
Types of study - Randomized Clinical comparative Trial
Place of work - OPD of Shalakyatantra
Duration of study - 18 months
Study Population - Patients of Karnasrava in Shalakyatantra OPD
SAMPLE SIZE CALCULATION
Sampling Method ndash Purposive sampling followed by random allocation in two
groups
Sample size calculation-
n = z2 p (1-p)
d2
Were
n = sample size
P = prevalence of disease=10
z = standard normal variable ie 196
d = error ie005
desired Sample Size would be
n = Z2 P(1-P)d2
= (196)2x (0021) x(0979)(005)2
= 34
Visiting ENT OPD (ShalakyaTantra) and IPD (ShalakyaTantra) 21 = 34
n raquo34
So one group includes 34patients
Page | 79
Sampling Method
Total 68 patient of Karnasrava are selected by Purposive sampling followed by
random allocation in two groups Written informed consent is taken prior to
commencement of trial They are divided in 2 groups
Group A (Trial Group) 34 patients treated with Agaruwadi Dhoopana for 7
days
Dose 5 minutes twice in a day
Group B (Control Group) 34 patients treated with Guggula Dhoopana for 7
days
Dose 5 minutes twice in a day
STUDY DESIGN ndash
Open labeled Randomized Comparative Clinical trial
STUDY DESIGN
Screening of patient
Inclusion criteria satisfied Exclusion criteria
Initial assessment Excluded
Counseling of patient Treated accordingly
Patient selection by Simple Random Sampling Method
Page | 80
68 Patients were divided in two groups lsquoArsquo and lsquoBrsquo
Trial group A-34 patients were given
Agaruwadi Dhoopana
Control group B- 34 patients were
given Guggul Dhoopana
Informed written consent
Treatment was given for 7 days
Assessment on 1st 4th and 7th day
Post assessments follow up on 15th day
Observation
Data Collection
Statistical analysis of data
Conclusion
Page | 81
(A) Agaruwadi Varti for group A (Trial group)
Table no 2
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
B) Guggula Varti for group B (Control group)
SOP of it is same as above Agaruwadi Varti
Table no 3
Drug Guggula Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
FOLLOW UP
For both groups follow ups were done on 1st 4th and 7th and post
assessment follow up15th day
EXAMINATIONS
Torch for Local examination of ear
Otoscope examination
Tuning fork Test
Page | 82
OBSERVATION TABLE
Table no 4
Sr no Subjective criteria Day 1 Day 4 Day 7 Day 15
1 करणशल
(pain)
2 करणकणड
(Itching)
3 करणसतराव (Discharge )
4 बाधिरण (Conductive Deafness)
OBSERVATIONS
a) करणशल (Pain) -
0 - Absent
1 ndash Present
b) करणकणड (Itching) -
0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
Page | 83
c) करणसतराव (Discharge)
0- Absent
1- Mild -Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाधिरण (conductive Loss of hearing)
0 - Absent
1- Present
Observations were carried out before and after completion of treatment and
during each follow up After observations the data collected and presented in
the form of graphs charts and table
Page | 84
TRIAL DRUG
Authentication and standardization of raw drug material done After
authentication and standardizing of raw drug material Agaruwadi Varti was
prepared by Varti as explained in Ayurvedic classics
Method of Varti preparations
Panchavidh Kashaya Kalpana that is five method of pharmaceutical
preparation constitutes the fundamental process of Ayurvedic pharmaceutics
which is well explained in Sushrut Samhita Varti Kalpana is one among them
which can be included in Kalka Kalpana
तीररसतरपतपतीनामपरककव तीत [106]
स डलहण शरच 151
Medicines are powered triturated and given the Varti shape that is like wick
of lamp so it is called as Varti Kalpana
Drug content Agaru Madan Yawa
Route of Administration Local
Dose Two times a day
Duration 7 days
Page | 85
Methodology
Standard operating procedure (SOP) of Agaruwadi Varti
Agaruwadi Varti is prepared according to the classical text
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization was done as recommended in pharmacy procedure The
raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 mixed together in
equal quantity to make Agaruwadi churn
Quantity of each churn is 4 grams all are mixed when the Varti get dry total
weight of Varti was 10gram
STEP 4 - Agaruwadi churn triturated with appropriate quantity of water or
Ghrita and prepared Varti in GMP Certified Ayurvedic pharmacy Standard
aseptic precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Varti was packed in sterile air packed container
STEP 6 - Agaruwadi Dhoopana was given with the help of Dhoopana yantra
Authentication and Standardization of raw drug of Agaruwadi Varti was done
Sterilization was done as recommended in pharmacy procedure Sterile
preparation packed in sterile container of suitable size Under all aseptic
precaution Karnadhoopana given to infected ear
Page | 86
Containers for packaging and their sterilization-
Sterilization of the containers for storing Varties was done by Ethylene Oxide
(Eto) method
Ethylene Oxide (Eto) procedure-
It includes exposure of materials to ethylene oxide gas under vacuum in a
sealed chamber It consists of four primary variables
1Gas Concentration
2Humidity
3Temperature
4 Time
EtO gas is an alkylating agent which disturbs the DNA of microorganism
preventing them from reproducing It penetrates the breathable packaging
and sterilizes all the accessible surface of the product to render products
sterility by alkylation of essentials proteins for cell reproduction
Most Eto sterilization methods involves three different stages These can be
separated into three different on the size or number of devices to treat
1Preconditioning stage-
First products are passed through a preconditioning phase to make
microorganism grow The batch load goes through a well time under a
controlled environment of temperature and humidity
2Sterilizer stage-
Performed using process phase specially designed to provide the required level
of EtO exposure to assure sterility for a device or family of devices
3Degasser Aerration stage-
Finally products need to go through a degassing phase to remove any residual
particles of Eto The batch load goes over well time under a temperature-
controlled environment
The sterile containers were then used to store Agaruwadi Varti and handed to
patients included in the study
Page | 87
Packing of Agaruwadi Varti
The ETO sterilize plastic container were used for packing of Agaruwadi Varti
Varti was filled into these sterilize containers (7 in each) In an aseptic
environment plugging and capping was done under aseptic precautions In this
way packing of Agaruwadi Varti done These Varti were given to patient and
advise to take two times a day under all hygienic precautions
History and Examination
bull Proper history and presenting complains was recorded on case record form
bull Ear examination with otoscope was done during initial assessment and each
follow up
bull Otoscopic examination was done during initial assessment and each follow
up
bull Systemic Examination that is Blood Pressure Temperature Respiration
rate Pulse was recorded on case record form
Page | 88
Raw material
Fig14 यव चरण Fig15 मदनफळ चरण
Fig16 अगर चरण Fig17 गगगळ चरण
Page | 89
Preparation of Agaruwadi Varti
Fig18 Preparation of Agaruwadi Varti
Fig19 अगरवादी वरती
Page | 90
Fig20 Instruments used for examination of Karnasrava
Fig19 Karnadhoopana Yantra
Page | 91
Karnadhoopana Procedure
Fig 22 Karnadhoopana Procedure
Page | 92
OBSERVATIONS AND RESULTS
Page | 93
BASED ON DRUGS
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 94
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
AUTHENTICATION CERTIFICATE
Page | 95
BASED ON STASTICIAL ANALYSIS OF DEMOGRAPHIC DATA
68 patients of Karnasrava ndash Otomycosis
Table no 5
No of Patients Total
Group A Group B
Registered 38 37 75
Completed 34 34 68
Discontinue 04 03 07
Total 68 patients were enrolled in study 38 patients registered in group A
amongst them 34 patients completed the treatment and04 patients
discontinued the treatment However in group B 37 patients completed the
treatment and 03 patients discontinued the treatment out of 37 registered
patients
Hence the total number of patients registered in the present study was 75
and out of which 68 patients were discontinued the treatment So they
dropped out from the study While 68 patients were successfully completed
the treatment So observations and result of 68 patients were given below
Here we are going to discuss the statistical analysis of the data obtained in
the form of master chart that was prepared in accordance with the data
collected from the patients that had been included in the study The purpose
of statistical analysis was to analyzed the relation between age gender
occupation diet addiction and education
Page | 96
1 Age wise distribution of patients
Table no 6
In trial group 10 (29412) patients were from age group 18-25 years 14
(41176) patients were from age group 25-35 years 8 (23529) patients
were from age group 35-45 years and 2 (58824) patients were from age
group 45-60 yearsIn control group 6 (17647) patients were from age group
18-25 years 14 (41176) patients were from age group 25-35 years 7
(20588) patients were from age group 35-45 years and 7 (20588)
patients were from age group 45-60 years
Fig 23 Age wise distribution of patients
0
2
4
6
8
10
12
14
15 -25 25-35 35-45 45-60
10
14
8
2
6
14
7 7
Age Distribution
Trial Group N Control Group N
Age Distribution
Trial Group Control Group
N N
18 -25 10 29412 6 17647
25-35 14 41176 14 41176
35-45 8 23529 7 20588
45-60 2 58824 7 20588
Total 34 100 34 100
Page | 97
1 Gender wise distribution of patients
Table no 7
Sex
Trial Group Control Group
N N
Female 23 67647 15 44118
Male 11 32353 19 55882
Total 34 100 34 100
In trial group 23 (67647) patients were female and 11 (32353) patients
were male
In Control group 15 (44118) patients were female and 19 (55882)
patients were male
Fig 24 Gender wise distribution of patients
0
5
10
15
20
25
N N
TRIAL GROUP CONTROL GROUP
23
15
11
19
Gender
Female Male
Page | 98
2 Education wise distribution of patients
Table no 8
Education
Trial Group Control Group
N N
Illiterate 4 11765 3 88235
SSC 4 11765 3 88235
HSC 8 23529 9 26471
Graduation 16 47059 10 29412
Primary 1 29412 3 88235
Post-Graduation 1 29412 6 17647
Total 34 100 34 100
In trial group 4 (11765) patients were illiterate 4 (11765) patients were
SSC educated 8 (23529) patients were HSC educated 16 (47059)
patients were graduated 1 (29412) patients were primary educated and
1(29412) patients were post graduated
In control grou 3 (88235) patients were illiterate 3 (88235) patients
were SSC educated 9 (26471) patients were HSC educated 10 (29412)
patients were graduated 3 (88235) patients were primary educated and
6 (17647) patients were post graduated
Page | 99
Fig 25 Education wise distribution of patients
0
2
4
6
8
10
12
14
16
ILLITERATE SSC HSC GRADUATION PRIMARY POST GRADUATION
4 4
8
16
1 1
3 3
910
3
6
Education
Trial Group N Control Group N
Page | 100
3 Occupation wise distribution of patients
Table no 9
Occupation
Trial Group Control Group
N N
Accountant 1 294 2 588
Housewife 11 3235 8 2353
Engineer 1 294 1 294
Job 1 294 4 1176
Labor 1 294 3 882
Mess 1 294 0 000
Naturotherapyst 1 294 0 000
Pharma 1 294 0 000
Shopkeeper 4 1176 2 588
Singer 1 294 0 000
Student 8 2353 4 1176
Tailor 1 294 1 294
Teacher 1 294 1 294
Worker 1 294 3 882
Farmer 0 000 1 294
Lab Tech 0 000 1 294
Page | 101
Daily Collection 0 000 1 294
Fruit seller 0 000 1 294
Bus Driver 0 000 1 294
Total 34 10000 34 10000
In trial group 11 (3235 ) were housewife 8(2353) were students
4(1176) were shopkeeper 1(294) was accountant 1(294) was
engineer 1(294) was doing job 1(294)was labour 1(294) was
catering 1(294) was Naturotherapyst 1(294) was Pharma 1(294)
was Singer 1(294) was Tailor 1(294) was Teacher and 1(294) was
worker
In Control group 8 (2353)were housewife 4(1176) were students
2(588) were shopkeeper 2(588) was accountant 1(294) was
engineer 4( 1176) was doing job 3(882)was labor 1(294) was
Farmer 1(294) was Lab tech 1(294) was Daily collection 1(294)
was Tailor 1(294) was Teacher and 3(882) was worker 1(294) was
Fruit seller and 1(294) Bus driver
Fig 26 Education wise distribution of patients
0
2
4
6
8
10
12
1
11
1 1 1 1 1 1
4
1
8
1 1 10 0 0 0 0
2
8
1
43
0 0 02
0
4
1 13
1 1 1 1 1
Occupation
Trial Group N Control Group N
Page | 102
4 Religion wise distribution of patients
Table no 10
Religion
Trial Group Control Group
N N
Hindu 31 9118 33 9706
Muslim 3 882 1 294
Total 34 10000 34 10000
In trial group 31 (9118) patients were Hindu and 3 (882) patients were
Muslim
In control group 33 (9706) patients were Hindu and 1 (294) patient
were Muslim
Fig 27 Religion wise distribution of patients
0
5
10
15
20
25
30
35
N N
TRIAL GROUP CONTROL GROUP
3133
31
Religion
Hindu Muslim
Page | 103
5 Diet wise distribution of patients
Table no 11
Diet
Trial Group Control Group
N N
Veg 14 4118 20 5882
Non-Veg 20 5882 14 4118
Total 34 10000 34 10000
In trial group 14 (4118) patients were vegetarian and 20 (5882)
patients were Non vegetarian
In control group 20 (5882) patients were vegetarian and 14 (4118)
patients were Non-Veg
Fig 28 Diet wise distribution of patients
0
5
10
15
20
N N
TRIAL GROUP CONTROL GROUP
14
2020
14
Diet
Veg Non Veg
Page | 104
6 Addiction wise distribution of patients
Table no 12
Addiction
Trial Group Control Group
N N
None 30 8824 27 7941
Alcohol 2 588 0 000
Tobacco 1 294 2 588
Mishri 0 000 1 294
Smoking 1 294 4 1176
Total 34 10000 34 10000
In trial group 30 (8824) patients have no addiction 2 (588) patients
have addiction of alcohol 1 (294) patients have addiction of Tobacco 0
(0) patients have addiction of Mishri and 1 (294) patients have addiction
of smoking
In control group 27 (7941) patients have no addiction 0 (0) patients
have addiction of alcohol 2 (588) patients have addiction of Tobacco 1
(294) patients have addiction of Mishri and 11 (1176) patients have
addiction of smoking
Page | 105
Fig 29 Addiction wise distribution of patients
0
5
10
15
20
25
30
NONE ALCOHOL TOBACCO MISHRI SMOKING
30
21
01
27
0
21
4
Addiction
Trial Group N Control Group N
Page | 106
Statistical Analysis and Results
Effect of study on Karnashoola-
Table no 13
Karnashoola
Group A Group B
BT AT BT AT
N N N N
Grade 2 0 000 0 000 0 000 0 000
Grade 1 30 10000 7 2333 32 10667 5 1667
Grade 0 4 1333 27 9000 2 667 29 9667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 30 Effect of study on Karnashoola
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
30
7
32
54
27
2
29
Karnashoola
Grade 2 Grade 1 Grade 0
Page | 107
Table no 14
Karnashoola Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 088 100 033 006
969 2829E-
08 7667 HS
AT 021 000 041 007
Group
B
BT 094 100 024 004
1037 7103E-
11 8438 HS
AT 015 000 036 007
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 31
000010020030040050060070080090100
BT AT BT AT
GROUP A GROUP B
088
021
094
015
Karnashoola
Mean
Page | 108
Table no 15
Karnashoola
Mean SD Effect
Group
A
Group
B Trial Control Trial Control
Day 1 088 094 033 024 000 000
Day 3 065 071 049 046 2667 2500
Day 5 024 038 043 049 7333 5938
Day 14 021 015 041 036 7667 8438
000
010
020
030
040
050
060
070
080
090
100
Day 1 Day 3 Day 5 Day 14
Karnashoola
Mean Group A Mean Group B
Page | 109
Table no 16
Karnashoola N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3250 110500
510000 275 Control group 34 3650 124100
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 110
Effect of study on Karnakandu
Table no 17
Karnakandu
Group A Group B
BT AT BT AT
N N N N
Grade 3 7 2333 0 000 4 1333 0 000
Grade 2 18 6000 0 000 18 6000 0 000
Grade 1 7 2333 7 2333 10 3333 15 5000
Grade 0 2 667 27 9000 2 667 19 6333
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 32 Effect of study on Karnakandu
0
5
10
15
20
25
30
N N N N
BT AT BT AT
GROUP A GROUP B
7
0
4
0
18
0
18
0
7 7
10
15
2
27
2
19
karnakandu
Grade 3 Grade 2 Grade 1 Grade 0
Page | 111
Table no 18
Karnakandu Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 188 200 081 015
1091 3119E-
10 8906 HS
AT 021 000 041 007
Group
B
BT 171 200 076 014
1032 4746E-
09 7414 HS
AT 044 000 050 009
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Page | 112
Fig 33
Table no 19
Karnakandu
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 188 171 081 076 000 000
Day 3 126 118 057 058 3281 3103
Day 5 071 074 046 051 6250 5690
Day 14 021 044 041 050 8906 7414
000
020
040
060
080
100
120
140
160
180
200
BT AT BT AT
GROUP A GROUP B
188
021
171
044
Karnakandu
Mean
Page | 113
Table no 20
Karnakandu N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 4051 137750
373500 006 Control group 34 2849 96850
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is less than
005 Hence we conclude that there is significant difference between Trial
Group and Control Group
000
020
040
060
080
100
120
140
160
180
200
Day 1 Day 3 Day 5 Day 14
Karnakandu
Mean Group A Mean Group B
Page | 114
Effect of study on Karnasrava
Table no 21
Karnasrava
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 11 3667 0 000 8 2667 0 000
Grade 1 23 7667 3 1000 26 8667 2 667
Grade 0 0 000 31 10333 0 000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 34
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
11
0
8
0
23
3
26
20
31
0
32
Karnasrava
Grade 3 Grade 2 Grade 1 Grade 0
Page | 115
Table no 22
Karnasrava Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 132 100 047 009
1122 4356E-
13 9333 HS
AT 009 000 029 005
Group
B
BT 124 100 043 008
1130 9364E-
14 9524 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 35
000
020
040
060
080
100
120
140
BT AT BT AT
GROUP A GROUP B
132
009
124
006
Karnasrava
Mean
Page | 116
Table no 23
Karnasrava
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 132 124 047 043 000 000
Day 3 100 100 025 025 2444 1905
Day 5 047 038 051 049 6444 6905
Day 14 009 006 029 024 9333 9524
000
020
040
060
080
100
120
140
Day 1 Day 3 Day 5 Day 14
Karnasrava
Mean Group A Mean Group B
Page | 117
Table no 24
Karnasrava N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3535 120200
549000 655 Control
group 34 3365 114400
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 118
Effect of study on Karnabadhirya
Table no 25
Karn
Badhirya
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 0 000 0 000 0 000 0 000
Grade 1 13 4333 0 000 16 5333 2 667
Grade 0 21 7000 34 11333 18 6000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 36
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 00 0 0 0
13
0
16
2
21
34
18
32
Karnabadhirya
Grade 3 Grade 2 Grade 1 Grade 0
Page | 119
Table no 26
Karn
Badhirya Mean Median SD SE
Wilcoxon
W P-Value
Effect Result
Group
A
BT 038 000 049 009
799 7173E-
05 10000 HS
AT 000 000 000 000
Group
B
BT 047 000 051 009
816 0000138 8750 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 38
000
005
010
015
020
025
030
035
040
045
050
BT AT BT AT
GROUP A GROUP B
038
000
047
006
Karnbadhirya
Mean
Page | 120
Table no 27
Karn
Badhirya
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 038 047 049 051 000 000
Day 3 009 006 029 024 7692 8750
Day 5 003 006 017 024 9231 8750
Day 14 000 006 000 024 10000 8750
000
005
010
015
020
025
030
035
040
045
050
Day 1 Day 3 Day 5 Day 14
Karn Badhirya
Mean Group A Mean Group B
Page | 121
Table no 28
Karn
Badhirya N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3400 115600
561000 806 Control
group 34 3500 119000
Total 68
Page | 122
COMPARISION BETWEEN GROUP A AND GROUP B
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Table no 29
Overall Effect
Trial Group Control Group
N N
Marked Improvement 21 6176 16 4706
Moderate Improvement 8 2353 13 3824
Mild Improvement 4 1176 5 1471
No Change 1 2941 0 0
TOTAL 34 100 34 100
Fig 39
0
5
10
15
20
25
MARKED IMPROVEMENT
MODERATE IMPROVEMENT
MILD IMPROVEMENT NO CHANGE
21
8
41
1613
5
0
Overall Effect
Trial Group N Control Group N
Page | 123
DISCUSSION
Page | 124
Discussion is nothing but the logical reasoning of observations In
every research work discussion part is very important because it brings into
light about the logical analysis which are helpful in filling the research gap in
the scientific world
The discussion is categorized into following ways for the ease of
understanding
1 Discussion on selection of topic
2 Discussion on review of literature
3 Discussion on drugs their mode of action on the disease mode of action
of Karnadhoopana
4 Discussion on observation and results
1 Discussion on selection of topic
Otomycosis is commonly encountered in day-to-day practice Majority
of Indian people affected with this pathology This disease commonly
manifests in developing countries low socio-economic standard and lack
of hygiene Now a days due to busy lifestyle people are not able to follow
the proper instruction of care of ear which may be responsible for the
recurrent nature of disease So for the management of this we use
Karnadhoopana with the help of Agaruwadi Varti Dhoopana is simple
easy cost-effective procedure which can be done even at OPD levelso
for the disease Karnasrava we selected Karna Dhoopana as therapeutic
procedure Karnadhoopana was done with Agaruwadi Varti and Guggula
Varti which was very effective for treatment
Page | 125
2 Discussion on review of literature
Karnasrava is one such disease among 28 Karnarogas mentioned by
Acharya Sushruta in the chapter named Karna Roga Vigyana Acharya
Charaka included Karnasrava as symptom under the four types of
Karnarogas due to vitiation of different doshas Acharya Vagbhata has
not described Karnasrava separately It is a fact that systemic
description of Karnarogas is available in all the ancients of pus from a
Vata afflicted ear may results from head injury or immersion in water
Karnasrava is a clinical entity which can be correlated with Otomycosis
Karnasrava is explained as symptom as well as a disease in Ayurveda
Nidana- Karnasrava occur due to Samanya Nidana and Vishesh Nidana
Vishesh Nidana like Shirobhighata Nimmajato jale Mithyayoga of Shashtra
The exact pathology behind Karnasrava is not understood clearly
Purvarupa ndash No specific Purvarupa are found for Karnasrava in classical
literature Acharya Madhukara describe Purvarupa as expression of
Rupa(lakshana) with less intensity that is less intensity itching sound in ear
may considered as Purvarupa of Lakshana
Samprapti- Aacharya Sushruta not explained the Samprapti of Karnasrava
separately and we must consider the general Samprapti of Karnaroga Due to
various aetiologias as cited above ear afflicted by Vata dosha causes Twak
Rakta Mamsa dushti results in Karnasrava According to Acharya Sushruta
Vata-Kapha dose is dominance in Karnasrava
Page | 126
Nidan
Nija Agantuja
Vata ndash kapha prakopak nidana Shirobhighata Nimmajato-jale
Mithya yoga of Shastra
Vata- kapha Prakopaka(Chaya prakopak) Vata-kapha prakopaka
( Achay prakopak)
Twak Rakta Mamsa dushti
Karnasrava
Page | 127
Chikitsa
The curative aspect and this must be done simultaneously giving due
importance to Nidan Parivarjana that is preventive measures So Nidan
Parivarjana that is avoidance of causative factors like Jalkrida Mithyayogen
shashtrasya Karnakandu Shirasnan Pratishaya is the first step in combating
the disease and form the part of line of treatment
Above Samprapti helps us to proceed towards the treatment of Karnasrava
The main protocol of treatment is removal of fungus and wound management
which include various measures to keep area day clean clear of microbes and
providing ideal condition for healing
Samany Chikitsa- Acharya Sushruta described general treatment for
Karnaroga as Snehapana (Drinking ghee) Rasayana (Rejuvenation therapy)
Bhramacharya Avoid excessive speaking Avoidance of physical exercise and
head bath
Vishesha Chikitsa ndash Acharya Sushruta mentioned some procedures in the
treatment of Karnasrava which is Shirovirechana Karnadhoopana
Karnapurana Karanpramarjana Dhavan Avachurnana Karnapurana Above
various procedures described in Ayurveda for management of fungus growth
in ear discharging ear fulfill these requirements of wound management
Page | 128
Discussion on observation and Result
Out of 68 patients 34 patients included for the trial The incidence of
Karnasrava is observed in trial and control groups
The statistical analysis provided the following data
AGE
Trial group- Maximum no of patients that is 14 (41176) patients were from
age group 25-35 years followed by 29412 patients were from age group
18-25 years 23529patients were from age group 35-45 years and
58824 patients were from age group 45-60 years
Control group - Maximum no of patients that is 14 (41176) patients were
from age group 25-35 years followed by 20588 patients were from age
group 35-45 years and 20588 patients were from age group 45-60 years
17647 patients were from age group 15-25 years
The maximum no of cases of Karnasrava found in age group between 25 to
35 years The reason behind this is repeated use of ear bud or emersed water
in ear More use of earphone or working more in cold environment
GENDER
Trial group ndash A higher prevalence seen in females 6764 and 3235 in
males
Control group - A higher prevalence seen in males 5588 and 4411 in
females
Females and males both are prone to disease
Page | 129
EDUCATION
Trial group-It is observed that amongst 34 patients maximum ie16
(47059) patients were graduated 8 (23529) patients were HSC
educated 4 (11765) patients were SSC educated 4 (11765) patients
were illiterate 1 (29412) patient were primary educated and 1(29412)
patient were post graduated
Control group- It is observed that 10 (29412) patients were graduated 9
(26471) patients were HSC educated 6 (17647) patients were post
graduated 3 (88235) patients were SSC educated 3 (88235) patients
were primary educated3 (88235) patients were illiterate
There is no direct relation between education and Otomycosis
RELIGION
Trial group- The incidence of patients of Hindu religion are 9118 and Muslim
religion are 882
Control group- The incidence of patients of Hindu religion are 9706 and
Muslim religion are 294
There is no probable explanation for this maximum number of patients in
Hindu religion it depends upon the patients attend the hospital and
community residing there
Page | 130
DIET
Trial group It was found that maximum ie5882 patients were taking
mixed diet while 4118 were taking vegetarian diet
Control group It was found that maximum ie5882 were taking
vegetarian diet while 4118 patients were taking mixed diet
The dietary habit of person is based on choice availability and religious
customs of the person
ADDICTION-
Trial group- It was found that maximum ie 30 (8824) patients have no
addiction 2 (588) patients have addiction of alcohol 1 (294) patients
have addiction of Tobacco 1 (294) patients have addiction of smoking and
0 (0) patients have addiction of Mishri
Control group - It was found that maximum ie 27 (7941) patients have
no addiction 4(1176) patients have addiction of smoking 2 (588)
patients have addiction of Tobacco 1 (294) patients have addiction of
Mishri and 0 (0) patients have addiction of alcohol
Very few patients were addicted to Alcohol Smoking Tobacco and Mishri
These factors can be taken as provoking factors for Otomycosis
Page | 131
Discussion based on probable Mode of action of Karnadhoopana
In Ayurveda classics Karna Dhoopana is therapeutic procedure explain for
Karnasrava Dhoopana is administration of Dhooma (Fumes) with the help of
Dhoopan Dravya References indicates that analgesic and disinfectant effect
of Dhoopana karma and mention for Dushta Vrana Chikitsa It reduces
Vedana Srava amp also does Vrana Ropana action
Various Dhoopanas and Dhoopan Dravas for different element in various
Samhitas of Ayurveda but there is a lacuna of availability of reference
regarding how to do it and method of procedure Matra Kala Contraindication
etc
Currently simple modified way of Karnadhoopana according to Yukti Praman
and experience but there is lac of standardization
Karnadhoopana is one among the topical Bahiparimajan type of treatment
Karna Parmarjana is procedure of cleaning ear with the help of cotton or gauze
piece soaked in honey
Page | 132
Dhoopan
The fumes coming out on burning Agaruwadi Varti
Administrated directly into external ear canal
Causes vasodilation
Due to this increase blood supply in external ear canal
It helps in absorption of drug
Fumes dries up Srava and bring the analgesic effect
Karnagata Kapha amp Avrut Vata Dosha Shaman
Decrease in signs and symptoms like karnasrava Karnshool Karnabadhirya amp
Karnandu
Page | 133
3 Discussion based on probable mode of action of Agaruwadi
Dhoopana
Agaru ndash
I Agaru is a fragrant tree aroma is a result of fungal pathogenesis when the
wood of tree is contaminated by fungi at wounds it develops scrap filled
with resin and turn out to be aroma Medicinal use of Agaru have been
recorded in ancient medicinal science in in inflammatory disease and some
infective disease
II Acharya Charaka has referred to Agaru as an Ushna dravya despite having
Tikta Rasa Ashtang Samgraha used Agaru as Dhupana Dravya along with
Madan and Yawa in Karnasrava Nighantu recommended is use as a
Dhoopana
III In various Samhitas and Nighantus Agaru described as Tikta Snighdha
Sheetaprashamana Vranaprasadana Tvachya Due to these properties
Agaru is used in the treatment of Karna-Akashi Roga and Dushta Vrana
Shodhaka
IV Agaru is reported to have Antimicrobial Analgesic Antioxidants
Antihistaminic and anxiolytic properties Its Antihistaminic property gives
relief from itching which is cardinal feature of Otomycosis Due to Katu
Ushna Tikta Guna improves blood circulation Bheda stage develop It is
Niram Awastha of Dosha Karnagata kapha and vata get decrease and
symptoms like karnashoolakarnasrava get decrease Agaru also have a
Antioxidant properties
V Chemically Agaru Contain 2-(2-Phenylethyl) Chromones Terpenoids
Flavonoids
VI Natural Agarwood had inhibitive activities towards Staphylococcus Aures
The chloroform extract of Agarwood prolongs the pain threshold[108]
Page | 134
Madan
I Madanphala have therapeutic properties like Anti-inflammatory
Antiallergic Analgesic and Wound healing
II It is Useful in treatment of disease like Shotha (inflammation) Vidradhi
(Abscess) Pratishaya (Common cold) Kushta(Skin disease)
III Extract of Madanphala mainly contain Glcosides Tritorpenct
Glycosides Saponin
IV Saponin glycosides are act as fire extinguisher This property is helpful
for vartiIt also act as a detergent which clean the surface of fungus
V Tritorpenct act as a anti-inflammatory antimicrobial and
immunomodulator compound Interaction of glycosides with sterol
causes disturbance of selective permeability in plasmic membraneso
exudates and discharge get decrease
VI Pharmacological activity [109]
Antibacterial Activity The preliminary antibacterial activity of Methanolic
extract of Randia D lam was done on some standard and wild pathogenic
strains The inhibition of the bacterial growth was more pronounced on E coli
as compared to the other tested organism This shows the antibacterial action
of Randia D secondary infection can prevent
Anti-Allergic Activity In Ayurveda Randia D Extract and its fraction of milk
induced leukocytosis and eosinophilia in mice
Anti-Inflammatory Activity The crude methanol extract of fruit of Randia D
effectively reduced the carrageenin induced oedema in hind paw of the rats
significant reduction in granular tissue formation was recorded This activity
seems to be significant at various acute phases of inflammation and om
formation of granular tissue This proves action of Madanaphala in shopa
(inflammation)
Page | 135
Analgesic Activity Analgesic activity was tested in mice weighing between 20-
250 with six number of animals in each group Methanlic extract of fruit Randia
d give analgesic activity in both models This proves its Shoolanashaka (pain
killer) action
Immunomodulatory Activity Randia D has immunostimulant activity and
chloroform fraction which strongly affected immune system seems to be
bioactive fraction of this plant
The overall effect of Agaru Mandanphala Yawa having Anti-inflammatory
Antiseptic Antimicrobial Property Active ingredient shows these properties
Agaru Yawa Madanphala
Vatakaphaghna
Act as
Vranashodhak
Vedanasthapaka
Sheetaprashamana
Shothara
Avarana of Vata get decrease so helps to Shaman of Vata dosha
Karnakandu Karnashoola Karnasrava
Prashamana
Page | 136
This fact can be taken into consideration and probably acknowledge that
Karnadhoopana with Agaruwadi Varti had not leave any residue in the ear
Removal of fibrin keratinocyte migration and in growth of epithelial tissue
plays a major role in healing It is technique of fumigation of ear with the
smoke of anti-infective drug In Karnadhoopana Sthanik Swedana increase the
blood supply and helps in absorption of the drug reduce Karnakandu amp
Karnshoola associated with infection
Page | 137
SUMMARY AND CONCLUSION
Page | 138
The dissertation entitled randomize comparative clinical trial to study the
effect of Agaruwadi Karnadhoopan and Guggula Karnadhoopan In Karnasrava
wsr to Otomycosis
The dissertation is divided into fallowing parts
Introduction
Review of literature
Ayurvedic review
Modern Review
Drug review
Procedure review
Material and Method
Observation and result
Discussion
Summary and conclusion
bull INTRODUCTION
It includes importance of Shalakyatantra in Sushrut Samhita Charka
Samhita And Ashtang Samgraha
Common and specific causes of Karnasrava
Karnasrava is a clinical entity which can be corelate with Otomycosis
In Ashtang Samgraha stated the procedure like Karnadhoopana with
Agaru Yawa Madanphala in Karnasrava
Page | 139
bull REVIEW OF LITERATURE
1 Ayurvedic review
2 Modern review
3 Drug review
Ayurvedic review-
It includes Rachana-Sharir and Kriya-Sharir of Karna detail description of
Karnaroga and its types Karnaroga Samanya hetu Poorvaroopa Rupa
Samprapti Upadrava Pathya-Apathya of Karnasrava Vishesh Nidan and
Chikitsa of Karnasrava Detail description of Karnadhoopana according to
various Acharays have been mentioned
Modern review-
It includes anatomy and physiology of Ear brief anatomy of ear anatomy of
External middle and Internal ear Detail description of the disease
Otomycosis mechanism of fungal infection in external canal pathophysiology
investigations diagnosis and management
Drug review-
Detail description of Agaru Yawa Madan Guggula and its synonyms
Ayurvedic properties Karma uses Pharmacological action and their
pharmacodynamic properties
Page | 140
MATERIAL AND METHOD
It includes description regarding materials required for the study Preparation
of Agaruwadi Varti its Standardization Sterilization and packaging
Plan of study
1 Total 68 patients completed the treatment Age criteria was kept
between 18-60 years Patient selection was done by done by simple
random sampling method and divided into two groups A (Trial) and
Group B (Control) 34 patients in each group
2 Patients in Group A were treated with Karnadhoopana with Agaruwadi
Varti for 7 days two times in a day while patients in Group B were treated
with Karnadhoopana with Guggula for 7 days two times in a day
3 Clinical examination done during each follow up ie 0th 4rd 7th and
observation were recorded
Page | 141
OBSERVATIONS AND RESULTS
Page | 142
1 It was observed that higher incidence of disease Karnasrava ie
Otomycosis found in age group 25-35 years
2 Disease otomycosis was equal in both male and female
3 The trial group there was significant relief in Karnakandu (8906)
Karnasrava(9333) Karnashoola(7667) and karnabadhirya(100)
4 In control group there was significant relief in Karnakandu (7414)
Karnasrava(9524) Karnashoola(8438) and
karnabadhirya(8750)
Page | 143
REFERANCES
Page | 144
1 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published byChaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 17 page no
5
2 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 19 page no
6
3 DRNarayan Vidwas Shero-Karna-Nasa and MukhrogaAnand publication
edition 4th 2014 Page no-52
4 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-205
page no 111
5 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 111
6 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Shlok no2012
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 112
8 Dr KBBhargavaDr SK BhargavaDr TMShahaA Short book of ENT
diseases Usha publication edition 10th
9 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 8 Page no -52
Page | 145
10 Research and Review Journal of Ayurvedic science yoga and
Naturopathy 2017 4(3) 1-5 pA Critical review of Otomycosis in cortex to
Karnaroga described in Ayurvedic classic by amisha patel D B Vaghala
Chandani goswami Vol4 no3 (2017)
11 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogpratished Adhaya Shlok no-213
page no127
12 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedh Adhaya Shlok no-
2140 page no 131
13 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyant shirasiya adhaya Shlok no 1712 page no-
258
14 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
15 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
16 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Aupadravik Adhaya Shlok no-15 page no
2
17 Vaidya Jaymini panday Harit Samhita hindi commentaryChaukhamba
vidhyabhartiVaranasiedition 2010 Shlok no- 13-14page no-10
18 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 146
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-20345
page no 112
19 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Karnarogavigyniyam Shlok
no 21 Page no-731
20 Charak
21 Pandit Harigovind Shashtri Namalinganusasana Amarkosha of
Amarsimha hindi commentary published by Chaukhamba Sanskrit
Sansthan page no- 463
22 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
23 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 37
24 Shree Taranath-Trkavachspati-Bhattacharyen Vchaspatym published
by Rashtriya Samskrit Sansthandelhi Volume 4 page no- 5149
25 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
26 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
27 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
28 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Page | 147
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
29 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Indriyaopakramaniya Adhaya Shlok no 811
page no- 125
30 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243
31 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-510 page no56
32 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no3108 page no- 385
33 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no33 page no- 366
34 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sarvabhutachintasharir Adhaya
Shlok no-126 page no9
35 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-522 page no60
36 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-532 page no61
37 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Page | 148
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-521page no58
38 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-527 page no61
39 VdBramhand Tripathi Ashtanghradaya Sharirsthansthan Published by
Chaukhamba prakashana 2005 Shlok no331 page no-372
40 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Siravarnavibhaktisharir Adhaya
Shlok no-725 page no83
41 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Sharirsankhyavykaransharir Adhaya Shlok
no-512
42 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Pratekmarmanirdeshsharir
Adhaya Shlok no-628 page no75
43 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
44 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Marmasharirsthan Shlok no429 page
no- 393
45 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243244
Page | 149
46 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
47 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan pu blished by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711
48 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
49 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
50 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Shlok no 711 page no- 847
51 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Adhaya Shlok no-628 page no- 75
52 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Gandushavidhiadhaya Shlok no2232
page no- 261
53 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Karnavydhbandhvidhi Adhaya Shlok no-
1611 page no- 86
54 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Nidansthan Published by Chaukhamba
Page | 150
Sanskrit SansthanVaranasi Vatvydhinidansa Adhaya Shlok no183 page
no- 304
55 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavaykaransharir
Adhaya Shlok no-532 page no61
56 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Tristaisniya adhaya Shlok no 1120 page no-
163
57 P Hazarika Dr Nayaka R Balkrishnan Textbook of EarNoseThroat and
Head-Neck Surgery CBS Publication Anatomy of Ear
58 DrKB Bhargava DrSKBhargava DrTMShaha A short book of ENT
Diseases Published by Usha Publication 10th edition page no10
59 MrSalah Mansour MrJacques MagnanMr Hassan Haidar MrKaren
Nicolas MRStephan Louryan Comprehensive and clinical anatomy of the
Middle Ear Published by Springer publication Chapter -Middle Ear cavity
Page no 19 to 121
60 DrPLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 7
61 James OPickles An introduction to Physiology of Hearing Published by
Emerald publication 4th edition page no- 1 to 265
62 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
63 VdBramhand Tripathi Ashtanghradaya Uttarsthan Published by
Chaukhamba prakashana 2005 Karnaroga vigyniyam adhaya Shlok
no1713 page no- 998
Page | 151
64 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Shlok no- 212 page no-
730
65 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no
1-2 page no- 309
66 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana
67 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyantshirasiya Adhaya Shlok no 1713 page no-
258
68 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no-
6 page no- 310
69 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Karnarogavigyniym Shlok no- 1725-26 Page no-
1003
70 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2140 page
no 131
71 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Adhyay 18 shlok 35
72 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt
Karnarogapratishedhoadhya Shlok no-2211 Page no- 735
73 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 152
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2141 page
no 131
74 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2142 page
no 131
75 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2144 page
no 131
76 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 34 page no- 649
77 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2145page
no 131
78 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 37 page no- 649
79 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2146page
no
80 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
81 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 153
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2143page
no
82 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publication Krnarogadhikara adhaya page no-
318
83 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary
Madhyamkhand Vatkalpana shlok no- 782-83 page no- 137
84 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 72-77 page no- 651
85 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
86 Vd Shree Laxmipatishastri Yogratnakara
87 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
Karnarogadhikara Shlok no- 808182 page no- 652
88 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 83 page no- 652
89 (PDF) Otomycosis A Comprehensive Review (researchgatenet)
90 httpswwwncbinlmnihgovpubmed24948980
91 A Simon Carney Scott-Browns Otorhinolaryngology Head and Neck
Surgery CRC press 8th publication Otitis externa and otomycosis
92 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no Page no -
93 wwwguggulipidcomtradhtm
Page | 154
94 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
95 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-28 page no-
43
96 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009Agaru page
no726-728
97 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishra chapter Karpuradi varga Shlok no-31-
43 Page no- 116
98 httpswwwthiemeinimagecatlogsample_chapter_GOMPpdf
99 (PDF) Chemical Constituents and Pharmacological Activity of Agarwood
and Aquilaria Plants (researchgatenet)
100 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 4 chapter no-2 page no-4
101 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 chapter no-152 Madanpage
no376-379
102 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
103 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-54 page no-
84
104 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 page no697-699
patol-yawa
Page | 155
105 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
106 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
Dhoompanvidhi page no- 252-254
107 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012Chikitasasthan Shlok
no- 151page no-406
108 httpswwwmdpicom1420-3049232342pdf
109 httpswwwijamcoinindexphpijamarticledownload0610201530
0
Page | 156
BIBILOGRAPHY
Page | 157
1 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
2 Scott-Brown WG Diseases of the EarNose and Throat Landon
Botterworth and co(publishers) Ltd1952 Volume 2
3 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012
4 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009
5 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi commantry
Purvakhand and Madhyamkhand
6 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Published by Chaukhamba Sanskrit
SansthanVaranasi
8 The Ayurvedic Pharmacopeia of India Ministry of Health and family welfare
department of Ayush Part 1 and part 4
9 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005
10 Acharya Trivedi Raguveer Prasad Ashtang sangrah published by
Vaidyanath Ayurveda bhavan pvt
11 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition
12 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary published by Chaukhamba
Orientalia
Page | 158
ANNEXURE
Page | 159
ANNEXURE- 1
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
CASE RECORD FORM
RESEARCH PROFORMA FOR MS (AYU) DESSERTATION
DEPARTMENT OF SHALAKYATANTRA
NAME -
ADDRESS -
GENDER - AGE - OCCUPATION-
RELIGION - EDUCATION - MARITAL STATUS-
OPD IPD NO-
DATE OF ADMISSIONCOMMESEMENT-
DATE OF DISCHARGECOMPLITION-
DATE OF COUNSELLING-
TEL NO-
CHIEF COMPLAINTS-
PAST MEDICAL AND SURGICAL HISTORY-
TREATMENT HISTORY-
FAMILY HISTORY-
Page | 160
PERSONAL HISTORY-
a) Ahar(Diet)
b) Vihar
c) History of addiction
GENERAL EXAMINATION
PULSE - MIN BP - mm of hg
TEMP - 0F RR - MIN
ASHATAVIDHA PARIKSHANA
Nadi- Mutra- Mala-
Jivha- Shabda- Sparsha-
Drik- Aakruti-
SYSTEMIC EXAMINATION
RS ndash
CNS-
CVS ndash
Page | 161
LOCAL EXAMINATION (KARNA PARIKSHAN)
OBSERVATION TABLE FOR SUBJECTIVE CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching )
RIGHT EAR LEFT EAR
KARNASHASHUKULI
KARNAPUTRAK
KARNAPALI
KARNAKUHARA -
SRAVA
GANDH
VARNA
SWARUPA
KARNAPATALA (TM)
Page | 162
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
Hearing Test
1Renne Test ndash
2 Weber Test -
Examination of Ear-
Pathological Investigation-
Other Examination-
Nidan Panchak-
1Hetu-
2Purvarup-
3Rupa-
4Upashayanupashaya-
5Samprapti
Signature of Guide Signature of Doctor(Researcher)
Page | 163
ANNEXURE 12
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Dhoopana Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization were done as recommended in pharmacy procedure
The raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 were mixed together
in equal quantity to make Agaruwadi churn
STEP 4 - Agaruwadi churn were triturated with appropriate quantity of water
and prepared Varti in GMP Certified Ayurvedic pharmacy Standard aseptic
precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Dhoopana Varti was packed in sterile air packed
container
STEP 6 - Agaruwadi Dhoopan was given with the help of Dhoopan yantra
TREATMENT DETAIL-
Purvakarma -
1 The patient is asked to sit comfortably on chair having sufficient light and
less amount of dust
2 The EAC is cleaned thoroughly by Pichu Varti (cotton swab) to remove the
discharge and other debris
Pradhankarma -
1 The patient is asked to relax completely on the chair
Page | 164
2 Fumes are passed to the ear with Dhoopana Yantra
3 Dhoopana yantra is funnel shaped and its one end will keep the ear covered
for the passage of Dhooma into the ear canal and other end where Agaruwadi
Dhoopana Varti were placed which produces fumes
4 This Dhoopana was given for 5 min
Pashchat karma -
1 The patient were advised to avoid cold refrigerated food drinks cold water
bath cold wind fog and prevent water from entering the ear
(A) Agaruwadi Dhoopana Varti
B) Guggula Dhoopana Varti SOP of it is same as above Agaruwadi Dhoopana
Varti
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Page | 165
ANNEXURE 21
INFORMED CONSENT DOCUMENT
Study Title
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
Introduction
- You are invited to take part in a research study RANDOMSIED COMPARATIVE
CLINICAL TRIAL TO STUDY THE EFFECT OF AGARUWADI DHOOPANA AND
GUGGULA DHOOPANA IN KARNASRAVA
- Before you decide it is important for you to understand why the
research is being done and what it will involve
- Please take time to read the following information carefully and discuss
it with friends relatives and your doctor if you wish
- Ask us if there is anything that is not clear or if you would like more
information
Purpose amp Nature of Study
- In this research project by examine you and ldquoKarnasravardquo (Otomycosis)
disease were treated
- In the part of treatment Agaruwadi Dhoopana or Guggula Dhoopan were
given
- Dhoopana means medicated drug fumes were given in ear with the help of
Dhoopan Yantra
Page | 166
- Treatment was given for 7 days
Study Duration
7days
Participation
- Your participation is entirely voluntary
- If you do decide to take part you were given this information sheet to keep
and be asked to sign a informed consent form
- If you decide to take part you are still free to withdraw at any time and
without giving a reason This will not affect the standard of current or future
medical care you may receive
Confidentiality
- All information which is collected about you during the research were
kept strictly confidential
- Any information about you which is collected from the center will have
your identity in the form of a code number so that it will remain confidential
Benefits Of Study
- The results obtained from this study would be helpful for providing better
quality of treatment amp other essential facilities for Karnasrava (Discharge)
patients
- You will get clinical benefit from the study
Page | 167
Risks Of Study
- In this treatment there are few chances of Irritation of Ear Nose and
congestion at EAC if any of these happens then treatment were given
Results Of Study
- If the Results obtained are profitable then they may get published
without disclosing your details
Signature of patient
Date
Time
Phone no of Researcher
Page | 168
रण मादहती पतरक
सशोिनाच शीषवक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE
EFFECT OF AGARUWADI DHOOPANA AND GUGGULA DHOOPANA
IN KARNASRAVA
परसतताना
- आपणास या सशोिनातपमक अभयासात सहिागी होणय़ाच आाहन करणयात यत आह
- सशोिनातील सहिाग तननदशचत करणयापी सशोिनाच उददश समजन घया
- खालील मादहती काळजीपवक ाचा आणण आशयक ािलयास आपलया डॉकिराशी कका
दहतशरचतकाशी चचाव करा
- काही सददिता असलयास कका आणखी मादहती ही असलयास आमछयाशी चचाव करा
सशोिनाच उददीटि सतरप
- सदर सशोिन परकलपामरधय आपलयाला तपासणी करन कणवसरा या वयाशरिची शरचककतपसा दणयात
यणार आह
- सदर वयाशरिची शरचककतपसा महणन आपणास अगरादी िपन कका गगल िपन
दणयात यणार आह
- सदर औषि आपणास 7 ददस घयायाच आह
Page | 169
कालािी
- 7 ददस
सहिाग
- आपला सहिाग हा पणवपण ऎनदछिक आह
- आपला सहिाग तननदशचत असलयास आपणास ही मादहती पतरतरका दणयात यईल आपणास यातील
समती पतरकार सही कराी लागल
- सहिाग तननदशचत असनही आपण कोणतपयाही ळस कोणतही कारण न दता माघार घ शकता
याचा आपलया दयकीय सविर कोणताही पररणाम होणार नाही
गोपनीयता
- सशोिना दरमयान गोळा कलली आपलया वषयाची सव मादहती गोपनीय ठणयात यईल
- आपली यनदकतक मादहती साकततक सतरपात गोपनीय ठणयात यईल
सशोिनाच फ़ायद
- सशोिनाच तनटकषव कणवसरा बाशरित रणाछया दयकीय इतर सविाचा दजाव सिारणयास
फायदशीर ठरतील
सशोिनातील जोणखम
- य़ा शरचककतपसमरधय कान दखण डॊळय़ातन नाकातन पाणी य़ण नाकात जळजळण डोक जड
होण ही लिण ददस शकतात यापकी लिण तनमावण झालयास तपयाची शरचककतपसा कली जाईल
Page | 170
सशोिनाच तनटकषव
सशोिनाच तनटकषव फ़ायदशीर ठरलयास आपली मादहती गोपनीय ठन परकाशशत करणय़ात यईल
रण सतािरी-
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
Page | 171
ANNEXURE 31
INFORMED CONSENT FORM
Patient OPD no __________
Subjectrsquos Identifier
Date of Birth Age Gender
I _____________________________________ age___________ years
exercising my free power of choice hereby give my consent to be included
as a participant in the clinical study entitled
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
1 I confirm that I have read have been read and understood the information
sheet for the above study and can ask questions
2 I understand that my participation in the study is voluntary and that I am
free to withdraw at any time without giving any reason without affecting my
medical care or legal rights
3 I understand that the Ethics Committee members investigators and study
doctors will not need my permission to look at my health records both in
respect of the current study and any further research that may be conducted
in relation to it even if I withdraw from the trial I agree to his access
However I understand that my identity will not be revealed in information
released to third parties or published
4I agree not to restrict the use of any data or results that arisefrom this study
provided such a use only for scientific purpose
5 I agree to take part in the above study
Page | 172
signature with Date-
Left hand thumb impression
Name amp signature of the witness ndash
Name amp signature of the student ndash
Page | 173
ANNEXURE 32
समतीपतरक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
वयकतीच य
ददनाक जरमददनाक
1) मी ह तननदशचत कररत आह ककसदर सशोिन परकलपाबाबतची सपणव मदहती मी ाचली असनमला ती
समजली आहतपयाबददल मला परशन वचारणयाची पणव मिा आह सदर मादहतीन माझ समािान झाल
आह
2) मी सदर सशोिनातन माझया मजीनसार किीही बाहर पड शकतो या माझया अशरिकाराची मला कलपना
आह
3) माझी दयककय मादहती तपासणयाची कागदपतर कळ सशोिनाकररता ापरली जाणार आहत याची
मला मादहती आहसदर सशोिन परकलपातील सबशरित घिकाना माझी दयककय मादहती पाहणयाची मी
समती दत आहतरावप या सदिावतील माझी ओळख दशववणारी मादहती कोणासही ददली जाणार नाहीयाची
मला कलपना दणयात आली आह
4) सदर अभयासातन शमळणारी मादहती अरा तनटकषव कळ शासततरीय हतसाठी ापरल जाणयासाठी माझी
समती आह
5) रील अभयासात सहिागी होणयास माझी समती आह
रण सतािरी-
Page | 174
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
ASSESSMENT CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching)
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
a) कणवशल ( pain )- 0 - Absent
1 ndash Present
Page | 175
b) कणवकणड (Itching)- 0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
c) कणवसततरा ( Discharge )
0- Absent
1-Mild- Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाशरियव ( conductive Loss of hearing )
0 - Present
1 - Absent
Page | 176
Page | 177
Page | 178
Page | 179
Page | 180
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
Page | 181
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 182
AUTHENTIFICATION CERTIFICATE
Page | 6
AIM OF STUDY
To evaluate the effect of Agaruwadi Varti Dhoopana and Guggula Varti
Dhoopana in management of Karnasrava
OBJECTIVE
To compare the efficacy of Agaruwadi Dhoopana and Guggula Dhoopana in
Karnasrava
HYPOTHESIS
NULL HYPOTHESIS -
H0- Agaruwadi Dhoopana is not effective than Guggula Dhoopana in
Karnasrava
ALTERNATE HYPOTHESIS -
H1- Agaruwadi Dhoopana is more or equally effective than Guggula
Dhoopana in Karnasrava
RESEARCH QUESTION
Whether there is significant difference between Agaruwadi Dhoopana and
Guggula Dhoopana in Karnasrava
Page | 7
PREVIOUS WORK DONE -
1 Anupama Patra B Effect Of Arka Taila In The Management Of
Karnasrava With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2007
2 Palmer Komalben K Further Study On Role Of Arka Taila In The
Management Of Karnasrava With Special Reference To
Otomycosis Shalakya Tantra Institute for Post Graduate Teaching amp
Research in Ayurveda Gujarat Ayurved University Jamnagar 2010
3 Sathisha Shankar B Management Of Karnasrava With Sthanika
Guggulu Dhoopana And Rasnaadi Guggulu-A Comparitive Study Shalakya
Tantra Government Ayurvedic Medical College Bangalore 2011
4 Shashikala DK Comparative Study On The Efficacy Of Vacha
Lashunaadi Taila Karna Pichu And Nimba Patraadi Dhoopana In The
Management Of Karna Srava Shalakya Tantra Government Ayurvedic
Medical College Bangalore 2014
5 Javale Anant A Clinical Study On The Efficacy Of Arka Taila In The
Management Of Karna-Srava Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2005
6 Pournima V Koti Management Of Karnasrava With Priyangvadi Taila
Pichu With And Without Saarivadi Vati Shalakya Tantra Sri Jagadguru
Gavisiddeswar Ayurvedic Medical College Koppal 2015
7 Amisha Patel A Clinical Evaluation Of Honey In The Management Of
Karna Shoola With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching and Research in Ayurveda
Gujarat Ayurved University Jamnagar 2016
Page | 8
REVIEW OF LITRATURE
Page | 9
Ayurvedic literature Ayurveda is a science of life practice since
thousands of years The ancient Indian system of medicine and surgery is
commonly known as Ayurveda This was given the status of Upaveda or
fifth Veda in the next stage of growth Among the available literature three
Samhita that is Charaka Samhita Sushrut Samhita Ashtang Hrudayam and
Ashtang Samgraha are the chief source of knowledge of Ayurveda
Ayurveda consist of eight branches Shalakyatantra is one among them
Shalakyatantra is one of its specialized branch deals with science of
ophthalmology otorhinolaryngology Oro dental surgery and head Acharya
Sushruta himself a practical surgeon was the first to advocate dissection of
dead bodies is indispensable for a successful student of surgery He had
described gross anatomy in the first chapter of Uttartantra Shalakyatantra
define by different Acharys as follows
शालाकय नामोरधवजतरगताना रोगाणा शरणनयनदनघराणाददसशरशरताना वयाशरिनामपशमनारव
स स ११०
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत [13]
चस १७१२
Shalakya Tantra Nirukti and Parichaya
शलाकायााः कमव शालाकय ततपपरिान शलाकयम डलहण [14]
The term Shalakyatantra is derived from Shalakya and Tantra
The word Shalakya means A probe and Tantra denotes teaching and
practices found in scripturesThe compendium in which application of
Shalaka in various surgical procedures is principally described is called as
Shalakya tantra
दनदटिवशारदााः शालाककनाः डलहण ( सउ ११३)[15]
An eye specialist is termed as Shalaki by Dalhana
Page | 10
Synonyms of Shalakya Tantra
Uttamanga Chikitsa Jatrurdhwa Chikitsa Urdhwang Chikitsa Shalakya
Chikitsa
Importance of Shalakyatantra-
Life of living being and all the Indriyas are situated in the head hence it is
known as Uttamanga
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत
चस १७१२
The treatment given to this part of the body is described specially in
Shalakya tantra While describing the importance of Shiras Vagbhata
correlates it to the root of tree (Urdhwa Mula) and body to the trunk of tree
(Adha Shaka)
Sushruta has deal with Mukha Roga in Nidan Shan and its treatment in
Chikitsasthan The description regarding the disease of eye ear nose and
head are found only in UttaraSthan Sushruta specially describes the
disease of Shalakyatantra as told by Videha in the beginning of Uttartantra
itself[16]
Shalakyatantra Itihas-
India Exhibits traditional of more than thousands of years in art literature
language logic and philosophy etc The convention was in its sophisticated
and advanced attire throughout the Vedic period
Vedic period ndash
1 Natush was treated for deafness by Ashwinikumars (Rigveda)
2 Rujaswa and Kanva were treated for blindness by Ashwani Kumaras
(Rigvedas)
Page | 11
3 There are several prayers mentioned for normal functioning of sense
organs (Yajurveda)
4 Structures and functions of Mastishka are described (Atharveda)
5 Mantras having reference to disease of Eye Ear Oral cavity etc are
found (Atharvaveda)
Upanishada Period ndash
1 Samhita Period
a) Sushrut Samhita ndash
bull Explanation regarding Netra Nasa and Shirorogas (Uttartantra 1-
26th chapter)
bull Details regarding Mukha and Karna Roga Nidan and
Chikitsa(Nidansthan 16th and Chikitsasthan 22nd chapter)
bull Description regarding Karna Chedana Sandhana Nasa
Ostasandhana Sutra Sthan 16th chapter
b) Charaka Samhita -
bull Explanation regarding Shirorogas (Sutrasthan 17th chapter)
bull Explanation of Gala rogas like Upajivika Galshundi and Rohini
bull Nasa Shiro Mukha Karna and Netra Chikitsa (Chikitsa sthan 26th
chapter)
bull Description regarding Lakshana and Chikitsa of Shankhaka
Ardhavbhedaka Shirovirechana and Shiro basti (siddhi sthan 9th
chapter)
c)Ashtnga Sangraha ndash
bull Detailed description regarding Shalakyatantara (Uttartantra 11-28
chapter)
bull Description of Kriyakalpa (Sutrasthan 32nd and 33rd)
Page | 12
d)Ashtang Hrudayam
bull Detailed description on Shalakya Tantra (Uttar tantra 8-24 chapters)
bull Kriyakalpas (Sutrasthan 23rd and 24th chapter)
e) Bhela Samhita
bull Chakshushya Vaisheshik and Buddhi Vaisheshik Alochaka pitta
f) Harita Samhita- Branch of Medical science offering elaborating
information about the procedure like Nasya Anjan Gandusha etc
comprehended with their applications in disease of Head Eyes Ears
Eyebrows Throat Temporal region and cervical spine is known as
Shalakyatantara
शशरोरोगा नतररोगा कणवरोगा वशषताः भरकरठशङकमरयास य रोगा समिनदरत दह १३
तषा परततकारकम व नसतयतपयवणजनातन च अभयङगमखगणडषकियााः शालकयसशमतााः १४
इतत शालाकयनाम [17]
Documentation of different ancient literature gives various references
regarding all aspects of Karnasrava in various periods It is very much
important to know the history of Karnasrava from Vedic Pauranic Samhita
and Samgraha period
Vedic period ndash The Vedas being the oldest source of knowledge have no
direct mentioning of Karnasrava
Page | 13
Samhita and Samgraha period ndash
Aacharya Sushruta described about Karnaroga Karnasrava Nidan
Roopa and Chikitsa The detail description is available in Sushrut
Samhita Uttartantra 20 and 21st chapters
Aacharya Charaka did not specify Karnasrava but mentioned 4 types
of Karnarogas that is Vataj Pittaj Kaphaja and Sannipataja and their
treatment in 26th chapter of Chikitsasthan
In Ashtang Hrudaya karnasrava is not explained as a separate disease
but Chikitsa is mentioned in 18th chapter of Astanga Hrudaya
uttartantra
In Ashtang Samgraha Chikitsa is mentioned in 22nd chapter of Astang
Samgraha Uttartantra
The details about Karnasrava are explained in Bhavprakasha
Madhyamakhanda 64th chapter
Madhavakara has explained about Karnasrava in 57th chapter of
Madhymakhanda
Karnasrava is also explained in Sharangadara Samhita Uttarkhand 11th
chapter
The reference for treatment of Karnasrava is available in
Yogaratnakara
In Gadhnigraha Karnasrava and its treatment is mentioned in
Karnarogadhikara Adhaya
Vangasena had mentioned about the disease and treatment in 69th
chapter
Chakradatta explained Karnasrava in 57th chapter
Dalhana has given commentary on Sushrut Samhita Uttartantra 20th
and 21st chapter
Sankhya Samprapti of Karnasrava ndash
Aachary Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga
Vigyniyam Aadhaya Aacharya charaka explain 4 Karnaroga in
Page | 14
Karnarohvigyniyam Adhaya based on doshas Acharya Vagabhata in
Ashtang Hrudaya explain 25 Karnaroga in Adhyaya
कणवशल परणादशरच बाशरियव कषड ए च
कणवसरााः कणवकणडाः कणव चवसतततर च
कशमकणवपरततनाहौ विशरिदवविसततरा
कणवपाकाः पततकणवसततराशवशरचतवविम
कणावबवद सपतवि शोफशरचावप चतवविाः
ऎत कणवगता रोगा अटिावशततरीररतााः
स उ २०- ३ त ५[18]
ातकणवरोग वपततकणवरोग कफकणवरोग
रकतकणवरोग सनदरनपातकणवरोग कणवनाद
बशरिरतप परततनाह कणडाः शोफ पततकणवक
किशमकणवक उियरपविरधयअशो अबवद
कशरचकणवक वपपपली वदाररका पाळीशोष
ततिका पररपोिो उतपपातो उरमरर दाःखिवन
शलहाखयााः परचवशनदरतकणवरोगा उकतााः
इदिीका अ स उ २१ [19]
चतपाराः कणवरोगााः
च स [20]
Page | 15
KARNA
Karna ndash करोतत शबद गरहण [21]
The organ of hearing
Karnasrava- कणवसतय कणवयोाव ससराा [22]
Discharge from the ear is referred as Karnasrava
KARNA SHAREERA
bull Nirukti
कणयवत अकणयवत अनन इती [23]
It means reception and conduction of sound waves
These are the functions of external and middle ear
bull Nirukti of Sravanam
शरयत अनन इती शरणम[24]
It means perception of sound
It can be attributed to the internal ear function
bull Karna Utpatti-
Karna is an organ formed by Akash Mahabhuta[25]
The fundamental characteristic is as follows
Indriya ndash Srotram [26]
Indriya Adhisthan ndash Karna [27]
Indriya Dravy ndash Akasha [28]
Indriya Arth ndashShabdha [29]
Indriya buddhi ndash Srotobyddhi
Page | 16
bull Paryaya of Karna- Shabdapatha Srotrapatha Sravanam shruti
Kuhuram Dwanigraham etc
bull Definition of Karna-
कणवशटकलयनदछिरनमिटिोपगरदहत शरोतरमछयत [30]
मा तन ५७१
The definition of Karna is stated in Madhav Nidanam Indriya which is not
seen with naked eye along with Shashkuli is called Shrotra that is Karna
Indriya is so minute that it is not perceived with any sense organ
In Charak Samhita the word Karna explain as the Indriya Adhisthan of
Shabdha Karna is described as one of the Prathyangas of the body He
emphasizes that all Indriyas manifest during the 3rd month of gestation
period
Acharya Sushruta while describing formation of Purusha from Prakriti or
Avyakta narrated that all Indriyas are developing from the Vikarika and
Taijas Ahankara Both Vagabhata and Sushruta stated that Karna as one of
the Bahirsrotas
शरण नयन दन घराण गदमढराणण न सततरोताशसराणा बदहमवखातन [31]
स शा ५-१०
In Ashtang Hradaya Vagbhata has states that all Indriyas are Atmaja
According to him lower lobule elevated helix projected posterior portion
fleshy and adherent ear are indications of long span of life[32]
ततरखातखातन दह अनदसतमन शरोतर शबद ववकतता [33]
ा शा ३-३
शबदाः शबदनदरिय सवनदछििसमहो ववकतता [34]
स शा १-२६
Page | 17
Ear has the prominence of Akash Mahabhuta The prominent dosha of ear
is Vata It is important seat of Vata The prominent Dhatus are Asthi and
Mamsa Karna is one of the Panchgnanendriyas and it meant for hearing
Sushruta narrated that Karnasthita Asthi and Sandhi
घराणकणवगरीाकषिकोषष तरणातन [35]
सशा ५-२२
शरोतरशरगािकष शखाताव [36]
सशा ५-३२
गडकणवशखटककम [37]
स शा ५-२२
One Sandhi and one Tarunasthi in ear
Sandhi ndash Karna contain two Sandhi one in each ear Type of Sandhi is
Shankhavartha which is present in Shringataka
Mansapeshi ndash 2[38]
Siras ndash 10 [39]
Vataj Sira - 4
Pittaj sira - 2
Kaphaj sira - 2
Raktaj Sira - 2
Avedhya sira-
कणवयोदवश तासा शबदादहनीनामकका पररहरत
सशा ७-२५[40]
Amongst above mentioned ten Siras each Karna lodges one Shabdavaha
Sira It is Avedhya
Page | 18
Dhamani -2
Length of ear is 4 Angula
Karna moola ndash 2 Angula
कणाविरतर चतदवशअगलम
स शा ३५-१४[41]
The distance between two ears through the back of the neck is 14 Angula
bull Marmas of Karna-
1 Vidhuras-
कणवपटठतो अिाःसशरशरत विर ततर बशरियवम
सशा ६-३७[42]
कणतपयादद सतनायममवणी ककनदचचनदरनममनाकर कलयकररणणच
डलहणाचयव[43]
अिसततात कणवयोतनवमन विर शरततहाररणण
ा शा ४-२९[44]
Sankhya-2
Vistara- frac12 Angula
Type- Snayumarma (Susha)
- Dhamanimarma(AH)
- Vaikalykar
Sthana- It is situated in the depressed portion in the back of the ear
Injury to them causes loss of hearing
Page | 19
2 Shringataka marma-
नदजवहाकषिनाशसकाशरोतरखचतटियसरमम
तालरयासतयातन चतपारर सरोतसा तष ममवस
वदि शरगातकाखयष सददसततपयजतत जीवतम
मा तन ५७१ [45]
Sankhya- 4
Type- Siramarma
Sthana- It is in head that is amidst Siras (blood vessels) nursing sense
organ
A palm size area near Talu
Injury to this Marma causes death
In modern anatomy ear divides into Bhayakarna or External ear Mdhyakarn
or Middle ear Antahkarna or Internal ear This is extremely appropriate
Even though the ear is divided into three divisions in the point of modern
anatomy Ayurveda denotes ear organ is one Ayurveda treats disease by
way of assessing Dosha and Dushya Here Dushya is one that is Karnendria
Dosha difference will call for different treatment for different disease Hence
treating the vitiated Dosha will cure the disease irrespective whether it is in
external middle or internal ear The thought is based on different
fundamental principle from Ayurveda
bull Parts of Karna
In Ayurveda classics detailed description about anatomy of ear is not
available But the various parts are mentioned as follows
Bhayakarna- External ear
Mdhyakarna ndash Middle ear
Antahkarna- Internal ear
Page | 20
द कणवशटकशलक दॊ कणवपतरकौ
च शा 7-11[46]
कणवशटकशलक कणवगतातवकौ कणवपतरकौ त बाहयकणा
चिदतत च शा 7-11[47]
शटकली बाहयपालयाशरिटिानम
डलहन- स शरच 25-1 12[48]
Karna Shashkulika ndash It is also called as Karna Shashakuli Charaka has
mentioned this term while describing different Pratyngas of the body
Acharaya Gananatha sen has given the clarification for it as a pinna or
auricle[49]
Karnapali ndash It is popularly known as lobule of the ear Daivakrita Chidra is
present in it
Karnaputrika- Ayurvedic scholars accepted two terms in this cortex They
are Karnaputrika and Karnaputrika The former is considered as Tragus and
antitragus[50]
Karna Prushtha- It can be taken as the cranial surface of mastoid or
auricle[51]
Karnapeetha- Aacharaya Sushruta firstly mention the term Karnapeetha
It is mentioned first by Sushruta while describing the procedure of
Karnavyadana Vagbhata has mentioned that it is Adhobhaga of Karna
Dalhana has clarified that it is the region above the Karnaputrika that is the
region which is at the bottom of the concha
Karnamoola ndash It can be considered as parotid region[52]
Karna lathika ndashAcharaya Dalhana mentioned lobule as a Karna Lathika
Page | 21
Karnaavatu ndashThis term is used by Sushruta while describing the
measurements of different Angapratyangas where he has mentioned that
the distance between the Karnaavatu is 14 Angul Dalhana has comments
that it can be taken as the distance between two ears from behind[53]
Shabdhavahasrotas ndash It also called as Shabdapatha or Srotapatha The
whole passage through which the sound waves pass can be taken as
Shabdavahasrotas[54]
Shrotashringataka ndash It can be taken as the labyrinth of ear[55]
bull Dosha in context to Karna-
Karna is principal location of Vayu
1 Prana Vayu- Prana Vayu circulating in oral cavity is responsible for
Dehadhruka that is keeping all body parts active Indriyadruka that is
keeping all Dnyanendriya healthy by proper nourishment (Purana) helps in
deglutition of food material and convey the stimulation of Indriyabuddhi
and atma
2 Udana Vayu- Bala(strength) Varna speech singing are its function It
is responsible for facial expressions due to pleasure sorrow anger love
frustration etc in general its circulation and actions are just opposite to
Pranavayu
3 Vyana Vayu- Its principal functions are circulation of Rasa and Rakta
through body and various movements Its main location is Hrudaya Five
types of movements for which it is responsible are expansion contraction
upward downward and oblique other activities are opening closure of
eyelid yawning perspiration During circulation if it gets obstructed due
to Srotodushti it generates disease of that Srotas Vyana Vayu gets vitiated
by disease of Rasa Rakta Oja and Chetanadhatu
Page | 22
4 Samana Vayu- It is circulating in the vicinity of stomach and intestine
and helps in keeping the Jatharagni (digestive juices and enzymes) in
equilibrium Disturbance in Jatharagni precipitates disease
5 Tarpaka Kapha- Entire body functions movements are controlled and
executed by various centers in the brain Sensation perceived by sense
organs is conveyed to Mann and Aatma residing in Hrudaya The motor
signals from them are then conveyed to the functioning
organsKarmendriya through Prana Vayu Shira head is therefore a
location of continuous activities motions of Vata All these centers are in
unctuous Majjadhatu in the Shira For stabilizing this ever-active Vata and
to nourish the Majja dhatu very unctuous Tarpaka Kapha situated in Shira
plays an important role
bull Ayurvedic aspect of sound perception [56]
According to Ayurveda Pratyaksha Dnyan or Perception of any sensation
including Shabda occurs due to interaction of the Karnendriya and the
Indriya- Arth -Karma resulting in Sravana
External Environmental acquaintance with living body is executed by five
sense organs namely Netra Karna Nasa Jivha and Twaka All
Dnyanendriya that is sense organ are Panchmahabhautic combination
Despite this fact every Indrya sense organ perceives object Tanmatra of
that Mahabhuta only from which it is originated from Akash Mahabhuta and
hence perceives Shabd only that is audio perception Shrotrendriya is one
of the principal locations of Vata and its function is to perceive Shabda that
is sound waves This sensation is conveyed through Shabdavahi Dhamanis
to Mana and Atma through Pranavayu and the sequence is responsible for
perception of sound in this way external sound is perceived and interpreted
when Atma is linked with Mann Mann is linked with Indriyabuddhi that is
minute virtual Dnyanendriya located in brain Indriyabuddhi is linked with
Adhishthana with prominent Mahabhuta and lastly with Indriya
ArthShabdatanmatra that is sense object Once this sequence is completed
Page | 23
the meaning of a particular sound is interpreted and understood In this
entire process of perception and interpretation of sound waves Pranavayu
and Tarpaka Kapha located in Shira play extremely important role Hence
the healthy status of all the sense organ depends upon the normal
physiologically homeostatic condition of Pranavayu and Tarpaka Kapha
MANAS
ATAMA
BUDDHI
AHANKARA
ARTHA
Page | 24
EAR ANATOMY
bull Embryology of the Ear [57]
1 The sound conducting apparatus develops from the branchial apparatus
whereas the sound perceptive apparatus from the ectodermal otocyst
2 The pinna develops from the six hillocks around the 1st branchial cleft
3 External auditory canal develops from 1st branchial cleft
4 The outpouching of the 1st pharyngeal pouch gives rise to a proximal
narrow part that forms the eustachian tube and distal dilated part that
forms the middle ear cavity
5 Prussakrsquos space is a potential space lateral to the Shrapnellrsquos membrane
and medically by the neck of malleus that can be involved during the
extension of cholesteatoma
6 Development starts in the 3rd week of the intrauterine life and is
completed by 16th week of intrauterine life Membranous and boney
labyrinth develops from the otic capsule
The Ear is divided into
1 External Ear
2 Middle Ear
3 Internal Ear or the labyrinth
Page | 25
Fig 1 Ear Anatomy
EXTERNAL EAR [58]
The outside ear contains pinna and lobule
Pinna is the noticeable piece of outer ear made from single sheet of yellow
flexible ligament covered by subcutaneous tissue and skin It has two
surfaces average and parallel It is intently disciple to perichondrium on its
sidelong surface while it is somewhat free on average surface Pinna
incorporates tragus helix against helix fossa three-sided scaphoid fossa
incisura terminalis
External auditory Canal ndash It extends from the bottom of the conchea to
the tympanic membrane and measures about 24 mm along its posterior
wallit is S shaped
Parts 1 Cartilaginous part
2 Bony part
Page | 26
Cartilaginous part ndash The outer one third is cartilaginous consist of fibro
cartilage is directed first inward backward and upward It has Fissure of
Santorium The skin of this part of the canal contains hair follicles
sebaceous gland and cruminous gland
Bony part ndash The inner two third part is boney It goes forward downward
and medially skin lined in this part is very thin Isthmus is the narrowest
part of the canal lying medial to junction of bony and cartilaginous part
nearly 5 mm lateral to tympanic membrane
The roof and posterior wall of the external auditory canal shorter than floor
and anterior wall The skin lining the tympanic membrane and boney canal
has a self-cleansing property due to migration of keratin layer of epithelium
from drum towards the cartilaginous portion
Relations- Anteriorly- Temporomandibular joint and parotid gland
Superiorly- Middle cranial fossa
Inferiorly- parotid gland
Posterior- Mastoid antrum mastoid air cells and facial nerve
Nerve supply ndashSensory nerve supply of the external ear The auricle
supplied by fibers of the great auricular nerve (C2 and C3) and lesser
occipital nerve (C2) Auriculo temporal branch of the 5th cranial nerve and
auricle branch of the vagus (Arnoldrsquos nerve) supply external canal Facial
nerve has small sensory contribution on posterior-inferior wall
Tympanic Membrane -It is the partition between EAC and middle ear It
is a thin semitranslucent membrane pearly white in colored lying obliquely
in the medial end of EAC with the angle of 55 It is forming major part of
lateral wall of middle ear Annulus tympanicus is attached at its
circumference to the sulcus The TM is oval shape It measures
approximately 10 mm in vertical diameter and 90 mm in horizontal
diameter
Page | 27
Layers ndash Tympanic membrane consist of three layers
1 Outer Epithelium or cuticular layer which is continuous with skin of
external ear
2 Middle fibrous layer has both circular and radial fibers middle layer
missing in upper part
3 Inner layer- Inner mucosal layer which is continuous with middle ear
mucosa
Parts ndash Tympanic membrane consist of two parts
1 Pars tensa -It is largest part below the malleolar folds The inner
surface at the center attached to the handle of malleus Angle of cone
is most illuminated part in the pars tensa at anteroinferior part of pars
tensa
2 Pars flaccida Sharpnells membrane -it is triangular area above the
malleolar folds which are thin and devoid of fibrous tissue and
annulus It fits into notch of Rivinous
Nerve supply 1 Anterior half of lateral surface Auriculotemporal V3
2 Posterior half of lateral surface Auricular branch of vagus cn 10
3 Medial Surface Tympanic branch of CN 9 (Jacobsons nerve)
Fig 2 Tympanic membrane of ear
Page | 28
MIDDLE EAR [59]
The middle ear or tympanic cavity is an irregular laterally compressed
space within the temporal bone It is filled with air that is supplied to you
from the nasal part of the throat through the ear canal It contains a chain
of mobile bones that connect its side with the medial wall and serve to
transmit vibrations transmitted to the eardrum through the cavity to the
inner ear Including the parapet the vertical and anteroposterior diameters
of the cavity are each approximately 15 mm The transverse diameter
measures about 6mm at the top and 4mm at the bottom Compared to the
eardrum it is only about 2mm The eardrum is limited laterally by the
eardrum medially by the lateral wall of the inner ear It communicates
behind with the tympanic antrum and through it with the air cells of the
mastoid and in front with the auditory canal The middle ear together with
the Eustachian tube aditus antral and mastoid air cells is called the
middle ear cleft It is lined by mucus membrane and filled with air
It is divided into 3 parts
1 Mesotympanum (located in front of the pars tensa)
2 Epitympanum or attic (located above the pars tensa but medial to
Sharpnells membrane and the lateral bony wall of the attic)
3 Hypotympanum (located under pars tensa) The middle ear is like a
hexagonal box with a roof
Carotid or Anterior wall- It separates middle ear cavity from internal
carotid artery The various structure passing through anterior wall of
tympanic cavity
bull Canal of chorda tympani nerve
bull Canal of tensor tympani muscle
bull Eustachian tube
bull Anterior malleolar ligament
bull Anterior tympanic artery
Page | 29
Posterior or mastoid wall ndash The upper part of the back wall shows the
opening of the auditorium Below the auditory is a triangular bony
projection known as the pyramidalis processors The stapedial tendon is
transmitted through the apex of the pyramidalis processes The vertical
portion of the facial nerve descends along the posterior wall until it opens
into the stylomastoid foramen
Roof or Tegmental wall (Pars terminalis)- It is formed by a thin bone
plate called the tegman tympanum that separates the skull and tympanic
cavities It is located on the anterior surface of the rocky part of the
temporal bone near the junction with the temporal shell it extends back to
the roof in the tympanic membrane and anteriorly to cover the half canal
of the tensor tympanic muscle The lateral border corresponds to the
remains of the Petro scaly suture
Floor ndash It is formed by a thin plate of bone which separate middle ear from
the bulb of the internal jugular vein lodged in the jugular fossa
Lateral wall ndash It is formed by tympanic membrane and partly by a portion
of squamous part of the temporal bone It separates the middle ear from
external ear
Medial wall- It separates the middle ear from the inner ear
bull The promontory is the most prominent and convex part formed by the
basal rotation of the cochlea
bull The bony lateral semicircular canal is postero-superior to the promontory
above the oval window
bull The oval window is located between the middle ear and the vestibular
slope of the cochlea It is closed by the stirrup footrest and the annular
ligament
Page | 30
bull The round window is located under and behind the cape The round
window recess is directed to the rear It is closed by the secondary eardrum
and separates the middle ear of the Scala tympani from the cochlea
bull The facial nerve passes through the bony fallopian tube above the oval
window
Mastoid Antrum ndash It is a large space with air in the upper part of the
mastoid and communicates with the attic through the aditus The roof is
formed by the antri tegmen which extends and separates the tympani
tegmen from the middle cranial fossa The lateral wall of the antrum is
formed by a bony plate that is on average 15 cm thick in adults It is
marked externally on the surface of the mastoid by the suprameatal triangle
(MacEwen)
Aditus and Antrum- Aditus is a gap through which the attic communicates
with the antrum The boney prominence of the horizontal canal lies on its
medial aspect even as the fossa incudes to thats attaches the quick system
of incus lies laterally Facial nerve publications simply underneath the
aditus
The mastoid and its air cell system-
The mastoid consists of bone cortex with a honeycomb of air cell
underneath Depending on development of air cell three types of mastoids
have been described
1Well-pneumatized or cellular- Mastoid cells are well developed and
intervening septa are thin
2Diploetic- Mastoid consist of marrow spaces and a few air cells
3Sclerotic or acellular ndash There are no cells or marrow spaces
With any type of mastoid pneumatization antrum is always present In
sclerotic mastoids antrum is usually small and the sigmoid sinus is
anteposed
Page | 31
Depending on the location mastoid air cells are divided into
1 Zygomatic cells (In the root of zygoma)
2 Tegman cell (Extending into tegmen tympani)
3 Perisinus cells (overlying the sinus plate)
4 Retrofecial cells (round the facial nerve)
5 Peri labyrinthine cells (located above below and behind the
labyrinthine some of them pass through the arch of superior
semicircular canal These cells may communicate with the petrous
apex)
6 Peritubal (around the Eustachian tube Along with hypotymoanic
cells they also communicate with the petrous apex)
7 Tip cells (which are quite large and lie medial and lateral to the
digastric ridge in the tip of mastoid)
8 Marginal cells (Lying behind the sinus plate and may extend into
the occipital bone)
9 Squamosal cells (Lying in the squamous part of temporal bone)
Development of Mastoid ndash
The mastoid develops from the scaly petrous bone The petrosquamosal
suture may persist in the form of a bone plate - Korners septum which
separates the superficial squamosal cells from the deep rock cells Korners
septum is surgically important because it can cause problems locating the
antrum and deeper cells and thus lead to incomplete removal of the disease
during mastoidectomy The mastoid antrum can only be reached if Korners
septum is removed
Page | 32
Fig 3 Cross section of Mastoid
Contents of the middle ear
Ossicles ndash Three tiny bones which conduct the sound from eardrum to oval
window
Malleus ndash It is the largest and most lateral ossicle measuring 8 mm in
length It has head neck handle anterior and lateral processes The head
is situated in the epitympanum A lateral process project laterally from the
neck while the handle is firmly fixed to the pars tensa of the ear drum
Incus- It has a body short process and long process The body short
process and long process The body articulate with the head of mallelus in
the attic and the short process project into the attic The long process
projects downwards behind the handle of malleus running parallel to it and
articulate with the head of the stapes via the lenticular process
Stapes ndash It is the smallest ossicle measuring about 35 mm and consist of
head neck footplate and anterior and posterior curcura The footplate of
stapes is held to the oval window by the annular ligament
Page | 33
Muscles ndash
1Tensor tympani ndash It is inserted is a branch of the facial nerve which carries
the sense of taste It is first arch muscle supplied by branch of mandibular
nerve V3
2 Stapedious muscles ndash It is inserted to the neck of stapes It is the second
arch muscle supplied by branch of facial nerve that is nerve to stapedius
Fig 4 Contents of the middle ear
Blood supply of Middle Ear
bull Anterior tympanic branch of maxillary artery which supplies tympanic
membrane
bull Stylomastoid branch of posterior auricular artery which supplies middle
ear and mastoid air cells
Page | 34
Four minor vessels are
bull Petrosal branch of middle meningeal artery runs along greater petrosal
nerve
bull Superior tympanic branch of middle meningeal srtery traversing along
the canal for tensor tympanic muscle
bull Branch of artery of pterygoid carotid
bull Tympanic branch of internal carotid
Lymphatic Drainage of Ear
Lymphatics from the middle ear drain into retropharyngeal and parotid
nodes while those of the Surgical Importance ndash Eustachian tube drain into
retropharyngeal group
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 middle is likely to pass to
middle ear
2 Moreover middle ear suppurative disease may spread to adjacent organs
and produce complication eg Labyrinthitis meningitis facial nerve palsy
etc
3 Lenticular process is vulnerable in suppurative ear diseases and causes
ocular disruption
4 Prussac space is the site of primary acquired cholesteatoma
Page | 35
INNER EAR [60]
Inner ear is divided into two parts
1 Bony Labyrinth
2 Membranous labyrinth
Anatomy of bony labyrinth
It is divided into two parts
1 Vestibule
2 Cochlea
3 Semicircular canal
The vestibule is located between the medial wall of the middle ear and the
lateral to internal acoustic meatus anterior to the semicircular canal and
posterior to the cochlea The vestibule is the central part of the inner ear
On its side is the oval window opening which is closed by the bracket foot
plate The bony cochlea is located in front of the vestibule It has 275 turns
wound around a bony axis called a modiolus The cochlea is about 30 mm
long The hollow center of the modiolus is a spiral canal that contains the
fibers and ganglion cells of the cochlear nerve A thin bony sheet the bony
lamina winda around the modiolus This divides the cochlear duct into two
galleries the Scala vestibuli above and the scala tympani below
There are three semicircular canals superior posterior and lateral They
are semicircular in shape and open into the vestibule One end of the
semicircle is enlarged and is known as the sphere
The membranous labyrinth is in the bony labyrinth It is connected to the
bony labyrinth by fibrous trabeculae and is surrounded by perilymph The
endolymph is located in the membranous labyrinth
Page | 36
The utricle is in the upper part of the vestibule while the saccule is found
below Both the utricle and saccule contain a single sensory patch called
the macula Each macula is covered with a neuroepithelium made up of
neuroepithelium made up of sensory hair cells and support cells these cells
are separated by a basement membrane Fibers of the vestibulo-cochlear
nerve enter the macula and pierce the basement membrane to terminate
at the base of the hair cell or cell bodies The utricle and the saccule with
their macula are called otolith organs Membrane semicircular canals are
the membrane canals of the corresponding bony semicircular canals They
open into the utricle through five openings One end of the opening of each
channel is dilated called the sphere in which the sensory organ of each
channel is located The cross section of the Scala standard looks like a right
angle The base is formed by the basilar membrane Sensory cells are
arranged on the surface of the basilar membrane These sensory cells with
their supporting cells form a complex neuroepithelium called the basilar
papilla or the cortical organ named after an Italian microscopist The
organs of the corti have a gelatinous membrane called the tectorial
membrane and they are supported by the pillar of the corti The cortical
pillars enclose a space called the corti tunnel which contains a fluid called
cortical lymph Vestibule is lies between the medial wall of the middle ear
and lateral to internal acoustic meatus anterior to semicircular canal and
posterior to the cochlea 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 Boney cochlea lies in front of the vestibule It has 275 turns
coiling around boney axis called modiolus Cochlea is approximately 30 mm
in length The hollow center of the modiolus is a spiral canal containing the
fibers and ganglion cells of cochlear nerve A thin boney sheet the osseous
lamina winda around the modiolus This divides the cochlear canal into two
galleries the Scala vestibuli above and the scala tympani below
Page | 37
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 boney labyrinth It is connected
to the bony labyrinth by fibrous trabeculae and is surrounded by perilymph
Endolymph 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 single sensory patch called macula Each
macula is covered by neuroepithelium consist of Neuroepithelium consists
of sensory hair cells and supporting cells these cells are separated by
basement membrane Fibers 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 are referred
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 corti lymph
Page | 38
Fig 5 Inner Ear
Blood supply of labyrinth
Labyrinthine artery
Common cochlear Anterior vestibular Artery
Vestibulocochlear artery Main cochlear artery
Cochlear branch posterior vestibular artery
Page | 39
PHYSIOLOGY OF HEARING [61]
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
bull Mechanical conduction of sound (conductive apparatus)
bull Transduction of mechanical energy to electrical impulses (sensory
system of cochlea)
bull Conduction of electrical impulses to brain (neural
Fig 6 PHYSIOLOGY OF HEARING
Page | 40
Conduction of sound
Under the surface of water we cannot hear the sound made in air because
9995 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 must 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 13 times longer than long process of incus providing
a mechanical advantage of 13
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 beings 211 As the effective
vibratory area of the tympanic membrane is only two- thirds the effective
areal ratio is reduced to 141 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
Page | 41
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 lobe
Page | 42
DISEASES REVIEW
करणसराव
Nirukti - करणसय कणवयोाव ससराा [62]
Nidana- Acharya Sushruta and Vagbhata describe the common etiological
factors for the Karnaroga
अशयाय जलिीडा कणवकणडयन मरत
शमथययोगन शसततरसतय कवपतो अरय च कोपन ||
सउ २० १२
1 Avashaya or Pratishaya
(Excessive exposure to cold)
2 Jalakrida
(Excessive swimming)
3 Karnakandunyanum
(Excessive scracing due to itching)
4 Mithyayogena Shatrasya
(Improper instrumentation during wax removal or foreign body removal)
5Shabdasya
(Louder sound for long durationperverted contact of sound)
6 Abhighata (Trauma)
7 Vitiation of Tridoshas
Page | 43
Samanya Nidana according to different Samhita
Vishesh Nidan of Karnasrava
Acharya Charaka has not mentioned any kind of Nidana regarding Karnaroga
but has described Utapati of Karnaroga from Siroroga in Karnasirasym
Adhyaya[67]
शशरोअशिघातादरा तनमजजतो जल परपकादरा अवप विि
सरतत पय शरणॊ अतनलात स कणवससरा इतत परककतीत
सउ २० १०
असस ३७२५ [68]
1 Shiroabhighatat - Head Injury-Fracture of middle cranial fossa
2 Jala nimajjana - CSF otorrhoea fracture of middle cranial fossa
3 Karnaprapaka
4 Karna Vidhradhi -Puyasrava
Sr
no
Samanya Nidana SU AH[63] AS[64] YR[65] MN[66]
1 Avashaya + + +
2 Pratishaya + +
3 Shabdha
mithyayoga
+
4 Shashtra
mithyayoga
+ + +
5 Karnakandooyan + + + + +
6 Jalkrida + + + + +
7 Abhighata + + +
Page | 44
Samanya samprapti
परापय शरोतरशसरा कयावत शल शरोतशस गान
त कणवगता रोगा अटिावशततरीता
सउ २० १२
Due to common and specific etiology factors the vitiated Doshas gets
Sthanasamshraya in Karna and causes Karnasrava It is the stages of
Samprapti were Doshas gets lodged in Srotas and start processes of Dosh
Dushya Sammurchsna Due to Shiroabhighata Jalanimmajana Karna Paka
Karna Vidhradi vitiated Vata Dosha and Karna becomes Avruta by Vata and
results in Karnasrava Normal physiology of Dosha Dhatus and Malas entirely
depends on the normality of Srotas Dosh Dushya Sammurchana or
manifestation of diseases will not take place if only vitiation of Doshas take
place without deformity of Srotas Here in Karnasrava vitiation of Srotas are
Atipravritti Sanga and Vimargagamana take place Atipravritti is being excess
production of fungus Sanga is obstruction in external acoustic canal
Vimargagamana is the propagation of discharge through ear
Vishesh Samprapti
Karnasrava occurs due to Nij nidana is Pratishaya while Agantuja nidanas are
Avashya Jalkrida and Karnakanduyan Due to etiological factors which are
Vata-Kapha provocative in nature gradual vitiation of Doshas will occur After
vitiation they get accumulated (Sthan samshraya) in external auditory canal
In other hand when patient does Sevana of Agantuj Nidan like water enter in
external ear scratching of ear unsterile instrumentation leads to Dosh
Prakopa These cause Twak and Mamsa Dhatu Dushti which leads to
discontinuity of epithelium of ear canal which creates suitable atmosphere for
fungal pathogen to grow The vitiated Vata will produce symptoms such as
Page | 45
pain hearing impairment and vitiated Kapha causes symptoms like itching
discharge ear blockage By assessing the symptoms it can be said that Kapha
Avrita Vata Dosha is responsible for the manifestation of clinical features like
pain itching discharge Which are seen in Karnasrava that is otomycosis
Acharya Charaka has mentioned while explaining Samanya Chikitsa of
Karnaroga that it should be treated like Vrana when Paka and Srava is present
as a symptom Fungal spores invade in the epithelial layer of EAC In response
to infection inflammatory process is start This is a Paka Avastha After
removing the fungal mass ulceration in external acoustic canal is commonly
seen As a result of infection process exudates was produced which will mix
up- with fungal colonies and appear as discharge As per Dosha involvement
in Vrana Shoola Srava can be differ According to Acharya Sushruta Ruk is
the Samanya Lakshana of Vrana and Vishesha Lakshana of Vrana includes
pain discharge discoloration itching etc according to Dosha involvement
which are also seen in otomycosis In otomycosis mainly watery and purulent
type of discharge is present which indicates Paka avastha If there is Dosha
involve in Vrana is called Dushta Vrana Acharya Sushruta and Acharya
Vagabhata have mentioned verity of Srava in Twak and Mamsa Vranavastu
which is found in otomycosis Based on this description otomycosis can be
correlated with Karnasrava
Page | 46
Representing the Samprapti of Karnasrava
Vishesh Nidana ndash Shiroabhighatat
Jala nimajjana
Prapaka Vidhradhi
Vitited vata
Avarana by kapha
Vimargagamana of Vata
Karnasrava
Samprapti Ghataka
Dosha ndash Kapha and Vata
Dushya ndash Rasa Rakta and Mansa
Strotodushti ndash Vimargagamana and Sang
Adhishthana ndash Karna (Bhayakarna)
Rogmarga ndash Madhyama
Page | 47
Purvarupa
The Purvarupa of Karnasrava are not mentioned separately in any ayurvedic
classics In routine practice cretin Purvarupa are noted
1 Karnakandu
2 Karnagurutwa
3 Alpa karnashoola
4 Discomfort in ear
Rupa
1 Karnashoola
2 Karnakandu
3 Karnasrava
4 karnabadhirya
5 Cotton wool like or wet newspaper like grayish brown or black colored mass
is seen
6 External auditory canal skin appears edematous and red
Upashaya and Anupashaya
Appropriate application of Aushadhi Ahara and Vihara when produces relief in
the symptom is called as Upashaya and when aggravates the symptoms is
called Anaupashaya There is not any reference available in the classics about
the Upashaya and Anupashaya of karnasrava
Sadhyasadhyata
Sushruta has not mentioned specially the Sadhyasadhyata of Karnarogas But
Vagbhata has mentioned Karnasrava as a Sadhyavyadhi[69]
Sadhysadhyatagives the clear picture of prognosis of the disease It depends
on many factors like nature of disease severity of disease Vaya Prakriti Bala
of the patient etc
Page | 48
Upadrava of Karnasrava
In Samhita there is no reference available regarding the Upadrava of
Karnasrava
Samanya Chikitsa ndash
The common treatment principle for all Karnaroga is Ghritapana Use of
Rasayana Bhrahmacharya Avyayama Shirasnana and Atibhashaya
सामरय कणवरोगष घतपान रसयनम
अवयायमो शशराःसतनान बरमहचयवम कतपरनम
स उ२१३
Ghratapana - Ghrita is a Yogavahi and follow Sanskara in addition to these
acquired properties and capable of retaining its own properties So Ghritapana
is effective in Karnasrava
Rasayana - Rasayana represent the basic approach of Ayurveda which
comprise preventive promotive and curative aspect of health
Brahmacharyaapalana -It is like Sadvrittapalana and is equals to Rasayana
effect
Vyayama - It leads to vitiation if Vatas a Karna is a Sthana of vata and
exercise causes Kshayaj Samprapti hence it is important to avoid exercise in
Karnasrava
Shirasnana- In Shirasnana water enters in external acoustic canal it changes
the PH of meatus skin from acid to alkali which favors the growth of pathogens
Atibhashya - Excessive speaking causes Vata Prakopa and Vatapraokopa is
basic Samprapti for Karnasrava as the preventive aspect avoidance of
excessive speaking is necessary
Page | 49
Ghritapana Rasayana and Brahmacharyapalana should be followed for
preservation of dhatu Samyata and restriction of vitiation of Vata Vayayama
Shirasnana and Atibhashaya should be avoided in Karnasrava to protect the
Siras from the affliction of Vata and Kapha
Vishesha Chikitsa ndash
The general treatment principle of Karnasrava described in classics is closely
related to Dushtavrana Chikitsa
शशरोवरचन च ए िपन परण तरा
परमाजवन िान च ीकषय ीकषय़ाचारत [70]
स उ २१४०
कणवसततरा ोददत कयावत पततकशमकणवयो [71]
ाउ १८३५
उपददि च सततरोत साय परात वपचततवशि परमजय
य अगर मदन सघत गगलना ा िपतयतपा मिना परयत [72]
असउ २२४२४३
In addition to that Shirovirechana Karnadhoopana Karnapurana
karnapramarjana Karnadhavana are also indicated
Page | 50
Treatment is also mentioned for Karnasrava
1 Karnaprakshalana Yoga - with Aargawadadi Gana Kashaya and Surasadi
Gana Kashaya [73]
2 Avachurnana Yoga ndash with Aargawadadi Gana Churna and Surasadi Gana
Churna[74]
3 Karnapoorna Yoga ndash
bull Rasanjana Laksha with Sarjachoorna[75]
bull Panchkashaya with Kapittha swarasa and Madhu[76]
bull Jambu AmrapallavShivalaKshuodra Mahavriksha and Madhuki 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 done[77]
bull Sarjatwak Choorna with Karpashiphalarasa and Madhu[78]
bull Abhaya LodraTindukaSamanga(Manjista) Kwatha of this Dravyas mixed
with Madhu and Kapittha Rasa[79]
bull Yogratnakara mention the following drugs for Karnapoorana-
a Samudraphena Churna[80]
b Jambwambpatra Yoga
4 Karnadhoopana Yoga ndash
bull Dhoopana with Churna of Bilvapatra Haridra Palandu[81]
bull Vartak Dhoopana [82]
5 Internal Medications-
bull Rasnadi Guggula [83]
bull Triphala Guggula [84]
bull Sarivadi Vati [85]
bull Gandhaka Rasayana [86]
Page | 51
According to Vagbhata-
Ear should be cleaned with the Pichu and Varti followed by Guggula Dhoopana
and then Karnapoorana with Madhu Followed by Avachurnanana with
Sukshmachootana of Surasadigana
Pathyaapathya ndash Pathya and Apathy mentioned for Samanya Karnaroga is
recommended in Karnasrava also
पथय[87]
सतदो वरको मन नसतय िमाः शशरावयिाः
गोिमाः शालयो मदगााः याशच परतन हवाः 80
लाो मयरो हररणानदसततततरो नकककिाः
पिोल शशगर ातावक सतनषराण कदठललकम
रसायनातन सवणण बरमहचयवमिाषणाम |
उपयकत यरादोषशमद कणावमय दहतम ||81||
िापर २१
Aharaja Upacharaja
bull Godhuma bull Vamana
bull Shala bull Virechana
bull Mudga bull Nasya
bull Yava bull Dhoomapana
bull Puranagitra bull Kavala
bull Lava Harina Tittiramamsa
Page | 52
अपथय[88]
दरत काटठ शशरसतनान वययाम शलटमल गर
कणडयन तषारशच कणवरोगी पररतपयजत
िापर २१
Viharaja
bull Patola ShigruVartaka bull Bhramacharaya
bull Sunishannaka bull Avyayama
bull Katthlika bull Aakthanam
bull All types of Rasayana bull Upacharaja
bull Vamana
Apathyas
bull Abhishyandakara Aharas
bull Shirasnana
bull Karna kandooyana
bull Tushara sevana
bull Guru Kaphakaraka Aaharas
bull Dantdhavana
Page | 53
OTOMYCOSIS
Definition-
Otomycosis is a superficial acute sub-acute or chronic infection of external
ear canal It is mostly unilateral It is characterized by inflammation purities
and scaling Otomycosis is a common condition encountered in ENT practice
more in chronic and persistent ear infection
The Fungal infections are not communicable in the usual sense but the
humans become an accidental host by their introduction into tissue trauma
The virulence factors favoring colonization of fungus in human host are yet to
be identified Ability of the fungus to grow at 37 C and elaboration of a variety
of enzymes and toxins are speculated to contribute to virulence Only 100 to
150 species are generally recognized as a cause of disease in humans[89]
Prevalence-
Otomycosis is a word wide in distribution and in various record stated that 5
to 20 of all cases of infective otitis externa Otomycosis prevalent is more in
warm and humid climates It is one of the commonest manifestations in India
during rainy season It occurs mostly in humid atmosphere otitis externa due
to fungal infection may resembles the desquamative form of diffuse infective
otitis externa The incidence in temperature climates has increased in
proportion to the use of topical antibiotics which have a medium sterilized of
other organism in which the fungus may flourish
Page | 54
Predisposing factors- [90]
1 Environmental factors such as climate contagious and polluting hygiene
more frequently during rainy season as the humidity increases
2 Individual susceptibility ndashGeneral Immunological status of the Individual
eg HIV infection Radiotherapy chemotherapy Diabetes mellitus
3 Self-inflicted trauma that is use of pins to clean the itching ear or use of ear
bud to clean the wax
4 Wide spread of topical antibiotics steroid preparations which have medium
sterilized of other organism in which the fungus may grow
5 Failure of defense mechanism in External auditory canal
6 During swimming or head bath water enters in External acoustic canal
causes quantitative and qualitative change in ear wax It causes change in pH
7 Long term use of hearing aids
Pathophysiology ndash
The life cycle of the average mold encountered in the ear may be reckoned
as two weeks and flare ups may be anticipated at such intervals Swimming is
held responsible for infection in many cases The sequence sequence of
pathogenic changes produced by molds in the external ear is as follows ndash
1 Implantation of the organism in external ear
2 Growth of organism follows the rate depending on condition of temperature
moisture or preexisting irritation
3 Invasion of epithelium occurs with attendant itching and discomfort which
may be quite severe
Page | 55
4 Exfoliation of epithelium occurs as nature attempts to overcome the
infection by casting off upper most cells
5 Denudation occurs from exfoliation as the top layers of epithelium are cast
off and the canal becomes filled with debris
6 Superficial ulceration and lizematoid dermatitis results if the pathologic
process goes for enough The changes do not always proceed through the
entire sequence sometimes the molds produce changes of the mildest
imaginable character which may be overlooked[91]
Clinical features -
Symptoms-
1 Irritation and itching ndash Irritation is mostly found when the infective
organism is aspergillus niger There is sensation of discomfort which is more
diffuse in the ear canal then localized in the deeper part Candida infection
causes marked itching In external ear it is intense and worse at night
2 Discharge through ear- Intermittent scanty colorless discharge through
ear Mucus being a fungal metabolic product appears as discharge Excessive
discharge is associated with mixed infection
3 Pain and discomfort ndash Mild to severe pain in the ear occasionally Mostly
seen in cases where ear is infected with Aspergillus flavus mixed infection
with gram negative organism or mixed infection with candida and aspergillus
Headache is sometimes associated with pain
4 Deafness- Varying degree of mild to moderate conductive deafness
5 A sensation of fullness in ear
6 Tinnitus 7 Vertigo
Page | 56
Signs ndash
1 The external acoustic meatus may contain a mass formed of epithelial
debris exudates cerumen and fungus
2 Erythematous external canal
Fungal appearance
A Niger - The color of the mass which is usually grey or black is mainly
determined by the type of fungus concerned Its appearance is like wet
newspaper or blotting paper or a cotton wool It has a peculiar musty odor In
this infection fruiting heads may be seen as black specks in the debris
Occasionally as inactive form occurs in which the canal is lined by mold giving
a fluffy appearance due to the presence of tiny mycelia
Candida ndash Candida infections generally show as white deposits on magenta
colored skin when the debris is removed it rapidly recovers in 24 hrs
The underlying canal skin is often inflamed and granular due to invasion by
fungal mycelia and be seen in all cases In rare cases excoriation and
ulceration with marked extensive shedding of the epithelium and deep
ulceration can be seen usually associated with a flavus and with pathogenic
bacteria[92]
Otoscope Appearance
1 Aspergillus Niger ndash Black headed
2 Aspergillus Fumigators ndash pale blue or green
3 Candida Albicans ndash White- or cream-colored deposits
Page | 57
4 Auricle is normal in most cases In severe cases small ulceration with crust
formation may be present on lateral surface
5 Tympanic Membrane
In most cases it is normal with normal mobility and normal hearing In a few
cases the surface of the tympanic membrane is congested and scaly There is
erosion or ulceration of the external epithelial layer and the membrane itself
may be edematous
Diagnosis
1 Above mentioned symptoms and signs
2 In the stage at which patient with otitis externa usually first present
themselves mycelia threads conidiophors not visible to naked eye may
sometimes be identified with the microscope
3 Confirmed by culture
Page | 58
Fig7 Aspergillus Niger Fig8 Candida Albicans
Fig9 Aspergillus Fumigators Fig 10 Wet Paper like appearance
Page | 59
Treatment
1 Antibiotic or steroid drops should be discontinued if they are being instilled
since long time
2 Removal of fungal mass epithelial debris and discharge from the external
canal or mastoid cavity repeatedly and thoroughly by forcepa or suction or
syringing or cautiously blow a stream of air into the canal through a fine
cannula and dry thoroughly by swabbing liquid petroleum on swab used in
cleaning the ear lessens the burning sensation when metacresy acetate is to
be employed in the subsequent treatment
Furuncle is developed as a complication if there is no gentleness in cleaning
Cleansing may have to be delayed until local sensitiveness is lessened which
can usually be accomplished within twenty-four hours If there is excessive
epithelial debris along with otomycosis then metacresyl acetate which is a
keratolytic in introduction into the external auditory canal on cotton wick and
is allowed to remain for twenty-four hours After twenty-four hours the cotton
wick is removed at which time the canal can usually be cleansed with little
discomfort as the medication is also anesthetic The epithelium of the canal
was white from contact with the drug The top layer was detached and this
epithelial debris can be easily wiped away The wick is reinserted and wet with
metacresyl acetate
The treatment is employed for three to four days in succession and then a
bland application is substituted Icthyol iodine is of value at this stage Iodine
ointment 2 in combination with Tannic acid 2 is also an excellent local
application following cresatin treatment
Next one of the fungicides may be applied
Page | 60
1 Nystin Effective for candida infection but less active against aspergillus
group Nystatin in boric powder consisting of 100000units of nystatingm of
powder 3 times week for 3 weeks
2 Clotrimazole Available as 11 cream or drops or lotions Phenyl
(zchlorophenyl) 1 ndash imidazole ndash methane is a chlorinated trityl imidazol 1
effective against candida and dermatophytes and for aspergilli infection
3 Amphotericin B Available as cream and as 3 solution and 015 drops
for topical application Very effective for candida infection can be fungistatic
or fungicidal
4 Econazole Available as solution (Econazole nitrate) and as cream (1)
Broad spectrum ndash more effective for Aspergillus Also active against some
gram-positive bacteria (Staphylococci and Streptococci and Dermatophytes)
5 Miconazole Highly effective against dermatophytes and candida infections
used as a 21 cream applied once or twice a day for 10 days
6 Gentian violet 21 Available as drops (recently some evidence of
carcinogenicity) Discolors the ear canal and this interfere with clinical
examination
Other topical antifungal agents are ketoconazole Natamycin Tolciclat Bifonas
zole Fenticonzole Oxiconazole Tioconazole ciclopiroxolomine Tolnafate
Haloprogin Flucytosine Acetic acid Whit field ointment selenium sulfide
undcyclenic acid triacetin etc
Page | 61
Minimal length of treatment
A month of drug treatment is usually required because the antifungal agents
used are not sporicidal and it is necessary that the period of treatment covers
germination time It may be advisable to give short gaps in the period of
treatment to ensure all spores have germinated before deciding to terminate
therapy
Prevention
Accomplished by strict attention to the predisposing causes
1 Water should be prevented from entering the ear
2 Avoidance of external ear trauma
3 Use of alcohol medicated or plain in the ears after swimming mercuric
cyanide (15000) in ethyl alcohol (70) is a satisfactory liquid to use
Ear stoppers do no good unless their use is followed by some antiseptic in the
canal Divers exposed to water for long periods of time may also use acidic
alcohol
4 During Summer months with their high humidity special efforts are needed
to maintain ear dry 5 Indiscriminate use of topical antibiotics steroid
preparations should be avoided
Page | 62
DRUG REVIEW
1 GUGGULA
Fig11 - Guggula
Historical review of Guggula [93]
bull Atharvaveda one of the well-known Vedas of Hindus The earliest
reference given by Atharvaveda medicinal and therapeutic properties of
Guggula Guggula has long history of use in Ayurveda
bull Acharya Charaka Sushruta and Vagbhata describe detail regarding the
actions uses and indication as well as the variety of Guggula
Page | 63
bull Various Nighantus (Medical lexicons) were written between 12th and 14th
centuries AD was based on the Ayurvedic literature also describes
Guggula
bull The explanation of word Guggula is that Gunjo Vyadhegurdti Rakshati
which means to relief against different diseases
bull Guggula is the best medicine because it develops through the rays of
hot sun on specific circumstances
bull Guggula has an aromatic odor
गगलो कणवदौगवररधय िपन शरटठमछयत[94]
स उ २२११२
Latin name- Commiphora mukul
Family ndash Burseraceae
Rasa- Tikta Katu
Guna ndash Laghu Rukshasukshma vishada sara
Veerya ndash Ushna
Vipaka ndash Katu
Action- Rasayana Lekhana
Doshaghanta - Tridoshhara
Page | 64
Chemical composition [95]
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Oleoresin-Z-Guggulsterone E-Guggulsterone
Gum- guggulignans 1 and 2 guggula Tetrols mukulol allylcembrol c
27
Guggulusterol 1 2 ans 3 Z and E ndash guggulusterol
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Parts Used ndash Gum oleoresin
Guggula purity test
1 Yellowish brown emulsion is obtained when Guggula is triturated with
water
2 An ethereal solution of the drug attains reddish colour when treated
with br2 vapors and purple colour when moistened with nitric acid
Biochemical action ndash Antiseptic Anti-inflammatory Disinfectant Diuretic
Immunostimulant stimulating expectorant Ant suppurative Antipyretic
Enhance phagocytosis
Karma- Rasayana cardiovascular disease
Page | 65
2 AGARU-
Fig 12 Agaru
Historical review of Agaru [96]
bull The word Agaru literally means the one which is the heaviest and no
aromatic wood is heavier than it Since thousands of years Agaru lsquoThe
wood of Godrsquo has been used for multiple purpose like commercial
medicinal spiritual aromatic historical
bull The medicinal use of Agaru have been recorded in many pieces of India
Greek Roman Chinese Middle eastern and European since ancient times
bull Acharya Charaka used Agaru and pest of Rasna to counteract the effect of
cold in Agraya Dravyas
bull Acharya Sushruta used Agaru as a Dhoopana Dravya along with Guggula
Ral and Shoma in the treatment of Karnasweda and Vrana
Page | 66
Types-
bull Dhanwantsri Nighantu describes Kaleyaka as a type of Agaru
bull Sodhala Nighantu describes three types of Agaru ndash Agaru Krishna
Agaru Kakatunda Agaru
bull Raj Nighantu describes five types of Agaru ndash Krishna Agaru Kasht
Agaru Daha Agaru Mangalya Agaru and Agurusaar
bull Arthashasstra describes three Agaru wood product
1 Jongaka ndash Black or variegated black in colour and having variegated
spots
2 Dongaka ndash Black in color
3 Parasamudraka- Black in colour and smells like Navamallika
अगर उटण कि तपछय ततकत ततकषण च वपततलम
लघ कणाविरोगघन शीत ात कफपरणत
िापर २१ [97]
Family- Thymelaccensis
Latin name- Aquilaria agallocha
Guna- Laghu Ruksha Tikshan
Rasa- Katu Tikta
Vipaka ndash Katu
Virya ndash Ushna
Karma- Sheetaprasasmana Vranaorasadan Tvachya Pittavardhaka
Shirovirechana Mangalya Sugandhik and Rochaka in properties [100]
Krishna Agaru karma- Katu Tikta rasa Ushna Sheeta when applied externally
and Pittahara when taken orally
Page | 67
Chemical Constituents -
Agaru hardwood is rich in essential oil resins alkaloids saponins Steroids
terpenoids tannins flavonoids and phenolic compound Agaru wood
predominantly contains 2-[-2-phenylethy]-4H-chromen-4-one derivatives and
sesquiterpenes Agaru oil contains selinene dihydroselinene agarnol b-
agarofuran vetispira-2(11)valerianol dihydrokaranone and tetradecanoic
acids[99]
Part Used ndash
Heartwood- Dark resinous wood which is formed when the plant becomes
infected with a type of fungus (ascomycetous mold) Species of Aspergillus
fusarium and penicillium are reported to be associated with the development
of infection Prior to infection the heartwood is odorless relatively light and
pale colored however as the infection progresses the tree produces a dark
aromatic resin in the heartwood The infected resin in response to the attack
which results in accumulation of a very dense dark resin in the heartwood
The infected resin embedded wood is known as Agarwood Infection is more
common on the trunk roots and the area when branches divide The formation
of Agarwood starts when the tree attains the age of 20 years On an average
approximately 30 ml oil is extracted from 100 kg of infected Agarwood[98]
Qualities of best Agaru-
It should be black in color
It should be extremely heavy and aromatic
It should be oily in appearance and test
It should be sink in water
It should burn easily with bright flame with a bright flame giving off a pleasant
smell
Page | 68
3 MADANA
Fig 13 MADANA
Madana consist of dried fruit of Xeromphis spinosa It is a deciduous thorny
shrub or a small tree reaching a high up to 9 m and girth about a meter
branches numerous thick and horizontal found in sub-Himalayan tracts[101]
मदनो मिरनदसततकतो ीयोटणो लखनो लघ
ानदरतिदवििीहर परततशयायवरणारतक
रि कटठकफ़ानाहशोथगलमवरणापह[102]
िा पर १६० १६1
Page | 69
Latin name-Randia dumetorum
Familly ndash Rubiaceae
Rasa - Madhura Tikta
Guna-Laghu Ruksha
Virya- Ushna
Vipaka ndash Katu
Karma- Vamana and Lekhana
Chemical Composition-
Essential Oil Valerianic acid Saponin tannin resin [103]
Page | 70
YAWA [104]
Fig 14 Yawa
1 In Samhitakala Aacharya Charaka Acharya Sushruta explain detail about
medicinal properties of Yawa
2The use of Yawa in Aaharya Dravya mainly described by Dhanwantari
Nighantu Raj Nighantu Bhavprakash Nighantu[105]
Macroscopic Description-
Fruit a caryopsis elliptical oblong Ovoid and tapering at both ends smooth
about 1cm long and 02- 03cm wide dorsally compressed and flattened on
the sides with a shallow longitudinal furrow 3-5 ridges having shallow
depression between them grains tightly enclosed and adhering the lemma
and palea pale greenish yellow odor not distinct taste sweetish acrid
Page | 71
Latin Name ndash Hordenum vulgare
Family- Poaceae
Rasa- Kashaya Madhura
Virya- Sita
Vipaka- Katu
Karma- Vatakrt Pittahara Kaphahara Medahara Balya Visrya
SthairyakaraLekhana
Page | 72
PROCEDURE REVIEW [105]
In Ayurvedic classics there are many references regarding Dhoopana Dravya
Dhoopana is administering Dhuma with the help of Dhoopana Dravya
In Kashyapa Samhita there are 40 types of Dhoopana advised for children
Anesthesia (Mohajananam Dhoopa) is also mentioned For this Dhoopana the
drug used were herbs hairs of animals legs horns old cloths of Buddhist
monks
From the references available regarding Dhoopana we can understand that
Karna can be protected from maggots (krimi) Bactria (Rakshogna) lice etc
References clearly indicate the analgesic and disinfectant effect of Dhoopana
Karma Dhoopana is mentioned for Dushta Vrana Chikitsa It reduces Vedana
Srava Pootigandha of Dushtavrana It also helps in Vranaropana
Dushtavrana Chikitsa is mentioned in the treatment of Karnasrava[106]
Origin of Dhoopana-
In ancient period children of sages were constantly harassed by the
Rakshasas Hence the sages approached lord Agni for shelter Agni in turn
gave them Dhoopana Dravya and asked sages to use the Dhoopana for
protection against Rakshasas bhutas pishachas
Classification of Dhoopana
1 It is classified into Dhupa Anudhupa Pratidhupa
2 On the basis of Origin it is classified into Jangama and Sthavara
Selection of Guggula for Dhoopana
Page | 73
bull Guggul is a best Vatahara
bull It is Krimighana
bull It contains Oleoresin
bull In Ashtang Hrudaya Guggula Dhoopana mentioned for Karnasrava
Selection of Agaru for Dhoopana
bull Agaru is Laghu Ruksha Katu Tikshna
bull Vranaorasadan Tvachya
bull It should burn easily with bright flame with a bright flame giving off a
pleasant smell
Karna Dhoopana Indication
1 Karnaarava
2 Putikarna
3 Krimikarna
4Vataj Karnashula
Contraindications
Especially for Karnadhoopan contraindication is not mentioned in classic texts
But Dhoopana is contraindicated in Pittaj vaydhi Sharad and Grishma Rutu
Page | 74
MATERIAL AND METHOD
Page | 75
For randomize comparative clinical trial to study the effect of Agaruwadi
Karnadhoopana and Guggula Karnadhoopana in Karnasrava following material
and method were required
Source of data
Patient irrespective of gender occupation religion social economic status
signs and symptoms of classical features of Karnasrava (Otomycosis) selected
from the OPD of Shalakyatantra department
Materials ndash
1Patients
2 Drugs-Agaruwadi Dhoopana
Guggula Dhoopana
3Torch
4Otoscope
5 Tuning fork
6Jobson horn probe
7Cotton
8Case record form
DRUG
Group A Trial Group
1Churana of Agaru Yawa Madan
2Ghrita
3Jala
Group B Control Group
1Googula Churna
Page | 76
Properties of Drug
Table no 1 Properties of Drug
Drug
Family
Rasa Veerya Vipaka Effect
on
Dosha
Guna Karma
Agaru
(Aquilegria
Agallocha)
Thymelaca
ceae
Katu
Tikta
Ushna Katu KV Laghu
Ruksha
Tikshna
Shitaprashamana
Shothahara
Vedanasthapak
Durghandhihara
Madan
(Randia
spinosa)
Rubiaceace
Kashaya
Madhur
Tikat
Katu
Ushna Katu KV Ruksha
Laghu
Vatakaphaghana
Shothahara
Vedanasthapak
Vranashodhak
Yawa
Poaceae
Hordeum
Vulgare
Kashaya
Madhur
Sheeta Madhur KP Ruksha
Laghu
Vataghana
Vernashodhana
Raktshodhaka
Guggula
Commiphora
Mukul
Burseracea
e
Tikta
Kashaya
Anushna Katu VPK Laghu
Ruksha
Shothahara
Vedanasthapaka
Kandughna
Ghrita Madhura Sheet Madhur VK Snigdha Vataghana
Shothahara
Vedanasthapaka
Page | 77
METHODOLOGY
SELECTION CRITERIA
1)INCLUSION CRITERIA
1 Patients having signs and symptoms of Karnasrava (Otomycosis) ie करणशल
( pain ) करणकणड ( Itching ) करणसतराव ( Discharge )बाधिरण ( conductive Loss of
hearing )
2 Patient from age group 19 to 70 years
3 Any Gender
2)EXCLUSION CRITERIA
1 Patients suffering from any systemic disease like DM TB HTN
2 Chronic suppurative otitis media (CSOM)
3 Acute supportive otitis media (ASOM)
3 Perforation of Tympanic membrane
4 Chronic otitis media
3)WITHDRAWAL CRITERIA
1If patient develops any adverse effect such as irritation pain burning
sensation in ear loss of hearing and such patients was withdrawn from trial
and receive prompt appropriate medical attention
2If patient shows aggravation in symptoms
3If patient refuses to continue with the treatment
Page | 78
STUDY SETTING
Types of study - Randomized Clinical comparative Trial
Place of work - OPD of Shalakyatantra
Duration of study - 18 months
Study Population - Patients of Karnasrava in Shalakyatantra OPD
SAMPLE SIZE CALCULATION
Sampling Method ndash Purposive sampling followed by random allocation in two
groups
Sample size calculation-
n = z2 p (1-p)
d2
Were
n = sample size
P = prevalence of disease=10
z = standard normal variable ie 196
d = error ie005
desired Sample Size would be
n = Z2 P(1-P)d2
= (196)2x (0021) x(0979)(005)2
= 34
Visiting ENT OPD (ShalakyaTantra) and IPD (ShalakyaTantra) 21 = 34
n raquo34
So one group includes 34patients
Page | 79
Sampling Method
Total 68 patient of Karnasrava are selected by Purposive sampling followed by
random allocation in two groups Written informed consent is taken prior to
commencement of trial They are divided in 2 groups
Group A (Trial Group) 34 patients treated with Agaruwadi Dhoopana for 7
days
Dose 5 minutes twice in a day
Group B (Control Group) 34 patients treated with Guggula Dhoopana for 7
days
Dose 5 minutes twice in a day
STUDY DESIGN ndash
Open labeled Randomized Comparative Clinical trial
STUDY DESIGN
Screening of patient
Inclusion criteria satisfied Exclusion criteria
Initial assessment Excluded
Counseling of patient Treated accordingly
Patient selection by Simple Random Sampling Method
Page | 80
68 Patients were divided in two groups lsquoArsquo and lsquoBrsquo
Trial group A-34 patients were given
Agaruwadi Dhoopana
Control group B- 34 patients were
given Guggul Dhoopana
Informed written consent
Treatment was given for 7 days
Assessment on 1st 4th and 7th day
Post assessments follow up on 15th day
Observation
Data Collection
Statistical analysis of data
Conclusion
Page | 81
(A) Agaruwadi Varti for group A (Trial group)
Table no 2
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
B) Guggula Varti for group B (Control group)
SOP of it is same as above Agaruwadi Varti
Table no 3
Drug Guggula Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
FOLLOW UP
For both groups follow ups were done on 1st 4th and 7th and post
assessment follow up15th day
EXAMINATIONS
Torch for Local examination of ear
Otoscope examination
Tuning fork Test
Page | 82
OBSERVATION TABLE
Table no 4
Sr no Subjective criteria Day 1 Day 4 Day 7 Day 15
1 करणशल
(pain)
2 करणकणड
(Itching)
3 करणसतराव (Discharge )
4 बाधिरण (Conductive Deafness)
OBSERVATIONS
a) करणशल (Pain) -
0 - Absent
1 ndash Present
b) करणकणड (Itching) -
0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
Page | 83
c) करणसतराव (Discharge)
0- Absent
1- Mild -Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाधिरण (conductive Loss of hearing)
0 - Absent
1- Present
Observations were carried out before and after completion of treatment and
during each follow up After observations the data collected and presented in
the form of graphs charts and table
Page | 84
TRIAL DRUG
Authentication and standardization of raw drug material done After
authentication and standardizing of raw drug material Agaruwadi Varti was
prepared by Varti as explained in Ayurvedic classics
Method of Varti preparations
Panchavidh Kashaya Kalpana that is five method of pharmaceutical
preparation constitutes the fundamental process of Ayurvedic pharmaceutics
which is well explained in Sushrut Samhita Varti Kalpana is one among them
which can be included in Kalka Kalpana
तीररसतरपतपतीनामपरककव तीत [106]
स डलहण शरच 151
Medicines are powered triturated and given the Varti shape that is like wick
of lamp so it is called as Varti Kalpana
Drug content Agaru Madan Yawa
Route of Administration Local
Dose Two times a day
Duration 7 days
Page | 85
Methodology
Standard operating procedure (SOP) of Agaruwadi Varti
Agaruwadi Varti is prepared according to the classical text
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization was done as recommended in pharmacy procedure The
raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 mixed together in
equal quantity to make Agaruwadi churn
Quantity of each churn is 4 grams all are mixed when the Varti get dry total
weight of Varti was 10gram
STEP 4 - Agaruwadi churn triturated with appropriate quantity of water or
Ghrita and prepared Varti in GMP Certified Ayurvedic pharmacy Standard
aseptic precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Varti was packed in sterile air packed container
STEP 6 - Agaruwadi Dhoopana was given with the help of Dhoopana yantra
Authentication and Standardization of raw drug of Agaruwadi Varti was done
Sterilization was done as recommended in pharmacy procedure Sterile
preparation packed in sterile container of suitable size Under all aseptic
precaution Karnadhoopana given to infected ear
Page | 86
Containers for packaging and their sterilization-
Sterilization of the containers for storing Varties was done by Ethylene Oxide
(Eto) method
Ethylene Oxide (Eto) procedure-
It includes exposure of materials to ethylene oxide gas under vacuum in a
sealed chamber It consists of four primary variables
1Gas Concentration
2Humidity
3Temperature
4 Time
EtO gas is an alkylating agent which disturbs the DNA of microorganism
preventing them from reproducing It penetrates the breathable packaging
and sterilizes all the accessible surface of the product to render products
sterility by alkylation of essentials proteins for cell reproduction
Most Eto sterilization methods involves three different stages These can be
separated into three different on the size or number of devices to treat
1Preconditioning stage-
First products are passed through a preconditioning phase to make
microorganism grow The batch load goes through a well time under a
controlled environment of temperature and humidity
2Sterilizer stage-
Performed using process phase specially designed to provide the required level
of EtO exposure to assure sterility for a device or family of devices
3Degasser Aerration stage-
Finally products need to go through a degassing phase to remove any residual
particles of Eto The batch load goes over well time under a temperature-
controlled environment
The sterile containers were then used to store Agaruwadi Varti and handed to
patients included in the study
Page | 87
Packing of Agaruwadi Varti
The ETO sterilize plastic container were used for packing of Agaruwadi Varti
Varti was filled into these sterilize containers (7 in each) In an aseptic
environment plugging and capping was done under aseptic precautions In this
way packing of Agaruwadi Varti done These Varti were given to patient and
advise to take two times a day under all hygienic precautions
History and Examination
bull Proper history and presenting complains was recorded on case record form
bull Ear examination with otoscope was done during initial assessment and each
follow up
bull Otoscopic examination was done during initial assessment and each follow
up
bull Systemic Examination that is Blood Pressure Temperature Respiration
rate Pulse was recorded on case record form
Page | 88
Raw material
Fig14 यव चरण Fig15 मदनफळ चरण
Fig16 अगर चरण Fig17 गगगळ चरण
Page | 89
Preparation of Agaruwadi Varti
Fig18 Preparation of Agaruwadi Varti
Fig19 अगरवादी वरती
Page | 90
Fig20 Instruments used for examination of Karnasrava
Fig19 Karnadhoopana Yantra
Page | 91
Karnadhoopana Procedure
Fig 22 Karnadhoopana Procedure
Page | 92
OBSERVATIONS AND RESULTS
Page | 93
BASED ON DRUGS
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 94
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
AUTHENTICATION CERTIFICATE
Page | 95
BASED ON STASTICIAL ANALYSIS OF DEMOGRAPHIC DATA
68 patients of Karnasrava ndash Otomycosis
Table no 5
No of Patients Total
Group A Group B
Registered 38 37 75
Completed 34 34 68
Discontinue 04 03 07
Total 68 patients were enrolled in study 38 patients registered in group A
amongst them 34 patients completed the treatment and04 patients
discontinued the treatment However in group B 37 patients completed the
treatment and 03 patients discontinued the treatment out of 37 registered
patients
Hence the total number of patients registered in the present study was 75
and out of which 68 patients were discontinued the treatment So they
dropped out from the study While 68 patients were successfully completed
the treatment So observations and result of 68 patients were given below
Here we are going to discuss the statistical analysis of the data obtained in
the form of master chart that was prepared in accordance with the data
collected from the patients that had been included in the study The purpose
of statistical analysis was to analyzed the relation between age gender
occupation diet addiction and education
Page | 96
1 Age wise distribution of patients
Table no 6
In trial group 10 (29412) patients were from age group 18-25 years 14
(41176) patients were from age group 25-35 years 8 (23529) patients
were from age group 35-45 years and 2 (58824) patients were from age
group 45-60 yearsIn control group 6 (17647) patients were from age group
18-25 years 14 (41176) patients were from age group 25-35 years 7
(20588) patients were from age group 35-45 years and 7 (20588)
patients were from age group 45-60 years
Fig 23 Age wise distribution of patients
0
2
4
6
8
10
12
14
15 -25 25-35 35-45 45-60
10
14
8
2
6
14
7 7
Age Distribution
Trial Group N Control Group N
Age Distribution
Trial Group Control Group
N N
18 -25 10 29412 6 17647
25-35 14 41176 14 41176
35-45 8 23529 7 20588
45-60 2 58824 7 20588
Total 34 100 34 100
Page | 97
1 Gender wise distribution of patients
Table no 7
Sex
Trial Group Control Group
N N
Female 23 67647 15 44118
Male 11 32353 19 55882
Total 34 100 34 100
In trial group 23 (67647) patients were female and 11 (32353) patients
were male
In Control group 15 (44118) patients were female and 19 (55882)
patients were male
Fig 24 Gender wise distribution of patients
0
5
10
15
20
25
N N
TRIAL GROUP CONTROL GROUP
23
15
11
19
Gender
Female Male
Page | 98
2 Education wise distribution of patients
Table no 8
Education
Trial Group Control Group
N N
Illiterate 4 11765 3 88235
SSC 4 11765 3 88235
HSC 8 23529 9 26471
Graduation 16 47059 10 29412
Primary 1 29412 3 88235
Post-Graduation 1 29412 6 17647
Total 34 100 34 100
In trial group 4 (11765) patients were illiterate 4 (11765) patients were
SSC educated 8 (23529) patients were HSC educated 16 (47059)
patients were graduated 1 (29412) patients were primary educated and
1(29412) patients were post graduated
In control grou 3 (88235) patients were illiterate 3 (88235) patients
were SSC educated 9 (26471) patients were HSC educated 10 (29412)
patients were graduated 3 (88235) patients were primary educated and
6 (17647) patients were post graduated
Page | 99
Fig 25 Education wise distribution of patients
0
2
4
6
8
10
12
14
16
ILLITERATE SSC HSC GRADUATION PRIMARY POST GRADUATION
4 4
8
16
1 1
3 3
910
3
6
Education
Trial Group N Control Group N
Page | 100
3 Occupation wise distribution of patients
Table no 9
Occupation
Trial Group Control Group
N N
Accountant 1 294 2 588
Housewife 11 3235 8 2353
Engineer 1 294 1 294
Job 1 294 4 1176
Labor 1 294 3 882
Mess 1 294 0 000
Naturotherapyst 1 294 0 000
Pharma 1 294 0 000
Shopkeeper 4 1176 2 588
Singer 1 294 0 000
Student 8 2353 4 1176
Tailor 1 294 1 294
Teacher 1 294 1 294
Worker 1 294 3 882
Farmer 0 000 1 294
Lab Tech 0 000 1 294
Page | 101
Daily Collection 0 000 1 294
Fruit seller 0 000 1 294
Bus Driver 0 000 1 294
Total 34 10000 34 10000
In trial group 11 (3235 ) were housewife 8(2353) were students
4(1176) were shopkeeper 1(294) was accountant 1(294) was
engineer 1(294) was doing job 1(294)was labour 1(294) was
catering 1(294) was Naturotherapyst 1(294) was Pharma 1(294)
was Singer 1(294) was Tailor 1(294) was Teacher and 1(294) was
worker
In Control group 8 (2353)were housewife 4(1176) were students
2(588) were shopkeeper 2(588) was accountant 1(294) was
engineer 4( 1176) was doing job 3(882)was labor 1(294) was
Farmer 1(294) was Lab tech 1(294) was Daily collection 1(294)
was Tailor 1(294) was Teacher and 3(882) was worker 1(294) was
Fruit seller and 1(294) Bus driver
Fig 26 Education wise distribution of patients
0
2
4
6
8
10
12
1
11
1 1 1 1 1 1
4
1
8
1 1 10 0 0 0 0
2
8
1
43
0 0 02
0
4
1 13
1 1 1 1 1
Occupation
Trial Group N Control Group N
Page | 102
4 Religion wise distribution of patients
Table no 10
Religion
Trial Group Control Group
N N
Hindu 31 9118 33 9706
Muslim 3 882 1 294
Total 34 10000 34 10000
In trial group 31 (9118) patients were Hindu and 3 (882) patients were
Muslim
In control group 33 (9706) patients were Hindu and 1 (294) patient
were Muslim
Fig 27 Religion wise distribution of patients
0
5
10
15
20
25
30
35
N N
TRIAL GROUP CONTROL GROUP
3133
31
Religion
Hindu Muslim
Page | 103
5 Diet wise distribution of patients
Table no 11
Diet
Trial Group Control Group
N N
Veg 14 4118 20 5882
Non-Veg 20 5882 14 4118
Total 34 10000 34 10000
In trial group 14 (4118) patients were vegetarian and 20 (5882)
patients were Non vegetarian
In control group 20 (5882) patients were vegetarian and 14 (4118)
patients were Non-Veg
Fig 28 Diet wise distribution of patients
0
5
10
15
20
N N
TRIAL GROUP CONTROL GROUP
14
2020
14
Diet
Veg Non Veg
Page | 104
6 Addiction wise distribution of patients
Table no 12
Addiction
Trial Group Control Group
N N
None 30 8824 27 7941
Alcohol 2 588 0 000
Tobacco 1 294 2 588
Mishri 0 000 1 294
Smoking 1 294 4 1176
Total 34 10000 34 10000
In trial group 30 (8824) patients have no addiction 2 (588) patients
have addiction of alcohol 1 (294) patients have addiction of Tobacco 0
(0) patients have addiction of Mishri and 1 (294) patients have addiction
of smoking
In control group 27 (7941) patients have no addiction 0 (0) patients
have addiction of alcohol 2 (588) patients have addiction of Tobacco 1
(294) patients have addiction of Mishri and 11 (1176) patients have
addiction of smoking
Page | 105
Fig 29 Addiction wise distribution of patients
0
5
10
15
20
25
30
NONE ALCOHOL TOBACCO MISHRI SMOKING
30
21
01
27
0
21
4
Addiction
Trial Group N Control Group N
Page | 106
Statistical Analysis and Results
Effect of study on Karnashoola-
Table no 13
Karnashoola
Group A Group B
BT AT BT AT
N N N N
Grade 2 0 000 0 000 0 000 0 000
Grade 1 30 10000 7 2333 32 10667 5 1667
Grade 0 4 1333 27 9000 2 667 29 9667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 30 Effect of study on Karnashoola
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
30
7
32
54
27
2
29
Karnashoola
Grade 2 Grade 1 Grade 0
Page | 107
Table no 14
Karnashoola Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 088 100 033 006
969 2829E-
08 7667 HS
AT 021 000 041 007
Group
B
BT 094 100 024 004
1037 7103E-
11 8438 HS
AT 015 000 036 007
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 31
000010020030040050060070080090100
BT AT BT AT
GROUP A GROUP B
088
021
094
015
Karnashoola
Mean
Page | 108
Table no 15
Karnashoola
Mean SD Effect
Group
A
Group
B Trial Control Trial Control
Day 1 088 094 033 024 000 000
Day 3 065 071 049 046 2667 2500
Day 5 024 038 043 049 7333 5938
Day 14 021 015 041 036 7667 8438
000
010
020
030
040
050
060
070
080
090
100
Day 1 Day 3 Day 5 Day 14
Karnashoola
Mean Group A Mean Group B
Page | 109
Table no 16
Karnashoola N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3250 110500
510000 275 Control group 34 3650 124100
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 110
Effect of study on Karnakandu
Table no 17
Karnakandu
Group A Group B
BT AT BT AT
N N N N
Grade 3 7 2333 0 000 4 1333 0 000
Grade 2 18 6000 0 000 18 6000 0 000
Grade 1 7 2333 7 2333 10 3333 15 5000
Grade 0 2 667 27 9000 2 667 19 6333
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 32 Effect of study on Karnakandu
0
5
10
15
20
25
30
N N N N
BT AT BT AT
GROUP A GROUP B
7
0
4
0
18
0
18
0
7 7
10
15
2
27
2
19
karnakandu
Grade 3 Grade 2 Grade 1 Grade 0
Page | 111
Table no 18
Karnakandu Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 188 200 081 015
1091 3119E-
10 8906 HS
AT 021 000 041 007
Group
B
BT 171 200 076 014
1032 4746E-
09 7414 HS
AT 044 000 050 009
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Page | 112
Fig 33
Table no 19
Karnakandu
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 188 171 081 076 000 000
Day 3 126 118 057 058 3281 3103
Day 5 071 074 046 051 6250 5690
Day 14 021 044 041 050 8906 7414
000
020
040
060
080
100
120
140
160
180
200
BT AT BT AT
GROUP A GROUP B
188
021
171
044
Karnakandu
Mean
Page | 113
Table no 20
Karnakandu N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 4051 137750
373500 006 Control group 34 2849 96850
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is less than
005 Hence we conclude that there is significant difference between Trial
Group and Control Group
000
020
040
060
080
100
120
140
160
180
200
Day 1 Day 3 Day 5 Day 14
Karnakandu
Mean Group A Mean Group B
Page | 114
Effect of study on Karnasrava
Table no 21
Karnasrava
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 11 3667 0 000 8 2667 0 000
Grade 1 23 7667 3 1000 26 8667 2 667
Grade 0 0 000 31 10333 0 000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 34
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
11
0
8
0
23
3
26
20
31
0
32
Karnasrava
Grade 3 Grade 2 Grade 1 Grade 0
Page | 115
Table no 22
Karnasrava Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 132 100 047 009
1122 4356E-
13 9333 HS
AT 009 000 029 005
Group
B
BT 124 100 043 008
1130 9364E-
14 9524 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 35
000
020
040
060
080
100
120
140
BT AT BT AT
GROUP A GROUP B
132
009
124
006
Karnasrava
Mean
Page | 116
Table no 23
Karnasrava
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 132 124 047 043 000 000
Day 3 100 100 025 025 2444 1905
Day 5 047 038 051 049 6444 6905
Day 14 009 006 029 024 9333 9524
000
020
040
060
080
100
120
140
Day 1 Day 3 Day 5 Day 14
Karnasrava
Mean Group A Mean Group B
Page | 117
Table no 24
Karnasrava N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3535 120200
549000 655 Control
group 34 3365 114400
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 118
Effect of study on Karnabadhirya
Table no 25
Karn
Badhirya
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 0 000 0 000 0 000 0 000
Grade 1 13 4333 0 000 16 5333 2 667
Grade 0 21 7000 34 11333 18 6000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 36
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 00 0 0 0
13
0
16
2
21
34
18
32
Karnabadhirya
Grade 3 Grade 2 Grade 1 Grade 0
Page | 119
Table no 26
Karn
Badhirya Mean Median SD SE
Wilcoxon
W P-Value
Effect Result
Group
A
BT 038 000 049 009
799 7173E-
05 10000 HS
AT 000 000 000 000
Group
B
BT 047 000 051 009
816 0000138 8750 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 38
000
005
010
015
020
025
030
035
040
045
050
BT AT BT AT
GROUP A GROUP B
038
000
047
006
Karnbadhirya
Mean
Page | 120
Table no 27
Karn
Badhirya
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 038 047 049 051 000 000
Day 3 009 006 029 024 7692 8750
Day 5 003 006 017 024 9231 8750
Day 14 000 006 000 024 10000 8750
000
005
010
015
020
025
030
035
040
045
050
Day 1 Day 3 Day 5 Day 14
Karn Badhirya
Mean Group A Mean Group B
Page | 121
Table no 28
Karn
Badhirya N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3400 115600
561000 806 Control
group 34 3500 119000
Total 68
Page | 122
COMPARISION BETWEEN GROUP A AND GROUP B
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Table no 29
Overall Effect
Trial Group Control Group
N N
Marked Improvement 21 6176 16 4706
Moderate Improvement 8 2353 13 3824
Mild Improvement 4 1176 5 1471
No Change 1 2941 0 0
TOTAL 34 100 34 100
Fig 39
0
5
10
15
20
25
MARKED IMPROVEMENT
MODERATE IMPROVEMENT
MILD IMPROVEMENT NO CHANGE
21
8
41
1613
5
0
Overall Effect
Trial Group N Control Group N
Page | 123
DISCUSSION
Page | 124
Discussion is nothing but the logical reasoning of observations In
every research work discussion part is very important because it brings into
light about the logical analysis which are helpful in filling the research gap in
the scientific world
The discussion is categorized into following ways for the ease of
understanding
1 Discussion on selection of topic
2 Discussion on review of literature
3 Discussion on drugs their mode of action on the disease mode of action
of Karnadhoopana
4 Discussion on observation and results
1 Discussion on selection of topic
Otomycosis is commonly encountered in day-to-day practice Majority
of Indian people affected with this pathology This disease commonly
manifests in developing countries low socio-economic standard and lack
of hygiene Now a days due to busy lifestyle people are not able to follow
the proper instruction of care of ear which may be responsible for the
recurrent nature of disease So for the management of this we use
Karnadhoopana with the help of Agaruwadi Varti Dhoopana is simple
easy cost-effective procedure which can be done even at OPD levelso
for the disease Karnasrava we selected Karna Dhoopana as therapeutic
procedure Karnadhoopana was done with Agaruwadi Varti and Guggula
Varti which was very effective for treatment
Page | 125
2 Discussion on review of literature
Karnasrava is one such disease among 28 Karnarogas mentioned by
Acharya Sushruta in the chapter named Karna Roga Vigyana Acharya
Charaka included Karnasrava as symptom under the four types of
Karnarogas due to vitiation of different doshas Acharya Vagbhata has
not described Karnasrava separately It is a fact that systemic
description of Karnarogas is available in all the ancients of pus from a
Vata afflicted ear may results from head injury or immersion in water
Karnasrava is a clinical entity which can be correlated with Otomycosis
Karnasrava is explained as symptom as well as a disease in Ayurveda
Nidana- Karnasrava occur due to Samanya Nidana and Vishesh Nidana
Vishesh Nidana like Shirobhighata Nimmajato jale Mithyayoga of Shashtra
The exact pathology behind Karnasrava is not understood clearly
Purvarupa ndash No specific Purvarupa are found for Karnasrava in classical
literature Acharya Madhukara describe Purvarupa as expression of
Rupa(lakshana) with less intensity that is less intensity itching sound in ear
may considered as Purvarupa of Lakshana
Samprapti- Aacharya Sushruta not explained the Samprapti of Karnasrava
separately and we must consider the general Samprapti of Karnaroga Due to
various aetiologias as cited above ear afflicted by Vata dosha causes Twak
Rakta Mamsa dushti results in Karnasrava According to Acharya Sushruta
Vata-Kapha dose is dominance in Karnasrava
Page | 126
Nidan
Nija Agantuja
Vata ndash kapha prakopak nidana Shirobhighata Nimmajato-jale
Mithya yoga of Shastra
Vata- kapha Prakopaka(Chaya prakopak) Vata-kapha prakopaka
( Achay prakopak)
Twak Rakta Mamsa dushti
Karnasrava
Page | 127
Chikitsa
The curative aspect and this must be done simultaneously giving due
importance to Nidan Parivarjana that is preventive measures So Nidan
Parivarjana that is avoidance of causative factors like Jalkrida Mithyayogen
shashtrasya Karnakandu Shirasnan Pratishaya is the first step in combating
the disease and form the part of line of treatment
Above Samprapti helps us to proceed towards the treatment of Karnasrava
The main protocol of treatment is removal of fungus and wound management
which include various measures to keep area day clean clear of microbes and
providing ideal condition for healing
Samany Chikitsa- Acharya Sushruta described general treatment for
Karnaroga as Snehapana (Drinking ghee) Rasayana (Rejuvenation therapy)
Bhramacharya Avoid excessive speaking Avoidance of physical exercise and
head bath
Vishesha Chikitsa ndash Acharya Sushruta mentioned some procedures in the
treatment of Karnasrava which is Shirovirechana Karnadhoopana
Karnapurana Karanpramarjana Dhavan Avachurnana Karnapurana Above
various procedures described in Ayurveda for management of fungus growth
in ear discharging ear fulfill these requirements of wound management
Page | 128
Discussion on observation and Result
Out of 68 patients 34 patients included for the trial The incidence of
Karnasrava is observed in trial and control groups
The statistical analysis provided the following data
AGE
Trial group- Maximum no of patients that is 14 (41176) patients were from
age group 25-35 years followed by 29412 patients were from age group
18-25 years 23529patients were from age group 35-45 years and
58824 patients were from age group 45-60 years
Control group - Maximum no of patients that is 14 (41176) patients were
from age group 25-35 years followed by 20588 patients were from age
group 35-45 years and 20588 patients were from age group 45-60 years
17647 patients were from age group 15-25 years
The maximum no of cases of Karnasrava found in age group between 25 to
35 years The reason behind this is repeated use of ear bud or emersed water
in ear More use of earphone or working more in cold environment
GENDER
Trial group ndash A higher prevalence seen in females 6764 and 3235 in
males
Control group - A higher prevalence seen in males 5588 and 4411 in
females
Females and males both are prone to disease
Page | 129
EDUCATION
Trial group-It is observed that amongst 34 patients maximum ie16
(47059) patients were graduated 8 (23529) patients were HSC
educated 4 (11765) patients were SSC educated 4 (11765) patients
were illiterate 1 (29412) patient were primary educated and 1(29412)
patient were post graduated
Control group- It is observed that 10 (29412) patients were graduated 9
(26471) patients were HSC educated 6 (17647) patients were post
graduated 3 (88235) patients were SSC educated 3 (88235) patients
were primary educated3 (88235) patients were illiterate
There is no direct relation between education and Otomycosis
RELIGION
Trial group- The incidence of patients of Hindu religion are 9118 and Muslim
religion are 882
Control group- The incidence of patients of Hindu religion are 9706 and
Muslim religion are 294
There is no probable explanation for this maximum number of patients in
Hindu religion it depends upon the patients attend the hospital and
community residing there
Page | 130
DIET
Trial group It was found that maximum ie5882 patients were taking
mixed diet while 4118 were taking vegetarian diet
Control group It was found that maximum ie5882 were taking
vegetarian diet while 4118 patients were taking mixed diet
The dietary habit of person is based on choice availability and religious
customs of the person
ADDICTION-
Trial group- It was found that maximum ie 30 (8824) patients have no
addiction 2 (588) patients have addiction of alcohol 1 (294) patients
have addiction of Tobacco 1 (294) patients have addiction of smoking and
0 (0) patients have addiction of Mishri
Control group - It was found that maximum ie 27 (7941) patients have
no addiction 4(1176) patients have addiction of smoking 2 (588)
patients have addiction of Tobacco 1 (294) patients have addiction of
Mishri and 0 (0) patients have addiction of alcohol
Very few patients were addicted to Alcohol Smoking Tobacco and Mishri
These factors can be taken as provoking factors for Otomycosis
Page | 131
Discussion based on probable Mode of action of Karnadhoopana
In Ayurveda classics Karna Dhoopana is therapeutic procedure explain for
Karnasrava Dhoopana is administration of Dhooma (Fumes) with the help of
Dhoopan Dravya References indicates that analgesic and disinfectant effect
of Dhoopana karma and mention for Dushta Vrana Chikitsa It reduces
Vedana Srava amp also does Vrana Ropana action
Various Dhoopanas and Dhoopan Dravas for different element in various
Samhitas of Ayurveda but there is a lacuna of availability of reference
regarding how to do it and method of procedure Matra Kala Contraindication
etc
Currently simple modified way of Karnadhoopana according to Yukti Praman
and experience but there is lac of standardization
Karnadhoopana is one among the topical Bahiparimajan type of treatment
Karna Parmarjana is procedure of cleaning ear with the help of cotton or gauze
piece soaked in honey
Page | 132
Dhoopan
The fumes coming out on burning Agaruwadi Varti
Administrated directly into external ear canal
Causes vasodilation
Due to this increase blood supply in external ear canal
It helps in absorption of drug
Fumes dries up Srava and bring the analgesic effect
Karnagata Kapha amp Avrut Vata Dosha Shaman
Decrease in signs and symptoms like karnasrava Karnshool Karnabadhirya amp
Karnandu
Page | 133
3 Discussion based on probable mode of action of Agaruwadi
Dhoopana
Agaru ndash
I Agaru is a fragrant tree aroma is a result of fungal pathogenesis when the
wood of tree is contaminated by fungi at wounds it develops scrap filled
with resin and turn out to be aroma Medicinal use of Agaru have been
recorded in ancient medicinal science in in inflammatory disease and some
infective disease
II Acharya Charaka has referred to Agaru as an Ushna dravya despite having
Tikta Rasa Ashtang Samgraha used Agaru as Dhupana Dravya along with
Madan and Yawa in Karnasrava Nighantu recommended is use as a
Dhoopana
III In various Samhitas and Nighantus Agaru described as Tikta Snighdha
Sheetaprashamana Vranaprasadana Tvachya Due to these properties
Agaru is used in the treatment of Karna-Akashi Roga and Dushta Vrana
Shodhaka
IV Agaru is reported to have Antimicrobial Analgesic Antioxidants
Antihistaminic and anxiolytic properties Its Antihistaminic property gives
relief from itching which is cardinal feature of Otomycosis Due to Katu
Ushna Tikta Guna improves blood circulation Bheda stage develop It is
Niram Awastha of Dosha Karnagata kapha and vata get decrease and
symptoms like karnashoolakarnasrava get decrease Agaru also have a
Antioxidant properties
V Chemically Agaru Contain 2-(2-Phenylethyl) Chromones Terpenoids
Flavonoids
VI Natural Agarwood had inhibitive activities towards Staphylococcus Aures
The chloroform extract of Agarwood prolongs the pain threshold[108]
Page | 134
Madan
I Madanphala have therapeutic properties like Anti-inflammatory
Antiallergic Analgesic and Wound healing
II It is Useful in treatment of disease like Shotha (inflammation) Vidradhi
(Abscess) Pratishaya (Common cold) Kushta(Skin disease)
III Extract of Madanphala mainly contain Glcosides Tritorpenct
Glycosides Saponin
IV Saponin glycosides are act as fire extinguisher This property is helpful
for vartiIt also act as a detergent which clean the surface of fungus
V Tritorpenct act as a anti-inflammatory antimicrobial and
immunomodulator compound Interaction of glycosides with sterol
causes disturbance of selective permeability in plasmic membraneso
exudates and discharge get decrease
VI Pharmacological activity [109]
Antibacterial Activity The preliminary antibacterial activity of Methanolic
extract of Randia D lam was done on some standard and wild pathogenic
strains The inhibition of the bacterial growth was more pronounced on E coli
as compared to the other tested organism This shows the antibacterial action
of Randia D secondary infection can prevent
Anti-Allergic Activity In Ayurveda Randia D Extract and its fraction of milk
induced leukocytosis and eosinophilia in mice
Anti-Inflammatory Activity The crude methanol extract of fruit of Randia D
effectively reduced the carrageenin induced oedema in hind paw of the rats
significant reduction in granular tissue formation was recorded This activity
seems to be significant at various acute phases of inflammation and om
formation of granular tissue This proves action of Madanaphala in shopa
(inflammation)
Page | 135
Analgesic Activity Analgesic activity was tested in mice weighing between 20-
250 with six number of animals in each group Methanlic extract of fruit Randia
d give analgesic activity in both models This proves its Shoolanashaka (pain
killer) action
Immunomodulatory Activity Randia D has immunostimulant activity and
chloroform fraction which strongly affected immune system seems to be
bioactive fraction of this plant
The overall effect of Agaru Mandanphala Yawa having Anti-inflammatory
Antiseptic Antimicrobial Property Active ingredient shows these properties
Agaru Yawa Madanphala
Vatakaphaghna
Act as
Vranashodhak
Vedanasthapaka
Sheetaprashamana
Shothara
Avarana of Vata get decrease so helps to Shaman of Vata dosha
Karnakandu Karnashoola Karnasrava
Prashamana
Page | 136
This fact can be taken into consideration and probably acknowledge that
Karnadhoopana with Agaruwadi Varti had not leave any residue in the ear
Removal of fibrin keratinocyte migration and in growth of epithelial tissue
plays a major role in healing It is technique of fumigation of ear with the
smoke of anti-infective drug In Karnadhoopana Sthanik Swedana increase the
blood supply and helps in absorption of the drug reduce Karnakandu amp
Karnshoola associated with infection
Page | 137
SUMMARY AND CONCLUSION
Page | 138
The dissertation entitled randomize comparative clinical trial to study the
effect of Agaruwadi Karnadhoopan and Guggula Karnadhoopan In Karnasrava
wsr to Otomycosis
The dissertation is divided into fallowing parts
Introduction
Review of literature
Ayurvedic review
Modern Review
Drug review
Procedure review
Material and Method
Observation and result
Discussion
Summary and conclusion
bull INTRODUCTION
It includes importance of Shalakyatantra in Sushrut Samhita Charka
Samhita And Ashtang Samgraha
Common and specific causes of Karnasrava
Karnasrava is a clinical entity which can be corelate with Otomycosis
In Ashtang Samgraha stated the procedure like Karnadhoopana with
Agaru Yawa Madanphala in Karnasrava
Page | 139
bull REVIEW OF LITERATURE
1 Ayurvedic review
2 Modern review
3 Drug review
Ayurvedic review-
It includes Rachana-Sharir and Kriya-Sharir of Karna detail description of
Karnaroga and its types Karnaroga Samanya hetu Poorvaroopa Rupa
Samprapti Upadrava Pathya-Apathya of Karnasrava Vishesh Nidan and
Chikitsa of Karnasrava Detail description of Karnadhoopana according to
various Acharays have been mentioned
Modern review-
It includes anatomy and physiology of Ear brief anatomy of ear anatomy of
External middle and Internal ear Detail description of the disease
Otomycosis mechanism of fungal infection in external canal pathophysiology
investigations diagnosis and management
Drug review-
Detail description of Agaru Yawa Madan Guggula and its synonyms
Ayurvedic properties Karma uses Pharmacological action and their
pharmacodynamic properties
Page | 140
MATERIAL AND METHOD
It includes description regarding materials required for the study Preparation
of Agaruwadi Varti its Standardization Sterilization and packaging
Plan of study
1 Total 68 patients completed the treatment Age criteria was kept
between 18-60 years Patient selection was done by done by simple
random sampling method and divided into two groups A (Trial) and
Group B (Control) 34 patients in each group
2 Patients in Group A were treated with Karnadhoopana with Agaruwadi
Varti for 7 days two times in a day while patients in Group B were treated
with Karnadhoopana with Guggula for 7 days two times in a day
3 Clinical examination done during each follow up ie 0th 4rd 7th and
observation were recorded
Page | 141
OBSERVATIONS AND RESULTS
Page | 142
1 It was observed that higher incidence of disease Karnasrava ie
Otomycosis found in age group 25-35 years
2 Disease otomycosis was equal in both male and female
3 The trial group there was significant relief in Karnakandu (8906)
Karnasrava(9333) Karnashoola(7667) and karnabadhirya(100)
4 In control group there was significant relief in Karnakandu (7414)
Karnasrava(9524) Karnashoola(8438) and
karnabadhirya(8750)
Page | 143
REFERANCES
Page | 144
1 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published byChaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 17 page no
5
2 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 19 page no
6
3 DRNarayan Vidwas Shero-Karna-Nasa and MukhrogaAnand publication
edition 4th 2014 Page no-52
4 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-205
page no 111
5 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 111
6 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Shlok no2012
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 112
8 Dr KBBhargavaDr SK BhargavaDr TMShahaA Short book of ENT
diseases Usha publication edition 10th
9 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 8 Page no -52
Page | 145
10 Research and Review Journal of Ayurvedic science yoga and
Naturopathy 2017 4(3) 1-5 pA Critical review of Otomycosis in cortex to
Karnaroga described in Ayurvedic classic by amisha patel D B Vaghala
Chandani goswami Vol4 no3 (2017)
11 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogpratished Adhaya Shlok no-213
page no127
12 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedh Adhaya Shlok no-
2140 page no 131
13 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyant shirasiya adhaya Shlok no 1712 page no-
258
14 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
15 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
16 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Aupadravik Adhaya Shlok no-15 page no
2
17 Vaidya Jaymini panday Harit Samhita hindi commentaryChaukhamba
vidhyabhartiVaranasiedition 2010 Shlok no- 13-14page no-10
18 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 146
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-20345
page no 112
19 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Karnarogavigyniyam Shlok
no 21 Page no-731
20 Charak
21 Pandit Harigovind Shashtri Namalinganusasana Amarkosha of
Amarsimha hindi commentary published by Chaukhamba Sanskrit
Sansthan page no- 463
22 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
23 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 37
24 Shree Taranath-Trkavachspati-Bhattacharyen Vchaspatym published
by Rashtriya Samskrit Sansthandelhi Volume 4 page no- 5149
25 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
26 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
27 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
28 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Page | 147
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
29 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Indriyaopakramaniya Adhaya Shlok no 811
page no- 125
30 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243
31 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-510 page no56
32 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no3108 page no- 385
33 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no33 page no- 366
34 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sarvabhutachintasharir Adhaya
Shlok no-126 page no9
35 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-522 page no60
36 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-532 page no61
37 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Page | 148
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-521page no58
38 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-527 page no61
39 VdBramhand Tripathi Ashtanghradaya Sharirsthansthan Published by
Chaukhamba prakashana 2005 Shlok no331 page no-372
40 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Siravarnavibhaktisharir Adhaya
Shlok no-725 page no83
41 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Sharirsankhyavykaransharir Adhaya Shlok
no-512
42 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Pratekmarmanirdeshsharir
Adhaya Shlok no-628 page no75
43 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
44 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Marmasharirsthan Shlok no429 page
no- 393
45 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243244
Page | 149
46 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
47 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan pu blished by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711
48 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
49 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
50 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Shlok no 711 page no- 847
51 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Adhaya Shlok no-628 page no- 75
52 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Gandushavidhiadhaya Shlok no2232
page no- 261
53 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Karnavydhbandhvidhi Adhaya Shlok no-
1611 page no- 86
54 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Nidansthan Published by Chaukhamba
Page | 150
Sanskrit SansthanVaranasi Vatvydhinidansa Adhaya Shlok no183 page
no- 304
55 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavaykaransharir
Adhaya Shlok no-532 page no61
56 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Tristaisniya adhaya Shlok no 1120 page no-
163
57 P Hazarika Dr Nayaka R Balkrishnan Textbook of EarNoseThroat and
Head-Neck Surgery CBS Publication Anatomy of Ear
58 DrKB Bhargava DrSKBhargava DrTMShaha A short book of ENT
Diseases Published by Usha Publication 10th edition page no10
59 MrSalah Mansour MrJacques MagnanMr Hassan Haidar MrKaren
Nicolas MRStephan Louryan Comprehensive and clinical anatomy of the
Middle Ear Published by Springer publication Chapter -Middle Ear cavity
Page no 19 to 121
60 DrPLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 7
61 James OPickles An introduction to Physiology of Hearing Published by
Emerald publication 4th edition page no- 1 to 265
62 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
63 VdBramhand Tripathi Ashtanghradaya Uttarsthan Published by
Chaukhamba prakashana 2005 Karnaroga vigyniyam adhaya Shlok
no1713 page no- 998
Page | 151
64 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Shlok no- 212 page no-
730
65 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no
1-2 page no- 309
66 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana
67 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyantshirasiya Adhaya Shlok no 1713 page no-
258
68 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no-
6 page no- 310
69 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Karnarogavigyniym Shlok no- 1725-26 Page no-
1003
70 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2140 page
no 131
71 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Adhyay 18 shlok 35
72 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt
Karnarogapratishedhoadhya Shlok no-2211 Page no- 735
73 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 152
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2141 page
no 131
74 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2142 page
no 131
75 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2144 page
no 131
76 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 34 page no- 649
77 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2145page
no 131
78 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 37 page no- 649
79 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2146page
no
80 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
81 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 153
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2143page
no
82 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publication Krnarogadhikara adhaya page no-
318
83 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary
Madhyamkhand Vatkalpana shlok no- 782-83 page no- 137
84 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 72-77 page no- 651
85 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
86 Vd Shree Laxmipatishastri Yogratnakara
87 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
Karnarogadhikara Shlok no- 808182 page no- 652
88 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 83 page no- 652
89 (PDF) Otomycosis A Comprehensive Review (researchgatenet)
90 httpswwwncbinlmnihgovpubmed24948980
91 A Simon Carney Scott-Browns Otorhinolaryngology Head and Neck
Surgery CRC press 8th publication Otitis externa and otomycosis
92 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no Page no -
93 wwwguggulipidcomtradhtm
Page | 154
94 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
95 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-28 page no-
43
96 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009Agaru page
no726-728
97 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishra chapter Karpuradi varga Shlok no-31-
43 Page no- 116
98 httpswwwthiemeinimagecatlogsample_chapter_GOMPpdf
99 (PDF) Chemical Constituents and Pharmacological Activity of Agarwood
and Aquilaria Plants (researchgatenet)
100 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 4 chapter no-2 page no-4
101 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 chapter no-152 Madanpage
no376-379
102 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
103 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-54 page no-
84
104 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 page no697-699
patol-yawa
Page | 155
105 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
106 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
Dhoompanvidhi page no- 252-254
107 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012Chikitasasthan Shlok
no- 151page no-406
108 httpswwwmdpicom1420-3049232342pdf
109 httpswwwijamcoinindexphpijamarticledownload0610201530
0
Page | 156
BIBILOGRAPHY
Page | 157
1 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
2 Scott-Brown WG Diseases of the EarNose and Throat Landon
Botterworth and co(publishers) Ltd1952 Volume 2
3 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012
4 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009
5 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi commantry
Purvakhand and Madhyamkhand
6 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Published by Chaukhamba Sanskrit
SansthanVaranasi
8 The Ayurvedic Pharmacopeia of India Ministry of Health and family welfare
department of Ayush Part 1 and part 4
9 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005
10 Acharya Trivedi Raguveer Prasad Ashtang sangrah published by
Vaidyanath Ayurveda bhavan pvt
11 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition
12 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary published by Chaukhamba
Orientalia
Page | 158
ANNEXURE
Page | 159
ANNEXURE- 1
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
CASE RECORD FORM
RESEARCH PROFORMA FOR MS (AYU) DESSERTATION
DEPARTMENT OF SHALAKYATANTRA
NAME -
ADDRESS -
GENDER - AGE - OCCUPATION-
RELIGION - EDUCATION - MARITAL STATUS-
OPD IPD NO-
DATE OF ADMISSIONCOMMESEMENT-
DATE OF DISCHARGECOMPLITION-
DATE OF COUNSELLING-
TEL NO-
CHIEF COMPLAINTS-
PAST MEDICAL AND SURGICAL HISTORY-
TREATMENT HISTORY-
FAMILY HISTORY-
Page | 160
PERSONAL HISTORY-
a) Ahar(Diet)
b) Vihar
c) History of addiction
GENERAL EXAMINATION
PULSE - MIN BP - mm of hg
TEMP - 0F RR - MIN
ASHATAVIDHA PARIKSHANA
Nadi- Mutra- Mala-
Jivha- Shabda- Sparsha-
Drik- Aakruti-
SYSTEMIC EXAMINATION
RS ndash
CNS-
CVS ndash
Page | 161
LOCAL EXAMINATION (KARNA PARIKSHAN)
OBSERVATION TABLE FOR SUBJECTIVE CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching )
RIGHT EAR LEFT EAR
KARNASHASHUKULI
KARNAPUTRAK
KARNAPALI
KARNAKUHARA -
SRAVA
GANDH
VARNA
SWARUPA
KARNAPATALA (TM)
Page | 162
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
Hearing Test
1Renne Test ndash
2 Weber Test -
Examination of Ear-
Pathological Investigation-
Other Examination-
Nidan Panchak-
1Hetu-
2Purvarup-
3Rupa-
4Upashayanupashaya-
5Samprapti
Signature of Guide Signature of Doctor(Researcher)
Page | 163
ANNEXURE 12
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Dhoopana Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization were done as recommended in pharmacy procedure
The raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 were mixed together
in equal quantity to make Agaruwadi churn
STEP 4 - Agaruwadi churn were triturated with appropriate quantity of water
and prepared Varti in GMP Certified Ayurvedic pharmacy Standard aseptic
precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Dhoopana Varti was packed in sterile air packed
container
STEP 6 - Agaruwadi Dhoopan was given with the help of Dhoopan yantra
TREATMENT DETAIL-
Purvakarma -
1 The patient is asked to sit comfortably on chair having sufficient light and
less amount of dust
2 The EAC is cleaned thoroughly by Pichu Varti (cotton swab) to remove the
discharge and other debris
Pradhankarma -
1 The patient is asked to relax completely on the chair
Page | 164
2 Fumes are passed to the ear with Dhoopana Yantra
3 Dhoopana yantra is funnel shaped and its one end will keep the ear covered
for the passage of Dhooma into the ear canal and other end where Agaruwadi
Dhoopana Varti were placed which produces fumes
4 This Dhoopana was given for 5 min
Pashchat karma -
1 The patient were advised to avoid cold refrigerated food drinks cold water
bath cold wind fog and prevent water from entering the ear
(A) Agaruwadi Dhoopana Varti
B) Guggula Dhoopana Varti SOP of it is same as above Agaruwadi Dhoopana
Varti
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Page | 165
ANNEXURE 21
INFORMED CONSENT DOCUMENT
Study Title
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
Introduction
- You are invited to take part in a research study RANDOMSIED COMPARATIVE
CLINICAL TRIAL TO STUDY THE EFFECT OF AGARUWADI DHOOPANA AND
GUGGULA DHOOPANA IN KARNASRAVA
- Before you decide it is important for you to understand why the
research is being done and what it will involve
- Please take time to read the following information carefully and discuss
it with friends relatives and your doctor if you wish
- Ask us if there is anything that is not clear or if you would like more
information
Purpose amp Nature of Study
- In this research project by examine you and ldquoKarnasravardquo (Otomycosis)
disease were treated
- In the part of treatment Agaruwadi Dhoopana or Guggula Dhoopan were
given
- Dhoopana means medicated drug fumes were given in ear with the help of
Dhoopan Yantra
Page | 166
- Treatment was given for 7 days
Study Duration
7days
Participation
- Your participation is entirely voluntary
- If you do decide to take part you were given this information sheet to keep
and be asked to sign a informed consent form
- If you decide to take part you are still free to withdraw at any time and
without giving a reason This will not affect the standard of current or future
medical care you may receive
Confidentiality
- All information which is collected about you during the research were
kept strictly confidential
- Any information about you which is collected from the center will have
your identity in the form of a code number so that it will remain confidential
Benefits Of Study
- The results obtained from this study would be helpful for providing better
quality of treatment amp other essential facilities for Karnasrava (Discharge)
patients
- You will get clinical benefit from the study
Page | 167
Risks Of Study
- In this treatment there are few chances of Irritation of Ear Nose and
congestion at EAC if any of these happens then treatment were given
Results Of Study
- If the Results obtained are profitable then they may get published
without disclosing your details
Signature of patient
Date
Time
Phone no of Researcher
Page | 168
रण मादहती पतरक
सशोिनाच शीषवक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE
EFFECT OF AGARUWADI DHOOPANA AND GUGGULA DHOOPANA
IN KARNASRAVA
परसतताना
- आपणास या सशोिनातपमक अभयासात सहिागी होणय़ाच आाहन करणयात यत आह
- सशोिनातील सहिाग तननदशचत करणयापी सशोिनाच उददश समजन घया
- खालील मादहती काळजीपवक ाचा आणण आशयक ािलयास आपलया डॉकिराशी कका
दहतशरचतकाशी चचाव करा
- काही सददिता असलयास कका आणखी मादहती ही असलयास आमछयाशी चचाव करा
सशोिनाच उददीटि सतरप
- सदर सशोिन परकलपामरधय आपलयाला तपासणी करन कणवसरा या वयाशरिची शरचककतपसा दणयात
यणार आह
- सदर वयाशरिची शरचककतपसा महणन आपणास अगरादी िपन कका गगल िपन
दणयात यणार आह
- सदर औषि आपणास 7 ददस घयायाच आह
Page | 169
कालािी
- 7 ददस
सहिाग
- आपला सहिाग हा पणवपण ऎनदछिक आह
- आपला सहिाग तननदशचत असलयास आपणास ही मादहती पतरतरका दणयात यईल आपणास यातील
समती पतरकार सही कराी लागल
- सहिाग तननदशचत असनही आपण कोणतपयाही ळस कोणतही कारण न दता माघार घ शकता
याचा आपलया दयकीय सविर कोणताही पररणाम होणार नाही
गोपनीयता
- सशोिना दरमयान गोळा कलली आपलया वषयाची सव मादहती गोपनीय ठणयात यईल
- आपली यनदकतक मादहती साकततक सतरपात गोपनीय ठणयात यईल
सशोिनाच फ़ायद
- सशोिनाच तनटकषव कणवसरा बाशरित रणाछया दयकीय इतर सविाचा दजाव सिारणयास
फायदशीर ठरतील
सशोिनातील जोणखम
- य़ा शरचककतपसमरधय कान दखण डॊळय़ातन नाकातन पाणी य़ण नाकात जळजळण डोक जड
होण ही लिण ददस शकतात यापकी लिण तनमावण झालयास तपयाची शरचककतपसा कली जाईल
Page | 170
सशोिनाच तनटकषव
सशोिनाच तनटकषव फ़ायदशीर ठरलयास आपली मादहती गोपनीय ठन परकाशशत करणय़ात यईल
रण सतािरी-
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
Page | 171
ANNEXURE 31
INFORMED CONSENT FORM
Patient OPD no __________
Subjectrsquos Identifier
Date of Birth Age Gender
I _____________________________________ age___________ years
exercising my free power of choice hereby give my consent to be included
as a participant in the clinical study entitled
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
1 I confirm that I have read have been read and understood the information
sheet for the above study and can ask questions
2 I understand that my participation in the study is voluntary and that I am
free to withdraw at any time without giving any reason without affecting my
medical care or legal rights
3 I understand that the Ethics Committee members investigators and study
doctors will not need my permission to look at my health records both in
respect of the current study and any further research that may be conducted
in relation to it even if I withdraw from the trial I agree to his access
However I understand that my identity will not be revealed in information
released to third parties or published
4I agree not to restrict the use of any data or results that arisefrom this study
provided such a use only for scientific purpose
5 I agree to take part in the above study
Page | 172
signature with Date-
Left hand thumb impression
Name amp signature of the witness ndash
Name amp signature of the student ndash
Page | 173
ANNEXURE 32
समतीपतरक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
वयकतीच य
ददनाक जरमददनाक
1) मी ह तननदशचत कररत आह ककसदर सशोिन परकलपाबाबतची सपणव मदहती मी ाचली असनमला ती
समजली आहतपयाबददल मला परशन वचारणयाची पणव मिा आह सदर मादहतीन माझ समािान झाल
आह
2) मी सदर सशोिनातन माझया मजीनसार किीही बाहर पड शकतो या माझया अशरिकाराची मला कलपना
आह
3) माझी दयककय मादहती तपासणयाची कागदपतर कळ सशोिनाकररता ापरली जाणार आहत याची
मला मादहती आहसदर सशोिन परकलपातील सबशरित घिकाना माझी दयककय मादहती पाहणयाची मी
समती दत आहतरावप या सदिावतील माझी ओळख दशववणारी मादहती कोणासही ददली जाणार नाहीयाची
मला कलपना दणयात आली आह
4) सदर अभयासातन शमळणारी मादहती अरा तनटकषव कळ शासततरीय हतसाठी ापरल जाणयासाठी माझी
समती आह
5) रील अभयासात सहिागी होणयास माझी समती आह
रण सतािरी-
Page | 174
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
ASSESSMENT CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching)
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
a) कणवशल ( pain )- 0 - Absent
1 ndash Present
Page | 175
b) कणवकणड (Itching)- 0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
c) कणवसततरा ( Discharge )
0- Absent
1-Mild- Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाशरियव ( conductive Loss of hearing )
0 - Present
1 - Absent
Page | 176
Page | 177
Page | 178
Page | 179
Page | 180
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
Page | 181
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 182
AUTHENTIFICATION CERTIFICATE
Page | 7
PREVIOUS WORK DONE -
1 Anupama Patra B Effect Of Arka Taila In The Management Of
Karnasrava With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2007
2 Palmer Komalben K Further Study On Role Of Arka Taila In The
Management Of Karnasrava With Special Reference To
Otomycosis Shalakya Tantra Institute for Post Graduate Teaching amp
Research in Ayurveda Gujarat Ayurved University Jamnagar 2010
3 Sathisha Shankar B Management Of Karnasrava With Sthanika
Guggulu Dhoopana And Rasnaadi Guggulu-A Comparitive Study Shalakya
Tantra Government Ayurvedic Medical College Bangalore 2011
4 Shashikala DK Comparative Study On The Efficacy Of Vacha
Lashunaadi Taila Karna Pichu And Nimba Patraadi Dhoopana In The
Management Of Karna Srava Shalakya Tantra Government Ayurvedic
Medical College Bangalore 2014
5 Javale Anant A Clinical Study On The Efficacy Of Arka Taila In The
Management Of Karna-Srava Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching amp Research in Ayurveda
Gujarat Ayurved University Jamnagar 2005
6 Pournima V Koti Management Of Karnasrava With Priyangvadi Taila
Pichu With And Without Saarivadi Vati Shalakya Tantra Sri Jagadguru
Gavisiddeswar Ayurvedic Medical College Koppal 2015
7 Amisha Patel A Clinical Evaluation Of Honey In The Management Of
Karna Shoola With Special Reference To Otomycosis Shalakya
Tantra Institute for Post Graduate Teaching and Research in Ayurveda
Gujarat Ayurved University Jamnagar 2016
Page | 8
REVIEW OF LITRATURE
Page | 9
Ayurvedic literature Ayurveda is a science of life practice since
thousands of years The ancient Indian system of medicine and surgery is
commonly known as Ayurveda This was given the status of Upaveda or
fifth Veda in the next stage of growth Among the available literature three
Samhita that is Charaka Samhita Sushrut Samhita Ashtang Hrudayam and
Ashtang Samgraha are the chief source of knowledge of Ayurveda
Ayurveda consist of eight branches Shalakyatantra is one among them
Shalakyatantra is one of its specialized branch deals with science of
ophthalmology otorhinolaryngology Oro dental surgery and head Acharya
Sushruta himself a practical surgeon was the first to advocate dissection of
dead bodies is indispensable for a successful student of surgery He had
described gross anatomy in the first chapter of Uttartantra Shalakyatantra
define by different Acharys as follows
शालाकय नामोरधवजतरगताना रोगाणा शरणनयनदनघराणाददसशरशरताना वयाशरिनामपशमनारव
स स ११०
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत [13]
चस १७१२
Shalakya Tantra Nirukti and Parichaya
शलाकायााः कमव शालाकय ततपपरिान शलाकयम डलहण [14]
The term Shalakyatantra is derived from Shalakya and Tantra
The word Shalakya means A probe and Tantra denotes teaching and
practices found in scripturesThe compendium in which application of
Shalaka in various surgical procedures is principally described is called as
Shalakya tantra
दनदटिवशारदााः शालाककनाः डलहण ( सउ ११३)[15]
An eye specialist is termed as Shalaki by Dalhana
Page | 10
Synonyms of Shalakya Tantra
Uttamanga Chikitsa Jatrurdhwa Chikitsa Urdhwang Chikitsa Shalakya
Chikitsa
Importance of Shalakyatantra-
Life of living being and all the Indriyas are situated in the head hence it is
known as Uttamanga
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत
चस १७१२
The treatment given to this part of the body is described specially in
Shalakya tantra While describing the importance of Shiras Vagbhata
correlates it to the root of tree (Urdhwa Mula) and body to the trunk of tree
(Adha Shaka)
Sushruta has deal with Mukha Roga in Nidan Shan and its treatment in
Chikitsasthan The description regarding the disease of eye ear nose and
head are found only in UttaraSthan Sushruta specially describes the
disease of Shalakyatantra as told by Videha in the beginning of Uttartantra
itself[16]
Shalakyatantra Itihas-
India Exhibits traditional of more than thousands of years in art literature
language logic and philosophy etc The convention was in its sophisticated
and advanced attire throughout the Vedic period
Vedic period ndash
1 Natush was treated for deafness by Ashwinikumars (Rigveda)
2 Rujaswa and Kanva were treated for blindness by Ashwani Kumaras
(Rigvedas)
Page | 11
3 There are several prayers mentioned for normal functioning of sense
organs (Yajurveda)
4 Structures and functions of Mastishka are described (Atharveda)
5 Mantras having reference to disease of Eye Ear Oral cavity etc are
found (Atharvaveda)
Upanishada Period ndash
1 Samhita Period
a) Sushrut Samhita ndash
bull Explanation regarding Netra Nasa and Shirorogas (Uttartantra 1-
26th chapter)
bull Details regarding Mukha and Karna Roga Nidan and
Chikitsa(Nidansthan 16th and Chikitsasthan 22nd chapter)
bull Description regarding Karna Chedana Sandhana Nasa
Ostasandhana Sutra Sthan 16th chapter
b) Charaka Samhita -
bull Explanation regarding Shirorogas (Sutrasthan 17th chapter)
bull Explanation of Gala rogas like Upajivika Galshundi and Rohini
bull Nasa Shiro Mukha Karna and Netra Chikitsa (Chikitsa sthan 26th
chapter)
bull Description regarding Lakshana and Chikitsa of Shankhaka
Ardhavbhedaka Shirovirechana and Shiro basti (siddhi sthan 9th
chapter)
c)Ashtnga Sangraha ndash
bull Detailed description regarding Shalakyatantara (Uttartantra 11-28
chapter)
bull Description of Kriyakalpa (Sutrasthan 32nd and 33rd)
Page | 12
d)Ashtang Hrudayam
bull Detailed description on Shalakya Tantra (Uttar tantra 8-24 chapters)
bull Kriyakalpas (Sutrasthan 23rd and 24th chapter)
e) Bhela Samhita
bull Chakshushya Vaisheshik and Buddhi Vaisheshik Alochaka pitta
f) Harita Samhita- Branch of Medical science offering elaborating
information about the procedure like Nasya Anjan Gandusha etc
comprehended with their applications in disease of Head Eyes Ears
Eyebrows Throat Temporal region and cervical spine is known as
Shalakyatantara
शशरोरोगा नतररोगा कणवरोगा वशषताः भरकरठशङकमरयास य रोगा समिनदरत दह १३
तषा परततकारकम व नसतयतपयवणजनातन च अभयङगमखगणडषकियााः शालकयसशमतााः १४
इतत शालाकयनाम [17]
Documentation of different ancient literature gives various references
regarding all aspects of Karnasrava in various periods It is very much
important to know the history of Karnasrava from Vedic Pauranic Samhita
and Samgraha period
Vedic period ndash The Vedas being the oldest source of knowledge have no
direct mentioning of Karnasrava
Page | 13
Samhita and Samgraha period ndash
Aacharya Sushruta described about Karnaroga Karnasrava Nidan
Roopa and Chikitsa The detail description is available in Sushrut
Samhita Uttartantra 20 and 21st chapters
Aacharya Charaka did not specify Karnasrava but mentioned 4 types
of Karnarogas that is Vataj Pittaj Kaphaja and Sannipataja and their
treatment in 26th chapter of Chikitsasthan
In Ashtang Hrudaya karnasrava is not explained as a separate disease
but Chikitsa is mentioned in 18th chapter of Astanga Hrudaya
uttartantra
In Ashtang Samgraha Chikitsa is mentioned in 22nd chapter of Astang
Samgraha Uttartantra
The details about Karnasrava are explained in Bhavprakasha
Madhyamakhanda 64th chapter
Madhavakara has explained about Karnasrava in 57th chapter of
Madhymakhanda
Karnasrava is also explained in Sharangadara Samhita Uttarkhand 11th
chapter
The reference for treatment of Karnasrava is available in
Yogaratnakara
In Gadhnigraha Karnasrava and its treatment is mentioned in
Karnarogadhikara Adhaya
Vangasena had mentioned about the disease and treatment in 69th
chapter
Chakradatta explained Karnasrava in 57th chapter
Dalhana has given commentary on Sushrut Samhita Uttartantra 20th
and 21st chapter
Sankhya Samprapti of Karnasrava ndash
Aachary Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga
Vigyniyam Aadhaya Aacharya charaka explain 4 Karnaroga in
Page | 14
Karnarohvigyniyam Adhaya based on doshas Acharya Vagabhata in
Ashtang Hrudaya explain 25 Karnaroga in Adhyaya
कणवशल परणादशरच बाशरियव कषड ए च
कणवसरााः कणवकणडाः कणव चवसतततर च
कशमकणवपरततनाहौ विशरिदवविसततरा
कणवपाकाः पततकणवसततराशवशरचतवविम
कणावबवद सपतवि शोफशरचावप चतवविाः
ऎत कणवगता रोगा अटिावशततरीररतााः
स उ २०- ३ त ५[18]
ातकणवरोग वपततकणवरोग कफकणवरोग
रकतकणवरोग सनदरनपातकणवरोग कणवनाद
बशरिरतप परततनाह कणडाः शोफ पततकणवक
किशमकणवक उियरपविरधयअशो अबवद
कशरचकणवक वपपपली वदाररका पाळीशोष
ततिका पररपोिो उतपपातो उरमरर दाःखिवन
शलहाखयााः परचवशनदरतकणवरोगा उकतााः
इदिीका अ स उ २१ [19]
चतपाराः कणवरोगााः
च स [20]
Page | 15
KARNA
Karna ndash करोतत शबद गरहण [21]
The organ of hearing
Karnasrava- कणवसतय कणवयोाव ससराा [22]
Discharge from the ear is referred as Karnasrava
KARNA SHAREERA
bull Nirukti
कणयवत अकणयवत अनन इती [23]
It means reception and conduction of sound waves
These are the functions of external and middle ear
bull Nirukti of Sravanam
शरयत अनन इती शरणम[24]
It means perception of sound
It can be attributed to the internal ear function
bull Karna Utpatti-
Karna is an organ formed by Akash Mahabhuta[25]
The fundamental characteristic is as follows
Indriya ndash Srotram [26]
Indriya Adhisthan ndash Karna [27]
Indriya Dravy ndash Akasha [28]
Indriya Arth ndashShabdha [29]
Indriya buddhi ndash Srotobyddhi
Page | 16
bull Paryaya of Karna- Shabdapatha Srotrapatha Sravanam shruti
Kuhuram Dwanigraham etc
bull Definition of Karna-
कणवशटकलयनदछिरनमिटिोपगरदहत शरोतरमछयत [30]
मा तन ५७१
The definition of Karna is stated in Madhav Nidanam Indriya which is not
seen with naked eye along with Shashkuli is called Shrotra that is Karna
Indriya is so minute that it is not perceived with any sense organ
In Charak Samhita the word Karna explain as the Indriya Adhisthan of
Shabdha Karna is described as one of the Prathyangas of the body He
emphasizes that all Indriyas manifest during the 3rd month of gestation
period
Acharya Sushruta while describing formation of Purusha from Prakriti or
Avyakta narrated that all Indriyas are developing from the Vikarika and
Taijas Ahankara Both Vagabhata and Sushruta stated that Karna as one of
the Bahirsrotas
शरण नयन दन घराण गदमढराणण न सततरोताशसराणा बदहमवखातन [31]
स शा ५-१०
In Ashtang Hradaya Vagbhata has states that all Indriyas are Atmaja
According to him lower lobule elevated helix projected posterior portion
fleshy and adherent ear are indications of long span of life[32]
ततरखातखातन दह अनदसतमन शरोतर शबद ववकतता [33]
ा शा ३-३
शबदाः शबदनदरिय सवनदछििसमहो ववकतता [34]
स शा १-२६
Page | 17
Ear has the prominence of Akash Mahabhuta The prominent dosha of ear
is Vata It is important seat of Vata The prominent Dhatus are Asthi and
Mamsa Karna is one of the Panchgnanendriyas and it meant for hearing
Sushruta narrated that Karnasthita Asthi and Sandhi
घराणकणवगरीाकषिकोषष तरणातन [35]
सशा ५-२२
शरोतरशरगािकष शखाताव [36]
सशा ५-३२
गडकणवशखटककम [37]
स शा ५-२२
One Sandhi and one Tarunasthi in ear
Sandhi ndash Karna contain two Sandhi one in each ear Type of Sandhi is
Shankhavartha which is present in Shringataka
Mansapeshi ndash 2[38]
Siras ndash 10 [39]
Vataj Sira - 4
Pittaj sira - 2
Kaphaj sira - 2
Raktaj Sira - 2
Avedhya sira-
कणवयोदवश तासा शबदादहनीनामकका पररहरत
सशा ७-२५[40]
Amongst above mentioned ten Siras each Karna lodges one Shabdavaha
Sira It is Avedhya
Page | 18
Dhamani -2
Length of ear is 4 Angula
Karna moola ndash 2 Angula
कणाविरतर चतदवशअगलम
स शा ३५-१४[41]
The distance between two ears through the back of the neck is 14 Angula
bull Marmas of Karna-
1 Vidhuras-
कणवपटठतो अिाःसशरशरत विर ततर बशरियवम
सशा ६-३७[42]
कणतपयादद सतनायममवणी ककनदचचनदरनममनाकर कलयकररणणच
डलहणाचयव[43]
अिसततात कणवयोतनवमन विर शरततहाररणण
ा शा ४-२९[44]
Sankhya-2
Vistara- frac12 Angula
Type- Snayumarma (Susha)
- Dhamanimarma(AH)
- Vaikalykar
Sthana- It is situated in the depressed portion in the back of the ear
Injury to them causes loss of hearing
Page | 19
2 Shringataka marma-
नदजवहाकषिनाशसकाशरोतरखचतटियसरमम
तालरयासतयातन चतपारर सरोतसा तष ममवस
वदि शरगातकाखयष सददसततपयजतत जीवतम
मा तन ५७१ [45]
Sankhya- 4
Type- Siramarma
Sthana- It is in head that is amidst Siras (blood vessels) nursing sense
organ
A palm size area near Talu
Injury to this Marma causes death
In modern anatomy ear divides into Bhayakarna or External ear Mdhyakarn
or Middle ear Antahkarna or Internal ear This is extremely appropriate
Even though the ear is divided into three divisions in the point of modern
anatomy Ayurveda denotes ear organ is one Ayurveda treats disease by
way of assessing Dosha and Dushya Here Dushya is one that is Karnendria
Dosha difference will call for different treatment for different disease Hence
treating the vitiated Dosha will cure the disease irrespective whether it is in
external middle or internal ear The thought is based on different
fundamental principle from Ayurveda
bull Parts of Karna
In Ayurveda classics detailed description about anatomy of ear is not
available But the various parts are mentioned as follows
Bhayakarna- External ear
Mdhyakarna ndash Middle ear
Antahkarna- Internal ear
Page | 20
द कणवशटकशलक दॊ कणवपतरकौ
च शा 7-11[46]
कणवशटकशलक कणवगतातवकौ कणवपतरकौ त बाहयकणा
चिदतत च शा 7-11[47]
शटकली बाहयपालयाशरिटिानम
डलहन- स शरच 25-1 12[48]
Karna Shashkulika ndash It is also called as Karna Shashakuli Charaka has
mentioned this term while describing different Pratyngas of the body
Acharaya Gananatha sen has given the clarification for it as a pinna or
auricle[49]
Karnapali ndash It is popularly known as lobule of the ear Daivakrita Chidra is
present in it
Karnaputrika- Ayurvedic scholars accepted two terms in this cortex They
are Karnaputrika and Karnaputrika The former is considered as Tragus and
antitragus[50]
Karna Prushtha- It can be taken as the cranial surface of mastoid or
auricle[51]
Karnapeetha- Aacharaya Sushruta firstly mention the term Karnapeetha
It is mentioned first by Sushruta while describing the procedure of
Karnavyadana Vagbhata has mentioned that it is Adhobhaga of Karna
Dalhana has clarified that it is the region above the Karnaputrika that is the
region which is at the bottom of the concha
Karnamoola ndash It can be considered as parotid region[52]
Karna lathika ndashAcharaya Dalhana mentioned lobule as a Karna Lathika
Page | 21
Karnaavatu ndashThis term is used by Sushruta while describing the
measurements of different Angapratyangas where he has mentioned that
the distance between the Karnaavatu is 14 Angul Dalhana has comments
that it can be taken as the distance between two ears from behind[53]
Shabdhavahasrotas ndash It also called as Shabdapatha or Srotapatha The
whole passage through which the sound waves pass can be taken as
Shabdavahasrotas[54]
Shrotashringataka ndash It can be taken as the labyrinth of ear[55]
bull Dosha in context to Karna-
Karna is principal location of Vayu
1 Prana Vayu- Prana Vayu circulating in oral cavity is responsible for
Dehadhruka that is keeping all body parts active Indriyadruka that is
keeping all Dnyanendriya healthy by proper nourishment (Purana) helps in
deglutition of food material and convey the stimulation of Indriyabuddhi
and atma
2 Udana Vayu- Bala(strength) Varna speech singing are its function It
is responsible for facial expressions due to pleasure sorrow anger love
frustration etc in general its circulation and actions are just opposite to
Pranavayu
3 Vyana Vayu- Its principal functions are circulation of Rasa and Rakta
through body and various movements Its main location is Hrudaya Five
types of movements for which it is responsible are expansion contraction
upward downward and oblique other activities are opening closure of
eyelid yawning perspiration During circulation if it gets obstructed due
to Srotodushti it generates disease of that Srotas Vyana Vayu gets vitiated
by disease of Rasa Rakta Oja and Chetanadhatu
Page | 22
4 Samana Vayu- It is circulating in the vicinity of stomach and intestine
and helps in keeping the Jatharagni (digestive juices and enzymes) in
equilibrium Disturbance in Jatharagni precipitates disease
5 Tarpaka Kapha- Entire body functions movements are controlled and
executed by various centers in the brain Sensation perceived by sense
organs is conveyed to Mann and Aatma residing in Hrudaya The motor
signals from them are then conveyed to the functioning
organsKarmendriya through Prana Vayu Shira head is therefore a
location of continuous activities motions of Vata All these centers are in
unctuous Majjadhatu in the Shira For stabilizing this ever-active Vata and
to nourish the Majja dhatu very unctuous Tarpaka Kapha situated in Shira
plays an important role
bull Ayurvedic aspect of sound perception [56]
According to Ayurveda Pratyaksha Dnyan or Perception of any sensation
including Shabda occurs due to interaction of the Karnendriya and the
Indriya- Arth -Karma resulting in Sravana
External Environmental acquaintance with living body is executed by five
sense organs namely Netra Karna Nasa Jivha and Twaka All
Dnyanendriya that is sense organ are Panchmahabhautic combination
Despite this fact every Indrya sense organ perceives object Tanmatra of
that Mahabhuta only from which it is originated from Akash Mahabhuta and
hence perceives Shabd only that is audio perception Shrotrendriya is one
of the principal locations of Vata and its function is to perceive Shabda that
is sound waves This sensation is conveyed through Shabdavahi Dhamanis
to Mana and Atma through Pranavayu and the sequence is responsible for
perception of sound in this way external sound is perceived and interpreted
when Atma is linked with Mann Mann is linked with Indriyabuddhi that is
minute virtual Dnyanendriya located in brain Indriyabuddhi is linked with
Adhishthana with prominent Mahabhuta and lastly with Indriya
ArthShabdatanmatra that is sense object Once this sequence is completed
Page | 23
the meaning of a particular sound is interpreted and understood In this
entire process of perception and interpretation of sound waves Pranavayu
and Tarpaka Kapha located in Shira play extremely important role Hence
the healthy status of all the sense organ depends upon the normal
physiologically homeostatic condition of Pranavayu and Tarpaka Kapha
MANAS
ATAMA
BUDDHI
AHANKARA
ARTHA
Page | 24
EAR ANATOMY
bull Embryology of the Ear [57]
1 The sound conducting apparatus develops from the branchial apparatus
whereas the sound perceptive apparatus from the ectodermal otocyst
2 The pinna develops from the six hillocks around the 1st branchial cleft
3 External auditory canal develops from 1st branchial cleft
4 The outpouching of the 1st pharyngeal pouch gives rise to a proximal
narrow part that forms the eustachian tube and distal dilated part that
forms the middle ear cavity
5 Prussakrsquos space is a potential space lateral to the Shrapnellrsquos membrane
and medically by the neck of malleus that can be involved during the
extension of cholesteatoma
6 Development starts in the 3rd week of the intrauterine life and is
completed by 16th week of intrauterine life Membranous and boney
labyrinth develops from the otic capsule
The Ear is divided into
1 External Ear
2 Middle Ear
3 Internal Ear or the labyrinth
Page | 25
Fig 1 Ear Anatomy
EXTERNAL EAR [58]
The outside ear contains pinna and lobule
Pinna is the noticeable piece of outer ear made from single sheet of yellow
flexible ligament covered by subcutaneous tissue and skin It has two
surfaces average and parallel It is intently disciple to perichondrium on its
sidelong surface while it is somewhat free on average surface Pinna
incorporates tragus helix against helix fossa three-sided scaphoid fossa
incisura terminalis
External auditory Canal ndash It extends from the bottom of the conchea to
the tympanic membrane and measures about 24 mm along its posterior
wallit is S shaped
Parts 1 Cartilaginous part
2 Bony part
Page | 26
Cartilaginous part ndash The outer one third is cartilaginous consist of fibro
cartilage is directed first inward backward and upward It has Fissure of
Santorium The skin of this part of the canal contains hair follicles
sebaceous gland and cruminous gland
Bony part ndash The inner two third part is boney It goes forward downward
and medially skin lined in this part is very thin Isthmus is the narrowest
part of the canal lying medial to junction of bony and cartilaginous part
nearly 5 mm lateral to tympanic membrane
The roof and posterior wall of the external auditory canal shorter than floor
and anterior wall The skin lining the tympanic membrane and boney canal
has a self-cleansing property due to migration of keratin layer of epithelium
from drum towards the cartilaginous portion
Relations- Anteriorly- Temporomandibular joint and parotid gland
Superiorly- Middle cranial fossa
Inferiorly- parotid gland
Posterior- Mastoid antrum mastoid air cells and facial nerve
Nerve supply ndashSensory nerve supply of the external ear The auricle
supplied by fibers of the great auricular nerve (C2 and C3) and lesser
occipital nerve (C2) Auriculo temporal branch of the 5th cranial nerve and
auricle branch of the vagus (Arnoldrsquos nerve) supply external canal Facial
nerve has small sensory contribution on posterior-inferior wall
Tympanic Membrane -It is the partition between EAC and middle ear It
is a thin semitranslucent membrane pearly white in colored lying obliquely
in the medial end of EAC with the angle of 55 It is forming major part of
lateral wall of middle ear Annulus tympanicus is attached at its
circumference to the sulcus The TM is oval shape It measures
approximately 10 mm in vertical diameter and 90 mm in horizontal
diameter
Page | 27
Layers ndash Tympanic membrane consist of three layers
1 Outer Epithelium or cuticular layer which is continuous with skin of
external ear
2 Middle fibrous layer has both circular and radial fibers middle layer
missing in upper part
3 Inner layer- Inner mucosal layer which is continuous with middle ear
mucosa
Parts ndash Tympanic membrane consist of two parts
1 Pars tensa -It is largest part below the malleolar folds The inner
surface at the center attached to the handle of malleus Angle of cone
is most illuminated part in the pars tensa at anteroinferior part of pars
tensa
2 Pars flaccida Sharpnells membrane -it is triangular area above the
malleolar folds which are thin and devoid of fibrous tissue and
annulus It fits into notch of Rivinous
Nerve supply 1 Anterior half of lateral surface Auriculotemporal V3
2 Posterior half of lateral surface Auricular branch of vagus cn 10
3 Medial Surface Tympanic branch of CN 9 (Jacobsons nerve)
Fig 2 Tympanic membrane of ear
Page | 28
MIDDLE EAR [59]
The middle ear or tympanic cavity is an irregular laterally compressed
space within the temporal bone It is filled with air that is supplied to you
from the nasal part of the throat through the ear canal It contains a chain
of mobile bones that connect its side with the medial wall and serve to
transmit vibrations transmitted to the eardrum through the cavity to the
inner ear Including the parapet the vertical and anteroposterior diameters
of the cavity are each approximately 15 mm The transverse diameter
measures about 6mm at the top and 4mm at the bottom Compared to the
eardrum it is only about 2mm The eardrum is limited laterally by the
eardrum medially by the lateral wall of the inner ear It communicates
behind with the tympanic antrum and through it with the air cells of the
mastoid and in front with the auditory canal The middle ear together with
the Eustachian tube aditus antral and mastoid air cells is called the
middle ear cleft It is lined by mucus membrane and filled with air
It is divided into 3 parts
1 Mesotympanum (located in front of the pars tensa)
2 Epitympanum or attic (located above the pars tensa but medial to
Sharpnells membrane and the lateral bony wall of the attic)
3 Hypotympanum (located under pars tensa) The middle ear is like a
hexagonal box with a roof
Carotid or Anterior wall- It separates middle ear cavity from internal
carotid artery The various structure passing through anterior wall of
tympanic cavity
bull Canal of chorda tympani nerve
bull Canal of tensor tympani muscle
bull Eustachian tube
bull Anterior malleolar ligament
bull Anterior tympanic artery
Page | 29
Posterior or mastoid wall ndash The upper part of the back wall shows the
opening of the auditorium Below the auditory is a triangular bony
projection known as the pyramidalis processors The stapedial tendon is
transmitted through the apex of the pyramidalis processes The vertical
portion of the facial nerve descends along the posterior wall until it opens
into the stylomastoid foramen
Roof or Tegmental wall (Pars terminalis)- It is formed by a thin bone
plate called the tegman tympanum that separates the skull and tympanic
cavities It is located on the anterior surface of the rocky part of the
temporal bone near the junction with the temporal shell it extends back to
the roof in the tympanic membrane and anteriorly to cover the half canal
of the tensor tympanic muscle The lateral border corresponds to the
remains of the Petro scaly suture
Floor ndash It is formed by a thin plate of bone which separate middle ear from
the bulb of the internal jugular vein lodged in the jugular fossa
Lateral wall ndash It is formed by tympanic membrane and partly by a portion
of squamous part of the temporal bone It separates the middle ear from
external ear
Medial wall- It separates the middle ear from the inner ear
bull The promontory is the most prominent and convex part formed by the
basal rotation of the cochlea
bull The bony lateral semicircular canal is postero-superior to the promontory
above the oval window
bull The oval window is located between the middle ear and the vestibular
slope of the cochlea It is closed by the stirrup footrest and the annular
ligament
Page | 30
bull The round window is located under and behind the cape The round
window recess is directed to the rear It is closed by the secondary eardrum
and separates the middle ear of the Scala tympani from the cochlea
bull The facial nerve passes through the bony fallopian tube above the oval
window
Mastoid Antrum ndash It is a large space with air in the upper part of the
mastoid and communicates with the attic through the aditus The roof is
formed by the antri tegmen which extends and separates the tympani
tegmen from the middle cranial fossa The lateral wall of the antrum is
formed by a bony plate that is on average 15 cm thick in adults It is
marked externally on the surface of the mastoid by the suprameatal triangle
(MacEwen)
Aditus and Antrum- Aditus is a gap through which the attic communicates
with the antrum The boney prominence of the horizontal canal lies on its
medial aspect even as the fossa incudes to thats attaches the quick system
of incus lies laterally Facial nerve publications simply underneath the
aditus
The mastoid and its air cell system-
The mastoid consists of bone cortex with a honeycomb of air cell
underneath Depending on development of air cell three types of mastoids
have been described
1Well-pneumatized or cellular- Mastoid cells are well developed and
intervening septa are thin
2Diploetic- Mastoid consist of marrow spaces and a few air cells
3Sclerotic or acellular ndash There are no cells or marrow spaces
With any type of mastoid pneumatization antrum is always present In
sclerotic mastoids antrum is usually small and the sigmoid sinus is
anteposed
Page | 31
Depending on the location mastoid air cells are divided into
1 Zygomatic cells (In the root of zygoma)
2 Tegman cell (Extending into tegmen tympani)
3 Perisinus cells (overlying the sinus plate)
4 Retrofecial cells (round the facial nerve)
5 Peri labyrinthine cells (located above below and behind the
labyrinthine some of them pass through the arch of superior
semicircular canal These cells may communicate with the petrous
apex)
6 Peritubal (around the Eustachian tube Along with hypotymoanic
cells they also communicate with the petrous apex)
7 Tip cells (which are quite large and lie medial and lateral to the
digastric ridge in the tip of mastoid)
8 Marginal cells (Lying behind the sinus plate and may extend into
the occipital bone)
9 Squamosal cells (Lying in the squamous part of temporal bone)
Development of Mastoid ndash
The mastoid develops from the scaly petrous bone The petrosquamosal
suture may persist in the form of a bone plate - Korners septum which
separates the superficial squamosal cells from the deep rock cells Korners
septum is surgically important because it can cause problems locating the
antrum and deeper cells and thus lead to incomplete removal of the disease
during mastoidectomy The mastoid antrum can only be reached if Korners
septum is removed
Page | 32
Fig 3 Cross section of Mastoid
Contents of the middle ear
Ossicles ndash Three tiny bones which conduct the sound from eardrum to oval
window
Malleus ndash It is the largest and most lateral ossicle measuring 8 mm in
length It has head neck handle anterior and lateral processes The head
is situated in the epitympanum A lateral process project laterally from the
neck while the handle is firmly fixed to the pars tensa of the ear drum
Incus- It has a body short process and long process The body short
process and long process The body articulate with the head of mallelus in
the attic and the short process project into the attic The long process
projects downwards behind the handle of malleus running parallel to it and
articulate with the head of the stapes via the lenticular process
Stapes ndash It is the smallest ossicle measuring about 35 mm and consist of
head neck footplate and anterior and posterior curcura The footplate of
stapes is held to the oval window by the annular ligament
Page | 33
Muscles ndash
1Tensor tympani ndash It is inserted is a branch of the facial nerve which carries
the sense of taste It is first arch muscle supplied by branch of mandibular
nerve V3
2 Stapedious muscles ndash It is inserted to the neck of stapes It is the second
arch muscle supplied by branch of facial nerve that is nerve to stapedius
Fig 4 Contents of the middle ear
Blood supply of Middle Ear
bull Anterior tympanic branch of maxillary artery which supplies tympanic
membrane
bull Stylomastoid branch of posterior auricular artery which supplies middle
ear and mastoid air cells
Page | 34
Four minor vessels are
bull Petrosal branch of middle meningeal artery runs along greater petrosal
nerve
bull Superior tympanic branch of middle meningeal srtery traversing along
the canal for tensor tympanic muscle
bull Branch of artery of pterygoid carotid
bull Tympanic branch of internal carotid
Lymphatic Drainage of Ear
Lymphatics from the middle ear drain into retropharyngeal and parotid
nodes while those of the Surgical Importance ndash Eustachian tube drain into
retropharyngeal group
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 middle is likely to pass to
middle ear
2 Moreover middle ear suppurative disease may spread to adjacent organs
and produce complication eg Labyrinthitis meningitis facial nerve palsy
etc
3 Lenticular process is vulnerable in suppurative ear diseases and causes
ocular disruption
4 Prussac space is the site of primary acquired cholesteatoma
Page | 35
INNER EAR [60]
Inner ear is divided into two parts
1 Bony Labyrinth
2 Membranous labyrinth
Anatomy of bony labyrinth
It is divided into two parts
1 Vestibule
2 Cochlea
3 Semicircular canal
The vestibule is located between the medial wall of the middle ear and the
lateral to internal acoustic meatus anterior to the semicircular canal and
posterior to the cochlea The vestibule is the central part of the inner ear
On its side is the oval window opening which is closed by the bracket foot
plate The bony cochlea is located in front of the vestibule It has 275 turns
wound around a bony axis called a modiolus The cochlea is about 30 mm
long The hollow center of the modiolus is a spiral canal that contains the
fibers and ganglion cells of the cochlear nerve A thin bony sheet the bony
lamina winda around the modiolus This divides the cochlear duct into two
galleries the Scala vestibuli above and the scala tympani below
There are three semicircular canals superior posterior and lateral They
are semicircular in shape and open into the vestibule One end of the
semicircle is enlarged and is known as the sphere
The membranous labyrinth is in the bony labyrinth It is connected to the
bony labyrinth by fibrous trabeculae and is surrounded by perilymph The
endolymph is located in the membranous labyrinth
Page | 36
The utricle is in the upper part of the vestibule while the saccule is found
below Both the utricle and saccule contain a single sensory patch called
the macula Each macula is covered with a neuroepithelium made up of
neuroepithelium made up of sensory hair cells and support cells these cells
are separated by a basement membrane Fibers of the vestibulo-cochlear
nerve enter the macula and pierce the basement membrane to terminate
at the base of the hair cell or cell bodies The utricle and the saccule with
their macula are called otolith organs Membrane semicircular canals are
the membrane canals of the corresponding bony semicircular canals They
open into the utricle through five openings One end of the opening of each
channel is dilated called the sphere in which the sensory organ of each
channel is located The cross section of the Scala standard looks like a right
angle The base is formed by the basilar membrane Sensory cells are
arranged on the surface of the basilar membrane These sensory cells with
their supporting cells form a complex neuroepithelium called the basilar
papilla or the cortical organ named after an Italian microscopist The
organs of the corti have a gelatinous membrane called the tectorial
membrane and they are supported by the pillar of the corti The cortical
pillars enclose a space called the corti tunnel which contains a fluid called
cortical lymph Vestibule is lies between the medial wall of the middle ear
and lateral to internal acoustic meatus anterior to semicircular canal and
posterior to the cochlea 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 Boney cochlea lies in front of the vestibule It has 275 turns
coiling around boney axis called modiolus Cochlea is approximately 30 mm
in length The hollow center of the modiolus is a spiral canal containing the
fibers and ganglion cells of cochlear nerve A thin boney sheet the osseous
lamina winda around the modiolus This divides the cochlear canal into two
galleries the Scala vestibuli above and the scala tympani below
Page | 37
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 boney labyrinth It is connected
to the bony labyrinth by fibrous trabeculae and is surrounded by perilymph
Endolymph 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 single sensory patch called macula Each
macula is covered by neuroepithelium consist of Neuroepithelium consists
of sensory hair cells and supporting cells these cells are separated by
basement membrane Fibers 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 are referred
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 corti lymph
Page | 38
Fig 5 Inner Ear
Blood supply of labyrinth
Labyrinthine artery
Common cochlear Anterior vestibular Artery
Vestibulocochlear artery Main cochlear artery
Cochlear branch posterior vestibular artery
Page | 39
PHYSIOLOGY OF HEARING [61]
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
bull Mechanical conduction of sound (conductive apparatus)
bull Transduction of mechanical energy to electrical impulses (sensory
system of cochlea)
bull Conduction of electrical impulses to brain (neural
Fig 6 PHYSIOLOGY OF HEARING
Page | 40
Conduction of sound
Under the surface of water we cannot hear the sound made in air because
9995 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 must 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 13 times longer than long process of incus providing
a mechanical advantage of 13
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 beings 211 As the effective
vibratory area of the tympanic membrane is only two- thirds the effective
areal ratio is reduced to 141 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
Page | 41
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 lobe
Page | 42
DISEASES REVIEW
करणसराव
Nirukti - करणसय कणवयोाव ससराा [62]
Nidana- Acharya Sushruta and Vagbhata describe the common etiological
factors for the Karnaroga
अशयाय जलिीडा कणवकणडयन मरत
शमथययोगन शसततरसतय कवपतो अरय च कोपन ||
सउ २० १२
1 Avashaya or Pratishaya
(Excessive exposure to cold)
2 Jalakrida
(Excessive swimming)
3 Karnakandunyanum
(Excessive scracing due to itching)
4 Mithyayogena Shatrasya
(Improper instrumentation during wax removal or foreign body removal)
5Shabdasya
(Louder sound for long durationperverted contact of sound)
6 Abhighata (Trauma)
7 Vitiation of Tridoshas
Page | 43
Samanya Nidana according to different Samhita
Vishesh Nidan of Karnasrava
Acharya Charaka has not mentioned any kind of Nidana regarding Karnaroga
but has described Utapati of Karnaroga from Siroroga in Karnasirasym
Adhyaya[67]
शशरोअशिघातादरा तनमजजतो जल परपकादरा अवप विि
सरतत पय शरणॊ अतनलात स कणवससरा इतत परककतीत
सउ २० १०
असस ३७२५ [68]
1 Shiroabhighatat - Head Injury-Fracture of middle cranial fossa
2 Jala nimajjana - CSF otorrhoea fracture of middle cranial fossa
3 Karnaprapaka
4 Karna Vidhradhi -Puyasrava
Sr
no
Samanya Nidana SU AH[63] AS[64] YR[65] MN[66]
1 Avashaya + + +
2 Pratishaya + +
3 Shabdha
mithyayoga
+
4 Shashtra
mithyayoga
+ + +
5 Karnakandooyan + + + + +
6 Jalkrida + + + + +
7 Abhighata + + +
Page | 44
Samanya samprapti
परापय शरोतरशसरा कयावत शल शरोतशस गान
त कणवगता रोगा अटिावशततरीता
सउ २० १२
Due to common and specific etiology factors the vitiated Doshas gets
Sthanasamshraya in Karna and causes Karnasrava It is the stages of
Samprapti were Doshas gets lodged in Srotas and start processes of Dosh
Dushya Sammurchsna Due to Shiroabhighata Jalanimmajana Karna Paka
Karna Vidhradi vitiated Vata Dosha and Karna becomes Avruta by Vata and
results in Karnasrava Normal physiology of Dosha Dhatus and Malas entirely
depends on the normality of Srotas Dosh Dushya Sammurchana or
manifestation of diseases will not take place if only vitiation of Doshas take
place without deformity of Srotas Here in Karnasrava vitiation of Srotas are
Atipravritti Sanga and Vimargagamana take place Atipravritti is being excess
production of fungus Sanga is obstruction in external acoustic canal
Vimargagamana is the propagation of discharge through ear
Vishesh Samprapti
Karnasrava occurs due to Nij nidana is Pratishaya while Agantuja nidanas are
Avashya Jalkrida and Karnakanduyan Due to etiological factors which are
Vata-Kapha provocative in nature gradual vitiation of Doshas will occur After
vitiation they get accumulated (Sthan samshraya) in external auditory canal
In other hand when patient does Sevana of Agantuj Nidan like water enter in
external ear scratching of ear unsterile instrumentation leads to Dosh
Prakopa These cause Twak and Mamsa Dhatu Dushti which leads to
discontinuity of epithelium of ear canal which creates suitable atmosphere for
fungal pathogen to grow The vitiated Vata will produce symptoms such as
Page | 45
pain hearing impairment and vitiated Kapha causes symptoms like itching
discharge ear blockage By assessing the symptoms it can be said that Kapha
Avrita Vata Dosha is responsible for the manifestation of clinical features like
pain itching discharge Which are seen in Karnasrava that is otomycosis
Acharya Charaka has mentioned while explaining Samanya Chikitsa of
Karnaroga that it should be treated like Vrana when Paka and Srava is present
as a symptom Fungal spores invade in the epithelial layer of EAC In response
to infection inflammatory process is start This is a Paka Avastha After
removing the fungal mass ulceration in external acoustic canal is commonly
seen As a result of infection process exudates was produced which will mix
up- with fungal colonies and appear as discharge As per Dosha involvement
in Vrana Shoola Srava can be differ According to Acharya Sushruta Ruk is
the Samanya Lakshana of Vrana and Vishesha Lakshana of Vrana includes
pain discharge discoloration itching etc according to Dosha involvement
which are also seen in otomycosis In otomycosis mainly watery and purulent
type of discharge is present which indicates Paka avastha If there is Dosha
involve in Vrana is called Dushta Vrana Acharya Sushruta and Acharya
Vagabhata have mentioned verity of Srava in Twak and Mamsa Vranavastu
which is found in otomycosis Based on this description otomycosis can be
correlated with Karnasrava
Page | 46
Representing the Samprapti of Karnasrava
Vishesh Nidana ndash Shiroabhighatat
Jala nimajjana
Prapaka Vidhradhi
Vitited vata
Avarana by kapha
Vimargagamana of Vata
Karnasrava
Samprapti Ghataka
Dosha ndash Kapha and Vata
Dushya ndash Rasa Rakta and Mansa
Strotodushti ndash Vimargagamana and Sang
Adhishthana ndash Karna (Bhayakarna)
Rogmarga ndash Madhyama
Page | 47
Purvarupa
The Purvarupa of Karnasrava are not mentioned separately in any ayurvedic
classics In routine practice cretin Purvarupa are noted
1 Karnakandu
2 Karnagurutwa
3 Alpa karnashoola
4 Discomfort in ear
Rupa
1 Karnashoola
2 Karnakandu
3 Karnasrava
4 karnabadhirya
5 Cotton wool like or wet newspaper like grayish brown or black colored mass
is seen
6 External auditory canal skin appears edematous and red
Upashaya and Anupashaya
Appropriate application of Aushadhi Ahara and Vihara when produces relief in
the symptom is called as Upashaya and when aggravates the symptoms is
called Anaupashaya There is not any reference available in the classics about
the Upashaya and Anupashaya of karnasrava
Sadhyasadhyata
Sushruta has not mentioned specially the Sadhyasadhyata of Karnarogas But
Vagbhata has mentioned Karnasrava as a Sadhyavyadhi[69]
Sadhysadhyatagives the clear picture of prognosis of the disease It depends
on many factors like nature of disease severity of disease Vaya Prakriti Bala
of the patient etc
Page | 48
Upadrava of Karnasrava
In Samhita there is no reference available regarding the Upadrava of
Karnasrava
Samanya Chikitsa ndash
The common treatment principle for all Karnaroga is Ghritapana Use of
Rasayana Bhrahmacharya Avyayama Shirasnana and Atibhashaya
सामरय कणवरोगष घतपान रसयनम
अवयायमो शशराःसतनान बरमहचयवम कतपरनम
स उ२१३
Ghratapana - Ghrita is a Yogavahi and follow Sanskara in addition to these
acquired properties and capable of retaining its own properties So Ghritapana
is effective in Karnasrava
Rasayana - Rasayana represent the basic approach of Ayurveda which
comprise preventive promotive and curative aspect of health
Brahmacharyaapalana -It is like Sadvrittapalana and is equals to Rasayana
effect
Vyayama - It leads to vitiation if Vatas a Karna is a Sthana of vata and
exercise causes Kshayaj Samprapti hence it is important to avoid exercise in
Karnasrava
Shirasnana- In Shirasnana water enters in external acoustic canal it changes
the PH of meatus skin from acid to alkali which favors the growth of pathogens
Atibhashya - Excessive speaking causes Vata Prakopa and Vatapraokopa is
basic Samprapti for Karnasrava as the preventive aspect avoidance of
excessive speaking is necessary
Page | 49
Ghritapana Rasayana and Brahmacharyapalana should be followed for
preservation of dhatu Samyata and restriction of vitiation of Vata Vayayama
Shirasnana and Atibhashaya should be avoided in Karnasrava to protect the
Siras from the affliction of Vata and Kapha
Vishesha Chikitsa ndash
The general treatment principle of Karnasrava described in classics is closely
related to Dushtavrana Chikitsa
शशरोवरचन च ए िपन परण तरा
परमाजवन िान च ीकषय ीकषय़ाचारत [70]
स उ २१४०
कणवसततरा ोददत कयावत पततकशमकणवयो [71]
ाउ १८३५
उपददि च सततरोत साय परात वपचततवशि परमजय
य अगर मदन सघत गगलना ा िपतयतपा मिना परयत [72]
असउ २२४२४३
In addition to that Shirovirechana Karnadhoopana Karnapurana
karnapramarjana Karnadhavana are also indicated
Page | 50
Treatment is also mentioned for Karnasrava
1 Karnaprakshalana Yoga - with Aargawadadi Gana Kashaya and Surasadi
Gana Kashaya [73]
2 Avachurnana Yoga ndash with Aargawadadi Gana Churna and Surasadi Gana
Churna[74]
3 Karnapoorna Yoga ndash
bull Rasanjana Laksha with Sarjachoorna[75]
bull Panchkashaya with Kapittha swarasa and Madhu[76]
bull Jambu AmrapallavShivalaKshuodra Mahavriksha and Madhuki 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 done[77]
bull Sarjatwak Choorna with Karpashiphalarasa and Madhu[78]
bull Abhaya LodraTindukaSamanga(Manjista) Kwatha of this Dravyas mixed
with Madhu and Kapittha Rasa[79]
bull Yogratnakara mention the following drugs for Karnapoorana-
a Samudraphena Churna[80]
b Jambwambpatra Yoga
4 Karnadhoopana Yoga ndash
bull Dhoopana with Churna of Bilvapatra Haridra Palandu[81]
bull Vartak Dhoopana [82]
5 Internal Medications-
bull Rasnadi Guggula [83]
bull Triphala Guggula [84]
bull Sarivadi Vati [85]
bull Gandhaka Rasayana [86]
Page | 51
According to Vagbhata-
Ear should be cleaned with the Pichu and Varti followed by Guggula Dhoopana
and then Karnapoorana with Madhu Followed by Avachurnanana with
Sukshmachootana of Surasadigana
Pathyaapathya ndash Pathya and Apathy mentioned for Samanya Karnaroga is
recommended in Karnasrava also
पथय[87]
सतदो वरको मन नसतय िमाः शशरावयिाः
गोिमाः शालयो मदगााः याशच परतन हवाः 80
लाो मयरो हररणानदसततततरो नकककिाः
पिोल शशगर ातावक सतनषराण कदठललकम
रसायनातन सवणण बरमहचयवमिाषणाम |
उपयकत यरादोषशमद कणावमय दहतम ||81||
िापर २१
Aharaja Upacharaja
bull Godhuma bull Vamana
bull Shala bull Virechana
bull Mudga bull Nasya
bull Yava bull Dhoomapana
bull Puranagitra bull Kavala
bull Lava Harina Tittiramamsa
Page | 52
अपथय[88]
दरत काटठ शशरसतनान वययाम शलटमल गर
कणडयन तषारशच कणवरोगी पररतपयजत
िापर २१
Viharaja
bull Patola ShigruVartaka bull Bhramacharaya
bull Sunishannaka bull Avyayama
bull Katthlika bull Aakthanam
bull All types of Rasayana bull Upacharaja
bull Vamana
Apathyas
bull Abhishyandakara Aharas
bull Shirasnana
bull Karna kandooyana
bull Tushara sevana
bull Guru Kaphakaraka Aaharas
bull Dantdhavana
Page | 53
OTOMYCOSIS
Definition-
Otomycosis is a superficial acute sub-acute or chronic infection of external
ear canal It is mostly unilateral It is characterized by inflammation purities
and scaling Otomycosis is a common condition encountered in ENT practice
more in chronic and persistent ear infection
The Fungal infections are not communicable in the usual sense but the
humans become an accidental host by their introduction into tissue trauma
The virulence factors favoring colonization of fungus in human host are yet to
be identified Ability of the fungus to grow at 37 C and elaboration of a variety
of enzymes and toxins are speculated to contribute to virulence Only 100 to
150 species are generally recognized as a cause of disease in humans[89]
Prevalence-
Otomycosis is a word wide in distribution and in various record stated that 5
to 20 of all cases of infective otitis externa Otomycosis prevalent is more in
warm and humid climates It is one of the commonest manifestations in India
during rainy season It occurs mostly in humid atmosphere otitis externa due
to fungal infection may resembles the desquamative form of diffuse infective
otitis externa The incidence in temperature climates has increased in
proportion to the use of topical antibiotics which have a medium sterilized of
other organism in which the fungus may flourish
Page | 54
Predisposing factors- [90]
1 Environmental factors such as climate contagious and polluting hygiene
more frequently during rainy season as the humidity increases
2 Individual susceptibility ndashGeneral Immunological status of the Individual
eg HIV infection Radiotherapy chemotherapy Diabetes mellitus
3 Self-inflicted trauma that is use of pins to clean the itching ear or use of ear
bud to clean the wax
4 Wide spread of topical antibiotics steroid preparations which have medium
sterilized of other organism in which the fungus may grow
5 Failure of defense mechanism in External auditory canal
6 During swimming or head bath water enters in External acoustic canal
causes quantitative and qualitative change in ear wax It causes change in pH
7 Long term use of hearing aids
Pathophysiology ndash
The life cycle of the average mold encountered in the ear may be reckoned
as two weeks and flare ups may be anticipated at such intervals Swimming is
held responsible for infection in many cases The sequence sequence of
pathogenic changes produced by molds in the external ear is as follows ndash
1 Implantation of the organism in external ear
2 Growth of organism follows the rate depending on condition of temperature
moisture or preexisting irritation
3 Invasion of epithelium occurs with attendant itching and discomfort which
may be quite severe
Page | 55
4 Exfoliation of epithelium occurs as nature attempts to overcome the
infection by casting off upper most cells
5 Denudation occurs from exfoliation as the top layers of epithelium are cast
off and the canal becomes filled with debris
6 Superficial ulceration and lizematoid dermatitis results if the pathologic
process goes for enough The changes do not always proceed through the
entire sequence sometimes the molds produce changes of the mildest
imaginable character which may be overlooked[91]
Clinical features -
Symptoms-
1 Irritation and itching ndash Irritation is mostly found when the infective
organism is aspergillus niger There is sensation of discomfort which is more
diffuse in the ear canal then localized in the deeper part Candida infection
causes marked itching In external ear it is intense and worse at night
2 Discharge through ear- Intermittent scanty colorless discharge through
ear Mucus being a fungal metabolic product appears as discharge Excessive
discharge is associated with mixed infection
3 Pain and discomfort ndash Mild to severe pain in the ear occasionally Mostly
seen in cases where ear is infected with Aspergillus flavus mixed infection
with gram negative organism or mixed infection with candida and aspergillus
Headache is sometimes associated with pain
4 Deafness- Varying degree of mild to moderate conductive deafness
5 A sensation of fullness in ear
6 Tinnitus 7 Vertigo
Page | 56
Signs ndash
1 The external acoustic meatus may contain a mass formed of epithelial
debris exudates cerumen and fungus
2 Erythematous external canal
Fungal appearance
A Niger - The color of the mass which is usually grey or black is mainly
determined by the type of fungus concerned Its appearance is like wet
newspaper or blotting paper or a cotton wool It has a peculiar musty odor In
this infection fruiting heads may be seen as black specks in the debris
Occasionally as inactive form occurs in which the canal is lined by mold giving
a fluffy appearance due to the presence of tiny mycelia
Candida ndash Candida infections generally show as white deposits on magenta
colored skin when the debris is removed it rapidly recovers in 24 hrs
The underlying canal skin is often inflamed and granular due to invasion by
fungal mycelia and be seen in all cases In rare cases excoriation and
ulceration with marked extensive shedding of the epithelium and deep
ulceration can be seen usually associated with a flavus and with pathogenic
bacteria[92]
Otoscope Appearance
1 Aspergillus Niger ndash Black headed
2 Aspergillus Fumigators ndash pale blue or green
3 Candida Albicans ndash White- or cream-colored deposits
Page | 57
4 Auricle is normal in most cases In severe cases small ulceration with crust
formation may be present on lateral surface
5 Tympanic Membrane
In most cases it is normal with normal mobility and normal hearing In a few
cases the surface of the tympanic membrane is congested and scaly There is
erosion or ulceration of the external epithelial layer and the membrane itself
may be edematous
Diagnosis
1 Above mentioned symptoms and signs
2 In the stage at which patient with otitis externa usually first present
themselves mycelia threads conidiophors not visible to naked eye may
sometimes be identified with the microscope
3 Confirmed by culture
Page | 58
Fig7 Aspergillus Niger Fig8 Candida Albicans
Fig9 Aspergillus Fumigators Fig 10 Wet Paper like appearance
Page | 59
Treatment
1 Antibiotic or steroid drops should be discontinued if they are being instilled
since long time
2 Removal of fungal mass epithelial debris and discharge from the external
canal or mastoid cavity repeatedly and thoroughly by forcepa or suction or
syringing or cautiously blow a stream of air into the canal through a fine
cannula and dry thoroughly by swabbing liquid petroleum on swab used in
cleaning the ear lessens the burning sensation when metacresy acetate is to
be employed in the subsequent treatment
Furuncle is developed as a complication if there is no gentleness in cleaning
Cleansing may have to be delayed until local sensitiveness is lessened which
can usually be accomplished within twenty-four hours If there is excessive
epithelial debris along with otomycosis then metacresyl acetate which is a
keratolytic in introduction into the external auditory canal on cotton wick and
is allowed to remain for twenty-four hours After twenty-four hours the cotton
wick is removed at which time the canal can usually be cleansed with little
discomfort as the medication is also anesthetic The epithelium of the canal
was white from contact with the drug The top layer was detached and this
epithelial debris can be easily wiped away The wick is reinserted and wet with
metacresyl acetate
The treatment is employed for three to four days in succession and then a
bland application is substituted Icthyol iodine is of value at this stage Iodine
ointment 2 in combination with Tannic acid 2 is also an excellent local
application following cresatin treatment
Next one of the fungicides may be applied
Page | 60
1 Nystin Effective for candida infection but less active against aspergillus
group Nystatin in boric powder consisting of 100000units of nystatingm of
powder 3 times week for 3 weeks
2 Clotrimazole Available as 11 cream or drops or lotions Phenyl
(zchlorophenyl) 1 ndash imidazole ndash methane is a chlorinated trityl imidazol 1
effective against candida and dermatophytes and for aspergilli infection
3 Amphotericin B Available as cream and as 3 solution and 015 drops
for topical application Very effective for candida infection can be fungistatic
or fungicidal
4 Econazole Available as solution (Econazole nitrate) and as cream (1)
Broad spectrum ndash more effective for Aspergillus Also active against some
gram-positive bacteria (Staphylococci and Streptococci and Dermatophytes)
5 Miconazole Highly effective against dermatophytes and candida infections
used as a 21 cream applied once or twice a day for 10 days
6 Gentian violet 21 Available as drops (recently some evidence of
carcinogenicity) Discolors the ear canal and this interfere with clinical
examination
Other topical antifungal agents are ketoconazole Natamycin Tolciclat Bifonas
zole Fenticonzole Oxiconazole Tioconazole ciclopiroxolomine Tolnafate
Haloprogin Flucytosine Acetic acid Whit field ointment selenium sulfide
undcyclenic acid triacetin etc
Page | 61
Minimal length of treatment
A month of drug treatment is usually required because the antifungal agents
used are not sporicidal and it is necessary that the period of treatment covers
germination time It may be advisable to give short gaps in the period of
treatment to ensure all spores have germinated before deciding to terminate
therapy
Prevention
Accomplished by strict attention to the predisposing causes
1 Water should be prevented from entering the ear
2 Avoidance of external ear trauma
3 Use of alcohol medicated or plain in the ears after swimming mercuric
cyanide (15000) in ethyl alcohol (70) is a satisfactory liquid to use
Ear stoppers do no good unless their use is followed by some antiseptic in the
canal Divers exposed to water for long periods of time may also use acidic
alcohol
4 During Summer months with their high humidity special efforts are needed
to maintain ear dry 5 Indiscriminate use of topical antibiotics steroid
preparations should be avoided
Page | 62
DRUG REVIEW
1 GUGGULA
Fig11 - Guggula
Historical review of Guggula [93]
bull Atharvaveda one of the well-known Vedas of Hindus The earliest
reference given by Atharvaveda medicinal and therapeutic properties of
Guggula Guggula has long history of use in Ayurveda
bull Acharya Charaka Sushruta and Vagbhata describe detail regarding the
actions uses and indication as well as the variety of Guggula
Page | 63
bull Various Nighantus (Medical lexicons) were written between 12th and 14th
centuries AD was based on the Ayurvedic literature also describes
Guggula
bull The explanation of word Guggula is that Gunjo Vyadhegurdti Rakshati
which means to relief against different diseases
bull Guggula is the best medicine because it develops through the rays of
hot sun on specific circumstances
bull Guggula has an aromatic odor
गगलो कणवदौगवररधय िपन शरटठमछयत[94]
स उ २२११२
Latin name- Commiphora mukul
Family ndash Burseraceae
Rasa- Tikta Katu
Guna ndash Laghu Rukshasukshma vishada sara
Veerya ndash Ushna
Vipaka ndash Katu
Action- Rasayana Lekhana
Doshaghanta - Tridoshhara
Page | 64
Chemical composition [95]
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Oleoresin-Z-Guggulsterone E-Guggulsterone
Gum- guggulignans 1 and 2 guggula Tetrols mukulol allylcembrol c
27
Guggulusterol 1 2 ans 3 Z and E ndash guggulusterol
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Parts Used ndash Gum oleoresin
Guggula purity test
1 Yellowish brown emulsion is obtained when Guggula is triturated with
water
2 An ethereal solution of the drug attains reddish colour when treated
with br2 vapors and purple colour when moistened with nitric acid
Biochemical action ndash Antiseptic Anti-inflammatory Disinfectant Diuretic
Immunostimulant stimulating expectorant Ant suppurative Antipyretic
Enhance phagocytosis
Karma- Rasayana cardiovascular disease
Page | 65
2 AGARU-
Fig 12 Agaru
Historical review of Agaru [96]
bull The word Agaru literally means the one which is the heaviest and no
aromatic wood is heavier than it Since thousands of years Agaru lsquoThe
wood of Godrsquo has been used for multiple purpose like commercial
medicinal spiritual aromatic historical
bull The medicinal use of Agaru have been recorded in many pieces of India
Greek Roman Chinese Middle eastern and European since ancient times
bull Acharya Charaka used Agaru and pest of Rasna to counteract the effect of
cold in Agraya Dravyas
bull Acharya Sushruta used Agaru as a Dhoopana Dravya along with Guggula
Ral and Shoma in the treatment of Karnasweda and Vrana
Page | 66
Types-
bull Dhanwantsri Nighantu describes Kaleyaka as a type of Agaru
bull Sodhala Nighantu describes three types of Agaru ndash Agaru Krishna
Agaru Kakatunda Agaru
bull Raj Nighantu describes five types of Agaru ndash Krishna Agaru Kasht
Agaru Daha Agaru Mangalya Agaru and Agurusaar
bull Arthashasstra describes three Agaru wood product
1 Jongaka ndash Black or variegated black in colour and having variegated
spots
2 Dongaka ndash Black in color
3 Parasamudraka- Black in colour and smells like Navamallika
अगर उटण कि तपछय ततकत ततकषण च वपततलम
लघ कणाविरोगघन शीत ात कफपरणत
िापर २१ [97]
Family- Thymelaccensis
Latin name- Aquilaria agallocha
Guna- Laghu Ruksha Tikshan
Rasa- Katu Tikta
Vipaka ndash Katu
Virya ndash Ushna
Karma- Sheetaprasasmana Vranaorasadan Tvachya Pittavardhaka
Shirovirechana Mangalya Sugandhik and Rochaka in properties [100]
Krishna Agaru karma- Katu Tikta rasa Ushna Sheeta when applied externally
and Pittahara when taken orally
Page | 67
Chemical Constituents -
Agaru hardwood is rich in essential oil resins alkaloids saponins Steroids
terpenoids tannins flavonoids and phenolic compound Agaru wood
predominantly contains 2-[-2-phenylethy]-4H-chromen-4-one derivatives and
sesquiterpenes Agaru oil contains selinene dihydroselinene agarnol b-
agarofuran vetispira-2(11)valerianol dihydrokaranone and tetradecanoic
acids[99]
Part Used ndash
Heartwood- Dark resinous wood which is formed when the plant becomes
infected with a type of fungus (ascomycetous mold) Species of Aspergillus
fusarium and penicillium are reported to be associated with the development
of infection Prior to infection the heartwood is odorless relatively light and
pale colored however as the infection progresses the tree produces a dark
aromatic resin in the heartwood The infected resin in response to the attack
which results in accumulation of a very dense dark resin in the heartwood
The infected resin embedded wood is known as Agarwood Infection is more
common on the trunk roots and the area when branches divide The formation
of Agarwood starts when the tree attains the age of 20 years On an average
approximately 30 ml oil is extracted from 100 kg of infected Agarwood[98]
Qualities of best Agaru-
It should be black in color
It should be extremely heavy and aromatic
It should be oily in appearance and test
It should be sink in water
It should burn easily with bright flame with a bright flame giving off a pleasant
smell
Page | 68
3 MADANA
Fig 13 MADANA
Madana consist of dried fruit of Xeromphis spinosa It is a deciduous thorny
shrub or a small tree reaching a high up to 9 m and girth about a meter
branches numerous thick and horizontal found in sub-Himalayan tracts[101]
मदनो मिरनदसततकतो ीयोटणो लखनो लघ
ानदरतिदवििीहर परततशयायवरणारतक
रि कटठकफ़ानाहशोथगलमवरणापह[102]
िा पर १६० १६1
Page | 69
Latin name-Randia dumetorum
Familly ndash Rubiaceae
Rasa - Madhura Tikta
Guna-Laghu Ruksha
Virya- Ushna
Vipaka ndash Katu
Karma- Vamana and Lekhana
Chemical Composition-
Essential Oil Valerianic acid Saponin tannin resin [103]
Page | 70
YAWA [104]
Fig 14 Yawa
1 In Samhitakala Aacharya Charaka Acharya Sushruta explain detail about
medicinal properties of Yawa
2The use of Yawa in Aaharya Dravya mainly described by Dhanwantari
Nighantu Raj Nighantu Bhavprakash Nighantu[105]
Macroscopic Description-
Fruit a caryopsis elliptical oblong Ovoid and tapering at both ends smooth
about 1cm long and 02- 03cm wide dorsally compressed and flattened on
the sides with a shallow longitudinal furrow 3-5 ridges having shallow
depression between them grains tightly enclosed and adhering the lemma
and palea pale greenish yellow odor not distinct taste sweetish acrid
Page | 71
Latin Name ndash Hordenum vulgare
Family- Poaceae
Rasa- Kashaya Madhura
Virya- Sita
Vipaka- Katu
Karma- Vatakrt Pittahara Kaphahara Medahara Balya Visrya
SthairyakaraLekhana
Page | 72
PROCEDURE REVIEW [105]
In Ayurvedic classics there are many references regarding Dhoopana Dravya
Dhoopana is administering Dhuma with the help of Dhoopana Dravya
In Kashyapa Samhita there are 40 types of Dhoopana advised for children
Anesthesia (Mohajananam Dhoopa) is also mentioned For this Dhoopana the
drug used were herbs hairs of animals legs horns old cloths of Buddhist
monks
From the references available regarding Dhoopana we can understand that
Karna can be protected from maggots (krimi) Bactria (Rakshogna) lice etc
References clearly indicate the analgesic and disinfectant effect of Dhoopana
Karma Dhoopana is mentioned for Dushta Vrana Chikitsa It reduces Vedana
Srava Pootigandha of Dushtavrana It also helps in Vranaropana
Dushtavrana Chikitsa is mentioned in the treatment of Karnasrava[106]
Origin of Dhoopana-
In ancient period children of sages were constantly harassed by the
Rakshasas Hence the sages approached lord Agni for shelter Agni in turn
gave them Dhoopana Dravya and asked sages to use the Dhoopana for
protection against Rakshasas bhutas pishachas
Classification of Dhoopana
1 It is classified into Dhupa Anudhupa Pratidhupa
2 On the basis of Origin it is classified into Jangama and Sthavara
Selection of Guggula for Dhoopana
Page | 73
bull Guggul is a best Vatahara
bull It is Krimighana
bull It contains Oleoresin
bull In Ashtang Hrudaya Guggula Dhoopana mentioned for Karnasrava
Selection of Agaru for Dhoopana
bull Agaru is Laghu Ruksha Katu Tikshna
bull Vranaorasadan Tvachya
bull It should burn easily with bright flame with a bright flame giving off a
pleasant smell
Karna Dhoopana Indication
1 Karnaarava
2 Putikarna
3 Krimikarna
4Vataj Karnashula
Contraindications
Especially for Karnadhoopan contraindication is not mentioned in classic texts
But Dhoopana is contraindicated in Pittaj vaydhi Sharad and Grishma Rutu
Page | 74
MATERIAL AND METHOD
Page | 75
For randomize comparative clinical trial to study the effect of Agaruwadi
Karnadhoopana and Guggula Karnadhoopana in Karnasrava following material
and method were required
Source of data
Patient irrespective of gender occupation religion social economic status
signs and symptoms of classical features of Karnasrava (Otomycosis) selected
from the OPD of Shalakyatantra department
Materials ndash
1Patients
2 Drugs-Agaruwadi Dhoopana
Guggula Dhoopana
3Torch
4Otoscope
5 Tuning fork
6Jobson horn probe
7Cotton
8Case record form
DRUG
Group A Trial Group
1Churana of Agaru Yawa Madan
2Ghrita
3Jala
Group B Control Group
1Googula Churna
Page | 76
Properties of Drug
Table no 1 Properties of Drug
Drug
Family
Rasa Veerya Vipaka Effect
on
Dosha
Guna Karma
Agaru
(Aquilegria
Agallocha)
Thymelaca
ceae
Katu
Tikta
Ushna Katu KV Laghu
Ruksha
Tikshna
Shitaprashamana
Shothahara
Vedanasthapak
Durghandhihara
Madan
(Randia
spinosa)
Rubiaceace
Kashaya
Madhur
Tikat
Katu
Ushna Katu KV Ruksha
Laghu
Vatakaphaghana
Shothahara
Vedanasthapak
Vranashodhak
Yawa
Poaceae
Hordeum
Vulgare
Kashaya
Madhur
Sheeta Madhur KP Ruksha
Laghu
Vataghana
Vernashodhana
Raktshodhaka
Guggula
Commiphora
Mukul
Burseracea
e
Tikta
Kashaya
Anushna Katu VPK Laghu
Ruksha
Shothahara
Vedanasthapaka
Kandughna
Ghrita Madhura Sheet Madhur VK Snigdha Vataghana
Shothahara
Vedanasthapaka
Page | 77
METHODOLOGY
SELECTION CRITERIA
1)INCLUSION CRITERIA
1 Patients having signs and symptoms of Karnasrava (Otomycosis) ie करणशल
( pain ) करणकणड ( Itching ) करणसतराव ( Discharge )बाधिरण ( conductive Loss of
hearing )
2 Patient from age group 19 to 70 years
3 Any Gender
2)EXCLUSION CRITERIA
1 Patients suffering from any systemic disease like DM TB HTN
2 Chronic suppurative otitis media (CSOM)
3 Acute supportive otitis media (ASOM)
3 Perforation of Tympanic membrane
4 Chronic otitis media
3)WITHDRAWAL CRITERIA
1If patient develops any adverse effect such as irritation pain burning
sensation in ear loss of hearing and such patients was withdrawn from trial
and receive prompt appropriate medical attention
2If patient shows aggravation in symptoms
3If patient refuses to continue with the treatment
Page | 78
STUDY SETTING
Types of study - Randomized Clinical comparative Trial
Place of work - OPD of Shalakyatantra
Duration of study - 18 months
Study Population - Patients of Karnasrava in Shalakyatantra OPD
SAMPLE SIZE CALCULATION
Sampling Method ndash Purposive sampling followed by random allocation in two
groups
Sample size calculation-
n = z2 p (1-p)
d2
Were
n = sample size
P = prevalence of disease=10
z = standard normal variable ie 196
d = error ie005
desired Sample Size would be
n = Z2 P(1-P)d2
= (196)2x (0021) x(0979)(005)2
= 34
Visiting ENT OPD (ShalakyaTantra) and IPD (ShalakyaTantra) 21 = 34
n raquo34
So one group includes 34patients
Page | 79
Sampling Method
Total 68 patient of Karnasrava are selected by Purposive sampling followed by
random allocation in two groups Written informed consent is taken prior to
commencement of trial They are divided in 2 groups
Group A (Trial Group) 34 patients treated with Agaruwadi Dhoopana for 7
days
Dose 5 minutes twice in a day
Group B (Control Group) 34 patients treated with Guggula Dhoopana for 7
days
Dose 5 minutes twice in a day
STUDY DESIGN ndash
Open labeled Randomized Comparative Clinical trial
STUDY DESIGN
Screening of patient
Inclusion criteria satisfied Exclusion criteria
Initial assessment Excluded
Counseling of patient Treated accordingly
Patient selection by Simple Random Sampling Method
Page | 80
68 Patients were divided in two groups lsquoArsquo and lsquoBrsquo
Trial group A-34 patients were given
Agaruwadi Dhoopana
Control group B- 34 patients were
given Guggul Dhoopana
Informed written consent
Treatment was given for 7 days
Assessment on 1st 4th and 7th day
Post assessments follow up on 15th day
Observation
Data Collection
Statistical analysis of data
Conclusion
Page | 81
(A) Agaruwadi Varti for group A (Trial group)
Table no 2
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
B) Guggula Varti for group B (Control group)
SOP of it is same as above Agaruwadi Varti
Table no 3
Drug Guggula Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
FOLLOW UP
For both groups follow ups were done on 1st 4th and 7th and post
assessment follow up15th day
EXAMINATIONS
Torch for Local examination of ear
Otoscope examination
Tuning fork Test
Page | 82
OBSERVATION TABLE
Table no 4
Sr no Subjective criteria Day 1 Day 4 Day 7 Day 15
1 करणशल
(pain)
2 करणकणड
(Itching)
3 करणसतराव (Discharge )
4 बाधिरण (Conductive Deafness)
OBSERVATIONS
a) करणशल (Pain) -
0 - Absent
1 ndash Present
b) करणकणड (Itching) -
0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
Page | 83
c) करणसतराव (Discharge)
0- Absent
1- Mild -Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाधिरण (conductive Loss of hearing)
0 - Absent
1- Present
Observations were carried out before and after completion of treatment and
during each follow up After observations the data collected and presented in
the form of graphs charts and table
Page | 84
TRIAL DRUG
Authentication and standardization of raw drug material done After
authentication and standardizing of raw drug material Agaruwadi Varti was
prepared by Varti as explained in Ayurvedic classics
Method of Varti preparations
Panchavidh Kashaya Kalpana that is five method of pharmaceutical
preparation constitutes the fundamental process of Ayurvedic pharmaceutics
which is well explained in Sushrut Samhita Varti Kalpana is one among them
which can be included in Kalka Kalpana
तीररसतरपतपतीनामपरककव तीत [106]
स डलहण शरच 151
Medicines are powered triturated and given the Varti shape that is like wick
of lamp so it is called as Varti Kalpana
Drug content Agaru Madan Yawa
Route of Administration Local
Dose Two times a day
Duration 7 days
Page | 85
Methodology
Standard operating procedure (SOP) of Agaruwadi Varti
Agaruwadi Varti is prepared according to the classical text
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization was done as recommended in pharmacy procedure The
raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 mixed together in
equal quantity to make Agaruwadi churn
Quantity of each churn is 4 grams all are mixed when the Varti get dry total
weight of Varti was 10gram
STEP 4 - Agaruwadi churn triturated with appropriate quantity of water or
Ghrita and prepared Varti in GMP Certified Ayurvedic pharmacy Standard
aseptic precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Varti was packed in sterile air packed container
STEP 6 - Agaruwadi Dhoopana was given with the help of Dhoopana yantra
Authentication and Standardization of raw drug of Agaruwadi Varti was done
Sterilization was done as recommended in pharmacy procedure Sterile
preparation packed in sterile container of suitable size Under all aseptic
precaution Karnadhoopana given to infected ear
Page | 86
Containers for packaging and their sterilization-
Sterilization of the containers for storing Varties was done by Ethylene Oxide
(Eto) method
Ethylene Oxide (Eto) procedure-
It includes exposure of materials to ethylene oxide gas under vacuum in a
sealed chamber It consists of four primary variables
1Gas Concentration
2Humidity
3Temperature
4 Time
EtO gas is an alkylating agent which disturbs the DNA of microorganism
preventing them from reproducing It penetrates the breathable packaging
and sterilizes all the accessible surface of the product to render products
sterility by alkylation of essentials proteins for cell reproduction
Most Eto sterilization methods involves three different stages These can be
separated into three different on the size or number of devices to treat
1Preconditioning stage-
First products are passed through a preconditioning phase to make
microorganism grow The batch load goes through a well time under a
controlled environment of temperature and humidity
2Sterilizer stage-
Performed using process phase specially designed to provide the required level
of EtO exposure to assure sterility for a device or family of devices
3Degasser Aerration stage-
Finally products need to go through a degassing phase to remove any residual
particles of Eto The batch load goes over well time under a temperature-
controlled environment
The sterile containers were then used to store Agaruwadi Varti and handed to
patients included in the study
Page | 87
Packing of Agaruwadi Varti
The ETO sterilize plastic container were used for packing of Agaruwadi Varti
Varti was filled into these sterilize containers (7 in each) In an aseptic
environment plugging and capping was done under aseptic precautions In this
way packing of Agaruwadi Varti done These Varti were given to patient and
advise to take two times a day under all hygienic precautions
History and Examination
bull Proper history and presenting complains was recorded on case record form
bull Ear examination with otoscope was done during initial assessment and each
follow up
bull Otoscopic examination was done during initial assessment and each follow
up
bull Systemic Examination that is Blood Pressure Temperature Respiration
rate Pulse was recorded on case record form
Page | 88
Raw material
Fig14 यव चरण Fig15 मदनफळ चरण
Fig16 अगर चरण Fig17 गगगळ चरण
Page | 89
Preparation of Agaruwadi Varti
Fig18 Preparation of Agaruwadi Varti
Fig19 अगरवादी वरती
Page | 90
Fig20 Instruments used for examination of Karnasrava
Fig19 Karnadhoopana Yantra
Page | 91
Karnadhoopana Procedure
Fig 22 Karnadhoopana Procedure
Page | 92
OBSERVATIONS AND RESULTS
Page | 93
BASED ON DRUGS
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 94
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
AUTHENTICATION CERTIFICATE
Page | 95
BASED ON STASTICIAL ANALYSIS OF DEMOGRAPHIC DATA
68 patients of Karnasrava ndash Otomycosis
Table no 5
No of Patients Total
Group A Group B
Registered 38 37 75
Completed 34 34 68
Discontinue 04 03 07
Total 68 patients were enrolled in study 38 patients registered in group A
amongst them 34 patients completed the treatment and04 patients
discontinued the treatment However in group B 37 patients completed the
treatment and 03 patients discontinued the treatment out of 37 registered
patients
Hence the total number of patients registered in the present study was 75
and out of which 68 patients were discontinued the treatment So they
dropped out from the study While 68 patients were successfully completed
the treatment So observations and result of 68 patients were given below
Here we are going to discuss the statistical analysis of the data obtained in
the form of master chart that was prepared in accordance with the data
collected from the patients that had been included in the study The purpose
of statistical analysis was to analyzed the relation between age gender
occupation diet addiction and education
Page | 96
1 Age wise distribution of patients
Table no 6
In trial group 10 (29412) patients were from age group 18-25 years 14
(41176) patients were from age group 25-35 years 8 (23529) patients
were from age group 35-45 years and 2 (58824) patients were from age
group 45-60 yearsIn control group 6 (17647) patients were from age group
18-25 years 14 (41176) patients were from age group 25-35 years 7
(20588) patients were from age group 35-45 years and 7 (20588)
patients were from age group 45-60 years
Fig 23 Age wise distribution of patients
0
2
4
6
8
10
12
14
15 -25 25-35 35-45 45-60
10
14
8
2
6
14
7 7
Age Distribution
Trial Group N Control Group N
Age Distribution
Trial Group Control Group
N N
18 -25 10 29412 6 17647
25-35 14 41176 14 41176
35-45 8 23529 7 20588
45-60 2 58824 7 20588
Total 34 100 34 100
Page | 97
1 Gender wise distribution of patients
Table no 7
Sex
Trial Group Control Group
N N
Female 23 67647 15 44118
Male 11 32353 19 55882
Total 34 100 34 100
In trial group 23 (67647) patients were female and 11 (32353) patients
were male
In Control group 15 (44118) patients were female and 19 (55882)
patients were male
Fig 24 Gender wise distribution of patients
0
5
10
15
20
25
N N
TRIAL GROUP CONTROL GROUP
23
15
11
19
Gender
Female Male
Page | 98
2 Education wise distribution of patients
Table no 8
Education
Trial Group Control Group
N N
Illiterate 4 11765 3 88235
SSC 4 11765 3 88235
HSC 8 23529 9 26471
Graduation 16 47059 10 29412
Primary 1 29412 3 88235
Post-Graduation 1 29412 6 17647
Total 34 100 34 100
In trial group 4 (11765) patients were illiterate 4 (11765) patients were
SSC educated 8 (23529) patients were HSC educated 16 (47059)
patients were graduated 1 (29412) patients were primary educated and
1(29412) patients were post graduated
In control grou 3 (88235) patients were illiterate 3 (88235) patients
were SSC educated 9 (26471) patients were HSC educated 10 (29412)
patients were graduated 3 (88235) patients were primary educated and
6 (17647) patients were post graduated
Page | 99
Fig 25 Education wise distribution of patients
0
2
4
6
8
10
12
14
16
ILLITERATE SSC HSC GRADUATION PRIMARY POST GRADUATION
4 4
8
16
1 1
3 3
910
3
6
Education
Trial Group N Control Group N
Page | 100
3 Occupation wise distribution of patients
Table no 9
Occupation
Trial Group Control Group
N N
Accountant 1 294 2 588
Housewife 11 3235 8 2353
Engineer 1 294 1 294
Job 1 294 4 1176
Labor 1 294 3 882
Mess 1 294 0 000
Naturotherapyst 1 294 0 000
Pharma 1 294 0 000
Shopkeeper 4 1176 2 588
Singer 1 294 0 000
Student 8 2353 4 1176
Tailor 1 294 1 294
Teacher 1 294 1 294
Worker 1 294 3 882
Farmer 0 000 1 294
Lab Tech 0 000 1 294
Page | 101
Daily Collection 0 000 1 294
Fruit seller 0 000 1 294
Bus Driver 0 000 1 294
Total 34 10000 34 10000
In trial group 11 (3235 ) were housewife 8(2353) were students
4(1176) were shopkeeper 1(294) was accountant 1(294) was
engineer 1(294) was doing job 1(294)was labour 1(294) was
catering 1(294) was Naturotherapyst 1(294) was Pharma 1(294)
was Singer 1(294) was Tailor 1(294) was Teacher and 1(294) was
worker
In Control group 8 (2353)were housewife 4(1176) were students
2(588) were shopkeeper 2(588) was accountant 1(294) was
engineer 4( 1176) was doing job 3(882)was labor 1(294) was
Farmer 1(294) was Lab tech 1(294) was Daily collection 1(294)
was Tailor 1(294) was Teacher and 3(882) was worker 1(294) was
Fruit seller and 1(294) Bus driver
Fig 26 Education wise distribution of patients
0
2
4
6
8
10
12
1
11
1 1 1 1 1 1
4
1
8
1 1 10 0 0 0 0
2
8
1
43
0 0 02
0
4
1 13
1 1 1 1 1
Occupation
Trial Group N Control Group N
Page | 102
4 Religion wise distribution of patients
Table no 10
Religion
Trial Group Control Group
N N
Hindu 31 9118 33 9706
Muslim 3 882 1 294
Total 34 10000 34 10000
In trial group 31 (9118) patients were Hindu and 3 (882) patients were
Muslim
In control group 33 (9706) patients were Hindu and 1 (294) patient
were Muslim
Fig 27 Religion wise distribution of patients
0
5
10
15
20
25
30
35
N N
TRIAL GROUP CONTROL GROUP
3133
31
Religion
Hindu Muslim
Page | 103
5 Diet wise distribution of patients
Table no 11
Diet
Trial Group Control Group
N N
Veg 14 4118 20 5882
Non-Veg 20 5882 14 4118
Total 34 10000 34 10000
In trial group 14 (4118) patients were vegetarian and 20 (5882)
patients were Non vegetarian
In control group 20 (5882) patients were vegetarian and 14 (4118)
patients were Non-Veg
Fig 28 Diet wise distribution of patients
0
5
10
15
20
N N
TRIAL GROUP CONTROL GROUP
14
2020
14
Diet
Veg Non Veg
Page | 104
6 Addiction wise distribution of patients
Table no 12
Addiction
Trial Group Control Group
N N
None 30 8824 27 7941
Alcohol 2 588 0 000
Tobacco 1 294 2 588
Mishri 0 000 1 294
Smoking 1 294 4 1176
Total 34 10000 34 10000
In trial group 30 (8824) patients have no addiction 2 (588) patients
have addiction of alcohol 1 (294) patients have addiction of Tobacco 0
(0) patients have addiction of Mishri and 1 (294) patients have addiction
of smoking
In control group 27 (7941) patients have no addiction 0 (0) patients
have addiction of alcohol 2 (588) patients have addiction of Tobacco 1
(294) patients have addiction of Mishri and 11 (1176) patients have
addiction of smoking
Page | 105
Fig 29 Addiction wise distribution of patients
0
5
10
15
20
25
30
NONE ALCOHOL TOBACCO MISHRI SMOKING
30
21
01
27
0
21
4
Addiction
Trial Group N Control Group N
Page | 106
Statistical Analysis and Results
Effect of study on Karnashoola-
Table no 13
Karnashoola
Group A Group B
BT AT BT AT
N N N N
Grade 2 0 000 0 000 0 000 0 000
Grade 1 30 10000 7 2333 32 10667 5 1667
Grade 0 4 1333 27 9000 2 667 29 9667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 30 Effect of study on Karnashoola
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
30
7
32
54
27
2
29
Karnashoola
Grade 2 Grade 1 Grade 0
Page | 107
Table no 14
Karnashoola Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 088 100 033 006
969 2829E-
08 7667 HS
AT 021 000 041 007
Group
B
BT 094 100 024 004
1037 7103E-
11 8438 HS
AT 015 000 036 007
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 31
000010020030040050060070080090100
BT AT BT AT
GROUP A GROUP B
088
021
094
015
Karnashoola
Mean
Page | 108
Table no 15
Karnashoola
Mean SD Effect
Group
A
Group
B Trial Control Trial Control
Day 1 088 094 033 024 000 000
Day 3 065 071 049 046 2667 2500
Day 5 024 038 043 049 7333 5938
Day 14 021 015 041 036 7667 8438
000
010
020
030
040
050
060
070
080
090
100
Day 1 Day 3 Day 5 Day 14
Karnashoola
Mean Group A Mean Group B
Page | 109
Table no 16
Karnashoola N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3250 110500
510000 275 Control group 34 3650 124100
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 110
Effect of study on Karnakandu
Table no 17
Karnakandu
Group A Group B
BT AT BT AT
N N N N
Grade 3 7 2333 0 000 4 1333 0 000
Grade 2 18 6000 0 000 18 6000 0 000
Grade 1 7 2333 7 2333 10 3333 15 5000
Grade 0 2 667 27 9000 2 667 19 6333
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 32 Effect of study on Karnakandu
0
5
10
15
20
25
30
N N N N
BT AT BT AT
GROUP A GROUP B
7
0
4
0
18
0
18
0
7 7
10
15
2
27
2
19
karnakandu
Grade 3 Grade 2 Grade 1 Grade 0
Page | 111
Table no 18
Karnakandu Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 188 200 081 015
1091 3119E-
10 8906 HS
AT 021 000 041 007
Group
B
BT 171 200 076 014
1032 4746E-
09 7414 HS
AT 044 000 050 009
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Page | 112
Fig 33
Table no 19
Karnakandu
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 188 171 081 076 000 000
Day 3 126 118 057 058 3281 3103
Day 5 071 074 046 051 6250 5690
Day 14 021 044 041 050 8906 7414
000
020
040
060
080
100
120
140
160
180
200
BT AT BT AT
GROUP A GROUP B
188
021
171
044
Karnakandu
Mean
Page | 113
Table no 20
Karnakandu N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 4051 137750
373500 006 Control group 34 2849 96850
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is less than
005 Hence we conclude that there is significant difference between Trial
Group and Control Group
000
020
040
060
080
100
120
140
160
180
200
Day 1 Day 3 Day 5 Day 14
Karnakandu
Mean Group A Mean Group B
Page | 114
Effect of study on Karnasrava
Table no 21
Karnasrava
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 11 3667 0 000 8 2667 0 000
Grade 1 23 7667 3 1000 26 8667 2 667
Grade 0 0 000 31 10333 0 000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 34
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
11
0
8
0
23
3
26
20
31
0
32
Karnasrava
Grade 3 Grade 2 Grade 1 Grade 0
Page | 115
Table no 22
Karnasrava Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 132 100 047 009
1122 4356E-
13 9333 HS
AT 009 000 029 005
Group
B
BT 124 100 043 008
1130 9364E-
14 9524 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 35
000
020
040
060
080
100
120
140
BT AT BT AT
GROUP A GROUP B
132
009
124
006
Karnasrava
Mean
Page | 116
Table no 23
Karnasrava
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 132 124 047 043 000 000
Day 3 100 100 025 025 2444 1905
Day 5 047 038 051 049 6444 6905
Day 14 009 006 029 024 9333 9524
000
020
040
060
080
100
120
140
Day 1 Day 3 Day 5 Day 14
Karnasrava
Mean Group A Mean Group B
Page | 117
Table no 24
Karnasrava N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3535 120200
549000 655 Control
group 34 3365 114400
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 118
Effect of study on Karnabadhirya
Table no 25
Karn
Badhirya
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 0 000 0 000 0 000 0 000
Grade 1 13 4333 0 000 16 5333 2 667
Grade 0 21 7000 34 11333 18 6000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 36
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 00 0 0 0
13
0
16
2
21
34
18
32
Karnabadhirya
Grade 3 Grade 2 Grade 1 Grade 0
Page | 119
Table no 26
Karn
Badhirya Mean Median SD SE
Wilcoxon
W P-Value
Effect Result
Group
A
BT 038 000 049 009
799 7173E-
05 10000 HS
AT 000 000 000 000
Group
B
BT 047 000 051 009
816 0000138 8750 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 38
000
005
010
015
020
025
030
035
040
045
050
BT AT BT AT
GROUP A GROUP B
038
000
047
006
Karnbadhirya
Mean
Page | 120
Table no 27
Karn
Badhirya
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 038 047 049 051 000 000
Day 3 009 006 029 024 7692 8750
Day 5 003 006 017 024 9231 8750
Day 14 000 006 000 024 10000 8750
000
005
010
015
020
025
030
035
040
045
050
Day 1 Day 3 Day 5 Day 14
Karn Badhirya
Mean Group A Mean Group B
Page | 121
Table no 28
Karn
Badhirya N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3400 115600
561000 806 Control
group 34 3500 119000
Total 68
Page | 122
COMPARISION BETWEEN GROUP A AND GROUP B
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Table no 29
Overall Effect
Trial Group Control Group
N N
Marked Improvement 21 6176 16 4706
Moderate Improvement 8 2353 13 3824
Mild Improvement 4 1176 5 1471
No Change 1 2941 0 0
TOTAL 34 100 34 100
Fig 39
0
5
10
15
20
25
MARKED IMPROVEMENT
MODERATE IMPROVEMENT
MILD IMPROVEMENT NO CHANGE
21
8
41
1613
5
0
Overall Effect
Trial Group N Control Group N
Page | 123
DISCUSSION
Page | 124
Discussion is nothing but the logical reasoning of observations In
every research work discussion part is very important because it brings into
light about the logical analysis which are helpful in filling the research gap in
the scientific world
The discussion is categorized into following ways for the ease of
understanding
1 Discussion on selection of topic
2 Discussion on review of literature
3 Discussion on drugs their mode of action on the disease mode of action
of Karnadhoopana
4 Discussion on observation and results
1 Discussion on selection of topic
Otomycosis is commonly encountered in day-to-day practice Majority
of Indian people affected with this pathology This disease commonly
manifests in developing countries low socio-economic standard and lack
of hygiene Now a days due to busy lifestyle people are not able to follow
the proper instruction of care of ear which may be responsible for the
recurrent nature of disease So for the management of this we use
Karnadhoopana with the help of Agaruwadi Varti Dhoopana is simple
easy cost-effective procedure which can be done even at OPD levelso
for the disease Karnasrava we selected Karna Dhoopana as therapeutic
procedure Karnadhoopana was done with Agaruwadi Varti and Guggula
Varti which was very effective for treatment
Page | 125
2 Discussion on review of literature
Karnasrava is one such disease among 28 Karnarogas mentioned by
Acharya Sushruta in the chapter named Karna Roga Vigyana Acharya
Charaka included Karnasrava as symptom under the four types of
Karnarogas due to vitiation of different doshas Acharya Vagbhata has
not described Karnasrava separately It is a fact that systemic
description of Karnarogas is available in all the ancients of pus from a
Vata afflicted ear may results from head injury or immersion in water
Karnasrava is a clinical entity which can be correlated with Otomycosis
Karnasrava is explained as symptom as well as a disease in Ayurveda
Nidana- Karnasrava occur due to Samanya Nidana and Vishesh Nidana
Vishesh Nidana like Shirobhighata Nimmajato jale Mithyayoga of Shashtra
The exact pathology behind Karnasrava is not understood clearly
Purvarupa ndash No specific Purvarupa are found for Karnasrava in classical
literature Acharya Madhukara describe Purvarupa as expression of
Rupa(lakshana) with less intensity that is less intensity itching sound in ear
may considered as Purvarupa of Lakshana
Samprapti- Aacharya Sushruta not explained the Samprapti of Karnasrava
separately and we must consider the general Samprapti of Karnaroga Due to
various aetiologias as cited above ear afflicted by Vata dosha causes Twak
Rakta Mamsa dushti results in Karnasrava According to Acharya Sushruta
Vata-Kapha dose is dominance in Karnasrava
Page | 126
Nidan
Nija Agantuja
Vata ndash kapha prakopak nidana Shirobhighata Nimmajato-jale
Mithya yoga of Shastra
Vata- kapha Prakopaka(Chaya prakopak) Vata-kapha prakopaka
( Achay prakopak)
Twak Rakta Mamsa dushti
Karnasrava
Page | 127
Chikitsa
The curative aspect and this must be done simultaneously giving due
importance to Nidan Parivarjana that is preventive measures So Nidan
Parivarjana that is avoidance of causative factors like Jalkrida Mithyayogen
shashtrasya Karnakandu Shirasnan Pratishaya is the first step in combating
the disease and form the part of line of treatment
Above Samprapti helps us to proceed towards the treatment of Karnasrava
The main protocol of treatment is removal of fungus and wound management
which include various measures to keep area day clean clear of microbes and
providing ideal condition for healing
Samany Chikitsa- Acharya Sushruta described general treatment for
Karnaroga as Snehapana (Drinking ghee) Rasayana (Rejuvenation therapy)
Bhramacharya Avoid excessive speaking Avoidance of physical exercise and
head bath
Vishesha Chikitsa ndash Acharya Sushruta mentioned some procedures in the
treatment of Karnasrava which is Shirovirechana Karnadhoopana
Karnapurana Karanpramarjana Dhavan Avachurnana Karnapurana Above
various procedures described in Ayurveda for management of fungus growth
in ear discharging ear fulfill these requirements of wound management
Page | 128
Discussion on observation and Result
Out of 68 patients 34 patients included for the trial The incidence of
Karnasrava is observed in trial and control groups
The statistical analysis provided the following data
AGE
Trial group- Maximum no of patients that is 14 (41176) patients were from
age group 25-35 years followed by 29412 patients were from age group
18-25 years 23529patients were from age group 35-45 years and
58824 patients were from age group 45-60 years
Control group - Maximum no of patients that is 14 (41176) patients were
from age group 25-35 years followed by 20588 patients were from age
group 35-45 years and 20588 patients were from age group 45-60 years
17647 patients were from age group 15-25 years
The maximum no of cases of Karnasrava found in age group between 25 to
35 years The reason behind this is repeated use of ear bud or emersed water
in ear More use of earphone or working more in cold environment
GENDER
Trial group ndash A higher prevalence seen in females 6764 and 3235 in
males
Control group - A higher prevalence seen in males 5588 and 4411 in
females
Females and males both are prone to disease
Page | 129
EDUCATION
Trial group-It is observed that amongst 34 patients maximum ie16
(47059) patients were graduated 8 (23529) patients were HSC
educated 4 (11765) patients were SSC educated 4 (11765) patients
were illiterate 1 (29412) patient were primary educated and 1(29412)
patient were post graduated
Control group- It is observed that 10 (29412) patients were graduated 9
(26471) patients were HSC educated 6 (17647) patients were post
graduated 3 (88235) patients were SSC educated 3 (88235) patients
were primary educated3 (88235) patients were illiterate
There is no direct relation between education and Otomycosis
RELIGION
Trial group- The incidence of patients of Hindu religion are 9118 and Muslim
religion are 882
Control group- The incidence of patients of Hindu religion are 9706 and
Muslim religion are 294
There is no probable explanation for this maximum number of patients in
Hindu religion it depends upon the patients attend the hospital and
community residing there
Page | 130
DIET
Trial group It was found that maximum ie5882 patients were taking
mixed diet while 4118 were taking vegetarian diet
Control group It was found that maximum ie5882 were taking
vegetarian diet while 4118 patients were taking mixed diet
The dietary habit of person is based on choice availability and religious
customs of the person
ADDICTION-
Trial group- It was found that maximum ie 30 (8824) patients have no
addiction 2 (588) patients have addiction of alcohol 1 (294) patients
have addiction of Tobacco 1 (294) patients have addiction of smoking and
0 (0) patients have addiction of Mishri
Control group - It was found that maximum ie 27 (7941) patients have
no addiction 4(1176) patients have addiction of smoking 2 (588)
patients have addiction of Tobacco 1 (294) patients have addiction of
Mishri and 0 (0) patients have addiction of alcohol
Very few patients were addicted to Alcohol Smoking Tobacco and Mishri
These factors can be taken as provoking factors for Otomycosis
Page | 131
Discussion based on probable Mode of action of Karnadhoopana
In Ayurveda classics Karna Dhoopana is therapeutic procedure explain for
Karnasrava Dhoopana is administration of Dhooma (Fumes) with the help of
Dhoopan Dravya References indicates that analgesic and disinfectant effect
of Dhoopana karma and mention for Dushta Vrana Chikitsa It reduces
Vedana Srava amp also does Vrana Ropana action
Various Dhoopanas and Dhoopan Dravas for different element in various
Samhitas of Ayurveda but there is a lacuna of availability of reference
regarding how to do it and method of procedure Matra Kala Contraindication
etc
Currently simple modified way of Karnadhoopana according to Yukti Praman
and experience but there is lac of standardization
Karnadhoopana is one among the topical Bahiparimajan type of treatment
Karna Parmarjana is procedure of cleaning ear with the help of cotton or gauze
piece soaked in honey
Page | 132
Dhoopan
The fumes coming out on burning Agaruwadi Varti
Administrated directly into external ear canal
Causes vasodilation
Due to this increase blood supply in external ear canal
It helps in absorption of drug
Fumes dries up Srava and bring the analgesic effect
Karnagata Kapha amp Avrut Vata Dosha Shaman
Decrease in signs and symptoms like karnasrava Karnshool Karnabadhirya amp
Karnandu
Page | 133
3 Discussion based on probable mode of action of Agaruwadi
Dhoopana
Agaru ndash
I Agaru is a fragrant tree aroma is a result of fungal pathogenesis when the
wood of tree is contaminated by fungi at wounds it develops scrap filled
with resin and turn out to be aroma Medicinal use of Agaru have been
recorded in ancient medicinal science in in inflammatory disease and some
infective disease
II Acharya Charaka has referred to Agaru as an Ushna dravya despite having
Tikta Rasa Ashtang Samgraha used Agaru as Dhupana Dravya along with
Madan and Yawa in Karnasrava Nighantu recommended is use as a
Dhoopana
III In various Samhitas and Nighantus Agaru described as Tikta Snighdha
Sheetaprashamana Vranaprasadana Tvachya Due to these properties
Agaru is used in the treatment of Karna-Akashi Roga and Dushta Vrana
Shodhaka
IV Agaru is reported to have Antimicrobial Analgesic Antioxidants
Antihistaminic and anxiolytic properties Its Antihistaminic property gives
relief from itching which is cardinal feature of Otomycosis Due to Katu
Ushna Tikta Guna improves blood circulation Bheda stage develop It is
Niram Awastha of Dosha Karnagata kapha and vata get decrease and
symptoms like karnashoolakarnasrava get decrease Agaru also have a
Antioxidant properties
V Chemically Agaru Contain 2-(2-Phenylethyl) Chromones Terpenoids
Flavonoids
VI Natural Agarwood had inhibitive activities towards Staphylococcus Aures
The chloroform extract of Agarwood prolongs the pain threshold[108]
Page | 134
Madan
I Madanphala have therapeutic properties like Anti-inflammatory
Antiallergic Analgesic and Wound healing
II It is Useful in treatment of disease like Shotha (inflammation) Vidradhi
(Abscess) Pratishaya (Common cold) Kushta(Skin disease)
III Extract of Madanphala mainly contain Glcosides Tritorpenct
Glycosides Saponin
IV Saponin glycosides are act as fire extinguisher This property is helpful
for vartiIt also act as a detergent which clean the surface of fungus
V Tritorpenct act as a anti-inflammatory antimicrobial and
immunomodulator compound Interaction of glycosides with sterol
causes disturbance of selective permeability in plasmic membraneso
exudates and discharge get decrease
VI Pharmacological activity [109]
Antibacterial Activity The preliminary antibacterial activity of Methanolic
extract of Randia D lam was done on some standard and wild pathogenic
strains The inhibition of the bacterial growth was more pronounced on E coli
as compared to the other tested organism This shows the antibacterial action
of Randia D secondary infection can prevent
Anti-Allergic Activity In Ayurveda Randia D Extract and its fraction of milk
induced leukocytosis and eosinophilia in mice
Anti-Inflammatory Activity The crude methanol extract of fruit of Randia D
effectively reduced the carrageenin induced oedema in hind paw of the rats
significant reduction in granular tissue formation was recorded This activity
seems to be significant at various acute phases of inflammation and om
formation of granular tissue This proves action of Madanaphala in shopa
(inflammation)
Page | 135
Analgesic Activity Analgesic activity was tested in mice weighing between 20-
250 with six number of animals in each group Methanlic extract of fruit Randia
d give analgesic activity in both models This proves its Shoolanashaka (pain
killer) action
Immunomodulatory Activity Randia D has immunostimulant activity and
chloroform fraction which strongly affected immune system seems to be
bioactive fraction of this plant
The overall effect of Agaru Mandanphala Yawa having Anti-inflammatory
Antiseptic Antimicrobial Property Active ingredient shows these properties
Agaru Yawa Madanphala
Vatakaphaghna
Act as
Vranashodhak
Vedanasthapaka
Sheetaprashamana
Shothara
Avarana of Vata get decrease so helps to Shaman of Vata dosha
Karnakandu Karnashoola Karnasrava
Prashamana
Page | 136
This fact can be taken into consideration and probably acknowledge that
Karnadhoopana with Agaruwadi Varti had not leave any residue in the ear
Removal of fibrin keratinocyte migration and in growth of epithelial tissue
plays a major role in healing It is technique of fumigation of ear with the
smoke of anti-infective drug In Karnadhoopana Sthanik Swedana increase the
blood supply and helps in absorption of the drug reduce Karnakandu amp
Karnshoola associated with infection
Page | 137
SUMMARY AND CONCLUSION
Page | 138
The dissertation entitled randomize comparative clinical trial to study the
effect of Agaruwadi Karnadhoopan and Guggula Karnadhoopan In Karnasrava
wsr to Otomycosis
The dissertation is divided into fallowing parts
Introduction
Review of literature
Ayurvedic review
Modern Review
Drug review
Procedure review
Material and Method
Observation and result
Discussion
Summary and conclusion
bull INTRODUCTION
It includes importance of Shalakyatantra in Sushrut Samhita Charka
Samhita And Ashtang Samgraha
Common and specific causes of Karnasrava
Karnasrava is a clinical entity which can be corelate with Otomycosis
In Ashtang Samgraha stated the procedure like Karnadhoopana with
Agaru Yawa Madanphala in Karnasrava
Page | 139
bull REVIEW OF LITERATURE
1 Ayurvedic review
2 Modern review
3 Drug review
Ayurvedic review-
It includes Rachana-Sharir and Kriya-Sharir of Karna detail description of
Karnaroga and its types Karnaroga Samanya hetu Poorvaroopa Rupa
Samprapti Upadrava Pathya-Apathya of Karnasrava Vishesh Nidan and
Chikitsa of Karnasrava Detail description of Karnadhoopana according to
various Acharays have been mentioned
Modern review-
It includes anatomy and physiology of Ear brief anatomy of ear anatomy of
External middle and Internal ear Detail description of the disease
Otomycosis mechanism of fungal infection in external canal pathophysiology
investigations diagnosis and management
Drug review-
Detail description of Agaru Yawa Madan Guggula and its synonyms
Ayurvedic properties Karma uses Pharmacological action and their
pharmacodynamic properties
Page | 140
MATERIAL AND METHOD
It includes description regarding materials required for the study Preparation
of Agaruwadi Varti its Standardization Sterilization and packaging
Plan of study
1 Total 68 patients completed the treatment Age criteria was kept
between 18-60 years Patient selection was done by done by simple
random sampling method and divided into two groups A (Trial) and
Group B (Control) 34 patients in each group
2 Patients in Group A were treated with Karnadhoopana with Agaruwadi
Varti for 7 days two times in a day while patients in Group B were treated
with Karnadhoopana with Guggula for 7 days two times in a day
3 Clinical examination done during each follow up ie 0th 4rd 7th and
observation were recorded
Page | 141
OBSERVATIONS AND RESULTS
Page | 142
1 It was observed that higher incidence of disease Karnasrava ie
Otomycosis found in age group 25-35 years
2 Disease otomycosis was equal in both male and female
3 The trial group there was significant relief in Karnakandu (8906)
Karnasrava(9333) Karnashoola(7667) and karnabadhirya(100)
4 In control group there was significant relief in Karnakandu (7414)
Karnasrava(9524) Karnashoola(8438) and
karnabadhirya(8750)
Page | 143
REFERANCES
Page | 144
1 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published byChaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 17 page no
5
2 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 19 page no
6
3 DRNarayan Vidwas Shero-Karna-Nasa and MukhrogaAnand publication
edition 4th 2014 Page no-52
4 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-205
page no 111
5 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 111
6 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Shlok no2012
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 112
8 Dr KBBhargavaDr SK BhargavaDr TMShahaA Short book of ENT
diseases Usha publication edition 10th
9 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 8 Page no -52
Page | 145
10 Research and Review Journal of Ayurvedic science yoga and
Naturopathy 2017 4(3) 1-5 pA Critical review of Otomycosis in cortex to
Karnaroga described in Ayurvedic classic by amisha patel D B Vaghala
Chandani goswami Vol4 no3 (2017)
11 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogpratished Adhaya Shlok no-213
page no127
12 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedh Adhaya Shlok no-
2140 page no 131
13 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyant shirasiya adhaya Shlok no 1712 page no-
258
14 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
15 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
16 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Aupadravik Adhaya Shlok no-15 page no
2
17 Vaidya Jaymini panday Harit Samhita hindi commentaryChaukhamba
vidhyabhartiVaranasiedition 2010 Shlok no- 13-14page no-10
18 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 146
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-20345
page no 112
19 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Karnarogavigyniyam Shlok
no 21 Page no-731
20 Charak
21 Pandit Harigovind Shashtri Namalinganusasana Amarkosha of
Amarsimha hindi commentary published by Chaukhamba Sanskrit
Sansthan page no- 463
22 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
23 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 37
24 Shree Taranath-Trkavachspati-Bhattacharyen Vchaspatym published
by Rashtriya Samskrit Sansthandelhi Volume 4 page no- 5149
25 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
26 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
27 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
28 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Page | 147
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
29 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Indriyaopakramaniya Adhaya Shlok no 811
page no- 125
30 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243
31 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-510 page no56
32 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no3108 page no- 385
33 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no33 page no- 366
34 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sarvabhutachintasharir Adhaya
Shlok no-126 page no9
35 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-522 page no60
36 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-532 page no61
37 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Page | 148
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-521page no58
38 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-527 page no61
39 VdBramhand Tripathi Ashtanghradaya Sharirsthansthan Published by
Chaukhamba prakashana 2005 Shlok no331 page no-372
40 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Siravarnavibhaktisharir Adhaya
Shlok no-725 page no83
41 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Sharirsankhyavykaransharir Adhaya Shlok
no-512
42 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Pratekmarmanirdeshsharir
Adhaya Shlok no-628 page no75
43 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
44 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Marmasharirsthan Shlok no429 page
no- 393
45 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243244
Page | 149
46 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
47 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan pu blished by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711
48 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
49 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
50 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Shlok no 711 page no- 847
51 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Adhaya Shlok no-628 page no- 75
52 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Gandushavidhiadhaya Shlok no2232
page no- 261
53 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Karnavydhbandhvidhi Adhaya Shlok no-
1611 page no- 86
54 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Nidansthan Published by Chaukhamba
Page | 150
Sanskrit SansthanVaranasi Vatvydhinidansa Adhaya Shlok no183 page
no- 304
55 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavaykaransharir
Adhaya Shlok no-532 page no61
56 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Tristaisniya adhaya Shlok no 1120 page no-
163
57 P Hazarika Dr Nayaka R Balkrishnan Textbook of EarNoseThroat and
Head-Neck Surgery CBS Publication Anatomy of Ear
58 DrKB Bhargava DrSKBhargava DrTMShaha A short book of ENT
Diseases Published by Usha Publication 10th edition page no10
59 MrSalah Mansour MrJacques MagnanMr Hassan Haidar MrKaren
Nicolas MRStephan Louryan Comprehensive and clinical anatomy of the
Middle Ear Published by Springer publication Chapter -Middle Ear cavity
Page no 19 to 121
60 DrPLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 7
61 James OPickles An introduction to Physiology of Hearing Published by
Emerald publication 4th edition page no- 1 to 265
62 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
63 VdBramhand Tripathi Ashtanghradaya Uttarsthan Published by
Chaukhamba prakashana 2005 Karnaroga vigyniyam adhaya Shlok
no1713 page no- 998
Page | 151
64 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Shlok no- 212 page no-
730
65 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no
1-2 page no- 309
66 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana
67 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyantshirasiya Adhaya Shlok no 1713 page no-
258
68 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no-
6 page no- 310
69 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Karnarogavigyniym Shlok no- 1725-26 Page no-
1003
70 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2140 page
no 131
71 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Adhyay 18 shlok 35
72 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt
Karnarogapratishedhoadhya Shlok no-2211 Page no- 735
73 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 152
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2141 page
no 131
74 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2142 page
no 131
75 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2144 page
no 131
76 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 34 page no- 649
77 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2145page
no 131
78 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 37 page no- 649
79 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2146page
no
80 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
81 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 153
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2143page
no
82 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publication Krnarogadhikara adhaya page no-
318
83 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary
Madhyamkhand Vatkalpana shlok no- 782-83 page no- 137
84 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 72-77 page no- 651
85 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
86 Vd Shree Laxmipatishastri Yogratnakara
87 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
Karnarogadhikara Shlok no- 808182 page no- 652
88 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 83 page no- 652
89 (PDF) Otomycosis A Comprehensive Review (researchgatenet)
90 httpswwwncbinlmnihgovpubmed24948980
91 A Simon Carney Scott-Browns Otorhinolaryngology Head and Neck
Surgery CRC press 8th publication Otitis externa and otomycosis
92 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no Page no -
93 wwwguggulipidcomtradhtm
Page | 154
94 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
95 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-28 page no-
43
96 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009Agaru page
no726-728
97 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishra chapter Karpuradi varga Shlok no-31-
43 Page no- 116
98 httpswwwthiemeinimagecatlogsample_chapter_GOMPpdf
99 (PDF) Chemical Constituents and Pharmacological Activity of Agarwood
and Aquilaria Plants (researchgatenet)
100 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 4 chapter no-2 page no-4
101 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 chapter no-152 Madanpage
no376-379
102 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
103 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-54 page no-
84
104 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 page no697-699
patol-yawa
Page | 155
105 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
106 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
Dhoompanvidhi page no- 252-254
107 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012Chikitasasthan Shlok
no- 151page no-406
108 httpswwwmdpicom1420-3049232342pdf
109 httpswwwijamcoinindexphpijamarticledownload0610201530
0
Page | 156
BIBILOGRAPHY
Page | 157
1 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
2 Scott-Brown WG Diseases of the EarNose and Throat Landon
Botterworth and co(publishers) Ltd1952 Volume 2
3 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012
4 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009
5 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi commantry
Purvakhand and Madhyamkhand
6 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Published by Chaukhamba Sanskrit
SansthanVaranasi
8 The Ayurvedic Pharmacopeia of India Ministry of Health and family welfare
department of Ayush Part 1 and part 4
9 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005
10 Acharya Trivedi Raguveer Prasad Ashtang sangrah published by
Vaidyanath Ayurveda bhavan pvt
11 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition
12 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary published by Chaukhamba
Orientalia
Page | 158
ANNEXURE
Page | 159
ANNEXURE- 1
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
CASE RECORD FORM
RESEARCH PROFORMA FOR MS (AYU) DESSERTATION
DEPARTMENT OF SHALAKYATANTRA
NAME -
ADDRESS -
GENDER - AGE - OCCUPATION-
RELIGION - EDUCATION - MARITAL STATUS-
OPD IPD NO-
DATE OF ADMISSIONCOMMESEMENT-
DATE OF DISCHARGECOMPLITION-
DATE OF COUNSELLING-
TEL NO-
CHIEF COMPLAINTS-
PAST MEDICAL AND SURGICAL HISTORY-
TREATMENT HISTORY-
FAMILY HISTORY-
Page | 160
PERSONAL HISTORY-
a) Ahar(Diet)
b) Vihar
c) History of addiction
GENERAL EXAMINATION
PULSE - MIN BP - mm of hg
TEMP - 0F RR - MIN
ASHATAVIDHA PARIKSHANA
Nadi- Mutra- Mala-
Jivha- Shabda- Sparsha-
Drik- Aakruti-
SYSTEMIC EXAMINATION
RS ndash
CNS-
CVS ndash
Page | 161
LOCAL EXAMINATION (KARNA PARIKSHAN)
OBSERVATION TABLE FOR SUBJECTIVE CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching )
RIGHT EAR LEFT EAR
KARNASHASHUKULI
KARNAPUTRAK
KARNAPALI
KARNAKUHARA -
SRAVA
GANDH
VARNA
SWARUPA
KARNAPATALA (TM)
Page | 162
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
Hearing Test
1Renne Test ndash
2 Weber Test -
Examination of Ear-
Pathological Investigation-
Other Examination-
Nidan Panchak-
1Hetu-
2Purvarup-
3Rupa-
4Upashayanupashaya-
5Samprapti
Signature of Guide Signature of Doctor(Researcher)
Page | 163
ANNEXURE 12
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Dhoopana Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization were done as recommended in pharmacy procedure
The raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 were mixed together
in equal quantity to make Agaruwadi churn
STEP 4 - Agaruwadi churn were triturated with appropriate quantity of water
and prepared Varti in GMP Certified Ayurvedic pharmacy Standard aseptic
precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Dhoopana Varti was packed in sterile air packed
container
STEP 6 - Agaruwadi Dhoopan was given with the help of Dhoopan yantra
TREATMENT DETAIL-
Purvakarma -
1 The patient is asked to sit comfortably on chair having sufficient light and
less amount of dust
2 The EAC is cleaned thoroughly by Pichu Varti (cotton swab) to remove the
discharge and other debris
Pradhankarma -
1 The patient is asked to relax completely on the chair
Page | 164
2 Fumes are passed to the ear with Dhoopana Yantra
3 Dhoopana yantra is funnel shaped and its one end will keep the ear covered
for the passage of Dhooma into the ear canal and other end where Agaruwadi
Dhoopana Varti were placed which produces fumes
4 This Dhoopana was given for 5 min
Pashchat karma -
1 The patient were advised to avoid cold refrigerated food drinks cold water
bath cold wind fog and prevent water from entering the ear
(A) Agaruwadi Dhoopana Varti
B) Guggula Dhoopana Varti SOP of it is same as above Agaruwadi Dhoopana
Varti
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Page | 165
ANNEXURE 21
INFORMED CONSENT DOCUMENT
Study Title
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
Introduction
- You are invited to take part in a research study RANDOMSIED COMPARATIVE
CLINICAL TRIAL TO STUDY THE EFFECT OF AGARUWADI DHOOPANA AND
GUGGULA DHOOPANA IN KARNASRAVA
- Before you decide it is important for you to understand why the
research is being done and what it will involve
- Please take time to read the following information carefully and discuss
it with friends relatives and your doctor if you wish
- Ask us if there is anything that is not clear or if you would like more
information
Purpose amp Nature of Study
- In this research project by examine you and ldquoKarnasravardquo (Otomycosis)
disease were treated
- In the part of treatment Agaruwadi Dhoopana or Guggula Dhoopan were
given
- Dhoopana means medicated drug fumes were given in ear with the help of
Dhoopan Yantra
Page | 166
- Treatment was given for 7 days
Study Duration
7days
Participation
- Your participation is entirely voluntary
- If you do decide to take part you were given this information sheet to keep
and be asked to sign a informed consent form
- If you decide to take part you are still free to withdraw at any time and
without giving a reason This will not affect the standard of current or future
medical care you may receive
Confidentiality
- All information which is collected about you during the research were
kept strictly confidential
- Any information about you which is collected from the center will have
your identity in the form of a code number so that it will remain confidential
Benefits Of Study
- The results obtained from this study would be helpful for providing better
quality of treatment amp other essential facilities for Karnasrava (Discharge)
patients
- You will get clinical benefit from the study
Page | 167
Risks Of Study
- In this treatment there are few chances of Irritation of Ear Nose and
congestion at EAC if any of these happens then treatment were given
Results Of Study
- If the Results obtained are profitable then they may get published
without disclosing your details
Signature of patient
Date
Time
Phone no of Researcher
Page | 168
रण मादहती पतरक
सशोिनाच शीषवक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE
EFFECT OF AGARUWADI DHOOPANA AND GUGGULA DHOOPANA
IN KARNASRAVA
परसतताना
- आपणास या सशोिनातपमक अभयासात सहिागी होणय़ाच आाहन करणयात यत आह
- सशोिनातील सहिाग तननदशचत करणयापी सशोिनाच उददश समजन घया
- खालील मादहती काळजीपवक ाचा आणण आशयक ािलयास आपलया डॉकिराशी कका
दहतशरचतकाशी चचाव करा
- काही सददिता असलयास कका आणखी मादहती ही असलयास आमछयाशी चचाव करा
सशोिनाच उददीटि सतरप
- सदर सशोिन परकलपामरधय आपलयाला तपासणी करन कणवसरा या वयाशरिची शरचककतपसा दणयात
यणार आह
- सदर वयाशरिची शरचककतपसा महणन आपणास अगरादी िपन कका गगल िपन
दणयात यणार आह
- सदर औषि आपणास 7 ददस घयायाच आह
Page | 169
कालािी
- 7 ददस
सहिाग
- आपला सहिाग हा पणवपण ऎनदछिक आह
- आपला सहिाग तननदशचत असलयास आपणास ही मादहती पतरतरका दणयात यईल आपणास यातील
समती पतरकार सही कराी लागल
- सहिाग तननदशचत असनही आपण कोणतपयाही ळस कोणतही कारण न दता माघार घ शकता
याचा आपलया दयकीय सविर कोणताही पररणाम होणार नाही
गोपनीयता
- सशोिना दरमयान गोळा कलली आपलया वषयाची सव मादहती गोपनीय ठणयात यईल
- आपली यनदकतक मादहती साकततक सतरपात गोपनीय ठणयात यईल
सशोिनाच फ़ायद
- सशोिनाच तनटकषव कणवसरा बाशरित रणाछया दयकीय इतर सविाचा दजाव सिारणयास
फायदशीर ठरतील
सशोिनातील जोणखम
- य़ा शरचककतपसमरधय कान दखण डॊळय़ातन नाकातन पाणी य़ण नाकात जळजळण डोक जड
होण ही लिण ददस शकतात यापकी लिण तनमावण झालयास तपयाची शरचककतपसा कली जाईल
Page | 170
सशोिनाच तनटकषव
सशोिनाच तनटकषव फ़ायदशीर ठरलयास आपली मादहती गोपनीय ठन परकाशशत करणय़ात यईल
रण सतािरी-
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
Page | 171
ANNEXURE 31
INFORMED CONSENT FORM
Patient OPD no __________
Subjectrsquos Identifier
Date of Birth Age Gender
I _____________________________________ age___________ years
exercising my free power of choice hereby give my consent to be included
as a participant in the clinical study entitled
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
1 I confirm that I have read have been read and understood the information
sheet for the above study and can ask questions
2 I understand that my participation in the study is voluntary and that I am
free to withdraw at any time without giving any reason without affecting my
medical care or legal rights
3 I understand that the Ethics Committee members investigators and study
doctors will not need my permission to look at my health records both in
respect of the current study and any further research that may be conducted
in relation to it even if I withdraw from the trial I agree to his access
However I understand that my identity will not be revealed in information
released to third parties or published
4I agree not to restrict the use of any data or results that arisefrom this study
provided such a use only for scientific purpose
5 I agree to take part in the above study
Page | 172
signature with Date-
Left hand thumb impression
Name amp signature of the witness ndash
Name amp signature of the student ndash
Page | 173
ANNEXURE 32
समतीपतरक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
वयकतीच य
ददनाक जरमददनाक
1) मी ह तननदशचत कररत आह ककसदर सशोिन परकलपाबाबतची सपणव मदहती मी ाचली असनमला ती
समजली आहतपयाबददल मला परशन वचारणयाची पणव मिा आह सदर मादहतीन माझ समािान झाल
आह
2) मी सदर सशोिनातन माझया मजीनसार किीही बाहर पड शकतो या माझया अशरिकाराची मला कलपना
आह
3) माझी दयककय मादहती तपासणयाची कागदपतर कळ सशोिनाकररता ापरली जाणार आहत याची
मला मादहती आहसदर सशोिन परकलपातील सबशरित घिकाना माझी दयककय मादहती पाहणयाची मी
समती दत आहतरावप या सदिावतील माझी ओळख दशववणारी मादहती कोणासही ददली जाणार नाहीयाची
मला कलपना दणयात आली आह
4) सदर अभयासातन शमळणारी मादहती अरा तनटकषव कळ शासततरीय हतसाठी ापरल जाणयासाठी माझी
समती आह
5) रील अभयासात सहिागी होणयास माझी समती आह
रण सतािरी-
Page | 174
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
ASSESSMENT CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching)
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
a) कणवशल ( pain )- 0 - Absent
1 ndash Present
Page | 175
b) कणवकणड (Itching)- 0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
c) कणवसततरा ( Discharge )
0- Absent
1-Mild- Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाशरियव ( conductive Loss of hearing )
0 - Present
1 - Absent
Page | 176
Page | 177
Page | 178
Page | 179
Page | 180
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
Page | 181
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 182
AUTHENTIFICATION CERTIFICATE
Page | 8
REVIEW OF LITRATURE
Page | 9
Ayurvedic literature Ayurveda is a science of life practice since
thousands of years The ancient Indian system of medicine and surgery is
commonly known as Ayurveda This was given the status of Upaveda or
fifth Veda in the next stage of growth Among the available literature three
Samhita that is Charaka Samhita Sushrut Samhita Ashtang Hrudayam and
Ashtang Samgraha are the chief source of knowledge of Ayurveda
Ayurveda consist of eight branches Shalakyatantra is one among them
Shalakyatantra is one of its specialized branch deals with science of
ophthalmology otorhinolaryngology Oro dental surgery and head Acharya
Sushruta himself a practical surgeon was the first to advocate dissection of
dead bodies is indispensable for a successful student of surgery He had
described gross anatomy in the first chapter of Uttartantra Shalakyatantra
define by different Acharys as follows
शालाकय नामोरधवजतरगताना रोगाणा शरणनयनदनघराणाददसशरशरताना वयाशरिनामपशमनारव
स स ११०
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत [13]
चस १७१२
Shalakya Tantra Nirukti and Parichaya
शलाकायााः कमव शालाकय ततपपरिान शलाकयम डलहण [14]
The term Shalakyatantra is derived from Shalakya and Tantra
The word Shalakya means A probe and Tantra denotes teaching and
practices found in scripturesThe compendium in which application of
Shalaka in various surgical procedures is principally described is called as
Shalakya tantra
दनदटिवशारदााः शालाककनाः डलहण ( सउ ११३)[15]
An eye specialist is termed as Shalaki by Dalhana
Page | 10
Synonyms of Shalakya Tantra
Uttamanga Chikitsa Jatrurdhwa Chikitsa Urdhwang Chikitsa Shalakya
Chikitsa
Importance of Shalakyatantra-
Life of living being and all the Indriyas are situated in the head hence it is
known as Uttamanga
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत
चस १७१२
The treatment given to this part of the body is described specially in
Shalakya tantra While describing the importance of Shiras Vagbhata
correlates it to the root of tree (Urdhwa Mula) and body to the trunk of tree
(Adha Shaka)
Sushruta has deal with Mukha Roga in Nidan Shan and its treatment in
Chikitsasthan The description regarding the disease of eye ear nose and
head are found only in UttaraSthan Sushruta specially describes the
disease of Shalakyatantra as told by Videha in the beginning of Uttartantra
itself[16]
Shalakyatantra Itihas-
India Exhibits traditional of more than thousands of years in art literature
language logic and philosophy etc The convention was in its sophisticated
and advanced attire throughout the Vedic period
Vedic period ndash
1 Natush was treated for deafness by Ashwinikumars (Rigveda)
2 Rujaswa and Kanva were treated for blindness by Ashwani Kumaras
(Rigvedas)
Page | 11
3 There are several prayers mentioned for normal functioning of sense
organs (Yajurveda)
4 Structures and functions of Mastishka are described (Atharveda)
5 Mantras having reference to disease of Eye Ear Oral cavity etc are
found (Atharvaveda)
Upanishada Period ndash
1 Samhita Period
a) Sushrut Samhita ndash
bull Explanation regarding Netra Nasa and Shirorogas (Uttartantra 1-
26th chapter)
bull Details regarding Mukha and Karna Roga Nidan and
Chikitsa(Nidansthan 16th and Chikitsasthan 22nd chapter)
bull Description regarding Karna Chedana Sandhana Nasa
Ostasandhana Sutra Sthan 16th chapter
b) Charaka Samhita -
bull Explanation regarding Shirorogas (Sutrasthan 17th chapter)
bull Explanation of Gala rogas like Upajivika Galshundi and Rohini
bull Nasa Shiro Mukha Karna and Netra Chikitsa (Chikitsa sthan 26th
chapter)
bull Description regarding Lakshana and Chikitsa of Shankhaka
Ardhavbhedaka Shirovirechana and Shiro basti (siddhi sthan 9th
chapter)
c)Ashtnga Sangraha ndash
bull Detailed description regarding Shalakyatantara (Uttartantra 11-28
chapter)
bull Description of Kriyakalpa (Sutrasthan 32nd and 33rd)
Page | 12
d)Ashtang Hrudayam
bull Detailed description on Shalakya Tantra (Uttar tantra 8-24 chapters)
bull Kriyakalpas (Sutrasthan 23rd and 24th chapter)
e) Bhela Samhita
bull Chakshushya Vaisheshik and Buddhi Vaisheshik Alochaka pitta
f) Harita Samhita- Branch of Medical science offering elaborating
information about the procedure like Nasya Anjan Gandusha etc
comprehended with their applications in disease of Head Eyes Ears
Eyebrows Throat Temporal region and cervical spine is known as
Shalakyatantara
शशरोरोगा नतररोगा कणवरोगा वशषताः भरकरठशङकमरयास य रोगा समिनदरत दह १३
तषा परततकारकम व नसतयतपयवणजनातन च अभयङगमखगणडषकियााः शालकयसशमतााः १४
इतत शालाकयनाम [17]
Documentation of different ancient literature gives various references
regarding all aspects of Karnasrava in various periods It is very much
important to know the history of Karnasrava from Vedic Pauranic Samhita
and Samgraha period
Vedic period ndash The Vedas being the oldest source of knowledge have no
direct mentioning of Karnasrava
Page | 13
Samhita and Samgraha period ndash
Aacharya Sushruta described about Karnaroga Karnasrava Nidan
Roopa and Chikitsa The detail description is available in Sushrut
Samhita Uttartantra 20 and 21st chapters
Aacharya Charaka did not specify Karnasrava but mentioned 4 types
of Karnarogas that is Vataj Pittaj Kaphaja and Sannipataja and their
treatment in 26th chapter of Chikitsasthan
In Ashtang Hrudaya karnasrava is not explained as a separate disease
but Chikitsa is mentioned in 18th chapter of Astanga Hrudaya
uttartantra
In Ashtang Samgraha Chikitsa is mentioned in 22nd chapter of Astang
Samgraha Uttartantra
The details about Karnasrava are explained in Bhavprakasha
Madhyamakhanda 64th chapter
Madhavakara has explained about Karnasrava in 57th chapter of
Madhymakhanda
Karnasrava is also explained in Sharangadara Samhita Uttarkhand 11th
chapter
The reference for treatment of Karnasrava is available in
Yogaratnakara
In Gadhnigraha Karnasrava and its treatment is mentioned in
Karnarogadhikara Adhaya
Vangasena had mentioned about the disease and treatment in 69th
chapter
Chakradatta explained Karnasrava in 57th chapter
Dalhana has given commentary on Sushrut Samhita Uttartantra 20th
and 21st chapter
Sankhya Samprapti of Karnasrava ndash
Aachary Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga
Vigyniyam Aadhaya Aacharya charaka explain 4 Karnaroga in
Page | 14
Karnarohvigyniyam Adhaya based on doshas Acharya Vagabhata in
Ashtang Hrudaya explain 25 Karnaroga in Adhyaya
कणवशल परणादशरच बाशरियव कषड ए च
कणवसरााः कणवकणडाः कणव चवसतततर च
कशमकणवपरततनाहौ विशरिदवविसततरा
कणवपाकाः पततकणवसततराशवशरचतवविम
कणावबवद सपतवि शोफशरचावप चतवविाः
ऎत कणवगता रोगा अटिावशततरीररतााः
स उ २०- ३ त ५[18]
ातकणवरोग वपततकणवरोग कफकणवरोग
रकतकणवरोग सनदरनपातकणवरोग कणवनाद
बशरिरतप परततनाह कणडाः शोफ पततकणवक
किशमकणवक उियरपविरधयअशो अबवद
कशरचकणवक वपपपली वदाररका पाळीशोष
ततिका पररपोिो उतपपातो उरमरर दाःखिवन
शलहाखयााः परचवशनदरतकणवरोगा उकतााः
इदिीका अ स उ २१ [19]
चतपाराः कणवरोगााः
च स [20]
Page | 15
KARNA
Karna ndash करोतत शबद गरहण [21]
The organ of hearing
Karnasrava- कणवसतय कणवयोाव ससराा [22]
Discharge from the ear is referred as Karnasrava
KARNA SHAREERA
bull Nirukti
कणयवत अकणयवत अनन इती [23]
It means reception and conduction of sound waves
These are the functions of external and middle ear
bull Nirukti of Sravanam
शरयत अनन इती शरणम[24]
It means perception of sound
It can be attributed to the internal ear function
bull Karna Utpatti-
Karna is an organ formed by Akash Mahabhuta[25]
The fundamental characteristic is as follows
Indriya ndash Srotram [26]
Indriya Adhisthan ndash Karna [27]
Indriya Dravy ndash Akasha [28]
Indriya Arth ndashShabdha [29]
Indriya buddhi ndash Srotobyddhi
Page | 16
bull Paryaya of Karna- Shabdapatha Srotrapatha Sravanam shruti
Kuhuram Dwanigraham etc
bull Definition of Karna-
कणवशटकलयनदछिरनमिटिोपगरदहत शरोतरमछयत [30]
मा तन ५७१
The definition of Karna is stated in Madhav Nidanam Indriya which is not
seen with naked eye along with Shashkuli is called Shrotra that is Karna
Indriya is so minute that it is not perceived with any sense organ
In Charak Samhita the word Karna explain as the Indriya Adhisthan of
Shabdha Karna is described as one of the Prathyangas of the body He
emphasizes that all Indriyas manifest during the 3rd month of gestation
period
Acharya Sushruta while describing formation of Purusha from Prakriti or
Avyakta narrated that all Indriyas are developing from the Vikarika and
Taijas Ahankara Both Vagabhata and Sushruta stated that Karna as one of
the Bahirsrotas
शरण नयन दन घराण गदमढराणण न सततरोताशसराणा बदहमवखातन [31]
स शा ५-१०
In Ashtang Hradaya Vagbhata has states that all Indriyas are Atmaja
According to him lower lobule elevated helix projected posterior portion
fleshy and adherent ear are indications of long span of life[32]
ततरखातखातन दह अनदसतमन शरोतर शबद ववकतता [33]
ा शा ३-३
शबदाः शबदनदरिय सवनदछििसमहो ववकतता [34]
स शा १-२६
Page | 17
Ear has the prominence of Akash Mahabhuta The prominent dosha of ear
is Vata It is important seat of Vata The prominent Dhatus are Asthi and
Mamsa Karna is one of the Panchgnanendriyas and it meant for hearing
Sushruta narrated that Karnasthita Asthi and Sandhi
घराणकणवगरीाकषिकोषष तरणातन [35]
सशा ५-२२
शरोतरशरगािकष शखाताव [36]
सशा ५-३२
गडकणवशखटककम [37]
स शा ५-२२
One Sandhi and one Tarunasthi in ear
Sandhi ndash Karna contain two Sandhi one in each ear Type of Sandhi is
Shankhavartha which is present in Shringataka
Mansapeshi ndash 2[38]
Siras ndash 10 [39]
Vataj Sira - 4
Pittaj sira - 2
Kaphaj sira - 2
Raktaj Sira - 2
Avedhya sira-
कणवयोदवश तासा शबदादहनीनामकका पररहरत
सशा ७-२५[40]
Amongst above mentioned ten Siras each Karna lodges one Shabdavaha
Sira It is Avedhya
Page | 18
Dhamani -2
Length of ear is 4 Angula
Karna moola ndash 2 Angula
कणाविरतर चतदवशअगलम
स शा ३५-१४[41]
The distance between two ears through the back of the neck is 14 Angula
bull Marmas of Karna-
1 Vidhuras-
कणवपटठतो अिाःसशरशरत विर ततर बशरियवम
सशा ६-३७[42]
कणतपयादद सतनायममवणी ककनदचचनदरनममनाकर कलयकररणणच
डलहणाचयव[43]
अिसततात कणवयोतनवमन विर शरततहाररणण
ा शा ४-२९[44]
Sankhya-2
Vistara- frac12 Angula
Type- Snayumarma (Susha)
- Dhamanimarma(AH)
- Vaikalykar
Sthana- It is situated in the depressed portion in the back of the ear
Injury to them causes loss of hearing
Page | 19
2 Shringataka marma-
नदजवहाकषिनाशसकाशरोतरखचतटियसरमम
तालरयासतयातन चतपारर सरोतसा तष ममवस
वदि शरगातकाखयष सददसततपयजतत जीवतम
मा तन ५७१ [45]
Sankhya- 4
Type- Siramarma
Sthana- It is in head that is amidst Siras (blood vessels) nursing sense
organ
A palm size area near Talu
Injury to this Marma causes death
In modern anatomy ear divides into Bhayakarna or External ear Mdhyakarn
or Middle ear Antahkarna or Internal ear This is extremely appropriate
Even though the ear is divided into three divisions in the point of modern
anatomy Ayurveda denotes ear organ is one Ayurveda treats disease by
way of assessing Dosha and Dushya Here Dushya is one that is Karnendria
Dosha difference will call for different treatment for different disease Hence
treating the vitiated Dosha will cure the disease irrespective whether it is in
external middle or internal ear The thought is based on different
fundamental principle from Ayurveda
bull Parts of Karna
In Ayurveda classics detailed description about anatomy of ear is not
available But the various parts are mentioned as follows
Bhayakarna- External ear
Mdhyakarna ndash Middle ear
Antahkarna- Internal ear
Page | 20
द कणवशटकशलक दॊ कणवपतरकौ
च शा 7-11[46]
कणवशटकशलक कणवगतातवकौ कणवपतरकौ त बाहयकणा
चिदतत च शा 7-11[47]
शटकली बाहयपालयाशरिटिानम
डलहन- स शरच 25-1 12[48]
Karna Shashkulika ndash It is also called as Karna Shashakuli Charaka has
mentioned this term while describing different Pratyngas of the body
Acharaya Gananatha sen has given the clarification for it as a pinna or
auricle[49]
Karnapali ndash It is popularly known as lobule of the ear Daivakrita Chidra is
present in it
Karnaputrika- Ayurvedic scholars accepted two terms in this cortex They
are Karnaputrika and Karnaputrika The former is considered as Tragus and
antitragus[50]
Karna Prushtha- It can be taken as the cranial surface of mastoid or
auricle[51]
Karnapeetha- Aacharaya Sushruta firstly mention the term Karnapeetha
It is mentioned first by Sushruta while describing the procedure of
Karnavyadana Vagbhata has mentioned that it is Adhobhaga of Karna
Dalhana has clarified that it is the region above the Karnaputrika that is the
region which is at the bottom of the concha
Karnamoola ndash It can be considered as parotid region[52]
Karna lathika ndashAcharaya Dalhana mentioned lobule as a Karna Lathika
Page | 21
Karnaavatu ndashThis term is used by Sushruta while describing the
measurements of different Angapratyangas where he has mentioned that
the distance between the Karnaavatu is 14 Angul Dalhana has comments
that it can be taken as the distance between two ears from behind[53]
Shabdhavahasrotas ndash It also called as Shabdapatha or Srotapatha The
whole passage through which the sound waves pass can be taken as
Shabdavahasrotas[54]
Shrotashringataka ndash It can be taken as the labyrinth of ear[55]
bull Dosha in context to Karna-
Karna is principal location of Vayu
1 Prana Vayu- Prana Vayu circulating in oral cavity is responsible for
Dehadhruka that is keeping all body parts active Indriyadruka that is
keeping all Dnyanendriya healthy by proper nourishment (Purana) helps in
deglutition of food material and convey the stimulation of Indriyabuddhi
and atma
2 Udana Vayu- Bala(strength) Varna speech singing are its function It
is responsible for facial expressions due to pleasure sorrow anger love
frustration etc in general its circulation and actions are just opposite to
Pranavayu
3 Vyana Vayu- Its principal functions are circulation of Rasa and Rakta
through body and various movements Its main location is Hrudaya Five
types of movements for which it is responsible are expansion contraction
upward downward and oblique other activities are opening closure of
eyelid yawning perspiration During circulation if it gets obstructed due
to Srotodushti it generates disease of that Srotas Vyana Vayu gets vitiated
by disease of Rasa Rakta Oja and Chetanadhatu
Page | 22
4 Samana Vayu- It is circulating in the vicinity of stomach and intestine
and helps in keeping the Jatharagni (digestive juices and enzymes) in
equilibrium Disturbance in Jatharagni precipitates disease
5 Tarpaka Kapha- Entire body functions movements are controlled and
executed by various centers in the brain Sensation perceived by sense
organs is conveyed to Mann and Aatma residing in Hrudaya The motor
signals from them are then conveyed to the functioning
organsKarmendriya through Prana Vayu Shira head is therefore a
location of continuous activities motions of Vata All these centers are in
unctuous Majjadhatu in the Shira For stabilizing this ever-active Vata and
to nourish the Majja dhatu very unctuous Tarpaka Kapha situated in Shira
plays an important role
bull Ayurvedic aspect of sound perception [56]
According to Ayurveda Pratyaksha Dnyan or Perception of any sensation
including Shabda occurs due to interaction of the Karnendriya and the
Indriya- Arth -Karma resulting in Sravana
External Environmental acquaintance with living body is executed by five
sense organs namely Netra Karna Nasa Jivha and Twaka All
Dnyanendriya that is sense organ are Panchmahabhautic combination
Despite this fact every Indrya sense organ perceives object Tanmatra of
that Mahabhuta only from which it is originated from Akash Mahabhuta and
hence perceives Shabd only that is audio perception Shrotrendriya is one
of the principal locations of Vata and its function is to perceive Shabda that
is sound waves This sensation is conveyed through Shabdavahi Dhamanis
to Mana and Atma through Pranavayu and the sequence is responsible for
perception of sound in this way external sound is perceived and interpreted
when Atma is linked with Mann Mann is linked with Indriyabuddhi that is
minute virtual Dnyanendriya located in brain Indriyabuddhi is linked with
Adhishthana with prominent Mahabhuta and lastly with Indriya
ArthShabdatanmatra that is sense object Once this sequence is completed
Page | 23
the meaning of a particular sound is interpreted and understood In this
entire process of perception and interpretation of sound waves Pranavayu
and Tarpaka Kapha located in Shira play extremely important role Hence
the healthy status of all the sense organ depends upon the normal
physiologically homeostatic condition of Pranavayu and Tarpaka Kapha
MANAS
ATAMA
BUDDHI
AHANKARA
ARTHA
Page | 24
EAR ANATOMY
bull Embryology of the Ear [57]
1 The sound conducting apparatus develops from the branchial apparatus
whereas the sound perceptive apparatus from the ectodermal otocyst
2 The pinna develops from the six hillocks around the 1st branchial cleft
3 External auditory canal develops from 1st branchial cleft
4 The outpouching of the 1st pharyngeal pouch gives rise to a proximal
narrow part that forms the eustachian tube and distal dilated part that
forms the middle ear cavity
5 Prussakrsquos space is a potential space lateral to the Shrapnellrsquos membrane
and medically by the neck of malleus that can be involved during the
extension of cholesteatoma
6 Development starts in the 3rd week of the intrauterine life and is
completed by 16th week of intrauterine life Membranous and boney
labyrinth develops from the otic capsule
The Ear is divided into
1 External Ear
2 Middle Ear
3 Internal Ear or the labyrinth
Page | 25
Fig 1 Ear Anatomy
EXTERNAL EAR [58]
The outside ear contains pinna and lobule
Pinna is the noticeable piece of outer ear made from single sheet of yellow
flexible ligament covered by subcutaneous tissue and skin It has two
surfaces average and parallel It is intently disciple to perichondrium on its
sidelong surface while it is somewhat free on average surface Pinna
incorporates tragus helix against helix fossa three-sided scaphoid fossa
incisura terminalis
External auditory Canal ndash It extends from the bottom of the conchea to
the tympanic membrane and measures about 24 mm along its posterior
wallit is S shaped
Parts 1 Cartilaginous part
2 Bony part
Page | 26
Cartilaginous part ndash The outer one third is cartilaginous consist of fibro
cartilage is directed first inward backward and upward It has Fissure of
Santorium The skin of this part of the canal contains hair follicles
sebaceous gland and cruminous gland
Bony part ndash The inner two third part is boney It goes forward downward
and medially skin lined in this part is very thin Isthmus is the narrowest
part of the canal lying medial to junction of bony and cartilaginous part
nearly 5 mm lateral to tympanic membrane
The roof and posterior wall of the external auditory canal shorter than floor
and anterior wall The skin lining the tympanic membrane and boney canal
has a self-cleansing property due to migration of keratin layer of epithelium
from drum towards the cartilaginous portion
Relations- Anteriorly- Temporomandibular joint and parotid gland
Superiorly- Middle cranial fossa
Inferiorly- parotid gland
Posterior- Mastoid antrum mastoid air cells and facial nerve
Nerve supply ndashSensory nerve supply of the external ear The auricle
supplied by fibers of the great auricular nerve (C2 and C3) and lesser
occipital nerve (C2) Auriculo temporal branch of the 5th cranial nerve and
auricle branch of the vagus (Arnoldrsquos nerve) supply external canal Facial
nerve has small sensory contribution on posterior-inferior wall
Tympanic Membrane -It is the partition between EAC and middle ear It
is a thin semitranslucent membrane pearly white in colored lying obliquely
in the medial end of EAC with the angle of 55 It is forming major part of
lateral wall of middle ear Annulus tympanicus is attached at its
circumference to the sulcus The TM is oval shape It measures
approximately 10 mm in vertical diameter and 90 mm in horizontal
diameter
Page | 27
Layers ndash Tympanic membrane consist of three layers
1 Outer Epithelium or cuticular layer which is continuous with skin of
external ear
2 Middle fibrous layer has both circular and radial fibers middle layer
missing in upper part
3 Inner layer- Inner mucosal layer which is continuous with middle ear
mucosa
Parts ndash Tympanic membrane consist of two parts
1 Pars tensa -It is largest part below the malleolar folds The inner
surface at the center attached to the handle of malleus Angle of cone
is most illuminated part in the pars tensa at anteroinferior part of pars
tensa
2 Pars flaccida Sharpnells membrane -it is triangular area above the
malleolar folds which are thin and devoid of fibrous tissue and
annulus It fits into notch of Rivinous
Nerve supply 1 Anterior half of lateral surface Auriculotemporal V3
2 Posterior half of lateral surface Auricular branch of vagus cn 10
3 Medial Surface Tympanic branch of CN 9 (Jacobsons nerve)
Fig 2 Tympanic membrane of ear
Page | 28
MIDDLE EAR [59]
The middle ear or tympanic cavity is an irregular laterally compressed
space within the temporal bone It is filled with air that is supplied to you
from the nasal part of the throat through the ear canal It contains a chain
of mobile bones that connect its side with the medial wall and serve to
transmit vibrations transmitted to the eardrum through the cavity to the
inner ear Including the parapet the vertical and anteroposterior diameters
of the cavity are each approximately 15 mm The transverse diameter
measures about 6mm at the top and 4mm at the bottom Compared to the
eardrum it is only about 2mm The eardrum is limited laterally by the
eardrum medially by the lateral wall of the inner ear It communicates
behind with the tympanic antrum and through it with the air cells of the
mastoid and in front with the auditory canal The middle ear together with
the Eustachian tube aditus antral and mastoid air cells is called the
middle ear cleft It is lined by mucus membrane and filled with air
It is divided into 3 parts
1 Mesotympanum (located in front of the pars tensa)
2 Epitympanum or attic (located above the pars tensa but medial to
Sharpnells membrane and the lateral bony wall of the attic)
3 Hypotympanum (located under pars tensa) The middle ear is like a
hexagonal box with a roof
Carotid or Anterior wall- It separates middle ear cavity from internal
carotid artery The various structure passing through anterior wall of
tympanic cavity
bull Canal of chorda tympani nerve
bull Canal of tensor tympani muscle
bull Eustachian tube
bull Anterior malleolar ligament
bull Anterior tympanic artery
Page | 29
Posterior or mastoid wall ndash The upper part of the back wall shows the
opening of the auditorium Below the auditory is a triangular bony
projection known as the pyramidalis processors The stapedial tendon is
transmitted through the apex of the pyramidalis processes The vertical
portion of the facial nerve descends along the posterior wall until it opens
into the stylomastoid foramen
Roof or Tegmental wall (Pars terminalis)- It is formed by a thin bone
plate called the tegman tympanum that separates the skull and tympanic
cavities It is located on the anterior surface of the rocky part of the
temporal bone near the junction with the temporal shell it extends back to
the roof in the tympanic membrane and anteriorly to cover the half canal
of the tensor tympanic muscle The lateral border corresponds to the
remains of the Petro scaly suture
Floor ndash It is formed by a thin plate of bone which separate middle ear from
the bulb of the internal jugular vein lodged in the jugular fossa
Lateral wall ndash It is formed by tympanic membrane and partly by a portion
of squamous part of the temporal bone It separates the middle ear from
external ear
Medial wall- It separates the middle ear from the inner ear
bull The promontory is the most prominent and convex part formed by the
basal rotation of the cochlea
bull The bony lateral semicircular canal is postero-superior to the promontory
above the oval window
bull The oval window is located between the middle ear and the vestibular
slope of the cochlea It is closed by the stirrup footrest and the annular
ligament
Page | 30
bull The round window is located under and behind the cape The round
window recess is directed to the rear It is closed by the secondary eardrum
and separates the middle ear of the Scala tympani from the cochlea
bull The facial nerve passes through the bony fallopian tube above the oval
window
Mastoid Antrum ndash It is a large space with air in the upper part of the
mastoid and communicates with the attic through the aditus The roof is
formed by the antri tegmen which extends and separates the tympani
tegmen from the middle cranial fossa The lateral wall of the antrum is
formed by a bony plate that is on average 15 cm thick in adults It is
marked externally on the surface of the mastoid by the suprameatal triangle
(MacEwen)
Aditus and Antrum- Aditus is a gap through which the attic communicates
with the antrum The boney prominence of the horizontal canal lies on its
medial aspect even as the fossa incudes to thats attaches the quick system
of incus lies laterally Facial nerve publications simply underneath the
aditus
The mastoid and its air cell system-
The mastoid consists of bone cortex with a honeycomb of air cell
underneath Depending on development of air cell three types of mastoids
have been described
1Well-pneumatized or cellular- Mastoid cells are well developed and
intervening septa are thin
2Diploetic- Mastoid consist of marrow spaces and a few air cells
3Sclerotic or acellular ndash There are no cells or marrow spaces
With any type of mastoid pneumatization antrum is always present In
sclerotic mastoids antrum is usually small and the sigmoid sinus is
anteposed
Page | 31
Depending on the location mastoid air cells are divided into
1 Zygomatic cells (In the root of zygoma)
2 Tegman cell (Extending into tegmen tympani)
3 Perisinus cells (overlying the sinus plate)
4 Retrofecial cells (round the facial nerve)
5 Peri labyrinthine cells (located above below and behind the
labyrinthine some of them pass through the arch of superior
semicircular canal These cells may communicate with the petrous
apex)
6 Peritubal (around the Eustachian tube Along with hypotymoanic
cells they also communicate with the petrous apex)
7 Tip cells (which are quite large and lie medial and lateral to the
digastric ridge in the tip of mastoid)
8 Marginal cells (Lying behind the sinus plate and may extend into
the occipital bone)
9 Squamosal cells (Lying in the squamous part of temporal bone)
Development of Mastoid ndash
The mastoid develops from the scaly petrous bone The petrosquamosal
suture may persist in the form of a bone plate - Korners septum which
separates the superficial squamosal cells from the deep rock cells Korners
septum is surgically important because it can cause problems locating the
antrum and deeper cells and thus lead to incomplete removal of the disease
during mastoidectomy The mastoid antrum can only be reached if Korners
septum is removed
Page | 32
Fig 3 Cross section of Mastoid
Contents of the middle ear
Ossicles ndash Three tiny bones which conduct the sound from eardrum to oval
window
Malleus ndash It is the largest and most lateral ossicle measuring 8 mm in
length It has head neck handle anterior and lateral processes The head
is situated in the epitympanum A lateral process project laterally from the
neck while the handle is firmly fixed to the pars tensa of the ear drum
Incus- It has a body short process and long process The body short
process and long process The body articulate with the head of mallelus in
the attic and the short process project into the attic The long process
projects downwards behind the handle of malleus running parallel to it and
articulate with the head of the stapes via the lenticular process
Stapes ndash It is the smallest ossicle measuring about 35 mm and consist of
head neck footplate and anterior and posterior curcura The footplate of
stapes is held to the oval window by the annular ligament
Page | 33
Muscles ndash
1Tensor tympani ndash It is inserted is a branch of the facial nerve which carries
the sense of taste It is first arch muscle supplied by branch of mandibular
nerve V3
2 Stapedious muscles ndash It is inserted to the neck of stapes It is the second
arch muscle supplied by branch of facial nerve that is nerve to stapedius
Fig 4 Contents of the middle ear
Blood supply of Middle Ear
bull Anterior tympanic branch of maxillary artery which supplies tympanic
membrane
bull Stylomastoid branch of posterior auricular artery which supplies middle
ear and mastoid air cells
Page | 34
Four minor vessels are
bull Petrosal branch of middle meningeal artery runs along greater petrosal
nerve
bull Superior tympanic branch of middle meningeal srtery traversing along
the canal for tensor tympanic muscle
bull Branch of artery of pterygoid carotid
bull Tympanic branch of internal carotid
Lymphatic Drainage of Ear
Lymphatics from the middle ear drain into retropharyngeal and parotid
nodes while those of the Surgical Importance ndash Eustachian tube drain into
retropharyngeal group
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 middle is likely to pass to
middle ear
2 Moreover middle ear suppurative disease may spread to adjacent organs
and produce complication eg Labyrinthitis meningitis facial nerve palsy
etc
3 Lenticular process is vulnerable in suppurative ear diseases and causes
ocular disruption
4 Prussac space is the site of primary acquired cholesteatoma
Page | 35
INNER EAR [60]
Inner ear is divided into two parts
1 Bony Labyrinth
2 Membranous labyrinth
Anatomy of bony labyrinth
It is divided into two parts
1 Vestibule
2 Cochlea
3 Semicircular canal
The vestibule is located between the medial wall of the middle ear and the
lateral to internal acoustic meatus anterior to the semicircular canal and
posterior to the cochlea The vestibule is the central part of the inner ear
On its side is the oval window opening which is closed by the bracket foot
plate The bony cochlea is located in front of the vestibule It has 275 turns
wound around a bony axis called a modiolus The cochlea is about 30 mm
long The hollow center of the modiolus is a spiral canal that contains the
fibers and ganglion cells of the cochlear nerve A thin bony sheet the bony
lamina winda around the modiolus This divides the cochlear duct into two
galleries the Scala vestibuli above and the scala tympani below
There are three semicircular canals superior posterior and lateral They
are semicircular in shape and open into the vestibule One end of the
semicircle is enlarged and is known as the sphere
The membranous labyrinth is in the bony labyrinth It is connected to the
bony labyrinth by fibrous trabeculae and is surrounded by perilymph The
endolymph is located in the membranous labyrinth
Page | 36
The utricle is in the upper part of the vestibule while the saccule is found
below Both the utricle and saccule contain a single sensory patch called
the macula Each macula is covered with a neuroepithelium made up of
neuroepithelium made up of sensory hair cells and support cells these cells
are separated by a basement membrane Fibers of the vestibulo-cochlear
nerve enter the macula and pierce the basement membrane to terminate
at the base of the hair cell or cell bodies The utricle and the saccule with
their macula are called otolith organs Membrane semicircular canals are
the membrane canals of the corresponding bony semicircular canals They
open into the utricle through five openings One end of the opening of each
channel is dilated called the sphere in which the sensory organ of each
channel is located The cross section of the Scala standard looks like a right
angle The base is formed by the basilar membrane Sensory cells are
arranged on the surface of the basilar membrane These sensory cells with
their supporting cells form a complex neuroepithelium called the basilar
papilla or the cortical organ named after an Italian microscopist The
organs of the corti have a gelatinous membrane called the tectorial
membrane and they are supported by the pillar of the corti The cortical
pillars enclose a space called the corti tunnel which contains a fluid called
cortical lymph Vestibule is lies between the medial wall of the middle ear
and lateral to internal acoustic meatus anterior to semicircular canal and
posterior to the cochlea 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 Boney cochlea lies in front of the vestibule It has 275 turns
coiling around boney axis called modiolus Cochlea is approximately 30 mm
in length The hollow center of the modiolus is a spiral canal containing the
fibers and ganglion cells of cochlear nerve A thin boney sheet the osseous
lamina winda around the modiolus This divides the cochlear canal into two
galleries the Scala vestibuli above and the scala tympani below
Page | 37
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 boney labyrinth It is connected
to the bony labyrinth by fibrous trabeculae and is surrounded by perilymph
Endolymph 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 single sensory patch called macula Each
macula is covered by neuroepithelium consist of Neuroepithelium consists
of sensory hair cells and supporting cells these cells are separated by
basement membrane Fibers 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 are referred
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 corti lymph
Page | 38
Fig 5 Inner Ear
Blood supply of labyrinth
Labyrinthine artery
Common cochlear Anterior vestibular Artery
Vestibulocochlear artery Main cochlear artery
Cochlear branch posterior vestibular artery
Page | 39
PHYSIOLOGY OF HEARING [61]
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
bull Mechanical conduction of sound (conductive apparatus)
bull Transduction of mechanical energy to electrical impulses (sensory
system of cochlea)
bull Conduction of electrical impulses to brain (neural
Fig 6 PHYSIOLOGY OF HEARING
Page | 40
Conduction of sound
Under the surface of water we cannot hear the sound made in air because
9995 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 must 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 13 times longer than long process of incus providing
a mechanical advantage of 13
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 beings 211 As the effective
vibratory area of the tympanic membrane is only two- thirds the effective
areal ratio is reduced to 141 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
Page | 41
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 lobe
Page | 42
DISEASES REVIEW
करणसराव
Nirukti - करणसय कणवयोाव ससराा [62]
Nidana- Acharya Sushruta and Vagbhata describe the common etiological
factors for the Karnaroga
अशयाय जलिीडा कणवकणडयन मरत
शमथययोगन शसततरसतय कवपतो अरय च कोपन ||
सउ २० १२
1 Avashaya or Pratishaya
(Excessive exposure to cold)
2 Jalakrida
(Excessive swimming)
3 Karnakandunyanum
(Excessive scracing due to itching)
4 Mithyayogena Shatrasya
(Improper instrumentation during wax removal or foreign body removal)
5Shabdasya
(Louder sound for long durationperverted contact of sound)
6 Abhighata (Trauma)
7 Vitiation of Tridoshas
Page | 43
Samanya Nidana according to different Samhita
Vishesh Nidan of Karnasrava
Acharya Charaka has not mentioned any kind of Nidana regarding Karnaroga
but has described Utapati of Karnaroga from Siroroga in Karnasirasym
Adhyaya[67]
शशरोअशिघातादरा तनमजजतो जल परपकादरा अवप विि
सरतत पय शरणॊ अतनलात स कणवससरा इतत परककतीत
सउ २० १०
असस ३७२५ [68]
1 Shiroabhighatat - Head Injury-Fracture of middle cranial fossa
2 Jala nimajjana - CSF otorrhoea fracture of middle cranial fossa
3 Karnaprapaka
4 Karna Vidhradhi -Puyasrava
Sr
no
Samanya Nidana SU AH[63] AS[64] YR[65] MN[66]
1 Avashaya + + +
2 Pratishaya + +
3 Shabdha
mithyayoga
+
4 Shashtra
mithyayoga
+ + +
5 Karnakandooyan + + + + +
6 Jalkrida + + + + +
7 Abhighata + + +
Page | 44
Samanya samprapti
परापय शरोतरशसरा कयावत शल शरोतशस गान
त कणवगता रोगा अटिावशततरीता
सउ २० १२
Due to common and specific etiology factors the vitiated Doshas gets
Sthanasamshraya in Karna and causes Karnasrava It is the stages of
Samprapti were Doshas gets lodged in Srotas and start processes of Dosh
Dushya Sammurchsna Due to Shiroabhighata Jalanimmajana Karna Paka
Karna Vidhradi vitiated Vata Dosha and Karna becomes Avruta by Vata and
results in Karnasrava Normal physiology of Dosha Dhatus and Malas entirely
depends on the normality of Srotas Dosh Dushya Sammurchana or
manifestation of diseases will not take place if only vitiation of Doshas take
place without deformity of Srotas Here in Karnasrava vitiation of Srotas are
Atipravritti Sanga and Vimargagamana take place Atipravritti is being excess
production of fungus Sanga is obstruction in external acoustic canal
Vimargagamana is the propagation of discharge through ear
Vishesh Samprapti
Karnasrava occurs due to Nij nidana is Pratishaya while Agantuja nidanas are
Avashya Jalkrida and Karnakanduyan Due to etiological factors which are
Vata-Kapha provocative in nature gradual vitiation of Doshas will occur After
vitiation they get accumulated (Sthan samshraya) in external auditory canal
In other hand when patient does Sevana of Agantuj Nidan like water enter in
external ear scratching of ear unsterile instrumentation leads to Dosh
Prakopa These cause Twak and Mamsa Dhatu Dushti which leads to
discontinuity of epithelium of ear canal which creates suitable atmosphere for
fungal pathogen to grow The vitiated Vata will produce symptoms such as
Page | 45
pain hearing impairment and vitiated Kapha causes symptoms like itching
discharge ear blockage By assessing the symptoms it can be said that Kapha
Avrita Vata Dosha is responsible for the manifestation of clinical features like
pain itching discharge Which are seen in Karnasrava that is otomycosis
Acharya Charaka has mentioned while explaining Samanya Chikitsa of
Karnaroga that it should be treated like Vrana when Paka and Srava is present
as a symptom Fungal spores invade in the epithelial layer of EAC In response
to infection inflammatory process is start This is a Paka Avastha After
removing the fungal mass ulceration in external acoustic canal is commonly
seen As a result of infection process exudates was produced which will mix
up- with fungal colonies and appear as discharge As per Dosha involvement
in Vrana Shoola Srava can be differ According to Acharya Sushruta Ruk is
the Samanya Lakshana of Vrana and Vishesha Lakshana of Vrana includes
pain discharge discoloration itching etc according to Dosha involvement
which are also seen in otomycosis In otomycosis mainly watery and purulent
type of discharge is present which indicates Paka avastha If there is Dosha
involve in Vrana is called Dushta Vrana Acharya Sushruta and Acharya
Vagabhata have mentioned verity of Srava in Twak and Mamsa Vranavastu
which is found in otomycosis Based on this description otomycosis can be
correlated with Karnasrava
Page | 46
Representing the Samprapti of Karnasrava
Vishesh Nidana ndash Shiroabhighatat
Jala nimajjana
Prapaka Vidhradhi
Vitited vata
Avarana by kapha
Vimargagamana of Vata
Karnasrava
Samprapti Ghataka
Dosha ndash Kapha and Vata
Dushya ndash Rasa Rakta and Mansa
Strotodushti ndash Vimargagamana and Sang
Adhishthana ndash Karna (Bhayakarna)
Rogmarga ndash Madhyama
Page | 47
Purvarupa
The Purvarupa of Karnasrava are not mentioned separately in any ayurvedic
classics In routine practice cretin Purvarupa are noted
1 Karnakandu
2 Karnagurutwa
3 Alpa karnashoola
4 Discomfort in ear
Rupa
1 Karnashoola
2 Karnakandu
3 Karnasrava
4 karnabadhirya
5 Cotton wool like or wet newspaper like grayish brown or black colored mass
is seen
6 External auditory canal skin appears edematous and red
Upashaya and Anupashaya
Appropriate application of Aushadhi Ahara and Vihara when produces relief in
the symptom is called as Upashaya and when aggravates the symptoms is
called Anaupashaya There is not any reference available in the classics about
the Upashaya and Anupashaya of karnasrava
Sadhyasadhyata
Sushruta has not mentioned specially the Sadhyasadhyata of Karnarogas But
Vagbhata has mentioned Karnasrava as a Sadhyavyadhi[69]
Sadhysadhyatagives the clear picture of prognosis of the disease It depends
on many factors like nature of disease severity of disease Vaya Prakriti Bala
of the patient etc
Page | 48
Upadrava of Karnasrava
In Samhita there is no reference available regarding the Upadrava of
Karnasrava
Samanya Chikitsa ndash
The common treatment principle for all Karnaroga is Ghritapana Use of
Rasayana Bhrahmacharya Avyayama Shirasnana and Atibhashaya
सामरय कणवरोगष घतपान रसयनम
अवयायमो शशराःसतनान बरमहचयवम कतपरनम
स उ२१३
Ghratapana - Ghrita is a Yogavahi and follow Sanskara in addition to these
acquired properties and capable of retaining its own properties So Ghritapana
is effective in Karnasrava
Rasayana - Rasayana represent the basic approach of Ayurveda which
comprise preventive promotive and curative aspect of health
Brahmacharyaapalana -It is like Sadvrittapalana and is equals to Rasayana
effect
Vyayama - It leads to vitiation if Vatas a Karna is a Sthana of vata and
exercise causes Kshayaj Samprapti hence it is important to avoid exercise in
Karnasrava
Shirasnana- In Shirasnana water enters in external acoustic canal it changes
the PH of meatus skin from acid to alkali which favors the growth of pathogens
Atibhashya - Excessive speaking causes Vata Prakopa and Vatapraokopa is
basic Samprapti for Karnasrava as the preventive aspect avoidance of
excessive speaking is necessary
Page | 49
Ghritapana Rasayana and Brahmacharyapalana should be followed for
preservation of dhatu Samyata and restriction of vitiation of Vata Vayayama
Shirasnana and Atibhashaya should be avoided in Karnasrava to protect the
Siras from the affliction of Vata and Kapha
Vishesha Chikitsa ndash
The general treatment principle of Karnasrava described in classics is closely
related to Dushtavrana Chikitsa
शशरोवरचन च ए िपन परण तरा
परमाजवन िान च ीकषय ीकषय़ाचारत [70]
स उ २१४०
कणवसततरा ोददत कयावत पततकशमकणवयो [71]
ाउ १८३५
उपददि च सततरोत साय परात वपचततवशि परमजय
य अगर मदन सघत गगलना ा िपतयतपा मिना परयत [72]
असउ २२४२४३
In addition to that Shirovirechana Karnadhoopana Karnapurana
karnapramarjana Karnadhavana are also indicated
Page | 50
Treatment is also mentioned for Karnasrava
1 Karnaprakshalana Yoga - with Aargawadadi Gana Kashaya and Surasadi
Gana Kashaya [73]
2 Avachurnana Yoga ndash with Aargawadadi Gana Churna and Surasadi Gana
Churna[74]
3 Karnapoorna Yoga ndash
bull Rasanjana Laksha with Sarjachoorna[75]
bull Panchkashaya with Kapittha swarasa and Madhu[76]
bull Jambu AmrapallavShivalaKshuodra Mahavriksha and Madhuki 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 done[77]
bull Sarjatwak Choorna with Karpashiphalarasa and Madhu[78]
bull Abhaya LodraTindukaSamanga(Manjista) Kwatha of this Dravyas mixed
with Madhu and Kapittha Rasa[79]
bull Yogratnakara mention the following drugs for Karnapoorana-
a Samudraphena Churna[80]
b Jambwambpatra Yoga
4 Karnadhoopana Yoga ndash
bull Dhoopana with Churna of Bilvapatra Haridra Palandu[81]
bull Vartak Dhoopana [82]
5 Internal Medications-
bull Rasnadi Guggula [83]
bull Triphala Guggula [84]
bull Sarivadi Vati [85]
bull Gandhaka Rasayana [86]
Page | 51
According to Vagbhata-
Ear should be cleaned with the Pichu and Varti followed by Guggula Dhoopana
and then Karnapoorana with Madhu Followed by Avachurnanana with
Sukshmachootana of Surasadigana
Pathyaapathya ndash Pathya and Apathy mentioned for Samanya Karnaroga is
recommended in Karnasrava also
पथय[87]
सतदो वरको मन नसतय िमाः शशरावयिाः
गोिमाः शालयो मदगााः याशच परतन हवाः 80
लाो मयरो हररणानदसततततरो नकककिाः
पिोल शशगर ातावक सतनषराण कदठललकम
रसायनातन सवणण बरमहचयवमिाषणाम |
उपयकत यरादोषशमद कणावमय दहतम ||81||
िापर २१
Aharaja Upacharaja
bull Godhuma bull Vamana
bull Shala bull Virechana
bull Mudga bull Nasya
bull Yava bull Dhoomapana
bull Puranagitra bull Kavala
bull Lava Harina Tittiramamsa
Page | 52
अपथय[88]
दरत काटठ शशरसतनान वययाम शलटमल गर
कणडयन तषारशच कणवरोगी पररतपयजत
िापर २१
Viharaja
bull Patola ShigruVartaka bull Bhramacharaya
bull Sunishannaka bull Avyayama
bull Katthlika bull Aakthanam
bull All types of Rasayana bull Upacharaja
bull Vamana
Apathyas
bull Abhishyandakara Aharas
bull Shirasnana
bull Karna kandooyana
bull Tushara sevana
bull Guru Kaphakaraka Aaharas
bull Dantdhavana
Page | 53
OTOMYCOSIS
Definition-
Otomycosis is a superficial acute sub-acute or chronic infection of external
ear canal It is mostly unilateral It is characterized by inflammation purities
and scaling Otomycosis is a common condition encountered in ENT practice
more in chronic and persistent ear infection
The Fungal infections are not communicable in the usual sense but the
humans become an accidental host by their introduction into tissue trauma
The virulence factors favoring colonization of fungus in human host are yet to
be identified Ability of the fungus to grow at 37 C and elaboration of a variety
of enzymes and toxins are speculated to contribute to virulence Only 100 to
150 species are generally recognized as a cause of disease in humans[89]
Prevalence-
Otomycosis is a word wide in distribution and in various record stated that 5
to 20 of all cases of infective otitis externa Otomycosis prevalent is more in
warm and humid climates It is one of the commonest manifestations in India
during rainy season It occurs mostly in humid atmosphere otitis externa due
to fungal infection may resembles the desquamative form of diffuse infective
otitis externa The incidence in temperature climates has increased in
proportion to the use of topical antibiotics which have a medium sterilized of
other organism in which the fungus may flourish
Page | 54
Predisposing factors- [90]
1 Environmental factors such as climate contagious and polluting hygiene
more frequently during rainy season as the humidity increases
2 Individual susceptibility ndashGeneral Immunological status of the Individual
eg HIV infection Radiotherapy chemotherapy Diabetes mellitus
3 Self-inflicted trauma that is use of pins to clean the itching ear or use of ear
bud to clean the wax
4 Wide spread of topical antibiotics steroid preparations which have medium
sterilized of other organism in which the fungus may grow
5 Failure of defense mechanism in External auditory canal
6 During swimming or head bath water enters in External acoustic canal
causes quantitative and qualitative change in ear wax It causes change in pH
7 Long term use of hearing aids
Pathophysiology ndash
The life cycle of the average mold encountered in the ear may be reckoned
as two weeks and flare ups may be anticipated at such intervals Swimming is
held responsible for infection in many cases The sequence sequence of
pathogenic changes produced by molds in the external ear is as follows ndash
1 Implantation of the organism in external ear
2 Growth of organism follows the rate depending on condition of temperature
moisture or preexisting irritation
3 Invasion of epithelium occurs with attendant itching and discomfort which
may be quite severe
Page | 55
4 Exfoliation of epithelium occurs as nature attempts to overcome the
infection by casting off upper most cells
5 Denudation occurs from exfoliation as the top layers of epithelium are cast
off and the canal becomes filled with debris
6 Superficial ulceration and lizematoid dermatitis results if the pathologic
process goes for enough The changes do not always proceed through the
entire sequence sometimes the molds produce changes of the mildest
imaginable character which may be overlooked[91]
Clinical features -
Symptoms-
1 Irritation and itching ndash Irritation is mostly found when the infective
organism is aspergillus niger There is sensation of discomfort which is more
diffuse in the ear canal then localized in the deeper part Candida infection
causes marked itching In external ear it is intense and worse at night
2 Discharge through ear- Intermittent scanty colorless discharge through
ear Mucus being a fungal metabolic product appears as discharge Excessive
discharge is associated with mixed infection
3 Pain and discomfort ndash Mild to severe pain in the ear occasionally Mostly
seen in cases where ear is infected with Aspergillus flavus mixed infection
with gram negative organism or mixed infection with candida and aspergillus
Headache is sometimes associated with pain
4 Deafness- Varying degree of mild to moderate conductive deafness
5 A sensation of fullness in ear
6 Tinnitus 7 Vertigo
Page | 56
Signs ndash
1 The external acoustic meatus may contain a mass formed of epithelial
debris exudates cerumen and fungus
2 Erythematous external canal
Fungal appearance
A Niger - The color of the mass which is usually grey or black is mainly
determined by the type of fungus concerned Its appearance is like wet
newspaper or blotting paper or a cotton wool It has a peculiar musty odor In
this infection fruiting heads may be seen as black specks in the debris
Occasionally as inactive form occurs in which the canal is lined by mold giving
a fluffy appearance due to the presence of tiny mycelia
Candida ndash Candida infections generally show as white deposits on magenta
colored skin when the debris is removed it rapidly recovers in 24 hrs
The underlying canal skin is often inflamed and granular due to invasion by
fungal mycelia and be seen in all cases In rare cases excoriation and
ulceration with marked extensive shedding of the epithelium and deep
ulceration can be seen usually associated with a flavus and with pathogenic
bacteria[92]
Otoscope Appearance
1 Aspergillus Niger ndash Black headed
2 Aspergillus Fumigators ndash pale blue or green
3 Candida Albicans ndash White- or cream-colored deposits
Page | 57
4 Auricle is normal in most cases In severe cases small ulceration with crust
formation may be present on lateral surface
5 Tympanic Membrane
In most cases it is normal with normal mobility and normal hearing In a few
cases the surface of the tympanic membrane is congested and scaly There is
erosion or ulceration of the external epithelial layer and the membrane itself
may be edematous
Diagnosis
1 Above mentioned symptoms and signs
2 In the stage at which patient with otitis externa usually first present
themselves mycelia threads conidiophors not visible to naked eye may
sometimes be identified with the microscope
3 Confirmed by culture
Page | 58
Fig7 Aspergillus Niger Fig8 Candida Albicans
Fig9 Aspergillus Fumigators Fig 10 Wet Paper like appearance
Page | 59
Treatment
1 Antibiotic or steroid drops should be discontinued if they are being instilled
since long time
2 Removal of fungal mass epithelial debris and discharge from the external
canal or mastoid cavity repeatedly and thoroughly by forcepa or suction or
syringing or cautiously blow a stream of air into the canal through a fine
cannula and dry thoroughly by swabbing liquid petroleum on swab used in
cleaning the ear lessens the burning sensation when metacresy acetate is to
be employed in the subsequent treatment
Furuncle is developed as a complication if there is no gentleness in cleaning
Cleansing may have to be delayed until local sensitiveness is lessened which
can usually be accomplished within twenty-four hours If there is excessive
epithelial debris along with otomycosis then metacresyl acetate which is a
keratolytic in introduction into the external auditory canal on cotton wick and
is allowed to remain for twenty-four hours After twenty-four hours the cotton
wick is removed at which time the canal can usually be cleansed with little
discomfort as the medication is also anesthetic The epithelium of the canal
was white from contact with the drug The top layer was detached and this
epithelial debris can be easily wiped away The wick is reinserted and wet with
metacresyl acetate
The treatment is employed for three to four days in succession and then a
bland application is substituted Icthyol iodine is of value at this stage Iodine
ointment 2 in combination with Tannic acid 2 is also an excellent local
application following cresatin treatment
Next one of the fungicides may be applied
Page | 60
1 Nystin Effective for candida infection but less active against aspergillus
group Nystatin in boric powder consisting of 100000units of nystatingm of
powder 3 times week for 3 weeks
2 Clotrimazole Available as 11 cream or drops or lotions Phenyl
(zchlorophenyl) 1 ndash imidazole ndash methane is a chlorinated trityl imidazol 1
effective against candida and dermatophytes and for aspergilli infection
3 Amphotericin B Available as cream and as 3 solution and 015 drops
for topical application Very effective for candida infection can be fungistatic
or fungicidal
4 Econazole Available as solution (Econazole nitrate) and as cream (1)
Broad spectrum ndash more effective for Aspergillus Also active against some
gram-positive bacteria (Staphylococci and Streptococci and Dermatophytes)
5 Miconazole Highly effective against dermatophytes and candida infections
used as a 21 cream applied once or twice a day for 10 days
6 Gentian violet 21 Available as drops (recently some evidence of
carcinogenicity) Discolors the ear canal and this interfere with clinical
examination
Other topical antifungal agents are ketoconazole Natamycin Tolciclat Bifonas
zole Fenticonzole Oxiconazole Tioconazole ciclopiroxolomine Tolnafate
Haloprogin Flucytosine Acetic acid Whit field ointment selenium sulfide
undcyclenic acid triacetin etc
Page | 61
Minimal length of treatment
A month of drug treatment is usually required because the antifungal agents
used are not sporicidal and it is necessary that the period of treatment covers
germination time It may be advisable to give short gaps in the period of
treatment to ensure all spores have germinated before deciding to terminate
therapy
Prevention
Accomplished by strict attention to the predisposing causes
1 Water should be prevented from entering the ear
2 Avoidance of external ear trauma
3 Use of alcohol medicated or plain in the ears after swimming mercuric
cyanide (15000) in ethyl alcohol (70) is a satisfactory liquid to use
Ear stoppers do no good unless their use is followed by some antiseptic in the
canal Divers exposed to water for long periods of time may also use acidic
alcohol
4 During Summer months with their high humidity special efforts are needed
to maintain ear dry 5 Indiscriminate use of topical antibiotics steroid
preparations should be avoided
Page | 62
DRUG REVIEW
1 GUGGULA
Fig11 - Guggula
Historical review of Guggula [93]
bull Atharvaveda one of the well-known Vedas of Hindus The earliest
reference given by Atharvaveda medicinal and therapeutic properties of
Guggula Guggula has long history of use in Ayurveda
bull Acharya Charaka Sushruta and Vagbhata describe detail regarding the
actions uses and indication as well as the variety of Guggula
Page | 63
bull Various Nighantus (Medical lexicons) were written between 12th and 14th
centuries AD was based on the Ayurvedic literature also describes
Guggula
bull The explanation of word Guggula is that Gunjo Vyadhegurdti Rakshati
which means to relief against different diseases
bull Guggula is the best medicine because it develops through the rays of
hot sun on specific circumstances
bull Guggula has an aromatic odor
गगलो कणवदौगवररधय िपन शरटठमछयत[94]
स उ २२११२
Latin name- Commiphora mukul
Family ndash Burseraceae
Rasa- Tikta Katu
Guna ndash Laghu Rukshasukshma vishada sara
Veerya ndash Ushna
Vipaka ndash Katu
Action- Rasayana Lekhana
Doshaghanta - Tridoshhara
Page | 64
Chemical composition [95]
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Oleoresin-Z-Guggulsterone E-Guggulsterone
Gum- guggulignans 1 and 2 guggula Tetrols mukulol allylcembrol c
27
Guggulusterol 1 2 ans 3 Z and E ndash guggulusterol
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Parts Used ndash Gum oleoresin
Guggula purity test
1 Yellowish brown emulsion is obtained when Guggula is triturated with
water
2 An ethereal solution of the drug attains reddish colour when treated
with br2 vapors and purple colour when moistened with nitric acid
Biochemical action ndash Antiseptic Anti-inflammatory Disinfectant Diuretic
Immunostimulant stimulating expectorant Ant suppurative Antipyretic
Enhance phagocytosis
Karma- Rasayana cardiovascular disease
Page | 65
2 AGARU-
Fig 12 Agaru
Historical review of Agaru [96]
bull The word Agaru literally means the one which is the heaviest and no
aromatic wood is heavier than it Since thousands of years Agaru lsquoThe
wood of Godrsquo has been used for multiple purpose like commercial
medicinal spiritual aromatic historical
bull The medicinal use of Agaru have been recorded in many pieces of India
Greek Roman Chinese Middle eastern and European since ancient times
bull Acharya Charaka used Agaru and pest of Rasna to counteract the effect of
cold in Agraya Dravyas
bull Acharya Sushruta used Agaru as a Dhoopana Dravya along with Guggula
Ral and Shoma in the treatment of Karnasweda and Vrana
Page | 66
Types-
bull Dhanwantsri Nighantu describes Kaleyaka as a type of Agaru
bull Sodhala Nighantu describes three types of Agaru ndash Agaru Krishna
Agaru Kakatunda Agaru
bull Raj Nighantu describes five types of Agaru ndash Krishna Agaru Kasht
Agaru Daha Agaru Mangalya Agaru and Agurusaar
bull Arthashasstra describes three Agaru wood product
1 Jongaka ndash Black or variegated black in colour and having variegated
spots
2 Dongaka ndash Black in color
3 Parasamudraka- Black in colour and smells like Navamallika
अगर उटण कि तपछय ततकत ततकषण च वपततलम
लघ कणाविरोगघन शीत ात कफपरणत
िापर २१ [97]
Family- Thymelaccensis
Latin name- Aquilaria agallocha
Guna- Laghu Ruksha Tikshan
Rasa- Katu Tikta
Vipaka ndash Katu
Virya ndash Ushna
Karma- Sheetaprasasmana Vranaorasadan Tvachya Pittavardhaka
Shirovirechana Mangalya Sugandhik and Rochaka in properties [100]
Krishna Agaru karma- Katu Tikta rasa Ushna Sheeta when applied externally
and Pittahara when taken orally
Page | 67
Chemical Constituents -
Agaru hardwood is rich in essential oil resins alkaloids saponins Steroids
terpenoids tannins flavonoids and phenolic compound Agaru wood
predominantly contains 2-[-2-phenylethy]-4H-chromen-4-one derivatives and
sesquiterpenes Agaru oil contains selinene dihydroselinene agarnol b-
agarofuran vetispira-2(11)valerianol dihydrokaranone and tetradecanoic
acids[99]
Part Used ndash
Heartwood- Dark resinous wood which is formed when the plant becomes
infected with a type of fungus (ascomycetous mold) Species of Aspergillus
fusarium and penicillium are reported to be associated with the development
of infection Prior to infection the heartwood is odorless relatively light and
pale colored however as the infection progresses the tree produces a dark
aromatic resin in the heartwood The infected resin in response to the attack
which results in accumulation of a very dense dark resin in the heartwood
The infected resin embedded wood is known as Agarwood Infection is more
common on the trunk roots and the area when branches divide The formation
of Agarwood starts when the tree attains the age of 20 years On an average
approximately 30 ml oil is extracted from 100 kg of infected Agarwood[98]
Qualities of best Agaru-
It should be black in color
It should be extremely heavy and aromatic
It should be oily in appearance and test
It should be sink in water
It should burn easily with bright flame with a bright flame giving off a pleasant
smell
Page | 68
3 MADANA
Fig 13 MADANA
Madana consist of dried fruit of Xeromphis spinosa It is a deciduous thorny
shrub or a small tree reaching a high up to 9 m and girth about a meter
branches numerous thick and horizontal found in sub-Himalayan tracts[101]
मदनो मिरनदसततकतो ीयोटणो लखनो लघ
ानदरतिदवििीहर परततशयायवरणारतक
रि कटठकफ़ानाहशोथगलमवरणापह[102]
िा पर १६० १६1
Page | 69
Latin name-Randia dumetorum
Familly ndash Rubiaceae
Rasa - Madhura Tikta
Guna-Laghu Ruksha
Virya- Ushna
Vipaka ndash Katu
Karma- Vamana and Lekhana
Chemical Composition-
Essential Oil Valerianic acid Saponin tannin resin [103]
Page | 70
YAWA [104]
Fig 14 Yawa
1 In Samhitakala Aacharya Charaka Acharya Sushruta explain detail about
medicinal properties of Yawa
2The use of Yawa in Aaharya Dravya mainly described by Dhanwantari
Nighantu Raj Nighantu Bhavprakash Nighantu[105]
Macroscopic Description-
Fruit a caryopsis elliptical oblong Ovoid and tapering at both ends smooth
about 1cm long and 02- 03cm wide dorsally compressed and flattened on
the sides with a shallow longitudinal furrow 3-5 ridges having shallow
depression between them grains tightly enclosed and adhering the lemma
and palea pale greenish yellow odor not distinct taste sweetish acrid
Page | 71
Latin Name ndash Hordenum vulgare
Family- Poaceae
Rasa- Kashaya Madhura
Virya- Sita
Vipaka- Katu
Karma- Vatakrt Pittahara Kaphahara Medahara Balya Visrya
SthairyakaraLekhana
Page | 72
PROCEDURE REVIEW [105]
In Ayurvedic classics there are many references regarding Dhoopana Dravya
Dhoopana is administering Dhuma with the help of Dhoopana Dravya
In Kashyapa Samhita there are 40 types of Dhoopana advised for children
Anesthesia (Mohajananam Dhoopa) is also mentioned For this Dhoopana the
drug used were herbs hairs of animals legs horns old cloths of Buddhist
monks
From the references available regarding Dhoopana we can understand that
Karna can be protected from maggots (krimi) Bactria (Rakshogna) lice etc
References clearly indicate the analgesic and disinfectant effect of Dhoopana
Karma Dhoopana is mentioned for Dushta Vrana Chikitsa It reduces Vedana
Srava Pootigandha of Dushtavrana It also helps in Vranaropana
Dushtavrana Chikitsa is mentioned in the treatment of Karnasrava[106]
Origin of Dhoopana-
In ancient period children of sages were constantly harassed by the
Rakshasas Hence the sages approached lord Agni for shelter Agni in turn
gave them Dhoopana Dravya and asked sages to use the Dhoopana for
protection against Rakshasas bhutas pishachas
Classification of Dhoopana
1 It is classified into Dhupa Anudhupa Pratidhupa
2 On the basis of Origin it is classified into Jangama and Sthavara
Selection of Guggula for Dhoopana
Page | 73
bull Guggul is a best Vatahara
bull It is Krimighana
bull It contains Oleoresin
bull In Ashtang Hrudaya Guggula Dhoopana mentioned for Karnasrava
Selection of Agaru for Dhoopana
bull Agaru is Laghu Ruksha Katu Tikshna
bull Vranaorasadan Tvachya
bull It should burn easily with bright flame with a bright flame giving off a
pleasant smell
Karna Dhoopana Indication
1 Karnaarava
2 Putikarna
3 Krimikarna
4Vataj Karnashula
Contraindications
Especially for Karnadhoopan contraindication is not mentioned in classic texts
But Dhoopana is contraindicated in Pittaj vaydhi Sharad and Grishma Rutu
Page | 74
MATERIAL AND METHOD
Page | 75
For randomize comparative clinical trial to study the effect of Agaruwadi
Karnadhoopana and Guggula Karnadhoopana in Karnasrava following material
and method were required
Source of data
Patient irrespective of gender occupation religion social economic status
signs and symptoms of classical features of Karnasrava (Otomycosis) selected
from the OPD of Shalakyatantra department
Materials ndash
1Patients
2 Drugs-Agaruwadi Dhoopana
Guggula Dhoopana
3Torch
4Otoscope
5 Tuning fork
6Jobson horn probe
7Cotton
8Case record form
DRUG
Group A Trial Group
1Churana of Agaru Yawa Madan
2Ghrita
3Jala
Group B Control Group
1Googula Churna
Page | 76
Properties of Drug
Table no 1 Properties of Drug
Drug
Family
Rasa Veerya Vipaka Effect
on
Dosha
Guna Karma
Agaru
(Aquilegria
Agallocha)
Thymelaca
ceae
Katu
Tikta
Ushna Katu KV Laghu
Ruksha
Tikshna
Shitaprashamana
Shothahara
Vedanasthapak
Durghandhihara
Madan
(Randia
spinosa)
Rubiaceace
Kashaya
Madhur
Tikat
Katu
Ushna Katu KV Ruksha
Laghu
Vatakaphaghana
Shothahara
Vedanasthapak
Vranashodhak
Yawa
Poaceae
Hordeum
Vulgare
Kashaya
Madhur
Sheeta Madhur KP Ruksha
Laghu
Vataghana
Vernashodhana
Raktshodhaka
Guggula
Commiphora
Mukul
Burseracea
e
Tikta
Kashaya
Anushna Katu VPK Laghu
Ruksha
Shothahara
Vedanasthapaka
Kandughna
Ghrita Madhura Sheet Madhur VK Snigdha Vataghana
Shothahara
Vedanasthapaka
Page | 77
METHODOLOGY
SELECTION CRITERIA
1)INCLUSION CRITERIA
1 Patients having signs and symptoms of Karnasrava (Otomycosis) ie करणशल
( pain ) करणकणड ( Itching ) करणसतराव ( Discharge )बाधिरण ( conductive Loss of
hearing )
2 Patient from age group 19 to 70 years
3 Any Gender
2)EXCLUSION CRITERIA
1 Patients suffering from any systemic disease like DM TB HTN
2 Chronic suppurative otitis media (CSOM)
3 Acute supportive otitis media (ASOM)
3 Perforation of Tympanic membrane
4 Chronic otitis media
3)WITHDRAWAL CRITERIA
1If patient develops any adverse effect such as irritation pain burning
sensation in ear loss of hearing and such patients was withdrawn from trial
and receive prompt appropriate medical attention
2If patient shows aggravation in symptoms
3If patient refuses to continue with the treatment
Page | 78
STUDY SETTING
Types of study - Randomized Clinical comparative Trial
Place of work - OPD of Shalakyatantra
Duration of study - 18 months
Study Population - Patients of Karnasrava in Shalakyatantra OPD
SAMPLE SIZE CALCULATION
Sampling Method ndash Purposive sampling followed by random allocation in two
groups
Sample size calculation-
n = z2 p (1-p)
d2
Were
n = sample size
P = prevalence of disease=10
z = standard normal variable ie 196
d = error ie005
desired Sample Size would be
n = Z2 P(1-P)d2
= (196)2x (0021) x(0979)(005)2
= 34
Visiting ENT OPD (ShalakyaTantra) and IPD (ShalakyaTantra) 21 = 34
n raquo34
So one group includes 34patients
Page | 79
Sampling Method
Total 68 patient of Karnasrava are selected by Purposive sampling followed by
random allocation in two groups Written informed consent is taken prior to
commencement of trial They are divided in 2 groups
Group A (Trial Group) 34 patients treated with Agaruwadi Dhoopana for 7
days
Dose 5 minutes twice in a day
Group B (Control Group) 34 patients treated with Guggula Dhoopana for 7
days
Dose 5 minutes twice in a day
STUDY DESIGN ndash
Open labeled Randomized Comparative Clinical trial
STUDY DESIGN
Screening of patient
Inclusion criteria satisfied Exclusion criteria
Initial assessment Excluded
Counseling of patient Treated accordingly
Patient selection by Simple Random Sampling Method
Page | 80
68 Patients were divided in two groups lsquoArsquo and lsquoBrsquo
Trial group A-34 patients were given
Agaruwadi Dhoopana
Control group B- 34 patients were
given Guggul Dhoopana
Informed written consent
Treatment was given for 7 days
Assessment on 1st 4th and 7th day
Post assessments follow up on 15th day
Observation
Data Collection
Statistical analysis of data
Conclusion
Page | 81
(A) Agaruwadi Varti for group A (Trial group)
Table no 2
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
B) Guggula Varti for group B (Control group)
SOP of it is same as above Agaruwadi Varti
Table no 3
Drug Guggula Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
FOLLOW UP
For both groups follow ups were done on 1st 4th and 7th and post
assessment follow up15th day
EXAMINATIONS
Torch for Local examination of ear
Otoscope examination
Tuning fork Test
Page | 82
OBSERVATION TABLE
Table no 4
Sr no Subjective criteria Day 1 Day 4 Day 7 Day 15
1 करणशल
(pain)
2 करणकणड
(Itching)
3 करणसतराव (Discharge )
4 बाधिरण (Conductive Deafness)
OBSERVATIONS
a) करणशल (Pain) -
0 - Absent
1 ndash Present
b) करणकणड (Itching) -
0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
Page | 83
c) करणसतराव (Discharge)
0- Absent
1- Mild -Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाधिरण (conductive Loss of hearing)
0 - Absent
1- Present
Observations were carried out before and after completion of treatment and
during each follow up After observations the data collected and presented in
the form of graphs charts and table
Page | 84
TRIAL DRUG
Authentication and standardization of raw drug material done After
authentication and standardizing of raw drug material Agaruwadi Varti was
prepared by Varti as explained in Ayurvedic classics
Method of Varti preparations
Panchavidh Kashaya Kalpana that is five method of pharmaceutical
preparation constitutes the fundamental process of Ayurvedic pharmaceutics
which is well explained in Sushrut Samhita Varti Kalpana is one among them
which can be included in Kalka Kalpana
तीररसतरपतपतीनामपरककव तीत [106]
स डलहण शरच 151
Medicines are powered triturated and given the Varti shape that is like wick
of lamp so it is called as Varti Kalpana
Drug content Agaru Madan Yawa
Route of Administration Local
Dose Two times a day
Duration 7 days
Page | 85
Methodology
Standard operating procedure (SOP) of Agaruwadi Varti
Agaruwadi Varti is prepared according to the classical text
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization was done as recommended in pharmacy procedure The
raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 mixed together in
equal quantity to make Agaruwadi churn
Quantity of each churn is 4 grams all are mixed when the Varti get dry total
weight of Varti was 10gram
STEP 4 - Agaruwadi churn triturated with appropriate quantity of water or
Ghrita and prepared Varti in GMP Certified Ayurvedic pharmacy Standard
aseptic precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Varti was packed in sterile air packed container
STEP 6 - Agaruwadi Dhoopana was given with the help of Dhoopana yantra
Authentication and Standardization of raw drug of Agaruwadi Varti was done
Sterilization was done as recommended in pharmacy procedure Sterile
preparation packed in sterile container of suitable size Under all aseptic
precaution Karnadhoopana given to infected ear
Page | 86
Containers for packaging and their sterilization-
Sterilization of the containers for storing Varties was done by Ethylene Oxide
(Eto) method
Ethylene Oxide (Eto) procedure-
It includes exposure of materials to ethylene oxide gas under vacuum in a
sealed chamber It consists of four primary variables
1Gas Concentration
2Humidity
3Temperature
4 Time
EtO gas is an alkylating agent which disturbs the DNA of microorganism
preventing them from reproducing It penetrates the breathable packaging
and sterilizes all the accessible surface of the product to render products
sterility by alkylation of essentials proteins for cell reproduction
Most Eto sterilization methods involves three different stages These can be
separated into three different on the size or number of devices to treat
1Preconditioning stage-
First products are passed through a preconditioning phase to make
microorganism grow The batch load goes through a well time under a
controlled environment of temperature and humidity
2Sterilizer stage-
Performed using process phase specially designed to provide the required level
of EtO exposure to assure sterility for a device or family of devices
3Degasser Aerration stage-
Finally products need to go through a degassing phase to remove any residual
particles of Eto The batch load goes over well time under a temperature-
controlled environment
The sterile containers were then used to store Agaruwadi Varti and handed to
patients included in the study
Page | 87
Packing of Agaruwadi Varti
The ETO sterilize plastic container were used for packing of Agaruwadi Varti
Varti was filled into these sterilize containers (7 in each) In an aseptic
environment plugging and capping was done under aseptic precautions In this
way packing of Agaruwadi Varti done These Varti were given to patient and
advise to take two times a day under all hygienic precautions
History and Examination
bull Proper history and presenting complains was recorded on case record form
bull Ear examination with otoscope was done during initial assessment and each
follow up
bull Otoscopic examination was done during initial assessment and each follow
up
bull Systemic Examination that is Blood Pressure Temperature Respiration
rate Pulse was recorded on case record form
Page | 88
Raw material
Fig14 यव चरण Fig15 मदनफळ चरण
Fig16 अगर चरण Fig17 गगगळ चरण
Page | 89
Preparation of Agaruwadi Varti
Fig18 Preparation of Agaruwadi Varti
Fig19 अगरवादी वरती
Page | 90
Fig20 Instruments used for examination of Karnasrava
Fig19 Karnadhoopana Yantra
Page | 91
Karnadhoopana Procedure
Fig 22 Karnadhoopana Procedure
Page | 92
OBSERVATIONS AND RESULTS
Page | 93
BASED ON DRUGS
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 94
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
AUTHENTICATION CERTIFICATE
Page | 95
BASED ON STASTICIAL ANALYSIS OF DEMOGRAPHIC DATA
68 patients of Karnasrava ndash Otomycosis
Table no 5
No of Patients Total
Group A Group B
Registered 38 37 75
Completed 34 34 68
Discontinue 04 03 07
Total 68 patients were enrolled in study 38 patients registered in group A
amongst them 34 patients completed the treatment and04 patients
discontinued the treatment However in group B 37 patients completed the
treatment and 03 patients discontinued the treatment out of 37 registered
patients
Hence the total number of patients registered in the present study was 75
and out of which 68 patients were discontinued the treatment So they
dropped out from the study While 68 patients were successfully completed
the treatment So observations and result of 68 patients were given below
Here we are going to discuss the statistical analysis of the data obtained in
the form of master chart that was prepared in accordance with the data
collected from the patients that had been included in the study The purpose
of statistical analysis was to analyzed the relation between age gender
occupation diet addiction and education
Page | 96
1 Age wise distribution of patients
Table no 6
In trial group 10 (29412) patients were from age group 18-25 years 14
(41176) patients were from age group 25-35 years 8 (23529) patients
were from age group 35-45 years and 2 (58824) patients were from age
group 45-60 yearsIn control group 6 (17647) patients were from age group
18-25 years 14 (41176) patients were from age group 25-35 years 7
(20588) patients were from age group 35-45 years and 7 (20588)
patients were from age group 45-60 years
Fig 23 Age wise distribution of patients
0
2
4
6
8
10
12
14
15 -25 25-35 35-45 45-60
10
14
8
2
6
14
7 7
Age Distribution
Trial Group N Control Group N
Age Distribution
Trial Group Control Group
N N
18 -25 10 29412 6 17647
25-35 14 41176 14 41176
35-45 8 23529 7 20588
45-60 2 58824 7 20588
Total 34 100 34 100
Page | 97
1 Gender wise distribution of patients
Table no 7
Sex
Trial Group Control Group
N N
Female 23 67647 15 44118
Male 11 32353 19 55882
Total 34 100 34 100
In trial group 23 (67647) patients were female and 11 (32353) patients
were male
In Control group 15 (44118) patients were female and 19 (55882)
patients were male
Fig 24 Gender wise distribution of patients
0
5
10
15
20
25
N N
TRIAL GROUP CONTROL GROUP
23
15
11
19
Gender
Female Male
Page | 98
2 Education wise distribution of patients
Table no 8
Education
Trial Group Control Group
N N
Illiterate 4 11765 3 88235
SSC 4 11765 3 88235
HSC 8 23529 9 26471
Graduation 16 47059 10 29412
Primary 1 29412 3 88235
Post-Graduation 1 29412 6 17647
Total 34 100 34 100
In trial group 4 (11765) patients were illiterate 4 (11765) patients were
SSC educated 8 (23529) patients were HSC educated 16 (47059)
patients were graduated 1 (29412) patients were primary educated and
1(29412) patients were post graduated
In control grou 3 (88235) patients were illiterate 3 (88235) patients
were SSC educated 9 (26471) patients were HSC educated 10 (29412)
patients were graduated 3 (88235) patients were primary educated and
6 (17647) patients were post graduated
Page | 99
Fig 25 Education wise distribution of patients
0
2
4
6
8
10
12
14
16
ILLITERATE SSC HSC GRADUATION PRIMARY POST GRADUATION
4 4
8
16
1 1
3 3
910
3
6
Education
Trial Group N Control Group N
Page | 100
3 Occupation wise distribution of patients
Table no 9
Occupation
Trial Group Control Group
N N
Accountant 1 294 2 588
Housewife 11 3235 8 2353
Engineer 1 294 1 294
Job 1 294 4 1176
Labor 1 294 3 882
Mess 1 294 0 000
Naturotherapyst 1 294 0 000
Pharma 1 294 0 000
Shopkeeper 4 1176 2 588
Singer 1 294 0 000
Student 8 2353 4 1176
Tailor 1 294 1 294
Teacher 1 294 1 294
Worker 1 294 3 882
Farmer 0 000 1 294
Lab Tech 0 000 1 294
Page | 101
Daily Collection 0 000 1 294
Fruit seller 0 000 1 294
Bus Driver 0 000 1 294
Total 34 10000 34 10000
In trial group 11 (3235 ) were housewife 8(2353) were students
4(1176) were shopkeeper 1(294) was accountant 1(294) was
engineer 1(294) was doing job 1(294)was labour 1(294) was
catering 1(294) was Naturotherapyst 1(294) was Pharma 1(294)
was Singer 1(294) was Tailor 1(294) was Teacher and 1(294) was
worker
In Control group 8 (2353)were housewife 4(1176) were students
2(588) were shopkeeper 2(588) was accountant 1(294) was
engineer 4( 1176) was doing job 3(882)was labor 1(294) was
Farmer 1(294) was Lab tech 1(294) was Daily collection 1(294)
was Tailor 1(294) was Teacher and 3(882) was worker 1(294) was
Fruit seller and 1(294) Bus driver
Fig 26 Education wise distribution of patients
0
2
4
6
8
10
12
1
11
1 1 1 1 1 1
4
1
8
1 1 10 0 0 0 0
2
8
1
43
0 0 02
0
4
1 13
1 1 1 1 1
Occupation
Trial Group N Control Group N
Page | 102
4 Religion wise distribution of patients
Table no 10
Religion
Trial Group Control Group
N N
Hindu 31 9118 33 9706
Muslim 3 882 1 294
Total 34 10000 34 10000
In trial group 31 (9118) patients were Hindu and 3 (882) patients were
Muslim
In control group 33 (9706) patients were Hindu and 1 (294) patient
were Muslim
Fig 27 Religion wise distribution of patients
0
5
10
15
20
25
30
35
N N
TRIAL GROUP CONTROL GROUP
3133
31
Religion
Hindu Muslim
Page | 103
5 Diet wise distribution of patients
Table no 11
Diet
Trial Group Control Group
N N
Veg 14 4118 20 5882
Non-Veg 20 5882 14 4118
Total 34 10000 34 10000
In trial group 14 (4118) patients were vegetarian and 20 (5882)
patients were Non vegetarian
In control group 20 (5882) patients were vegetarian and 14 (4118)
patients were Non-Veg
Fig 28 Diet wise distribution of patients
0
5
10
15
20
N N
TRIAL GROUP CONTROL GROUP
14
2020
14
Diet
Veg Non Veg
Page | 104
6 Addiction wise distribution of patients
Table no 12
Addiction
Trial Group Control Group
N N
None 30 8824 27 7941
Alcohol 2 588 0 000
Tobacco 1 294 2 588
Mishri 0 000 1 294
Smoking 1 294 4 1176
Total 34 10000 34 10000
In trial group 30 (8824) patients have no addiction 2 (588) patients
have addiction of alcohol 1 (294) patients have addiction of Tobacco 0
(0) patients have addiction of Mishri and 1 (294) patients have addiction
of smoking
In control group 27 (7941) patients have no addiction 0 (0) patients
have addiction of alcohol 2 (588) patients have addiction of Tobacco 1
(294) patients have addiction of Mishri and 11 (1176) patients have
addiction of smoking
Page | 105
Fig 29 Addiction wise distribution of patients
0
5
10
15
20
25
30
NONE ALCOHOL TOBACCO MISHRI SMOKING
30
21
01
27
0
21
4
Addiction
Trial Group N Control Group N
Page | 106
Statistical Analysis and Results
Effect of study on Karnashoola-
Table no 13
Karnashoola
Group A Group B
BT AT BT AT
N N N N
Grade 2 0 000 0 000 0 000 0 000
Grade 1 30 10000 7 2333 32 10667 5 1667
Grade 0 4 1333 27 9000 2 667 29 9667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 30 Effect of study on Karnashoola
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
30
7
32
54
27
2
29
Karnashoola
Grade 2 Grade 1 Grade 0
Page | 107
Table no 14
Karnashoola Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 088 100 033 006
969 2829E-
08 7667 HS
AT 021 000 041 007
Group
B
BT 094 100 024 004
1037 7103E-
11 8438 HS
AT 015 000 036 007
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 31
000010020030040050060070080090100
BT AT BT AT
GROUP A GROUP B
088
021
094
015
Karnashoola
Mean
Page | 108
Table no 15
Karnashoola
Mean SD Effect
Group
A
Group
B Trial Control Trial Control
Day 1 088 094 033 024 000 000
Day 3 065 071 049 046 2667 2500
Day 5 024 038 043 049 7333 5938
Day 14 021 015 041 036 7667 8438
000
010
020
030
040
050
060
070
080
090
100
Day 1 Day 3 Day 5 Day 14
Karnashoola
Mean Group A Mean Group B
Page | 109
Table no 16
Karnashoola N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3250 110500
510000 275 Control group 34 3650 124100
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 110
Effect of study on Karnakandu
Table no 17
Karnakandu
Group A Group B
BT AT BT AT
N N N N
Grade 3 7 2333 0 000 4 1333 0 000
Grade 2 18 6000 0 000 18 6000 0 000
Grade 1 7 2333 7 2333 10 3333 15 5000
Grade 0 2 667 27 9000 2 667 19 6333
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 32 Effect of study on Karnakandu
0
5
10
15
20
25
30
N N N N
BT AT BT AT
GROUP A GROUP B
7
0
4
0
18
0
18
0
7 7
10
15
2
27
2
19
karnakandu
Grade 3 Grade 2 Grade 1 Grade 0
Page | 111
Table no 18
Karnakandu Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 188 200 081 015
1091 3119E-
10 8906 HS
AT 021 000 041 007
Group
B
BT 171 200 076 014
1032 4746E-
09 7414 HS
AT 044 000 050 009
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Page | 112
Fig 33
Table no 19
Karnakandu
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 188 171 081 076 000 000
Day 3 126 118 057 058 3281 3103
Day 5 071 074 046 051 6250 5690
Day 14 021 044 041 050 8906 7414
000
020
040
060
080
100
120
140
160
180
200
BT AT BT AT
GROUP A GROUP B
188
021
171
044
Karnakandu
Mean
Page | 113
Table no 20
Karnakandu N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 4051 137750
373500 006 Control group 34 2849 96850
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is less than
005 Hence we conclude that there is significant difference between Trial
Group and Control Group
000
020
040
060
080
100
120
140
160
180
200
Day 1 Day 3 Day 5 Day 14
Karnakandu
Mean Group A Mean Group B
Page | 114
Effect of study on Karnasrava
Table no 21
Karnasrava
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 11 3667 0 000 8 2667 0 000
Grade 1 23 7667 3 1000 26 8667 2 667
Grade 0 0 000 31 10333 0 000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 34
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
11
0
8
0
23
3
26
20
31
0
32
Karnasrava
Grade 3 Grade 2 Grade 1 Grade 0
Page | 115
Table no 22
Karnasrava Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 132 100 047 009
1122 4356E-
13 9333 HS
AT 009 000 029 005
Group
B
BT 124 100 043 008
1130 9364E-
14 9524 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 35
000
020
040
060
080
100
120
140
BT AT BT AT
GROUP A GROUP B
132
009
124
006
Karnasrava
Mean
Page | 116
Table no 23
Karnasrava
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 132 124 047 043 000 000
Day 3 100 100 025 025 2444 1905
Day 5 047 038 051 049 6444 6905
Day 14 009 006 029 024 9333 9524
000
020
040
060
080
100
120
140
Day 1 Day 3 Day 5 Day 14
Karnasrava
Mean Group A Mean Group B
Page | 117
Table no 24
Karnasrava N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3535 120200
549000 655 Control
group 34 3365 114400
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 118
Effect of study on Karnabadhirya
Table no 25
Karn
Badhirya
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 0 000 0 000 0 000 0 000
Grade 1 13 4333 0 000 16 5333 2 667
Grade 0 21 7000 34 11333 18 6000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 36
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 00 0 0 0
13
0
16
2
21
34
18
32
Karnabadhirya
Grade 3 Grade 2 Grade 1 Grade 0
Page | 119
Table no 26
Karn
Badhirya Mean Median SD SE
Wilcoxon
W P-Value
Effect Result
Group
A
BT 038 000 049 009
799 7173E-
05 10000 HS
AT 000 000 000 000
Group
B
BT 047 000 051 009
816 0000138 8750 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 38
000
005
010
015
020
025
030
035
040
045
050
BT AT BT AT
GROUP A GROUP B
038
000
047
006
Karnbadhirya
Mean
Page | 120
Table no 27
Karn
Badhirya
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 038 047 049 051 000 000
Day 3 009 006 029 024 7692 8750
Day 5 003 006 017 024 9231 8750
Day 14 000 006 000 024 10000 8750
000
005
010
015
020
025
030
035
040
045
050
Day 1 Day 3 Day 5 Day 14
Karn Badhirya
Mean Group A Mean Group B
Page | 121
Table no 28
Karn
Badhirya N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3400 115600
561000 806 Control
group 34 3500 119000
Total 68
Page | 122
COMPARISION BETWEEN GROUP A AND GROUP B
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Table no 29
Overall Effect
Trial Group Control Group
N N
Marked Improvement 21 6176 16 4706
Moderate Improvement 8 2353 13 3824
Mild Improvement 4 1176 5 1471
No Change 1 2941 0 0
TOTAL 34 100 34 100
Fig 39
0
5
10
15
20
25
MARKED IMPROVEMENT
MODERATE IMPROVEMENT
MILD IMPROVEMENT NO CHANGE
21
8
41
1613
5
0
Overall Effect
Trial Group N Control Group N
Page | 123
DISCUSSION
Page | 124
Discussion is nothing but the logical reasoning of observations In
every research work discussion part is very important because it brings into
light about the logical analysis which are helpful in filling the research gap in
the scientific world
The discussion is categorized into following ways for the ease of
understanding
1 Discussion on selection of topic
2 Discussion on review of literature
3 Discussion on drugs their mode of action on the disease mode of action
of Karnadhoopana
4 Discussion on observation and results
1 Discussion on selection of topic
Otomycosis is commonly encountered in day-to-day practice Majority
of Indian people affected with this pathology This disease commonly
manifests in developing countries low socio-economic standard and lack
of hygiene Now a days due to busy lifestyle people are not able to follow
the proper instruction of care of ear which may be responsible for the
recurrent nature of disease So for the management of this we use
Karnadhoopana with the help of Agaruwadi Varti Dhoopana is simple
easy cost-effective procedure which can be done even at OPD levelso
for the disease Karnasrava we selected Karna Dhoopana as therapeutic
procedure Karnadhoopana was done with Agaruwadi Varti and Guggula
Varti which was very effective for treatment
Page | 125
2 Discussion on review of literature
Karnasrava is one such disease among 28 Karnarogas mentioned by
Acharya Sushruta in the chapter named Karna Roga Vigyana Acharya
Charaka included Karnasrava as symptom under the four types of
Karnarogas due to vitiation of different doshas Acharya Vagbhata has
not described Karnasrava separately It is a fact that systemic
description of Karnarogas is available in all the ancients of pus from a
Vata afflicted ear may results from head injury or immersion in water
Karnasrava is a clinical entity which can be correlated with Otomycosis
Karnasrava is explained as symptom as well as a disease in Ayurveda
Nidana- Karnasrava occur due to Samanya Nidana and Vishesh Nidana
Vishesh Nidana like Shirobhighata Nimmajato jale Mithyayoga of Shashtra
The exact pathology behind Karnasrava is not understood clearly
Purvarupa ndash No specific Purvarupa are found for Karnasrava in classical
literature Acharya Madhukara describe Purvarupa as expression of
Rupa(lakshana) with less intensity that is less intensity itching sound in ear
may considered as Purvarupa of Lakshana
Samprapti- Aacharya Sushruta not explained the Samprapti of Karnasrava
separately and we must consider the general Samprapti of Karnaroga Due to
various aetiologias as cited above ear afflicted by Vata dosha causes Twak
Rakta Mamsa dushti results in Karnasrava According to Acharya Sushruta
Vata-Kapha dose is dominance in Karnasrava
Page | 126
Nidan
Nija Agantuja
Vata ndash kapha prakopak nidana Shirobhighata Nimmajato-jale
Mithya yoga of Shastra
Vata- kapha Prakopaka(Chaya prakopak) Vata-kapha prakopaka
( Achay prakopak)
Twak Rakta Mamsa dushti
Karnasrava
Page | 127
Chikitsa
The curative aspect and this must be done simultaneously giving due
importance to Nidan Parivarjana that is preventive measures So Nidan
Parivarjana that is avoidance of causative factors like Jalkrida Mithyayogen
shashtrasya Karnakandu Shirasnan Pratishaya is the first step in combating
the disease and form the part of line of treatment
Above Samprapti helps us to proceed towards the treatment of Karnasrava
The main protocol of treatment is removal of fungus and wound management
which include various measures to keep area day clean clear of microbes and
providing ideal condition for healing
Samany Chikitsa- Acharya Sushruta described general treatment for
Karnaroga as Snehapana (Drinking ghee) Rasayana (Rejuvenation therapy)
Bhramacharya Avoid excessive speaking Avoidance of physical exercise and
head bath
Vishesha Chikitsa ndash Acharya Sushruta mentioned some procedures in the
treatment of Karnasrava which is Shirovirechana Karnadhoopana
Karnapurana Karanpramarjana Dhavan Avachurnana Karnapurana Above
various procedures described in Ayurveda for management of fungus growth
in ear discharging ear fulfill these requirements of wound management
Page | 128
Discussion on observation and Result
Out of 68 patients 34 patients included for the trial The incidence of
Karnasrava is observed in trial and control groups
The statistical analysis provided the following data
AGE
Trial group- Maximum no of patients that is 14 (41176) patients were from
age group 25-35 years followed by 29412 patients were from age group
18-25 years 23529patients were from age group 35-45 years and
58824 patients were from age group 45-60 years
Control group - Maximum no of patients that is 14 (41176) patients were
from age group 25-35 years followed by 20588 patients were from age
group 35-45 years and 20588 patients were from age group 45-60 years
17647 patients were from age group 15-25 years
The maximum no of cases of Karnasrava found in age group between 25 to
35 years The reason behind this is repeated use of ear bud or emersed water
in ear More use of earphone or working more in cold environment
GENDER
Trial group ndash A higher prevalence seen in females 6764 and 3235 in
males
Control group - A higher prevalence seen in males 5588 and 4411 in
females
Females and males both are prone to disease
Page | 129
EDUCATION
Trial group-It is observed that amongst 34 patients maximum ie16
(47059) patients were graduated 8 (23529) patients were HSC
educated 4 (11765) patients were SSC educated 4 (11765) patients
were illiterate 1 (29412) patient were primary educated and 1(29412)
patient were post graduated
Control group- It is observed that 10 (29412) patients were graduated 9
(26471) patients were HSC educated 6 (17647) patients were post
graduated 3 (88235) patients were SSC educated 3 (88235) patients
were primary educated3 (88235) patients were illiterate
There is no direct relation between education and Otomycosis
RELIGION
Trial group- The incidence of patients of Hindu religion are 9118 and Muslim
religion are 882
Control group- The incidence of patients of Hindu religion are 9706 and
Muslim religion are 294
There is no probable explanation for this maximum number of patients in
Hindu religion it depends upon the patients attend the hospital and
community residing there
Page | 130
DIET
Trial group It was found that maximum ie5882 patients were taking
mixed diet while 4118 were taking vegetarian diet
Control group It was found that maximum ie5882 were taking
vegetarian diet while 4118 patients were taking mixed diet
The dietary habit of person is based on choice availability and religious
customs of the person
ADDICTION-
Trial group- It was found that maximum ie 30 (8824) patients have no
addiction 2 (588) patients have addiction of alcohol 1 (294) patients
have addiction of Tobacco 1 (294) patients have addiction of smoking and
0 (0) patients have addiction of Mishri
Control group - It was found that maximum ie 27 (7941) patients have
no addiction 4(1176) patients have addiction of smoking 2 (588)
patients have addiction of Tobacco 1 (294) patients have addiction of
Mishri and 0 (0) patients have addiction of alcohol
Very few patients were addicted to Alcohol Smoking Tobacco and Mishri
These factors can be taken as provoking factors for Otomycosis
Page | 131
Discussion based on probable Mode of action of Karnadhoopana
In Ayurveda classics Karna Dhoopana is therapeutic procedure explain for
Karnasrava Dhoopana is administration of Dhooma (Fumes) with the help of
Dhoopan Dravya References indicates that analgesic and disinfectant effect
of Dhoopana karma and mention for Dushta Vrana Chikitsa It reduces
Vedana Srava amp also does Vrana Ropana action
Various Dhoopanas and Dhoopan Dravas for different element in various
Samhitas of Ayurveda but there is a lacuna of availability of reference
regarding how to do it and method of procedure Matra Kala Contraindication
etc
Currently simple modified way of Karnadhoopana according to Yukti Praman
and experience but there is lac of standardization
Karnadhoopana is one among the topical Bahiparimajan type of treatment
Karna Parmarjana is procedure of cleaning ear with the help of cotton or gauze
piece soaked in honey
Page | 132
Dhoopan
The fumes coming out on burning Agaruwadi Varti
Administrated directly into external ear canal
Causes vasodilation
Due to this increase blood supply in external ear canal
It helps in absorption of drug
Fumes dries up Srava and bring the analgesic effect
Karnagata Kapha amp Avrut Vata Dosha Shaman
Decrease in signs and symptoms like karnasrava Karnshool Karnabadhirya amp
Karnandu
Page | 133
3 Discussion based on probable mode of action of Agaruwadi
Dhoopana
Agaru ndash
I Agaru is a fragrant tree aroma is a result of fungal pathogenesis when the
wood of tree is contaminated by fungi at wounds it develops scrap filled
with resin and turn out to be aroma Medicinal use of Agaru have been
recorded in ancient medicinal science in in inflammatory disease and some
infective disease
II Acharya Charaka has referred to Agaru as an Ushna dravya despite having
Tikta Rasa Ashtang Samgraha used Agaru as Dhupana Dravya along with
Madan and Yawa in Karnasrava Nighantu recommended is use as a
Dhoopana
III In various Samhitas and Nighantus Agaru described as Tikta Snighdha
Sheetaprashamana Vranaprasadana Tvachya Due to these properties
Agaru is used in the treatment of Karna-Akashi Roga and Dushta Vrana
Shodhaka
IV Agaru is reported to have Antimicrobial Analgesic Antioxidants
Antihistaminic and anxiolytic properties Its Antihistaminic property gives
relief from itching which is cardinal feature of Otomycosis Due to Katu
Ushna Tikta Guna improves blood circulation Bheda stage develop It is
Niram Awastha of Dosha Karnagata kapha and vata get decrease and
symptoms like karnashoolakarnasrava get decrease Agaru also have a
Antioxidant properties
V Chemically Agaru Contain 2-(2-Phenylethyl) Chromones Terpenoids
Flavonoids
VI Natural Agarwood had inhibitive activities towards Staphylococcus Aures
The chloroform extract of Agarwood prolongs the pain threshold[108]
Page | 134
Madan
I Madanphala have therapeutic properties like Anti-inflammatory
Antiallergic Analgesic and Wound healing
II It is Useful in treatment of disease like Shotha (inflammation) Vidradhi
(Abscess) Pratishaya (Common cold) Kushta(Skin disease)
III Extract of Madanphala mainly contain Glcosides Tritorpenct
Glycosides Saponin
IV Saponin glycosides are act as fire extinguisher This property is helpful
for vartiIt also act as a detergent which clean the surface of fungus
V Tritorpenct act as a anti-inflammatory antimicrobial and
immunomodulator compound Interaction of glycosides with sterol
causes disturbance of selective permeability in plasmic membraneso
exudates and discharge get decrease
VI Pharmacological activity [109]
Antibacterial Activity The preliminary antibacterial activity of Methanolic
extract of Randia D lam was done on some standard and wild pathogenic
strains The inhibition of the bacterial growth was more pronounced on E coli
as compared to the other tested organism This shows the antibacterial action
of Randia D secondary infection can prevent
Anti-Allergic Activity In Ayurveda Randia D Extract and its fraction of milk
induced leukocytosis and eosinophilia in mice
Anti-Inflammatory Activity The crude methanol extract of fruit of Randia D
effectively reduced the carrageenin induced oedema in hind paw of the rats
significant reduction in granular tissue formation was recorded This activity
seems to be significant at various acute phases of inflammation and om
formation of granular tissue This proves action of Madanaphala in shopa
(inflammation)
Page | 135
Analgesic Activity Analgesic activity was tested in mice weighing between 20-
250 with six number of animals in each group Methanlic extract of fruit Randia
d give analgesic activity in both models This proves its Shoolanashaka (pain
killer) action
Immunomodulatory Activity Randia D has immunostimulant activity and
chloroform fraction which strongly affected immune system seems to be
bioactive fraction of this plant
The overall effect of Agaru Mandanphala Yawa having Anti-inflammatory
Antiseptic Antimicrobial Property Active ingredient shows these properties
Agaru Yawa Madanphala
Vatakaphaghna
Act as
Vranashodhak
Vedanasthapaka
Sheetaprashamana
Shothara
Avarana of Vata get decrease so helps to Shaman of Vata dosha
Karnakandu Karnashoola Karnasrava
Prashamana
Page | 136
This fact can be taken into consideration and probably acknowledge that
Karnadhoopana with Agaruwadi Varti had not leave any residue in the ear
Removal of fibrin keratinocyte migration and in growth of epithelial tissue
plays a major role in healing It is technique of fumigation of ear with the
smoke of anti-infective drug In Karnadhoopana Sthanik Swedana increase the
blood supply and helps in absorption of the drug reduce Karnakandu amp
Karnshoola associated with infection
Page | 137
SUMMARY AND CONCLUSION
Page | 138
The dissertation entitled randomize comparative clinical trial to study the
effect of Agaruwadi Karnadhoopan and Guggula Karnadhoopan In Karnasrava
wsr to Otomycosis
The dissertation is divided into fallowing parts
Introduction
Review of literature
Ayurvedic review
Modern Review
Drug review
Procedure review
Material and Method
Observation and result
Discussion
Summary and conclusion
bull INTRODUCTION
It includes importance of Shalakyatantra in Sushrut Samhita Charka
Samhita And Ashtang Samgraha
Common and specific causes of Karnasrava
Karnasrava is a clinical entity which can be corelate with Otomycosis
In Ashtang Samgraha stated the procedure like Karnadhoopana with
Agaru Yawa Madanphala in Karnasrava
Page | 139
bull REVIEW OF LITERATURE
1 Ayurvedic review
2 Modern review
3 Drug review
Ayurvedic review-
It includes Rachana-Sharir and Kriya-Sharir of Karna detail description of
Karnaroga and its types Karnaroga Samanya hetu Poorvaroopa Rupa
Samprapti Upadrava Pathya-Apathya of Karnasrava Vishesh Nidan and
Chikitsa of Karnasrava Detail description of Karnadhoopana according to
various Acharays have been mentioned
Modern review-
It includes anatomy and physiology of Ear brief anatomy of ear anatomy of
External middle and Internal ear Detail description of the disease
Otomycosis mechanism of fungal infection in external canal pathophysiology
investigations diagnosis and management
Drug review-
Detail description of Agaru Yawa Madan Guggula and its synonyms
Ayurvedic properties Karma uses Pharmacological action and their
pharmacodynamic properties
Page | 140
MATERIAL AND METHOD
It includes description regarding materials required for the study Preparation
of Agaruwadi Varti its Standardization Sterilization and packaging
Plan of study
1 Total 68 patients completed the treatment Age criteria was kept
between 18-60 years Patient selection was done by done by simple
random sampling method and divided into two groups A (Trial) and
Group B (Control) 34 patients in each group
2 Patients in Group A were treated with Karnadhoopana with Agaruwadi
Varti for 7 days two times in a day while patients in Group B were treated
with Karnadhoopana with Guggula for 7 days two times in a day
3 Clinical examination done during each follow up ie 0th 4rd 7th and
observation were recorded
Page | 141
OBSERVATIONS AND RESULTS
Page | 142
1 It was observed that higher incidence of disease Karnasrava ie
Otomycosis found in age group 25-35 years
2 Disease otomycosis was equal in both male and female
3 The trial group there was significant relief in Karnakandu (8906)
Karnasrava(9333) Karnashoola(7667) and karnabadhirya(100)
4 In control group there was significant relief in Karnakandu (7414)
Karnasrava(9524) Karnashoola(8438) and
karnabadhirya(8750)
Page | 143
REFERANCES
Page | 144
1 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published byChaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 17 page no
5
2 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 19 page no
6
3 DRNarayan Vidwas Shero-Karna-Nasa and MukhrogaAnand publication
edition 4th 2014 Page no-52
4 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-205
page no 111
5 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 111
6 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Shlok no2012
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 112
8 Dr KBBhargavaDr SK BhargavaDr TMShahaA Short book of ENT
diseases Usha publication edition 10th
9 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 8 Page no -52
Page | 145
10 Research and Review Journal of Ayurvedic science yoga and
Naturopathy 2017 4(3) 1-5 pA Critical review of Otomycosis in cortex to
Karnaroga described in Ayurvedic classic by amisha patel D B Vaghala
Chandani goswami Vol4 no3 (2017)
11 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogpratished Adhaya Shlok no-213
page no127
12 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedh Adhaya Shlok no-
2140 page no 131
13 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyant shirasiya adhaya Shlok no 1712 page no-
258
14 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
15 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
16 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Aupadravik Adhaya Shlok no-15 page no
2
17 Vaidya Jaymini panday Harit Samhita hindi commentaryChaukhamba
vidhyabhartiVaranasiedition 2010 Shlok no- 13-14page no-10
18 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 146
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-20345
page no 112
19 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Karnarogavigyniyam Shlok
no 21 Page no-731
20 Charak
21 Pandit Harigovind Shashtri Namalinganusasana Amarkosha of
Amarsimha hindi commentary published by Chaukhamba Sanskrit
Sansthan page no- 463
22 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
23 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 37
24 Shree Taranath-Trkavachspati-Bhattacharyen Vchaspatym published
by Rashtriya Samskrit Sansthandelhi Volume 4 page no- 5149
25 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
26 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
27 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
28 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Page | 147
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
29 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Indriyaopakramaniya Adhaya Shlok no 811
page no- 125
30 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243
31 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-510 page no56
32 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no3108 page no- 385
33 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no33 page no- 366
34 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sarvabhutachintasharir Adhaya
Shlok no-126 page no9
35 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-522 page no60
36 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-532 page no61
37 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Page | 148
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-521page no58
38 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-527 page no61
39 VdBramhand Tripathi Ashtanghradaya Sharirsthansthan Published by
Chaukhamba prakashana 2005 Shlok no331 page no-372
40 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Siravarnavibhaktisharir Adhaya
Shlok no-725 page no83
41 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Sharirsankhyavykaransharir Adhaya Shlok
no-512
42 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Pratekmarmanirdeshsharir
Adhaya Shlok no-628 page no75
43 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
44 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Marmasharirsthan Shlok no429 page
no- 393
45 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243244
Page | 149
46 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
47 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan pu blished by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711
48 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
49 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
50 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Shlok no 711 page no- 847
51 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Adhaya Shlok no-628 page no- 75
52 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Gandushavidhiadhaya Shlok no2232
page no- 261
53 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Karnavydhbandhvidhi Adhaya Shlok no-
1611 page no- 86
54 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Nidansthan Published by Chaukhamba
Page | 150
Sanskrit SansthanVaranasi Vatvydhinidansa Adhaya Shlok no183 page
no- 304
55 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavaykaransharir
Adhaya Shlok no-532 page no61
56 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Tristaisniya adhaya Shlok no 1120 page no-
163
57 P Hazarika Dr Nayaka R Balkrishnan Textbook of EarNoseThroat and
Head-Neck Surgery CBS Publication Anatomy of Ear
58 DrKB Bhargava DrSKBhargava DrTMShaha A short book of ENT
Diseases Published by Usha Publication 10th edition page no10
59 MrSalah Mansour MrJacques MagnanMr Hassan Haidar MrKaren
Nicolas MRStephan Louryan Comprehensive and clinical anatomy of the
Middle Ear Published by Springer publication Chapter -Middle Ear cavity
Page no 19 to 121
60 DrPLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 7
61 James OPickles An introduction to Physiology of Hearing Published by
Emerald publication 4th edition page no- 1 to 265
62 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
63 VdBramhand Tripathi Ashtanghradaya Uttarsthan Published by
Chaukhamba prakashana 2005 Karnaroga vigyniyam adhaya Shlok
no1713 page no- 998
Page | 151
64 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Shlok no- 212 page no-
730
65 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no
1-2 page no- 309
66 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana
67 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyantshirasiya Adhaya Shlok no 1713 page no-
258
68 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no-
6 page no- 310
69 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Karnarogavigyniym Shlok no- 1725-26 Page no-
1003
70 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2140 page
no 131
71 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Adhyay 18 shlok 35
72 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt
Karnarogapratishedhoadhya Shlok no-2211 Page no- 735
73 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 152
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2141 page
no 131
74 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2142 page
no 131
75 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2144 page
no 131
76 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 34 page no- 649
77 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2145page
no 131
78 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 37 page no- 649
79 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2146page
no
80 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
81 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 153
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2143page
no
82 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publication Krnarogadhikara adhaya page no-
318
83 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary
Madhyamkhand Vatkalpana shlok no- 782-83 page no- 137
84 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 72-77 page no- 651
85 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
86 Vd Shree Laxmipatishastri Yogratnakara
87 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
Karnarogadhikara Shlok no- 808182 page no- 652
88 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 83 page no- 652
89 (PDF) Otomycosis A Comprehensive Review (researchgatenet)
90 httpswwwncbinlmnihgovpubmed24948980
91 A Simon Carney Scott-Browns Otorhinolaryngology Head and Neck
Surgery CRC press 8th publication Otitis externa and otomycosis
92 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no Page no -
93 wwwguggulipidcomtradhtm
Page | 154
94 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
95 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-28 page no-
43
96 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009Agaru page
no726-728
97 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishra chapter Karpuradi varga Shlok no-31-
43 Page no- 116
98 httpswwwthiemeinimagecatlogsample_chapter_GOMPpdf
99 (PDF) Chemical Constituents and Pharmacological Activity of Agarwood
and Aquilaria Plants (researchgatenet)
100 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 4 chapter no-2 page no-4
101 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 chapter no-152 Madanpage
no376-379
102 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
103 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-54 page no-
84
104 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 page no697-699
patol-yawa
Page | 155
105 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
106 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
Dhoompanvidhi page no- 252-254
107 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012Chikitasasthan Shlok
no- 151page no-406
108 httpswwwmdpicom1420-3049232342pdf
109 httpswwwijamcoinindexphpijamarticledownload0610201530
0
Page | 156
BIBILOGRAPHY
Page | 157
1 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
2 Scott-Brown WG Diseases of the EarNose and Throat Landon
Botterworth and co(publishers) Ltd1952 Volume 2
3 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012
4 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009
5 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi commantry
Purvakhand and Madhyamkhand
6 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Published by Chaukhamba Sanskrit
SansthanVaranasi
8 The Ayurvedic Pharmacopeia of India Ministry of Health and family welfare
department of Ayush Part 1 and part 4
9 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005
10 Acharya Trivedi Raguveer Prasad Ashtang sangrah published by
Vaidyanath Ayurveda bhavan pvt
11 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition
12 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary published by Chaukhamba
Orientalia
Page | 158
ANNEXURE
Page | 159
ANNEXURE- 1
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
CASE RECORD FORM
RESEARCH PROFORMA FOR MS (AYU) DESSERTATION
DEPARTMENT OF SHALAKYATANTRA
NAME -
ADDRESS -
GENDER - AGE - OCCUPATION-
RELIGION - EDUCATION - MARITAL STATUS-
OPD IPD NO-
DATE OF ADMISSIONCOMMESEMENT-
DATE OF DISCHARGECOMPLITION-
DATE OF COUNSELLING-
TEL NO-
CHIEF COMPLAINTS-
PAST MEDICAL AND SURGICAL HISTORY-
TREATMENT HISTORY-
FAMILY HISTORY-
Page | 160
PERSONAL HISTORY-
a) Ahar(Diet)
b) Vihar
c) History of addiction
GENERAL EXAMINATION
PULSE - MIN BP - mm of hg
TEMP - 0F RR - MIN
ASHATAVIDHA PARIKSHANA
Nadi- Mutra- Mala-
Jivha- Shabda- Sparsha-
Drik- Aakruti-
SYSTEMIC EXAMINATION
RS ndash
CNS-
CVS ndash
Page | 161
LOCAL EXAMINATION (KARNA PARIKSHAN)
OBSERVATION TABLE FOR SUBJECTIVE CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching )
RIGHT EAR LEFT EAR
KARNASHASHUKULI
KARNAPUTRAK
KARNAPALI
KARNAKUHARA -
SRAVA
GANDH
VARNA
SWARUPA
KARNAPATALA (TM)
Page | 162
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
Hearing Test
1Renne Test ndash
2 Weber Test -
Examination of Ear-
Pathological Investigation-
Other Examination-
Nidan Panchak-
1Hetu-
2Purvarup-
3Rupa-
4Upashayanupashaya-
5Samprapti
Signature of Guide Signature of Doctor(Researcher)
Page | 163
ANNEXURE 12
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Dhoopana Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization were done as recommended in pharmacy procedure
The raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 were mixed together
in equal quantity to make Agaruwadi churn
STEP 4 - Agaruwadi churn were triturated with appropriate quantity of water
and prepared Varti in GMP Certified Ayurvedic pharmacy Standard aseptic
precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Dhoopana Varti was packed in sterile air packed
container
STEP 6 - Agaruwadi Dhoopan was given with the help of Dhoopan yantra
TREATMENT DETAIL-
Purvakarma -
1 The patient is asked to sit comfortably on chair having sufficient light and
less amount of dust
2 The EAC is cleaned thoroughly by Pichu Varti (cotton swab) to remove the
discharge and other debris
Pradhankarma -
1 The patient is asked to relax completely on the chair
Page | 164
2 Fumes are passed to the ear with Dhoopana Yantra
3 Dhoopana yantra is funnel shaped and its one end will keep the ear covered
for the passage of Dhooma into the ear canal and other end where Agaruwadi
Dhoopana Varti were placed which produces fumes
4 This Dhoopana was given for 5 min
Pashchat karma -
1 The patient were advised to avoid cold refrigerated food drinks cold water
bath cold wind fog and prevent water from entering the ear
(A) Agaruwadi Dhoopana Varti
B) Guggula Dhoopana Varti SOP of it is same as above Agaruwadi Dhoopana
Varti
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Page | 165
ANNEXURE 21
INFORMED CONSENT DOCUMENT
Study Title
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
Introduction
- You are invited to take part in a research study RANDOMSIED COMPARATIVE
CLINICAL TRIAL TO STUDY THE EFFECT OF AGARUWADI DHOOPANA AND
GUGGULA DHOOPANA IN KARNASRAVA
- Before you decide it is important for you to understand why the
research is being done and what it will involve
- Please take time to read the following information carefully and discuss
it with friends relatives and your doctor if you wish
- Ask us if there is anything that is not clear or if you would like more
information
Purpose amp Nature of Study
- In this research project by examine you and ldquoKarnasravardquo (Otomycosis)
disease were treated
- In the part of treatment Agaruwadi Dhoopana or Guggula Dhoopan were
given
- Dhoopana means medicated drug fumes were given in ear with the help of
Dhoopan Yantra
Page | 166
- Treatment was given for 7 days
Study Duration
7days
Participation
- Your participation is entirely voluntary
- If you do decide to take part you were given this information sheet to keep
and be asked to sign a informed consent form
- If you decide to take part you are still free to withdraw at any time and
without giving a reason This will not affect the standard of current or future
medical care you may receive
Confidentiality
- All information which is collected about you during the research were
kept strictly confidential
- Any information about you which is collected from the center will have
your identity in the form of a code number so that it will remain confidential
Benefits Of Study
- The results obtained from this study would be helpful for providing better
quality of treatment amp other essential facilities for Karnasrava (Discharge)
patients
- You will get clinical benefit from the study
Page | 167
Risks Of Study
- In this treatment there are few chances of Irritation of Ear Nose and
congestion at EAC if any of these happens then treatment were given
Results Of Study
- If the Results obtained are profitable then they may get published
without disclosing your details
Signature of patient
Date
Time
Phone no of Researcher
Page | 168
रण मादहती पतरक
सशोिनाच शीषवक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE
EFFECT OF AGARUWADI DHOOPANA AND GUGGULA DHOOPANA
IN KARNASRAVA
परसतताना
- आपणास या सशोिनातपमक अभयासात सहिागी होणय़ाच आाहन करणयात यत आह
- सशोिनातील सहिाग तननदशचत करणयापी सशोिनाच उददश समजन घया
- खालील मादहती काळजीपवक ाचा आणण आशयक ािलयास आपलया डॉकिराशी कका
दहतशरचतकाशी चचाव करा
- काही सददिता असलयास कका आणखी मादहती ही असलयास आमछयाशी चचाव करा
सशोिनाच उददीटि सतरप
- सदर सशोिन परकलपामरधय आपलयाला तपासणी करन कणवसरा या वयाशरिची शरचककतपसा दणयात
यणार आह
- सदर वयाशरिची शरचककतपसा महणन आपणास अगरादी िपन कका गगल िपन
दणयात यणार आह
- सदर औषि आपणास 7 ददस घयायाच आह
Page | 169
कालािी
- 7 ददस
सहिाग
- आपला सहिाग हा पणवपण ऎनदछिक आह
- आपला सहिाग तननदशचत असलयास आपणास ही मादहती पतरतरका दणयात यईल आपणास यातील
समती पतरकार सही कराी लागल
- सहिाग तननदशचत असनही आपण कोणतपयाही ळस कोणतही कारण न दता माघार घ शकता
याचा आपलया दयकीय सविर कोणताही पररणाम होणार नाही
गोपनीयता
- सशोिना दरमयान गोळा कलली आपलया वषयाची सव मादहती गोपनीय ठणयात यईल
- आपली यनदकतक मादहती साकततक सतरपात गोपनीय ठणयात यईल
सशोिनाच फ़ायद
- सशोिनाच तनटकषव कणवसरा बाशरित रणाछया दयकीय इतर सविाचा दजाव सिारणयास
फायदशीर ठरतील
सशोिनातील जोणखम
- य़ा शरचककतपसमरधय कान दखण डॊळय़ातन नाकातन पाणी य़ण नाकात जळजळण डोक जड
होण ही लिण ददस शकतात यापकी लिण तनमावण झालयास तपयाची शरचककतपसा कली जाईल
Page | 170
सशोिनाच तनटकषव
सशोिनाच तनटकषव फ़ायदशीर ठरलयास आपली मादहती गोपनीय ठन परकाशशत करणय़ात यईल
रण सतािरी-
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
Page | 171
ANNEXURE 31
INFORMED CONSENT FORM
Patient OPD no __________
Subjectrsquos Identifier
Date of Birth Age Gender
I _____________________________________ age___________ years
exercising my free power of choice hereby give my consent to be included
as a participant in the clinical study entitled
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
1 I confirm that I have read have been read and understood the information
sheet for the above study and can ask questions
2 I understand that my participation in the study is voluntary and that I am
free to withdraw at any time without giving any reason without affecting my
medical care or legal rights
3 I understand that the Ethics Committee members investigators and study
doctors will not need my permission to look at my health records both in
respect of the current study and any further research that may be conducted
in relation to it even if I withdraw from the trial I agree to his access
However I understand that my identity will not be revealed in information
released to third parties or published
4I agree not to restrict the use of any data or results that arisefrom this study
provided such a use only for scientific purpose
5 I agree to take part in the above study
Page | 172
signature with Date-
Left hand thumb impression
Name amp signature of the witness ndash
Name amp signature of the student ndash
Page | 173
ANNEXURE 32
समतीपतरक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
वयकतीच य
ददनाक जरमददनाक
1) मी ह तननदशचत कररत आह ककसदर सशोिन परकलपाबाबतची सपणव मदहती मी ाचली असनमला ती
समजली आहतपयाबददल मला परशन वचारणयाची पणव मिा आह सदर मादहतीन माझ समािान झाल
आह
2) मी सदर सशोिनातन माझया मजीनसार किीही बाहर पड शकतो या माझया अशरिकाराची मला कलपना
आह
3) माझी दयककय मादहती तपासणयाची कागदपतर कळ सशोिनाकररता ापरली जाणार आहत याची
मला मादहती आहसदर सशोिन परकलपातील सबशरित घिकाना माझी दयककय मादहती पाहणयाची मी
समती दत आहतरावप या सदिावतील माझी ओळख दशववणारी मादहती कोणासही ददली जाणार नाहीयाची
मला कलपना दणयात आली आह
4) सदर अभयासातन शमळणारी मादहती अरा तनटकषव कळ शासततरीय हतसाठी ापरल जाणयासाठी माझी
समती आह
5) रील अभयासात सहिागी होणयास माझी समती आह
रण सतािरी-
Page | 174
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
ASSESSMENT CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching)
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
a) कणवशल ( pain )- 0 - Absent
1 ndash Present
Page | 175
b) कणवकणड (Itching)- 0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
c) कणवसततरा ( Discharge )
0- Absent
1-Mild- Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाशरियव ( conductive Loss of hearing )
0 - Present
1 - Absent
Page | 176
Page | 177
Page | 178
Page | 179
Page | 180
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
Page | 181
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 182
AUTHENTIFICATION CERTIFICATE
Page | 9
Ayurvedic literature Ayurveda is a science of life practice since
thousands of years The ancient Indian system of medicine and surgery is
commonly known as Ayurveda This was given the status of Upaveda or
fifth Veda in the next stage of growth Among the available literature three
Samhita that is Charaka Samhita Sushrut Samhita Ashtang Hrudayam and
Ashtang Samgraha are the chief source of knowledge of Ayurveda
Ayurveda consist of eight branches Shalakyatantra is one among them
Shalakyatantra is one of its specialized branch deals with science of
ophthalmology otorhinolaryngology Oro dental surgery and head Acharya
Sushruta himself a practical surgeon was the first to advocate dissection of
dead bodies is indispensable for a successful student of surgery He had
described gross anatomy in the first chapter of Uttartantra Shalakyatantra
define by different Acharys as follows
शालाकय नामोरधवजतरगताना रोगाणा शरणनयनदनघराणाददसशरशरताना वयाशरिनामपशमनारव
स स ११०
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत [13]
चस १७१२
Shalakya Tantra Nirukti and Parichaya
शलाकायााः कमव शालाकय ततपपरिान शलाकयम डलहण [14]
The term Shalakyatantra is derived from Shalakya and Tantra
The word Shalakya means A probe and Tantra denotes teaching and
practices found in scripturesThe compendium in which application of
Shalaka in various surgical procedures is principally described is called as
Shalakya tantra
दनदटिवशारदााः शालाककनाः डलहण ( सउ ११३)[15]
An eye specialist is termed as Shalaki by Dalhana
Page | 10
Synonyms of Shalakya Tantra
Uttamanga Chikitsa Jatrurdhwa Chikitsa Urdhwang Chikitsa Shalakya
Chikitsa
Importance of Shalakyatantra-
Life of living being and all the Indriyas are situated in the head hence it is
known as Uttamanga
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत
चस १७१२
The treatment given to this part of the body is described specially in
Shalakya tantra While describing the importance of Shiras Vagbhata
correlates it to the root of tree (Urdhwa Mula) and body to the trunk of tree
(Adha Shaka)
Sushruta has deal with Mukha Roga in Nidan Shan and its treatment in
Chikitsasthan The description regarding the disease of eye ear nose and
head are found only in UttaraSthan Sushruta specially describes the
disease of Shalakyatantra as told by Videha in the beginning of Uttartantra
itself[16]
Shalakyatantra Itihas-
India Exhibits traditional of more than thousands of years in art literature
language logic and philosophy etc The convention was in its sophisticated
and advanced attire throughout the Vedic period
Vedic period ndash
1 Natush was treated for deafness by Ashwinikumars (Rigveda)
2 Rujaswa and Kanva were treated for blindness by Ashwani Kumaras
(Rigvedas)
Page | 11
3 There are several prayers mentioned for normal functioning of sense
organs (Yajurveda)
4 Structures and functions of Mastishka are described (Atharveda)
5 Mantras having reference to disease of Eye Ear Oral cavity etc are
found (Atharvaveda)
Upanishada Period ndash
1 Samhita Period
a) Sushrut Samhita ndash
bull Explanation regarding Netra Nasa and Shirorogas (Uttartantra 1-
26th chapter)
bull Details regarding Mukha and Karna Roga Nidan and
Chikitsa(Nidansthan 16th and Chikitsasthan 22nd chapter)
bull Description regarding Karna Chedana Sandhana Nasa
Ostasandhana Sutra Sthan 16th chapter
b) Charaka Samhita -
bull Explanation regarding Shirorogas (Sutrasthan 17th chapter)
bull Explanation of Gala rogas like Upajivika Galshundi and Rohini
bull Nasa Shiro Mukha Karna and Netra Chikitsa (Chikitsa sthan 26th
chapter)
bull Description regarding Lakshana and Chikitsa of Shankhaka
Ardhavbhedaka Shirovirechana and Shiro basti (siddhi sthan 9th
chapter)
c)Ashtnga Sangraha ndash
bull Detailed description regarding Shalakyatantara (Uttartantra 11-28
chapter)
bull Description of Kriyakalpa (Sutrasthan 32nd and 33rd)
Page | 12
d)Ashtang Hrudayam
bull Detailed description on Shalakya Tantra (Uttar tantra 8-24 chapters)
bull Kriyakalpas (Sutrasthan 23rd and 24th chapter)
e) Bhela Samhita
bull Chakshushya Vaisheshik and Buddhi Vaisheshik Alochaka pitta
f) Harita Samhita- Branch of Medical science offering elaborating
information about the procedure like Nasya Anjan Gandusha etc
comprehended with their applications in disease of Head Eyes Ears
Eyebrows Throat Temporal region and cervical spine is known as
Shalakyatantara
शशरोरोगा नतररोगा कणवरोगा वशषताः भरकरठशङकमरयास य रोगा समिनदरत दह १३
तषा परततकारकम व नसतयतपयवणजनातन च अभयङगमखगणडषकियााः शालकयसशमतााः १४
इतत शालाकयनाम [17]
Documentation of different ancient literature gives various references
regarding all aspects of Karnasrava in various periods It is very much
important to know the history of Karnasrava from Vedic Pauranic Samhita
and Samgraha period
Vedic period ndash The Vedas being the oldest source of knowledge have no
direct mentioning of Karnasrava
Page | 13
Samhita and Samgraha period ndash
Aacharya Sushruta described about Karnaroga Karnasrava Nidan
Roopa and Chikitsa The detail description is available in Sushrut
Samhita Uttartantra 20 and 21st chapters
Aacharya Charaka did not specify Karnasrava but mentioned 4 types
of Karnarogas that is Vataj Pittaj Kaphaja and Sannipataja and their
treatment in 26th chapter of Chikitsasthan
In Ashtang Hrudaya karnasrava is not explained as a separate disease
but Chikitsa is mentioned in 18th chapter of Astanga Hrudaya
uttartantra
In Ashtang Samgraha Chikitsa is mentioned in 22nd chapter of Astang
Samgraha Uttartantra
The details about Karnasrava are explained in Bhavprakasha
Madhyamakhanda 64th chapter
Madhavakara has explained about Karnasrava in 57th chapter of
Madhymakhanda
Karnasrava is also explained in Sharangadara Samhita Uttarkhand 11th
chapter
The reference for treatment of Karnasrava is available in
Yogaratnakara
In Gadhnigraha Karnasrava and its treatment is mentioned in
Karnarogadhikara Adhaya
Vangasena had mentioned about the disease and treatment in 69th
chapter
Chakradatta explained Karnasrava in 57th chapter
Dalhana has given commentary on Sushrut Samhita Uttartantra 20th
and 21st chapter
Sankhya Samprapti of Karnasrava ndash
Aachary Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga
Vigyniyam Aadhaya Aacharya charaka explain 4 Karnaroga in
Page | 14
Karnarohvigyniyam Adhaya based on doshas Acharya Vagabhata in
Ashtang Hrudaya explain 25 Karnaroga in Adhyaya
कणवशल परणादशरच बाशरियव कषड ए च
कणवसरााः कणवकणडाः कणव चवसतततर च
कशमकणवपरततनाहौ विशरिदवविसततरा
कणवपाकाः पततकणवसततराशवशरचतवविम
कणावबवद सपतवि शोफशरचावप चतवविाः
ऎत कणवगता रोगा अटिावशततरीररतााः
स उ २०- ३ त ५[18]
ातकणवरोग वपततकणवरोग कफकणवरोग
रकतकणवरोग सनदरनपातकणवरोग कणवनाद
बशरिरतप परततनाह कणडाः शोफ पततकणवक
किशमकणवक उियरपविरधयअशो अबवद
कशरचकणवक वपपपली वदाररका पाळीशोष
ततिका पररपोिो उतपपातो उरमरर दाःखिवन
शलहाखयााः परचवशनदरतकणवरोगा उकतााः
इदिीका अ स उ २१ [19]
चतपाराः कणवरोगााः
च स [20]
Page | 15
KARNA
Karna ndash करोतत शबद गरहण [21]
The organ of hearing
Karnasrava- कणवसतय कणवयोाव ससराा [22]
Discharge from the ear is referred as Karnasrava
KARNA SHAREERA
bull Nirukti
कणयवत अकणयवत अनन इती [23]
It means reception and conduction of sound waves
These are the functions of external and middle ear
bull Nirukti of Sravanam
शरयत अनन इती शरणम[24]
It means perception of sound
It can be attributed to the internal ear function
bull Karna Utpatti-
Karna is an organ formed by Akash Mahabhuta[25]
The fundamental characteristic is as follows
Indriya ndash Srotram [26]
Indriya Adhisthan ndash Karna [27]
Indriya Dravy ndash Akasha [28]
Indriya Arth ndashShabdha [29]
Indriya buddhi ndash Srotobyddhi
Page | 16
bull Paryaya of Karna- Shabdapatha Srotrapatha Sravanam shruti
Kuhuram Dwanigraham etc
bull Definition of Karna-
कणवशटकलयनदछिरनमिटिोपगरदहत शरोतरमछयत [30]
मा तन ५७१
The definition of Karna is stated in Madhav Nidanam Indriya which is not
seen with naked eye along with Shashkuli is called Shrotra that is Karna
Indriya is so minute that it is not perceived with any sense organ
In Charak Samhita the word Karna explain as the Indriya Adhisthan of
Shabdha Karna is described as one of the Prathyangas of the body He
emphasizes that all Indriyas manifest during the 3rd month of gestation
period
Acharya Sushruta while describing formation of Purusha from Prakriti or
Avyakta narrated that all Indriyas are developing from the Vikarika and
Taijas Ahankara Both Vagabhata and Sushruta stated that Karna as one of
the Bahirsrotas
शरण नयन दन घराण गदमढराणण न सततरोताशसराणा बदहमवखातन [31]
स शा ५-१०
In Ashtang Hradaya Vagbhata has states that all Indriyas are Atmaja
According to him lower lobule elevated helix projected posterior portion
fleshy and adherent ear are indications of long span of life[32]
ततरखातखातन दह अनदसतमन शरोतर शबद ववकतता [33]
ा शा ३-३
शबदाः शबदनदरिय सवनदछििसमहो ववकतता [34]
स शा १-२६
Page | 17
Ear has the prominence of Akash Mahabhuta The prominent dosha of ear
is Vata It is important seat of Vata The prominent Dhatus are Asthi and
Mamsa Karna is one of the Panchgnanendriyas and it meant for hearing
Sushruta narrated that Karnasthita Asthi and Sandhi
घराणकणवगरीाकषिकोषष तरणातन [35]
सशा ५-२२
शरोतरशरगािकष शखाताव [36]
सशा ५-३२
गडकणवशखटककम [37]
स शा ५-२२
One Sandhi and one Tarunasthi in ear
Sandhi ndash Karna contain two Sandhi one in each ear Type of Sandhi is
Shankhavartha which is present in Shringataka
Mansapeshi ndash 2[38]
Siras ndash 10 [39]
Vataj Sira - 4
Pittaj sira - 2
Kaphaj sira - 2
Raktaj Sira - 2
Avedhya sira-
कणवयोदवश तासा शबदादहनीनामकका पररहरत
सशा ७-२५[40]
Amongst above mentioned ten Siras each Karna lodges one Shabdavaha
Sira It is Avedhya
Page | 18
Dhamani -2
Length of ear is 4 Angula
Karna moola ndash 2 Angula
कणाविरतर चतदवशअगलम
स शा ३५-१४[41]
The distance between two ears through the back of the neck is 14 Angula
bull Marmas of Karna-
1 Vidhuras-
कणवपटठतो अिाःसशरशरत विर ततर बशरियवम
सशा ६-३७[42]
कणतपयादद सतनायममवणी ककनदचचनदरनममनाकर कलयकररणणच
डलहणाचयव[43]
अिसततात कणवयोतनवमन विर शरततहाररणण
ा शा ४-२९[44]
Sankhya-2
Vistara- frac12 Angula
Type- Snayumarma (Susha)
- Dhamanimarma(AH)
- Vaikalykar
Sthana- It is situated in the depressed portion in the back of the ear
Injury to them causes loss of hearing
Page | 19
2 Shringataka marma-
नदजवहाकषिनाशसकाशरोतरखचतटियसरमम
तालरयासतयातन चतपारर सरोतसा तष ममवस
वदि शरगातकाखयष सददसततपयजतत जीवतम
मा तन ५७१ [45]
Sankhya- 4
Type- Siramarma
Sthana- It is in head that is amidst Siras (blood vessels) nursing sense
organ
A palm size area near Talu
Injury to this Marma causes death
In modern anatomy ear divides into Bhayakarna or External ear Mdhyakarn
or Middle ear Antahkarna or Internal ear This is extremely appropriate
Even though the ear is divided into three divisions in the point of modern
anatomy Ayurveda denotes ear organ is one Ayurveda treats disease by
way of assessing Dosha and Dushya Here Dushya is one that is Karnendria
Dosha difference will call for different treatment for different disease Hence
treating the vitiated Dosha will cure the disease irrespective whether it is in
external middle or internal ear The thought is based on different
fundamental principle from Ayurveda
bull Parts of Karna
In Ayurveda classics detailed description about anatomy of ear is not
available But the various parts are mentioned as follows
Bhayakarna- External ear
Mdhyakarna ndash Middle ear
Antahkarna- Internal ear
Page | 20
द कणवशटकशलक दॊ कणवपतरकौ
च शा 7-11[46]
कणवशटकशलक कणवगतातवकौ कणवपतरकौ त बाहयकणा
चिदतत च शा 7-11[47]
शटकली बाहयपालयाशरिटिानम
डलहन- स शरच 25-1 12[48]
Karna Shashkulika ndash It is also called as Karna Shashakuli Charaka has
mentioned this term while describing different Pratyngas of the body
Acharaya Gananatha sen has given the clarification for it as a pinna or
auricle[49]
Karnapali ndash It is popularly known as lobule of the ear Daivakrita Chidra is
present in it
Karnaputrika- Ayurvedic scholars accepted two terms in this cortex They
are Karnaputrika and Karnaputrika The former is considered as Tragus and
antitragus[50]
Karna Prushtha- It can be taken as the cranial surface of mastoid or
auricle[51]
Karnapeetha- Aacharaya Sushruta firstly mention the term Karnapeetha
It is mentioned first by Sushruta while describing the procedure of
Karnavyadana Vagbhata has mentioned that it is Adhobhaga of Karna
Dalhana has clarified that it is the region above the Karnaputrika that is the
region which is at the bottom of the concha
Karnamoola ndash It can be considered as parotid region[52]
Karna lathika ndashAcharaya Dalhana mentioned lobule as a Karna Lathika
Page | 21
Karnaavatu ndashThis term is used by Sushruta while describing the
measurements of different Angapratyangas where he has mentioned that
the distance between the Karnaavatu is 14 Angul Dalhana has comments
that it can be taken as the distance between two ears from behind[53]
Shabdhavahasrotas ndash It also called as Shabdapatha or Srotapatha The
whole passage through which the sound waves pass can be taken as
Shabdavahasrotas[54]
Shrotashringataka ndash It can be taken as the labyrinth of ear[55]
bull Dosha in context to Karna-
Karna is principal location of Vayu
1 Prana Vayu- Prana Vayu circulating in oral cavity is responsible for
Dehadhruka that is keeping all body parts active Indriyadruka that is
keeping all Dnyanendriya healthy by proper nourishment (Purana) helps in
deglutition of food material and convey the stimulation of Indriyabuddhi
and atma
2 Udana Vayu- Bala(strength) Varna speech singing are its function It
is responsible for facial expressions due to pleasure sorrow anger love
frustration etc in general its circulation and actions are just opposite to
Pranavayu
3 Vyana Vayu- Its principal functions are circulation of Rasa and Rakta
through body and various movements Its main location is Hrudaya Five
types of movements for which it is responsible are expansion contraction
upward downward and oblique other activities are opening closure of
eyelid yawning perspiration During circulation if it gets obstructed due
to Srotodushti it generates disease of that Srotas Vyana Vayu gets vitiated
by disease of Rasa Rakta Oja and Chetanadhatu
Page | 22
4 Samana Vayu- It is circulating in the vicinity of stomach and intestine
and helps in keeping the Jatharagni (digestive juices and enzymes) in
equilibrium Disturbance in Jatharagni precipitates disease
5 Tarpaka Kapha- Entire body functions movements are controlled and
executed by various centers in the brain Sensation perceived by sense
organs is conveyed to Mann and Aatma residing in Hrudaya The motor
signals from them are then conveyed to the functioning
organsKarmendriya through Prana Vayu Shira head is therefore a
location of continuous activities motions of Vata All these centers are in
unctuous Majjadhatu in the Shira For stabilizing this ever-active Vata and
to nourish the Majja dhatu very unctuous Tarpaka Kapha situated in Shira
plays an important role
bull Ayurvedic aspect of sound perception [56]
According to Ayurveda Pratyaksha Dnyan or Perception of any sensation
including Shabda occurs due to interaction of the Karnendriya and the
Indriya- Arth -Karma resulting in Sravana
External Environmental acquaintance with living body is executed by five
sense organs namely Netra Karna Nasa Jivha and Twaka All
Dnyanendriya that is sense organ are Panchmahabhautic combination
Despite this fact every Indrya sense organ perceives object Tanmatra of
that Mahabhuta only from which it is originated from Akash Mahabhuta and
hence perceives Shabd only that is audio perception Shrotrendriya is one
of the principal locations of Vata and its function is to perceive Shabda that
is sound waves This sensation is conveyed through Shabdavahi Dhamanis
to Mana and Atma through Pranavayu and the sequence is responsible for
perception of sound in this way external sound is perceived and interpreted
when Atma is linked with Mann Mann is linked with Indriyabuddhi that is
minute virtual Dnyanendriya located in brain Indriyabuddhi is linked with
Adhishthana with prominent Mahabhuta and lastly with Indriya
ArthShabdatanmatra that is sense object Once this sequence is completed
Page | 23
the meaning of a particular sound is interpreted and understood In this
entire process of perception and interpretation of sound waves Pranavayu
and Tarpaka Kapha located in Shira play extremely important role Hence
the healthy status of all the sense organ depends upon the normal
physiologically homeostatic condition of Pranavayu and Tarpaka Kapha
MANAS
ATAMA
BUDDHI
AHANKARA
ARTHA
Page | 24
EAR ANATOMY
bull Embryology of the Ear [57]
1 The sound conducting apparatus develops from the branchial apparatus
whereas the sound perceptive apparatus from the ectodermal otocyst
2 The pinna develops from the six hillocks around the 1st branchial cleft
3 External auditory canal develops from 1st branchial cleft
4 The outpouching of the 1st pharyngeal pouch gives rise to a proximal
narrow part that forms the eustachian tube and distal dilated part that
forms the middle ear cavity
5 Prussakrsquos space is a potential space lateral to the Shrapnellrsquos membrane
and medically by the neck of malleus that can be involved during the
extension of cholesteatoma
6 Development starts in the 3rd week of the intrauterine life and is
completed by 16th week of intrauterine life Membranous and boney
labyrinth develops from the otic capsule
The Ear is divided into
1 External Ear
2 Middle Ear
3 Internal Ear or the labyrinth
Page | 25
Fig 1 Ear Anatomy
EXTERNAL EAR [58]
The outside ear contains pinna and lobule
Pinna is the noticeable piece of outer ear made from single sheet of yellow
flexible ligament covered by subcutaneous tissue and skin It has two
surfaces average and parallel It is intently disciple to perichondrium on its
sidelong surface while it is somewhat free on average surface Pinna
incorporates tragus helix against helix fossa three-sided scaphoid fossa
incisura terminalis
External auditory Canal ndash It extends from the bottom of the conchea to
the tympanic membrane and measures about 24 mm along its posterior
wallit is S shaped
Parts 1 Cartilaginous part
2 Bony part
Page | 26
Cartilaginous part ndash The outer one third is cartilaginous consist of fibro
cartilage is directed first inward backward and upward It has Fissure of
Santorium The skin of this part of the canal contains hair follicles
sebaceous gland and cruminous gland
Bony part ndash The inner two third part is boney It goes forward downward
and medially skin lined in this part is very thin Isthmus is the narrowest
part of the canal lying medial to junction of bony and cartilaginous part
nearly 5 mm lateral to tympanic membrane
The roof and posterior wall of the external auditory canal shorter than floor
and anterior wall The skin lining the tympanic membrane and boney canal
has a self-cleansing property due to migration of keratin layer of epithelium
from drum towards the cartilaginous portion
Relations- Anteriorly- Temporomandibular joint and parotid gland
Superiorly- Middle cranial fossa
Inferiorly- parotid gland
Posterior- Mastoid antrum mastoid air cells and facial nerve
Nerve supply ndashSensory nerve supply of the external ear The auricle
supplied by fibers of the great auricular nerve (C2 and C3) and lesser
occipital nerve (C2) Auriculo temporal branch of the 5th cranial nerve and
auricle branch of the vagus (Arnoldrsquos nerve) supply external canal Facial
nerve has small sensory contribution on posterior-inferior wall
Tympanic Membrane -It is the partition between EAC and middle ear It
is a thin semitranslucent membrane pearly white in colored lying obliquely
in the medial end of EAC with the angle of 55 It is forming major part of
lateral wall of middle ear Annulus tympanicus is attached at its
circumference to the sulcus The TM is oval shape It measures
approximately 10 mm in vertical diameter and 90 mm in horizontal
diameter
Page | 27
Layers ndash Tympanic membrane consist of three layers
1 Outer Epithelium or cuticular layer which is continuous with skin of
external ear
2 Middle fibrous layer has both circular and radial fibers middle layer
missing in upper part
3 Inner layer- Inner mucosal layer which is continuous with middle ear
mucosa
Parts ndash Tympanic membrane consist of two parts
1 Pars tensa -It is largest part below the malleolar folds The inner
surface at the center attached to the handle of malleus Angle of cone
is most illuminated part in the pars tensa at anteroinferior part of pars
tensa
2 Pars flaccida Sharpnells membrane -it is triangular area above the
malleolar folds which are thin and devoid of fibrous tissue and
annulus It fits into notch of Rivinous
Nerve supply 1 Anterior half of lateral surface Auriculotemporal V3
2 Posterior half of lateral surface Auricular branch of vagus cn 10
3 Medial Surface Tympanic branch of CN 9 (Jacobsons nerve)
Fig 2 Tympanic membrane of ear
Page | 28
MIDDLE EAR [59]
The middle ear or tympanic cavity is an irregular laterally compressed
space within the temporal bone It is filled with air that is supplied to you
from the nasal part of the throat through the ear canal It contains a chain
of mobile bones that connect its side with the medial wall and serve to
transmit vibrations transmitted to the eardrum through the cavity to the
inner ear Including the parapet the vertical and anteroposterior diameters
of the cavity are each approximately 15 mm The transverse diameter
measures about 6mm at the top and 4mm at the bottom Compared to the
eardrum it is only about 2mm The eardrum is limited laterally by the
eardrum medially by the lateral wall of the inner ear It communicates
behind with the tympanic antrum and through it with the air cells of the
mastoid and in front with the auditory canal The middle ear together with
the Eustachian tube aditus antral and mastoid air cells is called the
middle ear cleft It is lined by mucus membrane and filled with air
It is divided into 3 parts
1 Mesotympanum (located in front of the pars tensa)
2 Epitympanum or attic (located above the pars tensa but medial to
Sharpnells membrane and the lateral bony wall of the attic)
3 Hypotympanum (located under pars tensa) The middle ear is like a
hexagonal box with a roof
Carotid or Anterior wall- It separates middle ear cavity from internal
carotid artery The various structure passing through anterior wall of
tympanic cavity
bull Canal of chorda tympani nerve
bull Canal of tensor tympani muscle
bull Eustachian tube
bull Anterior malleolar ligament
bull Anterior tympanic artery
Page | 29
Posterior or mastoid wall ndash The upper part of the back wall shows the
opening of the auditorium Below the auditory is a triangular bony
projection known as the pyramidalis processors The stapedial tendon is
transmitted through the apex of the pyramidalis processes The vertical
portion of the facial nerve descends along the posterior wall until it opens
into the stylomastoid foramen
Roof or Tegmental wall (Pars terminalis)- It is formed by a thin bone
plate called the tegman tympanum that separates the skull and tympanic
cavities It is located on the anterior surface of the rocky part of the
temporal bone near the junction with the temporal shell it extends back to
the roof in the tympanic membrane and anteriorly to cover the half canal
of the tensor tympanic muscle The lateral border corresponds to the
remains of the Petro scaly suture
Floor ndash It is formed by a thin plate of bone which separate middle ear from
the bulb of the internal jugular vein lodged in the jugular fossa
Lateral wall ndash It is formed by tympanic membrane and partly by a portion
of squamous part of the temporal bone It separates the middle ear from
external ear
Medial wall- It separates the middle ear from the inner ear
bull The promontory is the most prominent and convex part formed by the
basal rotation of the cochlea
bull The bony lateral semicircular canal is postero-superior to the promontory
above the oval window
bull The oval window is located between the middle ear and the vestibular
slope of the cochlea It is closed by the stirrup footrest and the annular
ligament
Page | 30
bull The round window is located under and behind the cape The round
window recess is directed to the rear It is closed by the secondary eardrum
and separates the middle ear of the Scala tympani from the cochlea
bull The facial nerve passes through the bony fallopian tube above the oval
window
Mastoid Antrum ndash It is a large space with air in the upper part of the
mastoid and communicates with the attic through the aditus The roof is
formed by the antri tegmen which extends and separates the tympani
tegmen from the middle cranial fossa The lateral wall of the antrum is
formed by a bony plate that is on average 15 cm thick in adults It is
marked externally on the surface of the mastoid by the suprameatal triangle
(MacEwen)
Aditus and Antrum- Aditus is a gap through which the attic communicates
with the antrum The boney prominence of the horizontal canal lies on its
medial aspect even as the fossa incudes to thats attaches the quick system
of incus lies laterally Facial nerve publications simply underneath the
aditus
The mastoid and its air cell system-
The mastoid consists of bone cortex with a honeycomb of air cell
underneath Depending on development of air cell three types of mastoids
have been described
1Well-pneumatized or cellular- Mastoid cells are well developed and
intervening septa are thin
2Diploetic- Mastoid consist of marrow spaces and a few air cells
3Sclerotic or acellular ndash There are no cells or marrow spaces
With any type of mastoid pneumatization antrum is always present In
sclerotic mastoids antrum is usually small and the sigmoid sinus is
anteposed
Page | 31
Depending on the location mastoid air cells are divided into
1 Zygomatic cells (In the root of zygoma)
2 Tegman cell (Extending into tegmen tympani)
3 Perisinus cells (overlying the sinus plate)
4 Retrofecial cells (round the facial nerve)
5 Peri labyrinthine cells (located above below and behind the
labyrinthine some of them pass through the arch of superior
semicircular canal These cells may communicate with the petrous
apex)
6 Peritubal (around the Eustachian tube Along with hypotymoanic
cells they also communicate with the petrous apex)
7 Tip cells (which are quite large and lie medial and lateral to the
digastric ridge in the tip of mastoid)
8 Marginal cells (Lying behind the sinus plate and may extend into
the occipital bone)
9 Squamosal cells (Lying in the squamous part of temporal bone)
Development of Mastoid ndash
The mastoid develops from the scaly petrous bone The petrosquamosal
suture may persist in the form of a bone plate - Korners septum which
separates the superficial squamosal cells from the deep rock cells Korners
septum is surgically important because it can cause problems locating the
antrum and deeper cells and thus lead to incomplete removal of the disease
during mastoidectomy The mastoid antrum can only be reached if Korners
septum is removed
Page | 32
Fig 3 Cross section of Mastoid
Contents of the middle ear
Ossicles ndash Three tiny bones which conduct the sound from eardrum to oval
window
Malleus ndash It is the largest and most lateral ossicle measuring 8 mm in
length It has head neck handle anterior and lateral processes The head
is situated in the epitympanum A lateral process project laterally from the
neck while the handle is firmly fixed to the pars tensa of the ear drum
Incus- It has a body short process and long process The body short
process and long process The body articulate with the head of mallelus in
the attic and the short process project into the attic The long process
projects downwards behind the handle of malleus running parallel to it and
articulate with the head of the stapes via the lenticular process
Stapes ndash It is the smallest ossicle measuring about 35 mm and consist of
head neck footplate and anterior and posterior curcura The footplate of
stapes is held to the oval window by the annular ligament
Page | 33
Muscles ndash
1Tensor tympani ndash It is inserted is a branch of the facial nerve which carries
the sense of taste It is first arch muscle supplied by branch of mandibular
nerve V3
2 Stapedious muscles ndash It is inserted to the neck of stapes It is the second
arch muscle supplied by branch of facial nerve that is nerve to stapedius
Fig 4 Contents of the middle ear
Blood supply of Middle Ear
bull Anterior tympanic branch of maxillary artery which supplies tympanic
membrane
bull Stylomastoid branch of posterior auricular artery which supplies middle
ear and mastoid air cells
Page | 34
Four minor vessels are
bull Petrosal branch of middle meningeal artery runs along greater petrosal
nerve
bull Superior tympanic branch of middle meningeal srtery traversing along
the canal for tensor tympanic muscle
bull Branch of artery of pterygoid carotid
bull Tympanic branch of internal carotid
Lymphatic Drainage of Ear
Lymphatics from the middle ear drain into retropharyngeal and parotid
nodes while those of the Surgical Importance ndash Eustachian tube drain into
retropharyngeal group
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 middle is likely to pass to
middle ear
2 Moreover middle ear suppurative disease may spread to adjacent organs
and produce complication eg Labyrinthitis meningitis facial nerve palsy
etc
3 Lenticular process is vulnerable in suppurative ear diseases and causes
ocular disruption
4 Prussac space is the site of primary acquired cholesteatoma
Page | 35
INNER EAR [60]
Inner ear is divided into two parts
1 Bony Labyrinth
2 Membranous labyrinth
Anatomy of bony labyrinth
It is divided into two parts
1 Vestibule
2 Cochlea
3 Semicircular canal
The vestibule is located between the medial wall of the middle ear and the
lateral to internal acoustic meatus anterior to the semicircular canal and
posterior to the cochlea The vestibule is the central part of the inner ear
On its side is the oval window opening which is closed by the bracket foot
plate The bony cochlea is located in front of the vestibule It has 275 turns
wound around a bony axis called a modiolus The cochlea is about 30 mm
long The hollow center of the modiolus is a spiral canal that contains the
fibers and ganglion cells of the cochlear nerve A thin bony sheet the bony
lamina winda around the modiolus This divides the cochlear duct into two
galleries the Scala vestibuli above and the scala tympani below
There are three semicircular canals superior posterior and lateral They
are semicircular in shape and open into the vestibule One end of the
semicircle is enlarged and is known as the sphere
The membranous labyrinth is in the bony labyrinth It is connected to the
bony labyrinth by fibrous trabeculae and is surrounded by perilymph The
endolymph is located in the membranous labyrinth
Page | 36
The utricle is in the upper part of the vestibule while the saccule is found
below Both the utricle and saccule contain a single sensory patch called
the macula Each macula is covered with a neuroepithelium made up of
neuroepithelium made up of sensory hair cells and support cells these cells
are separated by a basement membrane Fibers of the vestibulo-cochlear
nerve enter the macula and pierce the basement membrane to terminate
at the base of the hair cell or cell bodies The utricle and the saccule with
their macula are called otolith organs Membrane semicircular canals are
the membrane canals of the corresponding bony semicircular canals They
open into the utricle through five openings One end of the opening of each
channel is dilated called the sphere in which the sensory organ of each
channel is located The cross section of the Scala standard looks like a right
angle The base is formed by the basilar membrane Sensory cells are
arranged on the surface of the basilar membrane These sensory cells with
their supporting cells form a complex neuroepithelium called the basilar
papilla or the cortical organ named after an Italian microscopist The
organs of the corti have a gelatinous membrane called the tectorial
membrane and they are supported by the pillar of the corti The cortical
pillars enclose a space called the corti tunnel which contains a fluid called
cortical lymph Vestibule is lies between the medial wall of the middle ear
and lateral to internal acoustic meatus anterior to semicircular canal and
posterior to the cochlea 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 Boney cochlea lies in front of the vestibule It has 275 turns
coiling around boney axis called modiolus Cochlea is approximately 30 mm
in length The hollow center of the modiolus is a spiral canal containing the
fibers and ganglion cells of cochlear nerve A thin boney sheet the osseous
lamina winda around the modiolus This divides the cochlear canal into two
galleries the Scala vestibuli above and the scala tympani below
Page | 37
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 boney labyrinth It is connected
to the bony labyrinth by fibrous trabeculae and is surrounded by perilymph
Endolymph 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 single sensory patch called macula Each
macula is covered by neuroepithelium consist of Neuroepithelium consists
of sensory hair cells and supporting cells these cells are separated by
basement membrane Fibers 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 are referred
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 corti lymph
Page | 38
Fig 5 Inner Ear
Blood supply of labyrinth
Labyrinthine artery
Common cochlear Anterior vestibular Artery
Vestibulocochlear artery Main cochlear artery
Cochlear branch posterior vestibular artery
Page | 39
PHYSIOLOGY OF HEARING [61]
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
bull Mechanical conduction of sound (conductive apparatus)
bull Transduction of mechanical energy to electrical impulses (sensory
system of cochlea)
bull Conduction of electrical impulses to brain (neural
Fig 6 PHYSIOLOGY OF HEARING
Page | 40
Conduction of sound
Under the surface of water we cannot hear the sound made in air because
9995 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 must 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 13 times longer than long process of incus providing
a mechanical advantage of 13
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 beings 211 As the effective
vibratory area of the tympanic membrane is only two- thirds the effective
areal ratio is reduced to 141 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
Page | 41
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 lobe
Page | 42
DISEASES REVIEW
करणसराव
Nirukti - करणसय कणवयोाव ससराा [62]
Nidana- Acharya Sushruta and Vagbhata describe the common etiological
factors for the Karnaroga
अशयाय जलिीडा कणवकणडयन मरत
शमथययोगन शसततरसतय कवपतो अरय च कोपन ||
सउ २० १२
1 Avashaya or Pratishaya
(Excessive exposure to cold)
2 Jalakrida
(Excessive swimming)
3 Karnakandunyanum
(Excessive scracing due to itching)
4 Mithyayogena Shatrasya
(Improper instrumentation during wax removal or foreign body removal)
5Shabdasya
(Louder sound for long durationperverted contact of sound)
6 Abhighata (Trauma)
7 Vitiation of Tridoshas
Page | 43
Samanya Nidana according to different Samhita
Vishesh Nidan of Karnasrava
Acharya Charaka has not mentioned any kind of Nidana regarding Karnaroga
but has described Utapati of Karnaroga from Siroroga in Karnasirasym
Adhyaya[67]
शशरोअशिघातादरा तनमजजतो जल परपकादरा अवप विि
सरतत पय शरणॊ अतनलात स कणवससरा इतत परककतीत
सउ २० १०
असस ३७२५ [68]
1 Shiroabhighatat - Head Injury-Fracture of middle cranial fossa
2 Jala nimajjana - CSF otorrhoea fracture of middle cranial fossa
3 Karnaprapaka
4 Karna Vidhradhi -Puyasrava
Sr
no
Samanya Nidana SU AH[63] AS[64] YR[65] MN[66]
1 Avashaya + + +
2 Pratishaya + +
3 Shabdha
mithyayoga
+
4 Shashtra
mithyayoga
+ + +
5 Karnakandooyan + + + + +
6 Jalkrida + + + + +
7 Abhighata + + +
Page | 44
Samanya samprapti
परापय शरोतरशसरा कयावत शल शरोतशस गान
त कणवगता रोगा अटिावशततरीता
सउ २० १२
Due to common and specific etiology factors the vitiated Doshas gets
Sthanasamshraya in Karna and causes Karnasrava It is the stages of
Samprapti were Doshas gets lodged in Srotas and start processes of Dosh
Dushya Sammurchsna Due to Shiroabhighata Jalanimmajana Karna Paka
Karna Vidhradi vitiated Vata Dosha and Karna becomes Avruta by Vata and
results in Karnasrava Normal physiology of Dosha Dhatus and Malas entirely
depends on the normality of Srotas Dosh Dushya Sammurchana or
manifestation of diseases will not take place if only vitiation of Doshas take
place without deformity of Srotas Here in Karnasrava vitiation of Srotas are
Atipravritti Sanga and Vimargagamana take place Atipravritti is being excess
production of fungus Sanga is obstruction in external acoustic canal
Vimargagamana is the propagation of discharge through ear
Vishesh Samprapti
Karnasrava occurs due to Nij nidana is Pratishaya while Agantuja nidanas are
Avashya Jalkrida and Karnakanduyan Due to etiological factors which are
Vata-Kapha provocative in nature gradual vitiation of Doshas will occur After
vitiation they get accumulated (Sthan samshraya) in external auditory canal
In other hand when patient does Sevana of Agantuj Nidan like water enter in
external ear scratching of ear unsterile instrumentation leads to Dosh
Prakopa These cause Twak and Mamsa Dhatu Dushti which leads to
discontinuity of epithelium of ear canal which creates suitable atmosphere for
fungal pathogen to grow The vitiated Vata will produce symptoms such as
Page | 45
pain hearing impairment and vitiated Kapha causes symptoms like itching
discharge ear blockage By assessing the symptoms it can be said that Kapha
Avrita Vata Dosha is responsible for the manifestation of clinical features like
pain itching discharge Which are seen in Karnasrava that is otomycosis
Acharya Charaka has mentioned while explaining Samanya Chikitsa of
Karnaroga that it should be treated like Vrana when Paka and Srava is present
as a symptom Fungal spores invade in the epithelial layer of EAC In response
to infection inflammatory process is start This is a Paka Avastha After
removing the fungal mass ulceration in external acoustic canal is commonly
seen As a result of infection process exudates was produced which will mix
up- with fungal colonies and appear as discharge As per Dosha involvement
in Vrana Shoola Srava can be differ According to Acharya Sushruta Ruk is
the Samanya Lakshana of Vrana and Vishesha Lakshana of Vrana includes
pain discharge discoloration itching etc according to Dosha involvement
which are also seen in otomycosis In otomycosis mainly watery and purulent
type of discharge is present which indicates Paka avastha If there is Dosha
involve in Vrana is called Dushta Vrana Acharya Sushruta and Acharya
Vagabhata have mentioned verity of Srava in Twak and Mamsa Vranavastu
which is found in otomycosis Based on this description otomycosis can be
correlated with Karnasrava
Page | 46
Representing the Samprapti of Karnasrava
Vishesh Nidana ndash Shiroabhighatat
Jala nimajjana
Prapaka Vidhradhi
Vitited vata
Avarana by kapha
Vimargagamana of Vata
Karnasrava
Samprapti Ghataka
Dosha ndash Kapha and Vata
Dushya ndash Rasa Rakta and Mansa
Strotodushti ndash Vimargagamana and Sang
Adhishthana ndash Karna (Bhayakarna)
Rogmarga ndash Madhyama
Page | 47
Purvarupa
The Purvarupa of Karnasrava are not mentioned separately in any ayurvedic
classics In routine practice cretin Purvarupa are noted
1 Karnakandu
2 Karnagurutwa
3 Alpa karnashoola
4 Discomfort in ear
Rupa
1 Karnashoola
2 Karnakandu
3 Karnasrava
4 karnabadhirya
5 Cotton wool like or wet newspaper like grayish brown or black colored mass
is seen
6 External auditory canal skin appears edematous and red
Upashaya and Anupashaya
Appropriate application of Aushadhi Ahara and Vihara when produces relief in
the symptom is called as Upashaya and when aggravates the symptoms is
called Anaupashaya There is not any reference available in the classics about
the Upashaya and Anupashaya of karnasrava
Sadhyasadhyata
Sushruta has not mentioned specially the Sadhyasadhyata of Karnarogas But
Vagbhata has mentioned Karnasrava as a Sadhyavyadhi[69]
Sadhysadhyatagives the clear picture of prognosis of the disease It depends
on many factors like nature of disease severity of disease Vaya Prakriti Bala
of the patient etc
Page | 48
Upadrava of Karnasrava
In Samhita there is no reference available regarding the Upadrava of
Karnasrava
Samanya Chikitsa ndash
The common treatment principle for all Karnaroga is Ghritapana Use of
Rasayana Bhrahmacharya Avyayama Shirasnana and Atibhashaya
सामरय कणवरोगष घतपान रसयनम
अवयायमो शशराःसतनान बरमहचयवम कतपरनम
स उ२१३
Ghratapana - Ghrita is a Yogavahi and follow Sanskara in addition to these
acquired properties and capable of retaining its own properties So Ghritapana
is effective in Karnasrava
Rasayana - Rasayana represent the basic approach of Ayurveda which
comprise preventive promotive and curative aspect of health
Brahmacharyaapalana -It is like Sadvrittapalana and is equals to Rasayana
effect
Vyayama - It leads to vitiation if Vatas a Karna is a Sthana of vata and
exercise causes Kshayaj Samprapti hence it is important to avoid exercise in
Karnasrava
Shirasnana- In Shirasnana water enters in external acoustic canal it changes
the PH of meatus skin from acid to alkali which favors the growth of pathogens
Atibhashya - Excessive speaking causes Vata Prakopa and Vatapraokopa is
basic Samprapti for Karnasrava as the preventive aspect avoidance of
excessive speaking is necessary
Page | 49
Ghritapana Rasayana and Brahmacharyapalana should be followed for
preservation of dhatu Samyata and restriction of vitiation of Vata Vayayama
Shirasnana and Atibhashaya should be avoided in Karnasrava to protect the
Siras from the affliction of Vata and Kapha
Vishesha Chikitsa ndash
The general treatment principle of Karnasrava described in classics is closely
related to Dushtavrana Chikitsa
शशरोवरचन च ए िपन परण तरा
परमाजवन िान च ीकषय ीकषय़ाचारत [70]
स उ २१४०
कणवसततरा ोददत कयावत पततकशमकणवयो [71]
ाउ १८३५
उपददि च सततरोत साय परात वपचततवशि परमजय
य अगर मदन सघत गगलना ा िपतयतपा मिना परयत [72]
असउ २२४२४३
In addition to that Shirovirechana Karnadhoopana Karnapurana
karnapramarjana Karnadhavana are also indicated
Page | 50
Treatment is also mentioned for Karnasrava
1 Karnaprakshalana Yoga - with Aargawadadi Gana Kashaya and Surasadi
Gana Kashaya [73]
2 Avachurnana Yoga ndash with Aargawadadi Gana Churna and Surasadi Gana
Churna[74]
3 Karnapoorna Yoga ndash
bull Rasanjana Laksha with Sarjachoorna[75]
bull Panchkashaya with Kapittha swarasa and Madhu[76]
bull Jambu AmrapallavShivalaKshuodra Mahavriksha and Madhuki 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 done[77]
bull Sarjatwak Choorna with Karpashiphalarasa and Madhu[78]
bull Abhaya LodraTindukaSamanga(Manjista) Kwatha of this Dravyas mixed
with Madhu and Kapittha Rasa[79]
bull Yogratnakara mention the following drugs for Karnapoorana-
a Samudraphena Churna[80]
b Jambwambpatra Yoga
4 Karnadhoopana Yoga ndash
bull Dhoopana with Churna of Bilvapatra Haridra Palandu[81]
bull Vartak Dhoopana [82]
5 Internal Medications-
bull Rasnadi Guggula [83]
bull Triphala Guggula [84]
bull Sarivadi Vati [85]
bull Gandhaka Rasayana [86]
Page | 51
According to Vagbhata-
Ear should be cleaned with the Pichu and Varti followed by Guggula Dhoopana
and then Karnapoorana with Madhu Followed by Avachurnanana with
Sukshmachootana of Surasadigana
Pathyaapathya ndash Pathya and Apathy mentioned for Samanya Karnaroga is
recommended in Karnasrava also
पथय[87]
सतदो वरको मन नसतय िमाः शशरावयिाः
गोिमाः शालयो मदगााः याशच परतन हवाः 80
लाो मयरो हररणानदसततततरो नकककिाः
पिोल शशगर ातावक सतनषराण कदठललकम
रसायनातन सवणण बरमहचयवमिाषणाम |
उपयकत यरादोषशमद कणावमय दहतम ||81||
िापर २१
Aharaja Upacharaja
bull Godhuma bull Vamana
bull Shala bull Virechana
bull Mudga bull Nasya
bull Yava bull Dhoomapana
bull Puranagitra bull Kavala
bull Lava Harina Tittiramamsa
Page | 52
अपथय[88]
दरत काटठ शशरसतनान वययाम शलटमल गर
कणडयन तषारशच कणवरोगी पररतपयजत
िापर २१
Viharaja
bull Patola ShigruVartaka bull Bhramacharaya
bull Sunishannaka bull Avyayama
bull Katthlika bull Aakthanam
bull All types of Rasayana bull Upacharaja
bull Vamana
Apathyas
bull Abhishyandakara Aharas
bull Shirasnana
bull Karna kandooyana
bull Tushara sevana
bull Guru Kaphakaraka Aaharas
bull Dantdhavana
Page | 53
OTOMYCOSIS
Definition-
Otomycosis is a superficial acute sub-acute or chronic infection of external
ear canal It is mostly unilateral It is characterized by inflammation purities
and scaling Otomycosis is a common condition encountered in ENT practice
more in chronic and persistent ear infection
The Fungal infections are not communicable in the usual sense but the
humans become an accidental host by their introduction into tissue trauma
The virulence factors favoring colonization of fungus in human host are yet to
be identified Ability of the fungus to grow at 37 C and elaboration of a variety
of enzymes and toxins are speculated to contribute to virulence Only 100 to
150 species are generally recognized as a cause of disease in humans[89]
Prevalence-
Otomycosis is a word wide in distribution and in various record stated that 5
to 20 of all cases of infective otitis externa Otomycosis prevalent is more in
warm and humid climates It is one of the commonest manifestations in India
during rainy season It occurs mostly in humid atmosphere otitis externa due
to fungal infection may resembles the desquamative form of diffuse infective
otitis externa The incidence in temperature climates has increased in
proportion to the use of topical antibiotics which have a medium sterilized of
other organism in which the fungus may flourish
Page | 54
Predisposing factors- [90]
1 Environmental factors such as climate contagious and polluting hygiene
more frequently during rainy season as the humidity increases
2 Individual susceptibility ndashGeneral Immunological status of the Individual
eg HIV infection Radiotherapy chemotherapy Diabetes mellitus
3 Self-inflicted trauma that is use of pins to clean the itching ear or use of ear
bud to clean the wax
4 Wide spread of topical antibiotics steroid preparations which have medium
sterilized of other organism in which the fungus may grow
5 Failure of defense mechanism in External auditory canal
6 During swimming or head bath water enters in External acoustic canal
causes quantitative and qualitative change in ear wax It causes change in pH
7 Long term use of hearing aids
Pathophysiology ndash
The life cycle of the average mold encountered in the ear may be reckoned
as two weeks and flare ups may be anticipated at such intervals Swimming is
held responsible for infection in many cases The sequence sequence of
pathogenic changes produced by molds in the external ear is as follows ndash
1 Implantation of the organism in external ear
2 Growth of organism follows the rate depending on condition of temperature
moisture or preexisting irritation
3 Invasion of epithelium occurs with attendant itching and discomfort which
may be quite severe
Page | 55
4 Exfoliation of epithelium occurs as nature attempts to overcome the
infection by casting off upper most cells
5 Denudation occurs from exfoliation as the top layers of epithelium are cast
off and the canal becomes filled with debris
6 Superficial ulceration and lizematoid dermatitis results if the pathologic
process goes for enough The changes do not always proceed through the
entire sequence sometimes the molds produce changes of the mildest
imaginable character which may be overlooked[91]
Clinical features -
Symptoms-
1 Irritation and itching ndash Irritation is mostly found when the infective
organism is aspergillus niger There is sensation of discomfort which is more
diffuse in the ear canal then localized in the deeper part Candida infection
causes marked itching In external ear it is intense and worse at night
2 Discharge through ear- Intermittent scanty colorless discharge through
ear Mucus being a fungal metabolic product appears as discharge Excessive
discharge is associated with mixed infection
3 Pain and discomfort ndash Mild to severe pain in the ear occasionally Mostly
seen in cases where ear is infected with Aspergillus flavus mixed infection
with gram negative organism or mixed infection with candida and aspergillus
Headache is sometimes associated with pain
4 Deafness- Varying degree of mild to moderate conductive deafness
5 A sensation of fullness in ear
6 Tinnitus 7 Vertigo
Page | 56
Signs ndash
1 The external acoustic meatus may contain a mass formed of epithelial
debris exudates cerumen and fungus
2 Erythematous external canal
Fungal appearance
A Niger - The color of the mass which is usually grey or black is mainly
determined by the type of fungus concerned Its appearance is like wet
newspaper or blotting paper or a cotton wool It has a peculiar musty odor In
this infection fruiting heads may be seen as black specks in the debris
Occasionally as inactive form occurs in which the canal is lined by mold giving
a fluffy appearance due to the presence of tiny mycelia
Candida ndash Candida infections generally show as white deposits on magenta
colored skin when the debris is removed it rapidly recovers in 24 hrs
The underlying canal skin is often inflamed and granular due to invasion by
fungal mycelia and be seen in all cases In rare cases excoriation and
ulceration with marked extensive shedding of the epithelium and deep
ulceration can be seen usually associated with a flavus and with pathogenic
bacteria[92]
Otoscope Appearance
1 Aspergillus Niger ndash Black headed
2 Aspergillus Fumigators ndash pale blue or green
3 Candida Albicans ndash White- or cream-colored deposits
Page | 57
4 Auricle is normal in most cases In severe cases small ulceration with crust
formation may be present on lateral surface
5 Tympanic Membrane
In most cases it is normal with normal mobility and normal hearing In a few
cases the surface of the tympanic membrane is congested and scaly There is
erosion or ulceration of the external epithelial layer and the membrane itself
may be edematous
Diagnosis
1 Above mentioned symptoms and signs
2 In the stage at which patient with otitis externa usually first present
themselves mycelia threads conidiophors not visible to naked eye may
sometimes be identified with the microscope
3 Confirmed by culture
Page | 58
Fig7 Aspergillus Niger Fig8 Candida Albicans
Fig9 Aspergillus Fumigators Fig 10 Wet Paper like appearance
Page | 59
Treatment
1 Antibiotic or steroid drops should be discontinued if they are being instilled
since long time
2 Removal of fungal mass epithelial debris and discharge from the external
canal or mastoid cavity repeatedly and thoroughly by forcepa or suction or
syringing or cautiously blow a stream of air into the canal through a fine
cannula and dry thoroughly by swabbing liquid petroleum on swab used in
cleaning the ear lessens the burning sensation when metacresy acetate is to
be employed in the subsequent treatment
Furuncle is developed as a complication if there is no gentleness in cleaning
Cleansing may have to be delayed until local sensitiveness is lessened which
can usually be accomplished within twenty-four hours If there is excessive
epithelial debris along with otomycosis then metacresyl acetate which is a
keratolytic in introduction into the external auditory canal on cotton wick and
is allowed to remain for twenty-four hours After twenty-four hours the cotton
wick is removed at which time the canal can usually be cleansed with little
discomfort as the medication is also anesthetic The epithelium of the canal
was white from contact with the drug The top layer was detached and this
epithelial debris can be easily wiped away The wick is reinserted and wet with
metacresyl acetate
The treatment is employed for three to four days in succession and then a
bland application is substituted Icthyol iodine is of value at this stage Iodine
ointment 2 in combination with Tannic acid 2 is also an excellent local
application following cresatin treatment
Next one of the fungicides may be applied
Page | 60
1 Nystin Effective for candida infection but less active against aspergillus
group Nystatin in boric powder consisting of 100000units of nystatingm of
powder 3 times week for 3 weeks
2 Clotrimazole Available as 11 cream or drops or lotions Phenyl
(zchlorophenyl) 1 ndash imidazole ndash methane is a chlorinated trityl imidazol 1
effective against candida and dermatophytes and for aspergilli infection
3 Amphotericin B Available as cream and as 3 solution and 015 drops
for topical application Very effective for candida infection can be fungistatic
or fungicidal
4 Econazole Available as solution (Econazole nitrate) and as cream (1)
Broad spectrum ndash more effective for Aspergillus Also active against some
gram-positive bacteria (Staphylococci and Streptococci and Dermatophytes)
5 Miconazole Highly effective against dermatophytes and candida infections
used as a 21 cream applied once or twice a day for 10 days
6 Gentian violet 21 Available as drops (recently some evidence of
carcinogenicity) Discolors the ear canal and this interfere with clinical
examination
Other topical antifungal agents are ketoconazole Natamycin Tolciclat Bifonas
zole Fenticonzole Oxiconazole Tioconazole ciclopiroxolomine Tolnafate
Haloprogin Flucytosine Acetic acid Whit field ointment selenium sulfide
undcyclenic acid triacetin etc
Page | 61
Minimal length of treatment
A month of drug treatment is usually required because the antifungal agents
used are not sporicidal and it is necessary that the period of treatment covers
germination time It may be advisable to give short gaps in the period of
treatment to ensure all spores have germinated before deciding to terminate
therapy
Prevention
Accomplished by strict attention to the predisposing causes
1 Water should be prevented from entering the ear
2 Avoidance of external ear trauma
3 Use of alcohol medicated or plain in the ears after swimming mercuric
cyanide (15000) in ethyl alcohol (70) is a satisfactory liquid to use
Ear stoppers do no good unless their use is followed by some antiseptic in the
canal Divers exposed to water for long periods of time may also use acidic
alcohol
4 During Summer months with their high humidity special efforts are needed
to maintain ear dry 5 Indiscriminate use of topical antibiotics steroid
preparations should be avoided
Page | 62
DRUG REVIEW
1 GUGGULA
Fig11 - Guggula
Historical review of Guggula [93]
bull Atharvaveda one of the well-known Vedas of Hindus The earliest
reference given by Atharvaveda medicinal and therapeutic properties of
Guggula Guggula has long history of use in Ayurveda
bull Acharya Charaka Sushruta and Vagbhata describe detail regarding the
actions uses and indication as well as the variety of Guggula
Page | 63
bull Various Nighantus (Medical lexicons) were written between 12th and 14th
centuries AD was based on the Ayurvedic literature also describes
Guggula
bull The explanation of word Guggula is that Gunjo Vyadhegurdti Rakshati
which means to relief against different diseases
bull Guggula is the best medicine because it develops through the rays of
hot sun on specific circumstances
bull Guggula has an aromatic odor
गगलो कणवदौगवररधय िपन शरटठमछयत[94]
स उ २२११२
Latin name- Commiphora mukul
Family ndash Burseraceae
Rasa- Tikta Katu
Guna ndash Laghu Rukshasukshma vishada sara
Veerya ndash Ushna
Vipaka ndash Katu
Action- Rasayana Lekhana
Doshaghanta - Tridoshhara
Page | 64
Chemical composition [95]
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Oleoresin-Z-Guggulsterone E-Guggulsterone
Gum- guggulignans 1 and 2 guggula Tetrols mukulol allylcembrol c
27
Guggulusterol 1 2 ans 3 Z and E ndash guggulusterol
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Parts Used ndash Gum oleoresin
Guggula purity test
1 Yellowish brown emulsion is obtained when Guggula is triturated with
water
2 An ethereal solution of the drug attains reddish colour when treated
with br2 vapors and purple colour when moistened with nitric acid
Biochemical action ndash Antiseptic Anti-inflammatory Disinfectant Diuretic
Immunostimulant stimulating expectorant Ant suppurative Antipyretic
Enhance phagocytosis
Karma- Rasayana cardiovascular disease
Page | 65
2 AGARU-
Fig 12 Agaru
Historical review of Agaru [96]
bull The word Agaru literally means the one which is the heaviest and no
aromatic wood is heavier than it Since thousands of years Agaru lsquoThe
wood of Godrsquo has been used for multiple purpose like commercial
medicinal spiritual aromatic historical
bull The medicinal use of Agaru have been recorded in many pieces of India
Greek Roman Chinese Middle eastern and European since ancient times
bull Acharya Charaka used Agaru and pest of Rasna to counteract the effect of
cold in Agraya Dravyas
bull Acharya Sushruta used Agaru as a Dhoopana Dravya along with Guggula
Ral and Shoma in the treatment of Karnasweda and Vrana
Page | 66
Types-
bull Dhanwantsri Nighantu describes Kaleyaka as a type of Agaru
bull Sodhala Nighantu describes three types of Agaru ndash Agaru Krishna
Agaru Kakatunda Agaru
bull Raj Nighantu describes five types of Agaru ndash Krishna Agaru Kasht
Agaru Daha Agaru Mangalya Agaru and Agurusaar
bull Arthashasstra describes three Agaru wood product
1 Jongaka ndash Black or variegated black in colour and having variegated
spots
2 Dongaka ndash Black in color
3 Parasamudraka- Black in colour and smells like Navamallika
अगर उटण कि तपछय ततकत ततकषण च वपततलम
लघ कणाविरोगघन शीत ात कफपरणत
िापर २१ [97]
Family- Thymelaccensis
Latin name- Aquilaria agallocha
Guna- Laghu Ruksha Tikshan
Rasa- Katu Tikta
Vipaka ndash Katu
Virya ndash Ushna
Karma- Sheetaprasasmana Vranaorasadan Tvachya Pittavardhaka
Shirovirechana Mangalya Sugandhik and Rochaka in properties [100]
Krishna Agaru karma- Katu Tikta rasa Ushna Sheeta when applied externally
and Pittahara when taken orally
Page | 67
Chemical Constituents -
Agaru hardwood is rich in essential oil resins alkaloids saponins Steroids
terpenoids tannins flavonoids and phenolic compound Agaru wood
predominantly contains 2-[-2-phenylethy]-4H-chromen-4-one derivatives and
sesquiterpenes Agaru oil contains selinene dihydroselinene agarnol b-
agarofuran vetispira-2(11)valerianol dihydrokaranone and tetradecanoic
acids[99]
Part Used ndash
Heartwood- Dark resinous wood which is formed when the plant becomes
infected with a type of fungus (ascomycetous mold) Species of Aspergillus
fusarium and penicillium are reported to be associated with the development
of infection Prior to infection the heartwood is odorless relatively light and
pale colored however as the infection progresses the tree produces a dark
aromatic resin in the heartwood The infected resin in response to the attack
which results in accumulation of a very dense dark resin in the heartwood
The infected resin embedded wood is known as Agarwood Infection is more
common on the trunk roots and the area when branches divide The formation
of Agarwood starts when the tree attains the age of 20 years On an average
approximately 30 ml oil is extracted from 100 kg of infected Agarwood[98]
Qualities of best Agaru-
It should be black in color
It should be extremely heavy and aromatic
It should be oily in appearance and test
It should be sink in water
It should burn easily with bright flame with a bright flame giving off a pleasant
smell
Page | 68
3 MADANA
Fig 13 MADANA
Madana consist of dried fruit of Xeromphis spinosa It is a deciduous thorny
shrub or a small tree reaching a high up to 9 m and girth about a meter
branches numerous thick and horizontal found in sub-Himalayan tracts[101]
मदनो मिरनदसततकतो ीयोटणो लखनो लघ
ानदरतिदवििीहर परततशयायवरणारतक
रि कटठकफ़ानाहशोथगलमवरणापह[102]
िा पर १६० १६1
Page | 69
Latin name-Randia dumetorum
Familly ndash Rubiaceae
Rasa - Madhura Tikta
Guna-Laghu Ruksha
Virya- Ushna
Vipaka ndash Katu
Karma- Vamana and Lekhana
Chemical Composition-
Essential Oil Valerianic acid Saponin tannin resin [103]
Page | 70
YAWA [104]
Fig 14 Yawa
1 In Samhitakala Aacharya Charaka Acharya Sushruta explain detail about
medicinal properties of Yawa
2The use of Yawa in Aaharya Dravya mainly described by Dhanwantari
Nighantu Raj Nighantu Bhavprakash Nighantu[105]
Macroscopic Description-
Fruit a caryopsis elliptical oblong Ovoid and tapering at both ends smooth
about 1cm long and 02- 03cm wide dorsally compressed and flattened on
the sides with a shallow longitudinal furrow 3-5 ridges having shallow
depression between them grains tightly enclosed and adhering the lemma
and palea pale greenish yellow odor not distinct taste sweetish acrid
Page | 71
Latin Name ndash Hordenum vulgare
Family- Poaceae
Rasa- Kashaya Madhura
Virya- Sita
Vipaka- Katu
Karma- Vatakrt Pittahara Kaphahara Medahara Balya Visrya
SthairyakaraLekhana
Page | 72
PROCEDURE REVIEW [105]
In Ayurvedic classics there are many references regarding Dhoopana Dravya
Dhoopana is administering Dhuma with the help of Dhoopana Dravya
In Kashyapa Samhita there are 40 types of Dhoopana advised for children
Anesthesia (Mohajananam Dhoopa) is also mentioned For this Dhoopana the
drug used were herbs hairs of animals legs horns old cloths of Buddhist
monks
From the references available regarding Dhoopana we can understand that
Karna can be protected from maggots (krimi) Bactria (Rakshogna) lice etc
References clearly indicate the analgesic and disinfectant effect of Dhoopana
Karma Dhoopana is mentioned for Dushta Vrana Chikitsa It reduces Vedana
Srava Pootigandha of Dushtavrana It also helps in Vranaropana
Dushtavrana Chikitsa is mentioned in the treatment of Karnasrava[106]
Origin of Dhoopana-
In ancient period children of sages were constantly harassed by the
Rakshasas Hence the sages approached lord Agni for shelter Agni in turn
gave them Dhoopana Dravya and asked sages to use the Dhoopana for
protection against Rakshasas bhutas pishachas
Classification of Dhoopana
1 It is classified into Dhupa Anudhupa Pratidhupa
2 On the basis of Origin it is classified into Jangama and Sthavara
Selection of Guggula for Dhoopana
Page | 73
bull Guggul is a best Vatahara
bull It is Krimighana
bull It contains Oleoresin
bull In Ashtang Hrudaya Guggula Dhoopana mentioned for Karnasrava
Selection of Agaru for Dhoopana
bull Agaru is Laghu Ruksha Katu Tikshna
bull Vranaorasadan Tvachya
bull It should burn easily with bright flame with a bright flame giving off a
pleasant smell
Karna Dhoopana Indication
1 Karnaarava
2 Putikarna
3 Krimikarna
4Vataj Karnashula
Contraindications
Especially for Karnadhoopan contraindication is not mentioned in classic texts
But Dhoopana is contraindicated in Pittaj vaydhi Sharad and Grishma Rutu
Page | 74
MATERIAL AND METHOD
Page | 75
For randomize comparative clinical trial to study the effect of Agaruwadi
Karnadhoopana and Guggula Karnadhoopana in Karnasrava following material
and method were required
Source of data
Patient irrespective of gender occupation religion social economic status
signs and symptoms of classical features of Karnasrava (Otomycosis) selected
from the OPD of Shalakyatantra department
Materials ndash
1Patients
2 Drugs-Agaruwadi Dhoopana
Guggula Dhoopana
3Torch
4Otoscope
5 Tuning fork
6Jobson horn probe
7Cotton
8Case record form
DRUG
Group A Trial Group
1Churana of Agaru Yawa Madan
2Ghrita
3Jala
Group B Control Group
1Googula Churna
Page | 76
Properties of Drug
Table no 1 Properties of Drug
Drug
Family
Rasa Veerya Vipaka Effect
on
Dosha
Guna Karma
Agaru
(Aquilegria
Agallocha)
Thymelaca
ceae
Katu
Tikta
Ushna Katu KV Laghu
Ruksha
Tikshna
Shitaprashamana
Shothahara
Vedanasthapak
Durghandhihara
Madan
(Randia
spinosa)
Rubiaceace
Kashaya
Madhur
Tikat
Katu
Ushna Katu KV Ruksha
Laghu
Vatakaphaghana
Shothahara
Vedanasthapak
Vranashodhak
Yawa
Poaceae
Hordeum
Vulgare
Kashaya
Madhur
Sheeta Madhur KP Ruksha
Laghu
Vataghana
Vernashodhana
Raktshodhaka
Guggula
Commiphora
Mukul
Burseracea
e
Tikta
Kashaya
Anushna Katu VPK Laghu
Ruksha
Shothahara
Vedanasthapaka
Kandughna
Ghrita Madhura Sheet Madhur VK Snigdha Vataghana
Shothahara
Vedanasthapaka
Page | 77
METHODOLOGY
SELECTION CRITERIA
1)INCLUSION CRITERIA
1 Patients having signs and symptoms of Karnasrava (Otomycosis) ie करणशल
( pain ) करणकणड ( Itching ) करणसतराव ( Discharge )बाधिरण ( conductive Loss of
hearing )
2 Patient from age group 19 to 70 years
3 Any Gender
2)EXCLUSION CRITERIA
1 Patients suffering from any systemic disease like DM TB HTN
2 Chronic suppurative otitis media (CSOM)
3 Acute supportive otitis media (ASOM)
3 Perforation of Tympanic membrane
4 Chronic otitis media
3)WITHDRAWAL CRITERIA
1If patient develops any adverse effect such as irritation pain burning
sensation in ear loss of hearing and such patients was withdrawn from trial
and receive prompt appropriate medical attention
2If patient shows aggravation in symptoms
3If patient refuses to continue with the treatment
Page | 78
STUDY SETTING
Types of study - Randomized Clinical comparative Trial
Place of work - OPD of Shalakyatantra
Duration of study - 18 months
Study Population - Patients of Karnasrava in Shalakyatantra OPD
SAMPLE SIZE CALCULATION
Sampling Method ndash Purposive sampling followed by random allocation in two
groups
Sample size calculation-
n = z2 p (1-p)
d2
Were
n = sample size
P = prevalence of disease=10
z = standard normal variable ie 196
d = error ie005
desired Sample Size would be
n = Z2 P(1-P)d2
= (196)2x (0021) x(0979)(005)2
= 34
Visiting ENT OPD (ShalakyaTantra) and IPD (ShalakyaTantra) 21 = 34
n raquo34
So one group includes 34patients
Page | 79
Sampling Method
Total 68 patient of Karnasrava are selected by Purposive sampling followed by
random allocation in two groups Written informed consent is taken prior to
commencement of trial They are divided in 2 groups
Group A (Trial Group) 34 patients treated with Agaruwadi Dhoopana for 7
days
Dose 5 minutes twice in a day
Group B (Control Group) 34 patients treated with Guggula Dhoopana for 7
days
Dose 5 minutes twice in a day
STUDY DESIGN ndash
Open labeled Randomized Comparative Clinical trial
STUDY DESIGN
Screening of patient
Inclusion criteria satisfied Exclusion criteria
Initial assessment Excluded
Counseling of patient Treated accordingly
Patient selection by Simple Random Sampling Method
Page | 80
68 Patients were divided in two groups lsquoArsquo and lsquoBrsquo
Trial group A-34 patients were given
Agaruwadi Dhoopana
Control group B- 34 patients were
given Guggul Dhoopana
Informed written consent
Treatment was given for 7 days
Assessment on 1st 4th and 7th day
Post assessments follow up on 15th day
Observation
Data Collection
Statistical analysis of data
Conclusion
Page | 81
(A) Agaruwadi Varti for group A (Trial group)
Table no 2
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
B) Guggula Varti for group B (Control group)
SOP of it is same as above Agaruwadi Varti
Table no 3
Drug Guggula Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
FOLLOW UP
For both groups follow ups were done on 1st 4th and 7th and post
assessment follow up15th day
EXAMINATIONS
Torch for Local examination of ear
Otoscope examination
Tuning fork Test
Page | 82
OBSERVATION TABLE
Table no 4
Sr no Subjective criteria Day 1 Day 4 Day 7 Day 15
1 करणशल
(pain)
2 करणकणड
(Itching)
3 करणसतराव (Discharge )
4 बाधिरण (Conductive Deafness)
OBSERVATIONS
a) करणशल (Pain) -
0 - Absent
1 ndash Present
b) करणकणड (Itching) -
0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
Page | 83
c) करणसतराव (Discharge)
0- Absent
1- Mild -Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाधिरण (conductive Loss of hearing)
0 - Absent
1- Present
Observations were carried out before and after completion of treatment and
during each follow up After observations the data collected and presented in
the form of graphs charts and table
Page | 84
TRIAL DRUG
Authentication and standardization of raw drug material done After
authentication and standardizing of raw drug material Agaruwadi Varti was
prepared by Varti as explained in Ayurvedic classics
Method of Varti preparations
Panchavidh Kashaya Kalpana that is five method of pharmaceutical
preparation constitutes the fundamental process of Ayurvedic pharmaceutics
which is well explained in Sushrut Samhita Varti Kalpana is one among them
which can be included in Kalka Kalpana
तीररसतरपतपतीनामपरककव तीत [106]
स डलहण शरच 151
Medicines are powered triturated and given the Varti shape that is like wick
of lamp so it is called as Varti Kalpana
Drug content Agaru Madan Yawa
Route of Administration Local
Dose Two times a day
Duration 7 days
Page | 85
Methodology
Standard operating procedure (SOP) of Agaruwadi Varti
Agaruwadi Varti is prepared according to the classical text
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization was done as recommended in pharmacy procedure The
raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 mixed together in
equal quantity to make Agaruwadi churn
Quantity of each churn is 4 grams all are mixed when the Varti get dry total
weight of Varti was 10gram
STEP 4 - Agaruwadi churn triturated with appropriate quantity of water or
Ghrita and prepared Varti in GMP Certified Ayurvedic pharmacy Standard
aseptic precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Varti was packed in sterile air packed container
STEP 6 - Agaruwadi Dhoopana was given with the help of Dhoopana yantra
Authentication and Standardization of raw drug of Agaruwadi Varti was done
Sterilization was done as recommended in pharmacy procedure Sterile
preparation packed in sterile container of suitable size Under all aseptic
precaution Karnadhoopana given to infected ear
Page | 86
Containers for packaging and their sterilization-
Sterilization of the containers for storing Varties was done by Ethylene Oxide
(Eto) method
Ethylene Oxide (Eto) procedure-
It includes exposure of materials to ethylene oxide gas under vacuum in a
sealed chamber It consists of four primary variables
1Gas Concentration
2Humidity
3Temperature
4 Time
EtO gas is an alkylating agent which disturbs the DNA of microorganism
preventing them from reproducing It penetrates the breathable packaging
and sterilizes all the accessible surface of the product to render products
sterility by alkylation of essentials proteins for cell reproduction
Most Eto sterilization methods involves three different stages These can be
separated into three different on the size or number of devices to treat
1Preconditioning stage-
First products are passed through a preconditioning phase to make
microorganism grow The batch load goes through a well time under a
controlled environment of temperature and humidity
2Sterilizer stage-
Performed using process phase specially designed to provide the required level
of EtO exposure to assure sterility for a device or family of devices
3Degasser Aerration stage-
Finally products need to go through a degassing phase to remove any residual
particles of Eto The batch load goes over well time under a temperature-
controlled environment
The sterile containers were then used to store Agaruwadi Varti and handed to
patients included in the study
Page | 87
Packing of Agaruwadi Varti
The ETO sterilize plastic container were used for packing of Agaruwadi Varti
Varti was filled into these sterilize containers (7 in each) In an aseptic
environment plugging and capping was done under aseptic precautions In this
way packing of Agaruwadi Varti done These Varti were given to patient and
advise to take two times a day under all hygienic precautions
History and Examination
bull Proper history and presenting complains was recorded on case record form
bull Ear examination with otoscope was done during initial assessment and each
follow up
bull Otoscopic examination was done during initial assessment and each follow
up
bull Systemic Examination that is Blood Pressure Temperature Respiration
rate Pulse was recorded on case record form
Page | 88
Raw material
Fig14 यव चरण Fig15 मदनफळ चरण
Fig16 अगर चरण Fig17 गगगळ चरण
Page | 89
Preparation of Agaruwadi Varti
Fig18 Preparation of Agaruwadi Varti
Fig19 अगरवादी वरती
Page | 90
Fig20 Instruments used for examination of Karnasrava
Fig19 Karnadhoopana Yantra
Page | 91
Karnadhoopana Procedure
Fig 22 Karnadhoopana Procedure
Page | 92
OBSERVATIONS AND RESULTS
Page | 93
BASED ON DRUGS
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 94
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
AUTHENTICATION CERTIFICATE
Page | 95
BASED ON STASTICIAL ANALYSIS OF DEMOGRAPHIC DATA
68 patients of Karnasrava ndash Otomycosis
Table no 5
No of Patients Total
Group A Group B
Registered 38 37 75
Completed 34 34 68
Discontinue 04 03 07
Total 68 patients were enrolled in study 38 patients registered in group A
amongst them 34 patients completed the treatment and04 patients
discontinued the treatment However in group B 37 patients completed the
treatment and 03 patients discontinued the treatment out of 37 registered
patients
Hence the total number of patients registered in the present study was 75
and out of which 68 patients were discontinued the treatment So they
dropped out from the study While 68 patients were successfully completed
the treatment So observations and result of 68 patients were given below
Here we are going to discuss the statistical analysis of the data obtained in
the form of master chart that was prepared in accordance with the data
collected from the patients that had been included in the study The purpose
of statistical analysis was to analyzed the relation between age gender
occupation diet addiction and education
Page | 96
1 Age wise distribution of patients
Table no 6
In trial group 10 (29412) patients were from age group 18-25 years 14
(41176) patients were from age group 25-35 years 8 (23529) patients
were from age group 35-45 years and 2 (58824) patients were from age
group 45-60 yearsIn control group 6 (17647) patients were from age group
18-25 years 14 (41176) patients were from age group 25-35 years 7
(20588) patients were from age group 35-45 years and 7 (20588)
patients were from age group 45-60 years
Fig 23 Age wise distribution of patients
0
2
4
6
8
10
12
14
15 -25 25-35 35-45 45-60
10
14
8
2
6
14
7 7
Age Distribution
Trial Group N Control Group N
Age Distribution
Trial Group Control Group
N N
18 -25 10 29412 6 17647
25-35 14 41176 14 41176
35-45 8 23529 7 20588
45-60 2 58824 7 20588
Total 34 100 34 100
Page | 97
1 Gender wise distribution of patients
Table no 7
Sex
Trial Group Control Group
N N
Female 23 67647 15 44118
Male 11 32353 19 55882
Total 34 100 34 100
In trial group 23 (67647) patients were female and 11 (32353) patients
were male
In Control group 15 (44118) patients were female and 19 (55882)
patients were male
Fig 24 Gender wise distribution of patients
0
5
10
15
20
25
N N
TRIAL GROUP CONTROL GROUP
23
15
11
19
Gender
Female Male
Page | 98
2 Education wise distribution of patients
Table no 8
Education
Trial Group Control Group
N N
Illiterate 4 11765 3 88235
SSC 4 11765 3 88235
HSC 8 23529 9 26471
Graduation 16 47059 10 29412
Primary 1 29412 3 88235
Post-Graduation 1 29412 6 17647
Total 34 100 34 100
In trial group 4 (11765) patients were illiterate 4 (11765) patients were
SSC educated 8 (23529) patients were HSC educated 16 (47059)
patients were graduated 1 (29412) patients were primary educated and
1(29412) patients were post graduated
In control grou 3 (88235) patients were illiterate 3 (88235) patients
were SSC educated 9 (26471) patients were HSC educated 10 (29412)
patients were graduated 3 (88235) patients were primary educated and
6 (17647) patients were post graduated
Page | 99
Fig 25 Education wise distribution of patients
0
2
4
6
8
10
12
14
16
ILLITERATE SSC HSC GRADUATION PRIMARY POST GRADUATION
4 4
8
16
1 1
3 3
910
3
6
Education
Trial Group N Control Group N
Page | 100
3 Occupation wise distribution of patients
Table no 9
Occupation
Trial Group Control Group
N N
Accountant 1 294 2 588
Housewife 11 3235 8 2353
Engineer 1 294 1 294
Job 1 294 4 1176
Labor 1 294 3 882
Mess 1 294 0 000
Naturotherapyst 1 294 0 000
Pharma 1 294 0 000
Shopkeeper 4 1176 2 588
Singer 1 294 0 000
Student 8 2353 4 1176
Tailor 1 294 1 294
Teacher 1 294 1 294
Worker 1 294 3 882
Farmer 0 000 1 294
Lab Tech 0 000 1 294
Page | 101
Daily Collection 0 000 1 294
Fruit seller 0 000 1 294
Bus Driver 0 000 1 294
Total 34 10000 34 10000
In trial group 11 (3235 ) were housewife 8(2353) were students
4(1176) were shopkeeper 1(294) was accountant 1(294) was
engineer 1(294) was doing job 1(294)was labour 1(294) was
catering 1(294) was Naturotherapyst 1(294) was Pharma 1(294)
was Singer 1(294) was Tailor 1(294) was Teacher and 1(294) was
worker
In Control group 8 (2353)were housewife 4(1176) were students
2(588) were shopkeeper 2(588) was accountant 1(294) was
engineer 4( 1176) was doing job 3(882)was labor 1(294) was
Farmer 1(294) was Lab tech 1(294) was Daily collection 1(294)
was Tailor 1(294) was Teacher and 3(882) was worker 1(294) was
Fruit seller and 1(294) Bus driver
Fig 26 Education wise distribution of patients
0
2
4
6
8
10
12
1
11
1 1 1 1 1 1
4
1
8
1 1 10 0 0 0 0
2
8
1
43
0 0 02
0
4
1 13
1 1 1 1 1
Occupation
Trial Group N Control Group N
Page | 102
4 Religion wise distribution of patients
Table no 10
Religion
Trial Group Control Group
N N
Hindu 31 9118 33 9706
Muslim 3 882 1 294
Total 34 10000 34 10000
In trial group 31 (9118) patients were Hindu and 3 (882) patients were
Muslim
In control group 33 (9706) patients were Hindu and 1 (294) patient
were Muslim
Fig 27 Religion wise distribution of patients
0
5
10
15
20
25
30
35
N N
TRIAL GROUP CONTROL GROUP
3133
31
Religion
Hindu Muslim
Page | 103
5 Diet wise distribution of patients
Table no 11
Diet
Trial Group Control Group
N N
Veg 14 4118 20 5882
Non-Veg 20 5882 14 4118
Total 34 10000 34 10000
In trial group 14 (4118) patients were vegetarian and 20 (5882)
patients were Non vegetarian
In control group 20 (5882) patients were vegetarian and 14 (4118)
patients were Non-Veg
Fig 28 Diet wise distribution of patients
0
5
10
15
20
N N
TRIAL GROUP CONTROL GROUP
14
2020
14
Diet
Veg Non Veg
Page | 104
6 Addiction wise distribution of patients
Table no 12
Addiction
Trial Group Control Group
N N
None 30 8824 27 7941
Alcohol 2 588 0 000
Tobacco 1 294 2 588
Mishri 0 000 1 294
Smoking 1 294 4 1176
Total 34 10000 34 10000
In trial group 30 (8824) patients have no addiction 2 (588) patients
have addiction of alcohol 1 (294) patients have addiction of Tobacco 0
(0) patients have addiction of Mishri and 1 (294) patients have addiction
of smoking
In control group 27 (7941) patients have no addiction 0 (0) patients
have addiction of alcohol 2 (588) patients have addiction of Tobacco 1
(294) patients have addiction of Mishri and 11 (1176) patients have
addiction of smoking
Page | 105
Fig 29 Addiction wise distribution of patients
0
5
10
15
20
25
30
NONE ALCOHOL TOBACCO MISHRI SMOKING
30
21
01
27
0
21
4
Addiction
Trial Group N Control Group N
Page | 106
Statistical Analysis and Results
Effect of study on Karnashoola-
Table no 13
Karnashoola
Group A Group B
BT AT BT AT
N N N N
Grade 2 0 000 0 000 0 000 0 000
Grade 1 30 10000 7 2333 32 10667 5 1667
Grade 0 4 1333 27 9000 2 667 29 9667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 30 Effect of study on Karnashoola
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
30
7
32
54
27
2
29
Karnashoola
Grade 2 Grade 1 Grade 0
Page | 107
Table no 14
Karnashoola Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 088 100 033 006
969 2829E-
08 7667 HS
AT 021 000 041 007
Group
B
BT 094 100 024 004
1037 7103E-
11 8438 HS
AT 015 000 036 007
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 31
000010020030040050060070080090100
BT AT BT AT
GROUP A GROUP B
088
021
094
015
Karnashoola
Mean
Page | 108
Table no 15
Karnashoola
Mean SD Effect
Group
A
Group
B Trial Control Trial Control
Day 1 088 094 033 024 000 000
Day 3 065 071 049 046 2667 2500
Day 5 024 038 043 049 7333 5938
Day 14 021 015 041 036 7667 8438
000
010
020
030
040
050
060
070
080
090
100
Day 1 Day 3 Day 5 Day 14
Karnashoola
Mean Group A Mean Group B
Page | 109
Table no 16
Karnashoola N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3250 110500
510000 275 Control group 34 3650 124100
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 110
Effect of study on Karnakandu
Table no 17
Karnakandu
Group A Group B
BT AT BT AT
N N N N
Grade 3 7 2333 0 000 4 1333 0 000
Grade 2 18 6000 0 000 18 6000 0 000
Grade 1 7 2333 7 2333 10 3333 15 5000
Grade 0 2 667 27 9000 2 667 19 6333
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 32 Effect of study on Karnakandu
0
5
10
15
20
25
30
N N N N
BT AT BT AT
GROUP A GROUP B
7
0
4
0
18
0
18
0
7 7
10
15
2
27
2
19
karnakandu
Grade 3 Grade 2 Grade 1 Grade 0
Page | 111
Table no 18
Karnakandu Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 188 200 081 015
1091 3119E-
10 8906 HS
AT 021 000 041 007
Group
B
BT 171 200 076 014
1032 4746E-
09 7414 HS
AT 044 000 050 009
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Page | 112
Fig 33
Table no 19
Karnakandu
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 188 171 081 076 000 000
Day 3 126 118 057 058 3281 3103
Day 5 071 074 046 051 6250 5690
Day 14 021 044 041 050 8906 7414
000
020
040
060
080
100
120
140
160
180
200
BT AT BT AT
GROUP A GROUP B
188
021
171
044
Karnakandu
Mean
Page | 113
Table no 20
Karnakandu N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 4051 137750
373500 006 Control group 34 2849 96850
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is less than
005 Hence we conclude that there is significant difference between Trial
Group and Control Group
000
020
040
060
080
100
120
140
160
180
200
Day 1 Day 3 Day 5 Day 14
Karnakandu
Mean Group A Mean Group B
Page | 114
Effect of study on Karnasrava
Table no 21
Karnasrava
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 11 3667 0 000 8 2667 0 000
Grade 1 23 7667 3 1000 26 8667 2 667
Grade 0 0 000 31 10333 0 000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 34
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
11
0
8
0
23
3
26
20
31
0
32
Karnasrava
Grade 3 Grade 2 Grade 1 Grade 0
Page | 115
Table no 22
Karnasrava Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 132 100 047 009
1122 4356E-
13 9333 HS
AT 009 000 029 005
Group
B
BT 124 100 043 008
1130 9364E-
14 9524 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 35
000
020
040
060
080
100
120
140
BT AT BT AT
GROUP A GROUP B
132
009
124
006
Karnasrava
Mean
Page | 116
Table no 23
Karnasrava
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 132 124 047 043 000 000
Day 3 100 100 025 025 2444 1905
Day 5 047 038 051 049 6444 6905
Day 14 009 006 029 024 9333 9524
000
020
040
060
080
100
120
140
Day 1 Day 3 Day 5 Day 14
Karnasrava
Mean Group A Mean Group B
Page | 117
Table no 24
Karnasrava N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3535 120200
549000 655 Control
group 34 3365 114400
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 118
Effect of study on Karnabadhirya
Table no 25
Karn
Badhirya
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 0 000 0 000 0 000 0 000
Grade 1 13 4333 0 000 16 5333 2 667
Grade 0 21 7000 34 11333 18 6000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 36
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 00 0 0 0
13
0
16
2
21
34
18
32
Karnabadhirya
Grade 3 Grade 2 Grade 1 Grade 0
Page | 119
Table no 26
Karn
Badhirya Mean Median SD SE
Wilcoxon
W P-Value
Effect Result
Group
A
BT 038 000 049 009
799 7173E-
05 10000 HS
AT 000 000 000 000
Group
B
BT 047 000 051 009
816 0000138 8750 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 38
000
005
010
015
020
025
030
035
040
045
050
BT AT BT AT
GROUP A GROUP B
038
000
047
006
Karnbadhirya
Mean
Page | 120
Table no 27
Karn
Badhirya
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 038 047 049 051 000 000
Day 3 009 006 029 024 7692 8750
Day 5 003 006 017 024 9231 8750
Day 14 000 006 000 024 10000 8750
000
005
010
015
020
025
030
035
040
045
050
Day 1 Day 3 Day 5 Day 14
Karn Badhirya
Mean Group A Mean Group B
Page | 121
Table no 28
Karn
Badhirya N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3400 115600
561000 806 Control
group 34 3500 119000
Total 68
Page | 122
COMPARISION BETWEEN GROUP A AND GROUP B
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Table no 29
Overall Effect
Trial Group Control Group
N N
Marked Improvement 21 6176 16 4706
Moderate Improvement 8 2353 13 3824
Mild Improvement 4 1176 5 1471
No Change 1 2941 0 0
TOTAL 34 100 34 100
Fig 39
0
5
10
15
20
25
MARKED IMPROVEMENT
MODERATE IMPROVEMENT
MILD IMPROVEMENT NO CHANGE
21
8
41
1613
5
0
Overall Effect
Trial Group N Control Group N
Page | 123
DISCUSSION
Page | 124
Discussion is nothing but the logical reasoning of observations In
every research work discussion part is very important because it brings into
light about the logical analysis which are helpful in filling the research gap in
the scientific world
The discussion is categorized into following ways for the ease of
understanding
1 Discussion on selection of topic
2 Discussion on review of literature
3 Discussion on drugs their mode of action on the disease mode of action
of Karnadhoopana
4 Discussion on observation and results
1 Discussion on selection of topic
Otomycosis is commonly encountered in day-to-day practice Majority
of Indian people affected with this pathology This disease commonly
manifests in developing countries low socio-economic standard and lack
of hygiene Now a days due to busy lifestyle people are not able to follow
the proper instruction of care of ear which may be responsible for the
recurrent nature of disease So for the management of this we use
Karnadhoopana with the help of Agaruwadi Varti Dhoopana is simple
easy cost-effective procedure which can be done even at OPD levelso
for the disease Karnasrava we selected Karna Dhoopana as therapeutic
procedure Karnadhoopana was done with Agaruwadi Varti and Guggula
Varti which was very effective for treatment
Page | 125
2 Discussion on review of literature
Karnasrava is one such disease among 28 Karnarogas mentioned by
Acharya Sushruta in the chapter named Karna Roga Vigyana Acharya
Charaka included Karnasrava as symptom under the four types of
Karnarogas due to vitiation of different doshas Acharya Vagbhata has
not described Karnasrava separately It is a fact that systemic
description of Karnarogas is available in all the ancients of pus from a
Vata afflicted ear may results from head injury or immersion in water
Karnasrava is a clinical entity which can be correlated with Otomycosis
Karnasrava is explained as symptom as well as a disease in Ayurveda
Nidana- Karnasrava occur due to Samanya Nidana and Vishesh Nidana
Vishesh Nidana like Shirobhighata Nimmajato jale Mithyayoga of Shashtra
The exact pathology behind Karnasrava is not understood clearly
Purvarupa ndash No specific Purvarupa are found for Karnasrava in classical
literature Acharya Madhukara describe Purvarupa as expression of
Rupa(lakshana) with less intensity that is less intensity itching sound in ear
may considered as Purvarupa of Lakshana
Samprapti- Aacharya Sushruta not explained the Samprapti of Karnasrava
separately and we must consider the general Samprapti of Karnaroga Due to
various aetiologias as cited above ear afflicted by Vata dosha causes Twak
Rakta Mamsa dushti results in Karnasrava According to Acharya Sushruta
Vata-Kapha dose is dominance in Karnasrava
Page | 126
Nidan
Nija Agantuja
Vata ndash kapha prakopak nidana Shirobhighata Nimmajato-jale
Mithya yoga of Shastra
Vata- kapha Prakopaka(Chaya prakopak) Vata-kapha prakopaka
( Achay prakopak)
Twak Rakta Mamsa dushti
Karnasrava
Page | 127
Chikitsa
The curative aspect and this must be done simultaneously giving due
importance to Nidan Parivarjana that is preventive measures So Nidan
Parivarjana that is avoidance of causative factors like Jalkrida Mithyayogen
shashtrasya Karnakandu Shirasnan Pratishaya is the first step in combating
the disease and form the part of line of treatment
Above Samprapti helps us to proceed towards the treatment of Karnasrava
The main protocol of treatment is removal of fungus and wound management
which include various measures to keep area day clean clear of microbes and
providing ideal condition for healing
Samany Chikitsa- Acharya Sushruta described general treatment for
Karnaroga as Snehapana (Drinking ghee) Rasayana (Rejuvenation therapy)
Bhramacharya Avoid excessive speaking Avoidance of physical exercise and
head bath
Vishesha Chikitsa ndash Acharya Sushruta mentioned some procedures in the
treatment of Karnasrava which is Shirovirechana Karnadhoopana
Karnapurana Karanpramarjana Dhavan Avachurnana Karnapurana Above
various procedures described in Ayurveda for management of fungus growth
in ear discharging ear fulfill these requirements of wound management
Page | 128
Discussion on observation and Result
Out of 68 patients 34 patients included for the trial The incidence of
Karnasrava is observed in trial and control groups
The statistical analysis provided the following data
AGE
Trial group- Maximum no of patients that is 14 (41176) patients were from
age group 25-35 years followed by 29412 patients were from age group
18-25 years 23529patients were from age group 35-45 years and
58824 patients were from age group 45-60 years
Control group - Maximum no of patients that is 14 (41176) patients were
from age group 25-35 years followed by 20588 patients were from age
group 35-45 years and 20588 patients were from age group 45-60 years
17647 patients were from age group 15-25 years
The maximum no of cases of Karnasrava found in age group between 25 to
35 years The reason behind this is repeated use of ear bud or emersed water
in ear More use of earphone or working more in cold environment
GENDER
Trial group ndash A higher prevalence seen in females 6764 and 3235 in
males
Control group - A higher prevalence seen in males 5588 and 4411 in
females
Females and males both are prone to disease
Page | 129
EDUCATION
Trial group-It is observed that amongst 34 patients maximum ie16
(47059) patients were graduated 8 (23529) patients were HSC
educated 4 (11765) patients were SSC educated 4 (11765) patients
were illiterate 1 (29412) patient were primary educated and 1(29412)
patient were post graduated
Control group- It is observed that 10 (29412) patients were graduated 9
(26471) patients were HSC educated 6 (17647) patients were post
graduated 3 (88235) patients were SSC educated 3 (88235) patients
were primary educated3 (88235) patients were illiterate
There is no direct relation between education and Otomycosis
RELIGION
Trial group- The incidence of patients of Hindu religion are 9118 and Muslim
religion are 882
Control group- The incidence of patients of Hindu religion are 9706 and
Muslim religion are 294
There is no probable explanation for this maximum number of patients in
Hindu religion it depends upon the patients attend the hospital and
community residing there
Page | 130
DIET
Trial group It was found that maximum ie5882 patients were taking
mixed diet while 4118 were taking vegetarian diet
Control group It was found that maximum ie5882 were taking
vegetarian diet while 4118 patients were taking mixed diet
The dietary habit of person is based on choice availability and religious
customs of the person
ADDICTION-
Trial group- It was found that maximum ie 30 (8824) patients have no
addiction 2 (588) patients have addiction of alcohol 1 (294) patients
have addiction of Tobacco 1 (294) patients have addiction of smoking and
0 (0) patients have addiction of Mishri
Control group - It was found that maximum ie 27 (7941) patients have
no addiction 4(1176) patients have addiction of smoking 2 (588)
patients have addiction of Tobacco 1 (294) patients have addiction of
Mishri and 0 (0) patients have addiction of alcohol
Very few patients were addicted to Alcohol Smoking Tobacco and Mishri
These factors can be taken as provoking factors for Otomycosis
Page | 131
Discussion based on probable Mode of action of Karnadhoopana
In Ayurveda classics Karna Dhoopana is therapeutic procedure explain for
Karnasrava Dhoopana is administration of Dhooma (Fumes) with the help of
Dhoopan Dravya References indicates that analgesic and disinfectant effect
of Dhoopana karma and mention for Dushta Vrana Chikitsa It reduces
Vedana Srava amp also does Vrana Ropana action
Various Dhoopanas and Dhoopan Dravas for different element in various
Samhitas of Ayurveda but there is a lacuna of availability of reference
regarding how to do it and method of procedure Matra Kala Contraindication
etc
Currently simple modified way of Karnadhoopana according to Yukti Praman
and experience but there is lac of standardization
Karnadhoopana is one among the topical Bahiparimajan type of treatment
Karna Parmarjana is procedure of cleaning ear with the help of cotton or gauze
piece soaked in honey
Page | 132
Dhoopan
The fumes coming out on burning Agaruwadi Varti
Administrated directly into external ear canal
Causes vasodilation
Due to this increase blood supply in external ear canal
It helps in absorption of drug
Fumes dries up Srava and bring the analgesic effect
Karnagata Kapha amp Avrut Vata Dosha Shaman
Decrease in signs and symptoms like karnasrava Karnshool Karnabadhirya amp
Karnandu
Page | 133
3 Discussion based on probable mode of action of Agaruwadi
Dhoopana
Agaru ndash
I Agaru is a fragrant tree aroma is a result of fungal pathogenesis when the
wood of tree is contaminated by fungi at wounds it develops scrap filled
with resin and turn out to be aroma Medicinal use of Agaru have been
recorded in ancient medicinal science in in inflammatory disease and some
infective disease
II Acharya Charaka has referred to Agaru as an Ushna dravya despite having
Tikta Rasa Ashtang Samgraha used Agaru as Dhupana Dravya along with
Madan and Yawa in Karnasrava Nighantu recommended is use as a
Dhoopana
III In various Samhitas and Nighantus Agaru described as Tikta Snighdha
Sheetaprashamana Vranaprasadana Tvachya Due to these properties
Agaru is used in the treatment of Karna-Akashi Roga and Dushta Vrana
Shodhaka
IV Agaru is reported to have Antimicrobial Analgesic Antioxidants
Antihistaminic and anxiolytic properties Its Antihistaminic property gives
relief from itching which is cardinal feature of Otomycosis Due to Katu
Ushna Tikta Guna improves blood circulation Bheda stage develop It is
Niram Awastha of Dosha Karnagata kapha and vata get decrease and
symptoms like karnashoolakarnasrava get decrease Agaru also have a
Antioxidant properties
V Chemically Agaru Contain 2-(2-Phenylethyl) Chromones Terpenoids
Flavonoids
VI Natural Agarwood had inhibitive activities towards Staphylococcus Aures
The chloroform extract of Agarwood prolongs the pain threshold[108]
Page | 134
Madan
I Madanphala have therapeutic properties like Anti-inflammatory
Antiallergic Analgesic and Wound healing
II It is Useful in treatment of disease like Shotha (inflammation) Vidradhi
(Abscess) Pratishaya (Common cold) Kushta(Skin disease)
III Extract of Madanphala mainly contain Glcosides Tritorpenct
Glycosides Saponin
IV Saponin glycosides are act as fire extinguisher This property is helpful
for vartiIt also act as a detergent which clean the surface of fungus
V Tritorpenct act as a anti-inflammatory antimicrobial and
immunomodulator compound Interaction of glycosides with sterol
causes disturbance of selective permeability in plasmic membraneso
exudates and discharge get decrease
VI Pharmacological activity [109]
Antibacterial Activity The preliminary antibacterial activity of Methanolic
extract of Randia D lam was done on some standard and wild pathogenic
strains The inhibition of the bacterial growth was more pronounced on E coli
as compared to the other tested organism This shows the antibacterial action
of Randia D secondary infection can prevent
Anti-Allergic Activity In Ayurveda Randia D Extract and its fraction of milk
induced leukocytosis and eosinophilia in mice
Anti-Inflammatory Activity The crude methanol extract of fruit of Randia D
effectively reduced the carrageenin induced oedema in hind paw of the rats
significant reduction in granular tissue formation was recorded This activity
seems to be significant at various acute phases of inflammation and om
formation of granular tissue This proves action of Madanaphala in shopa
(inflammation)
Page | 135
Analgesic Activity Analgesic activity was tested in mice weighing between 20-
250 with six number of animals in each group Methanlic extract of fruit Randia
d give analgesic activity in both models This proves its Shoolanashaka (pain
killer) action
Immunomodulatory Activity Randia D has immunostimulant activity and
chloroform fraction which strongly affected immune system seems to be
bioactive fraction of this plant
The overall effect of Agaru Mandanphala Yawa having Anti-inflammatory
Antiseptic Antimicrobial Property Active ingredient shows these properties
Agaru Yawa Madanphala
Vatakaphaghna
Act as
Vranashodhak
Vedanasthapaka
Sheetaprashamana
Shothara
Avarana of Vata get decrease so helps to Shaman of Vata dosha
Karnakandu Karnashoola Karnasrava
Prashamana
Page | 136
This fact can be taken into consideration and probably acknowledge that
Karnadhoopana with Agaruwadi Varti had not leave any residue in the ear
Removal of fibrin keratinocyte migration and in growth of epithelial tissue
plays a major role in healing It is technique of fumigation of ear with the
smoke of anti-infective drug In Karnadhoopana Sthanik Swedana increase the
blood supply and helps in absorption of the drug reduce Karnakandu amp
Karnshoola associated with infection
Page | 137
SUMMARY AND CONCLUSION
Page | 138
The dissertation entitled randomize comparative clinical trial to study the
effect of Agaruwadi Karnadhoopan and Guggula Karnadhoopan In Karnasrava
wsr to Otomycosis
The dissertation is divided into fallowing parts
Introduction
Review of literature
Ayurvedic review
Modern Review
Drug review
Procedure review
Material and Method
Observation and result
Discussion
Summary and conclusion
bull INTRODUCTION
It includes importance of Shalakyatantra in Sushrut Samhita Charka
Samhita And Ashtang Samgraha
Common and specific causes of Karnasrava
Karnasrava is a clinical entity which can be corelate with Otomycosis
In Ashtang Samgraha stated the procedure like Karnadhoopana with
Agaru Yawa Madanphala in Karnasrava
Page | 139
bull REVIEW OF LITERATURE
1 Ayurvedic review
2 Modern review
3 Drug review
Ayurvedic review-
It includes Rachana-Sharir and Kriya-Sharir of Karna detail description of
Karnaroga and its types Karnaroga Samanya hetu Poorvaroopa Rupa
Samprapti Upadrava Pathya-Apathya of Karnasrava Vishesh Nidan and
Chikitsa of Karnasrava Detail description of Karnadhoopana according to
various Acharays have been mentioned
Modern review-
It includes anatomy and physiology of Ear brief anatomy of ear anatomy of
External middle and Internal ear Detail description of the disease
Otomycosis mechanism of fungal infection in external canal pathophysiology
investigations diagnosis and management
Drug review-
Detail description of Agaru Yawa Madan Guggula and its synonyms
Ayurvedic properties Karma uses Pharmacological action and their
pharmacodynamic properties
Page | 140
MATERIAL AND METHOD
It includes description regarding materials required for the study Preparation
of Agaruwadi Varti its Standardization Sterilization and packaging
Plan of study
1 Total 68 patients completed the treatment Age criteria was kept
between 18-60 years Patient selection was done by done by simple
random sampling method and divided into two groups A (Trial) and
Group B (Control) 34 patients in each group
2 Patients in Group A were treated with Karnadhoopana with Agaruwadi
Varti for 7 days two times in a day while patients in Group B were treated
with Karnadhoopana with Guggula for 7 days two times in a day
3 Clinical examination done during each follow up ie 0th 4rd 7th and
observation were recorded
Page | 141
OBSERVATIONS AND RESULTS
Page | 142
1 It was observed that higher incidence of disease Karnasrava ie
Otomycosis found in age group 25-35 years
2 Disease otomycosis was equal in both male and female
3 The trial group there was significant relief in Karnakandu (8906)
Karnasrava(9333) Karnashoola(7667) and karnabadhirya(100)
4 In control group there was significant relief in Karnakandu (7414)
Karnasrava(9524) Karnashoola(8438) and
karnabadhirya(8750)
Page | 143
REFERANCES
Page | 144
1 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published byChaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 17 page no
5
2 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 19 page no
6
3 DRNarayan Vidwas Shero-Karna-Nasa and MukhrogaAnand publication
edition 4th 2014 Page no-52
4 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-205
page no 111
5 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 111
6 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Shlok no2012
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 112
8 Dr KBBhargavaDr SK BhargavaDr TMShahaA Short book of ENT
diseases Usha publication edition 10th
9 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 8 Page no -52
Page | 145
10 Research and Review Journal of Ayurvedic science yoga and
Naturopathy 2017 4(3) 1-5 pA Critical review of Otomycosis in cortex to
Karnaroga described in Ayurvedic classic by amisha patel D B Vaghala
Chandani goswami Vol4 no3 (2017)
11 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogpratished Adhaya Shlok no-213
page no127
12 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedh Adhaya Shlok no-
2140 page no 131
13 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyant shirasiya adhaya Shlok no 1712 page no-
258
14 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
15 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
16 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Aupadravik Adhaya Shlok no-15 page no
2
17 Vaidya Jaymini panday Harit Samhita hindi commentaryChaukhamba
vidhyabhartiVaranasiedition 2010 Shlok no- 13-14page no-10
18 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 146
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-20345
page no 112
19 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Karnarogavigyniyam Shlok
no 21 Page no-731
20 Charak
21 Pandit Harigovind Shashtri Namalinganusasana Amarkosha of
Amarsimha hindi commentary published by Chaukhamba Sanskrit
Sansthan page no- 463
22 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
23 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 37
24 Shree Taranath-Trkavachspati-Bhattacharyen Vchaspatym published
by Rashtriya Samskrit Sansthandelhi Volume 4 page no- 5149
25 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
26 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
27 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
28 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Page | 147
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
29 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Indriyaopakramaniya Adhaya Shlok no 811
page no- 125
30 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243
31 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-510 page no56
32 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no3108 page no- 385
33 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no33 page no- 366
34 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sarvabhutachintasharir Adhaya
Shlok no-126 page no9
35 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-522 page no60
36 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-532 page no61
37 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Page | 148
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-521page no58
38 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-527 page no61
39 VdBramhand Tripathi Ashtanghradaya Sharirsthansthan Published by
Chaukhamba prakashana 2005 Shlok no331 page no-372
40 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Siravarnavibhaktisharir Adhaya
Shlok no-725 page no83
41 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Sharirsankhyavykaransharir Adhaya Shlok
no-512
42 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Pratekmarmanirdeshsharir
Adhaya Shlok no-628 page no75
43 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
44 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Marmasharirsthan Shlok no429 page
no- 393
45 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243244
Page | 149
46 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
47 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan pu blished by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711
48 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
49 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
50 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Shlok no 711 page no- 847
51 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Adhaya Shlok no-628 page no- 75
52 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Gandushavidhiadhaya Shlok no2232
page no- 261
53 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Karnavydhbandhvidhi Adhaya Shlok no-
1611 page no- 86
54 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Nidansthan Published by Chaukhamba
Page | 150
Sanskrit SansthanVaranasi Vatvydhinidansa Adhaya Shlok no183 page
no- 304
55 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavaykaransharir
Adhaya Shlok no-532 page no61
56 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Tristaisniya adhaya Shlok no 1120 page no-
163
57 P Hazarika Dr Nayaka R Balkrishnan Textbook of EarNoseThroat and
Head-Neck Surgery CBS Publication Anatomy of Ear
58 DrKB Bhargava DrSKBhargava DrTMShaha A short book of ENT
Diseases Published by Usha Publication 10th edition page no10
59 MrSalah Mansour MrJacques MagnanMr Hassan Haidar MrKaren
Nicolas MRStephan Louryan Comprehensive and clinical anatomy of the
Middle Ear Published by Springer publication Chapter -Middle Ear cavity
Page no 19 to 121
60 DrPLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 7
61 James OPickles An introduction to Physiology of Hearing Published by
Emerald publication 4th edition page no- 1 to 265
62 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
63 VdBramhand Tripathi Ashtanghradaya Uttarsthan Published by
Chaukhamba prakashana 2005 Karnaroga vigyniyam adhaya Shlok
no1713 page no- 998
Page | 151
64 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Shlok no- 212 page no-
730
65 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no
1-2 page no- 309
66 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana
67 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyantshirasiya Adhaya Shlok no 1713 page no-
258
68 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no-
6 page no- 310
69 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Karnarogavigyniym Shlok no- 1725-26 Page no-
1003
70 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2140 page
no 131
71 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Adhyay 18 shlok 35
72 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt
Karnarogapratishedhoadhya Shlok no-2211 Page no- 735
73 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 152
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2141 page
no 131
74 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2142 page
no 131
75 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2144 page
no 131
76 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 34 page no- 649
77 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2145page
no 131
78 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 37 page no- 649
79 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2146page
no
80 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
81 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 153
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2143page
no
82 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publication Krnarogadhikara adhaya page no-
318
83 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary
Madhyamkhand Vatkalpana shlok no- 782-83 page no- 137
84 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 72-77 page no- 651
85 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
86 Vd Shree Laxmipatishastri Yogratnakara
87 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
Karnarogadhikara Shlok no- 808182 page no- 652
88 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 83 page no- 652
89 (PDF) Otomycosis A Comprehensive Review (researchgatenet)
90 httpswwwncbinlmnihgovpubmed24948980
91 A Simon Carney Scott-Browns Otorhinolaryngology Head and Neck
Surgery CRC press 8th publication Otitis externa and otomycosis
92 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no Page no -
93 wwwguggulipidcomtradhtm
Page | 154
94 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
95 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-28 page no-
43
96 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009Agaru page
no726-728
97 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishra chapter Karpuradi varga Shlok no-31-
43 Page no- 116
98 httpswwwthiemeinimagecatlogsample_chapter_GOMPpdf
99 (PDF) Chemical Constituents and Pharmacological Activity of Agarwood
and Aquilaria Plants (researchgatenet)
100 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 4 chapter no-2 page no-4
101 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 chapter no-152 Madanpage
no376-379
102 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
103 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-54 page no-
84
104 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 page no697-699
patol-yawa
Page | 155
105 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
106 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
Dhoompanvidhi page no- 252-254
107 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012Chikitasasthan Shlok
no- 151page no-406
108 httpswwwmdpicom1420-3049232342pdf
109 httpswwwijamcoinindexphpijamarticledownload0610201530
0
Page | 156
BIBILOGRAPHY
Page | 157
1 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
2 Scott-Brown WG Diseases of the EarNose and Throat Landon
Botterworth and co(publishers) Ltd1952 Volume 2
3 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012
4 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009
5 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi commantry
Purvakhand and Madhyamkhand
6 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Published by Chaukhamba Sanskrit
SansthanVaranasi
8 The Ayurvedic Pharmacopeia of India Ministry of Health and family welfare
department of Ayush Part 1 and part 4
9 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005
10 Acharya Trivedi Raguveer Prasad Ashtang sangrah published by
Vaidyanath Ayurveda bhavan pvt
11 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition
12 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary published by Chaukhamba
Orientalia
Page | 158
ANNEXURE
Page | 159
ANNEXURE- 1
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
CASE RECORD FORM
RESEARCH PROFORMA FOR MS (AYU) DESSERTATION
DEPARTMENT OF SHALAKYATANTRA
NAME -
ADDRESS -
GENDER - AGE - OCCUPATION-
RELIGION - EDUCATION - MARITAL STATUS-
OPD IPD NO-
DATE OF ADMISSIONCOMMESEMENT-
DATE OF DISCHARGECOMPLITION-
DATE OF COUNSELLING-
TEL NO-
CHIEF COMPLAINTS-
PAST MEDICAL AND SURGICAL HISTORY-
TREATMENT HISTORY-
FAMILY HISTORY-
Page | 160
PERSONAL HISTORY-
a) Ahar(Diet)
b) Vihar
c) History of addiction
GENERAL EXAMINATION
PULSE - MIN BP - mm of hg
TEMP - 0F RR - MIN
ASHATAVIDHA PARIKSHANA
Nadi- Mutra- Mala-
Jivha- Shabda- Sparsha-
Drik- Aakruti-
SYSTEMIC EXAMINATION
RS ndash
CNS-
CVS ndash
Page | 161
LOCAL EXAMINATION (KARNA PARIKSHAN)
OBSERVATION TABLE FOR SUBJECTIVE CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching )
RIGHT EAR LEFT EAR
KARNASHASHUKULI
KARNAPUTRAK
KARNAPALI
KARNAKUHARA -
SRAVA
GANDH
VARNA
SWARUPA
KARNAPATALA (TM)
Page | 162
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
Hearing Test
1Renne Test ndash
2 Weber Test -
Examination of Ear-
Pathological Investigation-
Other Examination-
Nidan Panchak-
1Hetu-
2Purvarup-
3Rupa-
4Upashayanupashaya-
5Samprapti
Signature of Guide Signature of Doctor(Researcher)
Page | 163
ANNEXURE 12
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Dhoopana Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization were done as recommended in pharmacy procedure
The raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 were mixed together
in equal quantity to make Agaruwadi churn
STEP 4 - Agaruwadi churn were triturated with appropriate quantity of water
and prepared Varti in GMP Certified Ayurvedic pharmacy Standard aseptic
precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Dhoopana Varti was packed in sterile air packed
container
STEP 6 - Agaruwadi Dhoopan was given with the help of Dhoopan yantra
TREATMENT DETAIL-
Purvakarma -
1 The patient is asked to sit comfortably on chair having sufficient light and
less amount of dust
2 The EAC is cleaned thoroughly by Pichu Varti (cotton swab) to remove the
discharge and other debris
Pradhankarma -
1 The patient is asked to relax completely on the chair
Page | 164
2 Fumes are passed to the ear with Dhoopana Yantra
3 Dhoopana yantra is funnel shaped and its one end will keep the ear covered
for the passage of Dhooma into the ear canal and other end where Agaruwadi
Dhoopana Varti were placed which produces fumes
4 This Dhoopana was given for 5 min
Pashchat karma -
1 The patient were advised to avoid cold refrigerated food drinks cold water
bath cold wind fog and prevent water from entering the ear
(A) Agaruwadi Dhoopana Varti
B) Guggula Dhoopana Varti SOP of it is same as above Agaruwadi Dhoopana
Varti
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Page | 165
ANNEXURE 21
INFORMED CONSENT DOCUMENT
Study Title
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
Introduction
- You are invited to take part in a research study RANDOMSIED COMPARATIVE
CLINICAL TRIAL TO STUDY THE EFFECT OF AGARUWADI DHOOPANA AND
GUGGULA DHOOPANA IN KARNASRAVA
- Before you decide it is important for you to understand why the
research is being done and what it will involve
- Please take time to read the following information carefully and discuss
it with friends relatives and your doctor if you wish
- Ask us if there is anything that is not clear or if you would like more
information
Purpose amp Nature of Study
- In this research project by examine you and ldquoKarnasravardquo (Otomycosis)
disease were treated
- In the part of treatment Agaruwadi Dhoopana or Guggula Dhoopan were
given
- Dhoopana means medicated drug fumes were given in ear with the help of
Dhoopan Yantra
Page | 166
- Treatment was given for 7 days
Study Duration
7days
Participation
- Your participation is entirely voluntary
- If you do decide to take part you were given this information sheet to keep
and be asked to sign a informed consent form
- If you decide to take part you are still free to withdraw at any time and
without giving a reason This will not affect the standard of current or future
medical care you may receive
Confidentiality
- All information which is collected about you during the research were
kept strictly confidential
- Any information about you which is collected from the center will have
your identity in the form of a code number so that it will remain confidential
Benefits Of Study
- The results obtained from this study would be helpful for providing better
quality of treatment amp other essential facilities for Karnasrava (Discharge)
patients
- You will get clinical benefit from the study
Page | 167
Risks Of Study
- In this treatment there are few chances of Irritation of Ear Nose and
congestion at EAC if any of these happens then treatment were given
Results Of Study
- If the Results obtained are profitable then they may get published
without disclosing your details
Signature of patient
Date
Time
Phone no of Researcher
Page | 168
रण मादहती पतरक
सशोिनाच शीषवक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE
EFFECT OF AGARUWADI DHOOPANA AND GUGGULA DHOOPANA
IN KARNASRAVA
परसतताना
- आपणास या सशोिनातपमक अभयासात सहिागी होणय़ाच आाहन करणयात यत आह
- सशोिनातील सहिाग तननदशचत करणयापी सशोिनाच उददश समजन घया
- खालील मादहती काळजीपवक ाचा आणण आशयक ािलयास आपलया डॉकिराशी कका
दहतशरचतकाशी चचाव करा
- काही सददिता असलयास कका आणखी मादहती ही असलयास आमछयाशी चचाव करा
सशोिनाच उददीटि सतरप
- सदर सशोिन परकलपामरधय आपलयाला तपासणी करन कणवसरा या वयाशरिची शरचककतपसा दणयात
यणार आह
- सदर वयाशरिची शरचककतपसा महणन आपणास अगरादी िपन कका गगल िपन
दणयात यणार आह
- सदर औषि आपणास 7 ददस घयायाच आह
Page | 169
कालािी
- 7 ददस
सहिाग
- आपला सहिाग हा पणवपण ऎनदछिक आह
- आपला सहिाग तननदशचत असलयास आपणास ही मादहती पतरतरका दणयात यईल आपणास यातील
समती पतरकार सही कराी लागल
- सहिाग तननदशचत असनही आपण कोणतपयाही ळस कोणतही कारण न दता माघार घ शकता
याचा आपलया दयकीय सविर कोणताही पररणाम होणार नाही
गोपनीयता
- सशोिना दरमयान गोळा कलली आपलया वषयाची सव मादहती गोपनीय ठणयात यईल
- आपली यनदकतक मादहती साकततक सतरपात गोपनीय ठणयात यईल
सशोिनाच फ़ायद
- सशोिनाच तनटकषव कणवसरा बाशरित रणाछया दयकीय इतर सविाचा दजाव सिारणयास
फायदशीर ठरतील
सशोिनातील जोणखम
- य़ा शरचककतपसमरधय कान दखण डॊळय़ातन नाकातन पाणी य़ण नाकात जळजळण डोक जड
होण ही लिण ददस शकतात यापकी लिण तनमावण झालयास तपयाची शरचककतपसा कली जाईल
Page | 170
सशोिनाच तनटकषव
सशोिनाच तनटकषव फ़ायदशीर ठरलयास आपली मादहती गोपनीय ठन परकाशशत करणय़ात यईल
रण सतािरी-
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
Page | 171
ANNEXURE 31
INFORMED CONSENT FORM
Patient OPD no __________
Subjectrsquos Identifier
Date of Birth Age Gender
I _____________________________________ age___________ years
exercising my free power of choice hereby give my consent to be included
as a participant in the clinical study entitled
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
1 I confirm that I have read have been read and understood the information
sheet for the above study and can ask questions
2 I understand that my participation in the study is voluntary and that I am
free to withdraw at any time without giving any reason without affecting my
medical care or legal rights
3 I understand that the Ethics Committee members investigators and study
doctors will not need my permission to look at my health records both in
respect of the current study and any further research that may be conducted
in relation to it even if I withdraw from the trial I agree to his access
However I understand that my identity will not be revealed in information
released to third parties or published
4I agree not to restrict the use of any data or results that arisefrom this study
provided such a use only for scientific purpose
5 I agree to take part in the above study
Page | 172
signature with Date-
Left hand thumb impression
Name amp signature of the witness ndash
Name amp signature of the student ndash
Page | 173
ANNEXURE 32
समतीपतरक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
वयकतीच य
ददनाक जरमददनाक
1) मी ह तननदशचत कररत आह ककसदर सशोिन परकलपाबाबतची सपणव मदहती मी ाचली असनमला ती
समजली आहतपयाबददल मला परशन वचारणयाची पणव मिा आह सदर मादहतीन माझ समािान झाल
आह
2) मी सदर सशोिनातन माझया मजीनसार किीही बाहर पड शकतो या माझया अशरिकाराची मला कलपना
आह
3) माझी दयककय मादहती तपासणयाची कागदपतर कळ सशोिनाकररता ापरली जाणार आहत याची
मला मादहती आहसदर सशोिन परकलपातील सबशरित घिकाना माझी दयककय मादहती पाहणयाची मी
समती दत आहतरावप या सदिावतील माझी ओळख दशववणारी मादहती कोणासही ददली जाणार नाहीयाची
मला कलपना दणयात आली आह
4) सदर अभयासातन शमळणारी मादहती अरा तनटकषव कळ शासततरीय हतसाठी ापरल जाणयासाठी माझी
समती आह
5) रील अभयासात सहिागी होणयास माझी समती आह
रण सतािरी-
Page | 174
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
ASSESSMENT CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching)
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
a) कणवशल ( pain )- 0 - Absent
1 ndash Present
Page | 175
b) कणवकणड (Itching)- 0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
c) कणवसततरा ( Discharge )
0- Absent
1-Mild- Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाशरियव ( conductive Loss of hearing )
0 - Present
1 - Absent
Page | 176
Page | 177
Page | 178
Page | 179
Page | 180
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
Page | 181
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 182
AUTHENTIFICATION CERTIFICATE
Page | 10
Synonyms of Shalakya Tantra
Uttamanga Chikitsa Jatrurdhwa Chikitsa Urdhwang Chikitsa Shalakya
Chikitsa
Importance of Shalakyatantra-
Life of living being and all the Indriyas are situated in the head hence it is
known as Uttamanga
पराणभरता यतराशरशरतााः सइनदरियणण च यदततमागाना शशरसतततदशिशरियत
चस १७१२
The treatment given to this part of the body is described specially in
Shalakya tantra While describing the importance of Shiras Vagbhata
correlates it to the root of tree (Urdhwa Mula) and body to the trunk of tree
(Adha Shaka)
Sushruta has deal with Mukha Roga in Nidan Shan and its treatment in
Chikitsasthan The description regarding the disease of eye ear nose and
head are found only in UttaraSthan Sushruta specially describes the
disease of Shalakyatantra as told by Videha in the beginning of Uttartantra
itself[16]
Shalakyatantra Itihas-
India Exhibits traditional of more than thousands of years in art literature
language logic and philosophy etc The convention was in its sophisticated
and advanced attire throughout the Vedic period
Vedic period ndash
1 Natush was treated for deafness by Ashwinikumars (Rigveda)
2 Rujaswa and Kanva were treated for blindness by Ashwani Kumaras
(Rigvedas)
Page | 11
3 There are several prayers mentioned for normal functioning of sense
organs (Yajurveda)
4 Structures and functions of Mastishka are described (Atharveda)
5 Mantras having reference to disease of Eye Ear Oral cavity etc are
found (Atharvaveda)
Upanishada Period ndash
1 Samhita Period
a) Sushrut Samhita ndash
bull Explanation regarding Netra Nasa and Shirorogas (Uttartantra 1-
26th chapter)
bull Details regarding Mukha and Karna Roga Nidan and
Chikitsa(Nidansthan 16th and Chikitsasthan 22nd chapter)
bull Description regarding Karna Chedana Sandhana Nasa
Ostasandhana Sutra Sthan 16th chapter
b) Charaka Samhita -
bull Explanation regarding Shirorogas (Sutrasthan 17th chapter)
bull Explanation of Gala rogas like Upajivika Galshundi and Rohini
bull Nasa Shiro Mukha Karna and Netra Chikitsa (Chikitsa sthan 26th
chapter)
bull Description regarding Lakshana and Chikitsa of Shankhaka
Ardhavbhedaka Shirovirechana and Shiro basti (siddhi sthan 9th
chapter)
c)Ashtnga Sangraha ndash
bull Detailed description regarding Shalakyatantara (Uttartantra 11-28
chapter)
bull Description of Kriyakalpa (Sutrasthan 32nd and 33rd)
Page | 12
d)Ashtang Hrudayam
bull Detailed description on Shalakya Tantra (Uttar tantra 8-24 chapters)
bull Kriyakalpas (Sutrasthan 23rd and 24th chapter)
e) Bhela Samhita
bull Chakshushya Vaisheshik and Buddhi Vaisheshik Alochaka pitta
f) Harita Samhita- Branch of Medical science offering elaborating
information about the procedure like Nasya Anjan Gandusha etc
comprehended with their applications in disease of Head Eyes Ears
Eyebrows Throat Temporal region and cervical spine is known as
Shalakyatantara
शशरोरोगा नतररोगा कणवरोगा वशषताः भरकरठशङकमरयास य रोगा समिनदरत दह १३
तषा परततकारकम व नसतयतपयवणजनातन च अभयङगमखगणडषकियााः शालकयसशमतााः १४
इतत शालाकयनाम [17]
Documentation of different ancient literature gives various references
regarding all aspects of Karnasrava in various periods It is very much
important to know the history of Karnasrava from Vedic Pauranic Samhita
and Samgraha period
Vedic period ndash The Vedas being the oldest source of knowledge have no
direct mentioning of Karnasrava
Page | 13
Samhita and Samgraha period ndash
Aacharya Sushruta described about Karnaroga Karnasrava Nidan
Roopa and Chikitsa The detail description is available in Sushrut
Samhita Uttartantra 20 and 21st chapters
Aacharya Charaka did not specify Karnasrava but mentioned 4 types
of Karnarogas that is Vataj Pittaj Kaphaja and Sannipataja and their
treatment in 26th chapter of Chikitsasthan
In Ashtang Hrudaya karnasrava is not explained as a separate disease
but Chikitsa is mentioned in 18th chapter of Astanga Hrudaya
uttartantra
In Ashtang Samgraha Chikitsa is mentioned in 22nd chapter of Astang
Samgraha Uttartantra
The details about Karnasrava are explained in Bhavprakasha
Madhyamakhanda 64th chapter
Madhavakara has explained about Karnasrava in 57th chapter of
Madhymakhanda
Karnasrava is also explained in Sharangadara Samhita Uttarkhand 11th
chapter
The reference for treatment of Karnasrava is available in
Yogaratnakara
In Gadhnigraha Karnasrava and its treatment is mentioned in
Karnarogadhikara Adhaya
Vangasena had mentioned about the disease and treatment in 69th
chapter
Chakradatta explained Karnasrava in 57th chapter
Dalhana has given commentary on Sushrut Samhita Uttartantra 20th
and 21st chapter
Sankhya Samprapti of Karnasrava ndash
Aachary Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga
Vigyniyam Aadhaya Aacharya charaka explain 4 Karnaroga in
Page | 14
Karnarohvigyniyam Adhaya based on doshas Acharya Vagabhata in
Ashtang Hrudaya explain 25 Karnaroga in Adhyaya
कणवशल परणादशरच बाशरियव कषड ए च
कणवसरााः कणवकणडाः कणव चवसतततर च
कशमकणवपरततनाहौ विशरिदवविसततरा
कणवपाकाः पततकणवसततराशवशरचतवविम
कणावबवद सपतवि शोफशरचावप चतवविाः
ऎत कणवगता रोगा अटिावशततरीररतााः
स उ २०- ३ त ५[18]
ातकणवरोग वपततकणवरोग कफकणवरोग
रकतकणवरोग सनदरनपातकणवरोग कणवनाद
बशरिरतप परततनाह कणडाः शोफ पततकणवक
किशमकणवक उियरपविरधयअशो अबवद
कशरचकणवक वपपपली वदाररका पाळीशोष
ततिका पररपोिो उतपपातो उरमरर दाःखिवन
शलहाखयााः परचवशनदरतकणवरोगा उकतााः
इदिीका अ स उ २१ [19]
चतपाराः कणवरोगााः
च स [20]
Page | 15
KARNA
Karna ndash करोतत शबद गरहण [21]
The organ of hearing
Karnasrava- कणवसतय कणवयोाव ससराा [22]
Discharge from the ear is referred as Karnasrava
KARNA SHAREERA
bull Nirukti
कणयवत अकणयवत अनन इती [23]
It means reception and conduction of sound waves
These are the functions of external and middle ear
bull Nirukti of Sravanam
शरयत अनन इती शरणम[24]
It means perception of sound
It can be attributed to the internal ear function
bull Karna Utpatti-
Karna is an organ formed by Akash Mahabhuta[25]
The fundamental characteristic is as follows
Indriya ndash Srotram [26]
Indriya Adhisthan ndash Karna [27]
Indriya Dravy ndash Akasha [28]
Indriya Arth ndashShabdha [29]
Indriya buddhi ndash Srotobyddhi
Page | 16
bull Paryaya of Karna- Shabdapatha Srotrapatha Sravanam shruti
Kuhuram Dwanigraham etc
bull Definition of Karna-
कणवशटकलयनदछिरनमिटिोपगरदहत शरोतरमछयत [30]
मा तन ५७१
The definition of Karna is stated in Madhav Nidanam Indriya which is not
seen with naked eye along with Shashkuli is called Shrotra that is Karna
Indriya is so minute that it is not perceived with any sense organ
In Charak Samhita the word Karna explain as the Indriya Adhisthan of
Shabdha Karna is described as one of the Prathyangas of the body He
emphasizes that all Indriyas manifest during the 3rd month of gestation
period
Acharya Sushruta while describing formation of Purusha from Prakriti or
Avyakta narrated that all Indriyas are developing from the Vikarika and
Taijas Ahankara Both Vagabhata and Sushruta stated that Karna as one of
the Bahirsrotas
शरण नयन दन घराण गदमढराणण न सततरोताशसराणा बदहमवखातन [31]
स शा ५-१०
In Ashtang Hradaya Vagbhata has states that all Indriyas are Atmaja
According to him lower lobule elevated helix projected posterior portion
fleshy and adherent ear are indications of long span of life[32]
ततरखातखातन दह अनदसतमन शरोतर शबद ववकतता [33]
ा शा ३-३
शबदाः शबदनदरिय सवनदछििसमहो ववकतता [34]
स शा १-२६
Page | 17
Ear has the prominence of Akash Mahabhuta The prominent dosha of ear
is Vata It is important seat of Vata The prominent Dhatus are Asthi and
Mamsa Karna is one of the Panchgnanendriyas and it meant for hearing
Sushruta narrated that Karnasthita Asthi and Sandhi
घराणकणवगरीाकषिकोषष तरणातन [35]
सशा ५-२२
शरोतरशरगािकष शखाताव [36]
सशा ५-३२
गडकणवशखटककम [37]
स शा ५-२२
One Sandhi and one Tarunasthi in ear
Sandhi ndash Karna contain two Sandhi one in each ear Type of Sandhi is
Shankhavartha which is present in Shringataka
Mansapeshi ndash 2[38]
Siras ndash 10 [39]
Vataj Sira - 4
Pittaj sira - 2
Kaphaj sira - 2
Raktaj Sira - 2
Avedhya sira-
कणवयोदवश तासा शबदादहनीनामकका पररहरत
सशा ७-२५[40]
Amongst above mentioned ten Siras each Karna lodges one Shabdavaha
Sira It is Avedhya
Page | 18
Dhamani -2
Length of ear is 4 Angula
Karna moola ndash 2 Angula
कणाविरतर चतदवशअगलम
स शा ३५-१४[41]
The distance between two ears through the back of the neck is 14 Angula
bull Marmas of Karna-
1 Vidhuras-
कणवपटठतो अिाःसशरशरत विर ततर बशरियवम
सशा ६-३७[42]
कणतपयादद सतनायममवणी ककनदचचनदरनममनाकर कलयकररणणच
डलहणाचयव[43]
अिसततात कणवयोतनवमन विर शरततहाररणण
ा शा ४-२९[44]
Sankhya-2
Vistara- frac12 Angula
Type- Snayumarma (Susha)
- Dhamanimarma(AH)
- Vaikalykar
Sthana- It is situated in the depressed portion in the back of the ear
Injury to them causes loss of hearing
Page | 19
2 Shringataka marma-
नदजवहाकषिनाशसकाशरोतरखचतटियसरमम
तालरयासतयातन चतपारर सरोतसा तष ममवस
वदि शरगातकाखयष सददसततपयजतत जीवतम
मा तन ५७१ [45]
Sankhya- 4
Type- Siramarma
Sthana- It is in head that is amidst Siras (blood vessels) nursing sense
organ
A palm size area near Talu
Injury to this Marma causes death
In modern anatomy ear divides into Bhayakarna or External ear Mdhyakarn
or Middle ear Antahkarna or Internal ear This is extremely appropriate
Even though the ear is divided into three divisions in the point of modern
anatomy Ayurveda denotes ear organ is one Ayurveda treats disease by
way of assessing Dosha and Dushya Here Dushya is one that is Karnendria
Dosha difference will call for different treatment for different disease Hence
treating the vitiated Dosha will cure the disease irrespective whether it is in
external middle or internal ear The thought is based on different
fundamental principle from Ayurveda
bull Parts of Karna
In Ayurveda classics detailed description about anatomy of ear is not
available But the various parts are mentioned as follows
Bhayakarna- External ear
Mdhyakarna ndash Middle ear
Antahkarna- Internal ear
Page | 20
द कणवशटकशलक दॊ कणवपतरकौ
च शा 7-11[46]
कणवशटकशलक कणवगतातवकौ कणवपतरकौ त बाहयकणा
चिदतत च शा 7-11[47]
शटकली बाहयपालयाशरिटिानम
डलहन- स शरच 25-1 12[48]
Karna Shashkulika ndash It is also called as Karna Shashakuli Charaka has
mentioned this term while describing different Pratyngas of the body
Acharaya Gananatha sen has given the clarification for it as a pinna or
auricle[49]
Karnapali ndash It is popularly known as lobule of the ear Daivakrita Chidra is
present in it
Karnaputrika- Ayurvedic scholars accepted two terms in this cortex They
are Karnaputrika and Karnaputrika The former is considered as Tragus and
antitragus[50]
Karna Prushtha- It can be taken as the cranial surface of mastoid or
auricle[51]
Karnapeetha- Aacharaya Sushruta firstly mention the term Karnapeetha
It is mentioned first by Sushruta while describing the procedure of
Karnavyadana Vagbhata has mentioned that it is Adhobhaga of Karna
Dalhana has clarified that it is the region above the Karnaputrika that is the
region which is at the bottom of the concha
Karnamoola ndash It can be considered as parotid region[52]
Karna lathika ndashAcharaya Dalhana mentioned lobule as a Karna Lathika
Page | 21
Karnaavatu ndashThis term is used by Sushruta while describing the
measurements of different Angapratyangas where he has mentioned that
the distance between the Karnaavatu is 14 Angul Dalhana has comments
that it can be taken as the distance between two ears from behind[53]
Shabdhavahasrotas ndash It also called as Shabdapatha or Srotapatha The
whole passage through which the sound waves pass can be taken as
Shabdavahasrotas[54]
Shrotashringataka ndash It can be taken as the labyrinth of ear[55]
bull Dosha in context to Karna-
Karna is principal location of Vayu
1 Prana Vayu- Prana Vayu circulating in oral cavity is responsible for
Dehadhruka that is keeping all body parts active Indriyadruka that is
keeping all Dnyanendriya healthy by proper nourishment (Purana) helps in
deglutition of food material and convey the stimulation of Indriyabuddhi
and atma
2 Udana Vayu- Bala(strength) Varna speech singing are its function It
is responsible for facial expressions due to pleasure sorrow anger love
frustration etc in general its circulation and actions are just opposite to
Pranavayu
3 Vyana Vayu- Its principal functions are circulation of Rasa and Rakta
through body and various movements Its main location is Hrudaya Five
types of movements for which it is responsible are expansion contraction
upward downward and oblique other activities are opening closure of
eyelid yawning perspiration During circulation if it gets obstructed due
to Srotodushti it generates disease of that Srotas Vyana Vayu gets vitiated
by disease of Rasa Rakta Oja and Chetanadhatu
Page | 22
4 Samana Vayu- It is circulating in the vicinity of stomach and intestine
and helps in keeping the Jatharagni (digestive juices and enzymes) in
equilibrium Disturbance in Jatharagni precipitates disease
5 Tarpaka Kapha- Entire body functions movements are controlled and
executed by various centers in the brain Sensation perceived by sense
organs is conveyed to Mann and Aatma residing in Hrudaya The motor
signals from them are then conveyed to the functioning
organsKarmendriya through Prana Vayu Shira head is therefore a
location of continuous activities motions of Vata All these centers are in
unctuous Majjadhatu in the Shira For stabilizing this ever-active Vata and
to nourish the Majja dhatu very unctuous Tarpaka Kapha situated in Shira
plays an important role
bull Ayurvedic aspect of sound perception [56]
According to Ayurveda Pratyaksha Dnyan or Perception of any sensation
including Shabda occurs due to interaction of the Karnendriya and the
Indriya- Arth -Karma resulting in Sravana
External Environmental acquaintance with living body is executed by five
sense organs namely Netra Karna Nasa Jivha and Twaka All
Dnyanendriya that is sense organ are Panchmahabhautic combination
Despite this fact every Indrya sense organ perceives object Tanmatra of
that Mahabhuta only from which it is originated from Akash Mahabhuta and
hence perceives Shabd only that is audio perception Shrotrendriya is one
of the principal locations of Vata and its function is to perceive Shabda that
is sound waves This sensation is conveyed through Shabdavahi Dhamanis
to Mana and Atma through Pranavayu and the sequence is responsible for
perception of sound in this way external sound is perceived and interpreted
when Atma is linked with Mann Mann is linked with Indriyabuddhi that is
minute virtual Dnyanendriya located in brain Indriyabuddhi is linked with
Adhishthana with prominent Mahabhuta and lastly with Indriya
ArthShabdatanmatra that is sense object Once this sequence is completed
Page | 23
the meaning of a particular sound is interpreted and understood In this
entire process of perception and interpretation of sound waves Pranavayu
and Tarpaka Kapha located in Shira play extremely important role Hence
the healthy status of all the sense organ depends upon the normal
physiologically homeostatic condition of Pranavayu and Tarpaka Kapha
MANAS
ATAMA
BUDDHI
AHANKARA
ARTHA
Page | 24
EAR ANATOMY
bull Embryology of the Ear [57]
1 The sound conducting apparatus develops from the branchial apparatus
whereas the sound perceptive apparatus from the ectodermal otocyst
2 The pinna develops from the six hillocks around the 1st branchial cleft
3 External auditory canal develops from 1st branchial cleft
4 The outpouching of the 1st pharyngeal pouch gives rise to a proximal
narrow part that forms the eustachian tube and distal dilated part that
forms the middle ear cavity
5 Prussakrsquos space is a potential space lateral to the Shrapnellrsquos membrane
and medically by the neck of malleus that can be involved during the
extension of cholesteatoma
6 Development starts in the 3rd week of the intrauterine life and is
completed by 16th week of intrauterine life Membranous and boney
labyrinth develops from the otic capsule
The Ear is divided into
1 External Ear
2 Middle Ear
3 Internal Ear or the labyrinth
Page | 25
Fig 1 Ear Anatomy
EXTERNAL EAR [58]
The outside ear contains pinna and lobule
Pinna is the noticeable piece of outer ear made from single sheet of yellow
flexible ligament covered by subcutaneous tissue and skin It has two
surfaces average and parallel It is intently disciple to perichondrium on its
sidelong surface while it is somewhat free on average surface Pinna
incorporates tragus helix against helix fossa three-sided scaphoid fossa
incisura terminalis
External auditory Canal ndash It extends from the bottom of the conchea to
the tympanic membrane and measures about 24 mm along its posterior
wallit is S shaped
Parts 1 Cartilaginous part
2 Bony part
Page | 26
Cartilaginous part ndash The outer one third is cartilaginous consist of fibro
cartilage is directed first inward backward and upward It has Fissure of
Santorium The skin of this part of the canal contains hair follicles
sebaceous gland and cruminous gland
Bony part ndash The inner two third part is boney It goes forward downward
and medially skin lined in this part is very thin Isthmus is the narrowest
part of the canal lying medial to junction of bony and cartilaginous part
nearly 5 mm lateral to tympanic membrane
The roof and posterior wall of the external auditory canal shorter than floor
and anterior wall The skin lining the tympanic membrane and boney canal
has a self-cleansing property due to migration of keratin layer of epithelium
from drum towards the cartilaginous portion
Relations- Anteriorly- Temporomandibular joint and parotid gland
Superiorly- Middle cranial fossa
Inferiorly- parotid gland
Posterior- Mastoid antrum mastoid air cells and facial nerve
Nerve supply ndashSensory nerve supply of the external ear The auricle
supplied by fibers of the great auricular nerve (C2 and C3) and lesser
occipital nerve (C2) Auriculo temporal branch of the 5th cranial nerve and
auricle branch of the vagus (Arnoldrsquos nerve) supply external canal Facial
nerve has small sensory contribution on posterior-inferior wall
Tympanic Membrane -It is the partition between EAC and middle ear It
is a thin semitranslucent membrane pearly white in colored lying obliquely
in the medial end of EAC with the angle of 55 It is forming major part of
lateral wall of middle ear Annulus tympanicus is attached at its
circumference to the sulcus The TM is oval shape It measures
approximately 10 mm in vertical diameter and 90 mm in horizontal
diameter
Page | 27
Layers ndash Tympanic membrane consist of three layers
1 Outer Epithelium or cuticular layer which is continuous with skin of
external ear
2 Middle fibrous layer has both circular and radial fibers middle layer
missing in upper part
3 Inner layer- Inner mucosal layer which is continuous with middle ear
mucosa
Parts ndash Tympanic membrane consist of two parts
1 Pars tensa -It is largest part below the malleolar folds The inner
surface at the center attached to the handle of malleus Angle of cone
is most illuminated part in the pars tensa at anteroinferior part of pars
tensa
2 Pars flaccida Sharpnells membrane -it is triangular area above the
malleolar folds which are thin and devoid of fibrous tissue and
annulus It fits into notch of Rivinous
Nerve supply 1 Anterior half of lateral surface Auriculotemporal V3
2 Posterior half of lateral surface Auricular branch of vagus cn 10
3 Medial Surface Tympanic branch of CN 9 (Jacobsons nerve)
Fig 2 Tympanic membrane of ear
Page | 28
MIDDLE EAR [59]
The middle ear or tympanic cavity is an irregular laterally compressed
space within the temporal bone It is filled with air that is supplied to you
from the nasal part of the throat through the ear canal It contains a chain
of mobile bones that connect its side with the medial wall and serve to
transmit vibrations transmitted to the eardrum through the cavity to the
inner ear Including the parapet the vertical and anteroposterior diameters
of the cavity are each approximately 15 mm The transverse diameter
measures about 6mm at the top and 4mm at the bottom Compared to the
eardrum it is only about 2mm The eardrum is limited laterally by the
eardrum medially by the lateral wall of the inner ear It communicates
behind with the tympanic antrum and through it with the air cells of the
mastoid and in front with the auditory canal The middle ear together with
the Eustachian tube aditus antral and mastoid air cells is called the
middle ear cleft It is lined by mucus membrane and filled with air
It is divided into 3 parts
1 Mesotympanum (located in front of the pars tensa)
2 Epitympanum or attic (located above the pars tensa but medial to
Sharpnells membrane and the lateral bony wall of the attic)
3 Hypotympanum (located under pars tensa) The middle ear is like a
hexagonal box with a roof
Carotid or Anterior wall- It separates middle ear cavity from internal
carotid artery The various structure passing through anterior wall of
tympanic cavity
bull Canal of chorda tympani nerve
bull Canal of tensor tympani muscle
bull Eustachian tube
bull Anterior malleolar ligament
bull Anterior tympanic artery
Page | 29
Posterior or mastoid wall ndash The upper part of the back wall shows the
opening of the auditorium Below the auditory is a triangular bony
projection known as the pyramidalis processors The stapedial tendon is
transmitted through the apex of the pyramidalis processes The vertical
portion of the facial nerve descends along the posterior wall until it opens
into the stylomastoid foramen
Roof or Tegmental wall (Pars terminalis)- It is formed by a thin bone
plate called the tegman tympanum that separates the skull and tympanic
cavities It is located on the anterior surface of the rocky part of the
temporal bone near the junction with the temporal shell it extends back to
the roof in the tympanic membrane and anteriorly to cover the half canal
of the tensor tympanic muscle The lateral border corresponds to the
remains of the Petro scaly suture
Floor ndash It is formed by a thin plate of bone which separate middle ear from
the bulb of the internal jugular vein lodged in the jugular fossa
Lateral wall ndash It is formed by tympanic membrane and partly by a portion
of squamous part of the temporal bone It separates the middle ear from
external ear
Medial wall- It separates the middle ear from the inner ear
bull The promontory is the most prominent and convex part formed by the
basal rotation of the cochlea
bull The bony lateral semicircular canal is postero-superior to the promontory
above the oval window
bull The oval window is located between the middle ear and the vestibular
slope of the cochlea It is closed by the stirrup footrest and the annular
ligament
Page | 30
bull The round window is located under and behind the cape The round
window recess is directed to the rear It is closed by the secondary eardrum
and separates the middle ear of the Scala tympani from the cochlea
bull The facial nerve passes through the bony fallopian tube above the oval
window
Mastoid Antrum ndash It is a large space with air in the upper part of the
mastoid and communicates with the attic through the aditus The roof is
formed by the antri tegmen which extends and separates the tympani
tegmen from the middle cranial fossa The lateral wall of the antrum is
formed by a bony plate that is on average 15 cm thick in adults It is
marked externally on the surface of the mastoid by the suprameatal triangle
(MacEwen)
Aditus and Antrum- Aditus is a gap through which the attic communicates
with the antrum The boney prominence of the horizontal canal lies on its
medial aspect even as the fossa incudes to thats attaches the quick system
of incus lies laterally Facial nerve publications simply underneath the
aditus
The mastoid and its air cell system-
The mastoid consists of bone cortex with a honeycomb of air cell
underneath Depending on development of air cell three types of mastoids
have been described
1Well-pneumatized or cellular- Mastoid cells are well developed and
intervening septa are thin
2Diploetic- Mastoid consist of marrow spaces and a few air cells
3Sclerotic or acellular ndash There are no cells or marrow spaces
With any type of mastoid pneumatization antrum is always present In
sclerotic mastoids antrum is usually small and the sigmoid sinus is
anteposed
Page | 31
Depending on the location mastoid air cells are divided into
1 Zygomatic cells (In the root of zygoma)
2 Tegman cell (Extending into tegmen tympani)
3 Perisinus cells (overlying the sinus plate)
4 Retrofecial cells (round the facial nerve)
5 Peri labyrinthine cells (located above below and behind the
labyrinthine some of them pass through the arch of superior
semicircular canal These cells may communicate with the petrous
apex)
6 Peritubal (around the Eustachian tube Along with hypotymoanic
cells they also communicate with the petrous apex)
7 Tip cells (which are quite large and lie medial and lateral to the
digastric ridge in the tip of mastoid)
8 Marginal cells (Lying behind the sinus plate and may extend into
the occipital bone)
9 Squamosal cells (Lying in the squamous part of temporal bone)
Development of Mastoid ndash
The mastoid develops from the scaly petrous bone The petrosquamosal
suture may persist in the form of a bone plate - Korners septum which
separates the superficial squamosal cells from the deep rock cells Korners
septum is surgically important because it can cause problems locating the
antrum and deeper cells and thus lead to incomplete removal of the disease
during mastoidectomy The mastoid antrum can only be reached if Korners
septum is removed
Page | 32
Fig 3 Cross section of Mastoid
Contents of the middle ear
Ossicles ndash Three tiny bones which conduct the sound from eardrum to oval
window
Malleus ndash It is the largest and most lateral ossicle measuring 8 mm in
length It has head neck handle anterior and lateral processes The head
is situated in the epitympanum A lateral process project laterally from the
neck while the handle is firmly fixed to the pars tensa of the ear drum
Incus- It has a body short process and long process The body short
process and long process The body articulate with the head of mallelus in
the attic and the short process project into the attic The long process
projects downwards behind the handle of malleus running parallel to it and
articulate with the head of the stapes via the lenticular process
Stapes ndash It is the smallest ossicle measuring about 35 mm and consist of
head neck footplate and anterior and posterior curcura The footplate of
stapes is held to the oval window by the annular ligament
Page | 33
Muscles ndash
1Tensor tympani ndash It is inserted is a branch of the facial nerve which carries
the sense of taste It is first arch muscle supplied by branch of mandibular
nerve V3
2 Stapedious muscles ndash It is inserted to the neck of stapes It is the second
arch muscle supplied by branch of facial nerve that is nerve to stapedius
Fig 4 Contents of the middle ear
Blood supply of Middle Ear
bull Anterior tympanic branch of maxillary artery which supplies tympanic
membrane
bull Stylomastoid branch of posterior auricular artery which supplies middle
ear and mastoid air cells
Page | 34
Four minor vessels are
bull Petrosal branch of middle meningeal artery runs along greater petrosal
nerve
bull Superior tympanic branch of middle meningeal srtery traversing along
the canal for tensor tympanic muscle
bull Branch of artery of pterygoid carotid
bull Tympanic branch of internal carotid
Lymphatic Drainage of Ear
Lymphatics from the middle ear drain into retropharyngeal and parotid
nodes while those of the Surgical Importance ndash Eustachian tube drain into
retropharyngeal group
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 middle is likely to pass to
middle ear
2 Moreover middle ear suppurative disease may spread to adjacent organs
and produce complication eg Labyrinthitis meningitis facial nerve palsy
etc
3 Lenticular process is vulnerable in suppurative ear diseases and causes
ocular disruption
4 Prussac space is the site of primary acquired cholesteatoma
Page | 35
INNER EAR [60]
Inner ear is divided into two parts
1 Bony Labyrinth
2 Membranous labyrinth
Anatomy of bony labyrinth
It is divided into two parts
1 Vestibule
2 Cochlea
3 Semicircular canal
The vestibule is located between the medial wall of the middle ear and the
lateral to internal acoustic meatus anterior to the semicircular canal and
posterior to the cochlea The vestibule is the central part of the inner ear
On its side is the oval window opening which is closed by the bracket foot
plate The bony cochlea is located in front of the vestibule It has 275 turns
wound around a bony axis called a modiolus The cochlea is about 30 mm
long The hollow center of the modiolus is a spiral canal that contains the
fibers and ganglion cells of the cochlear nerve A thin bony sheet the bony
lamina winda around the modiolus This divides the cochlear duct into two
galleries the Scala vestibuli above and the scala tympani below
There are three semicircular canals superior posterior and lateral They
are semicircular in shape and open into the vestibule One end of the
semicircle is enlarged and is known as the sphere
The membranous labyrinth is in the bony labyrinth It is connected to the
bony labyrinth by fibrous trabeculae and is surrounded by perilymph The
endolymph is located in the membranous labyrinth
Page | 36
The utricle is in the upper part of the vestibule while the saccule is found
below Both the utricle and saccule contain a single sensory patch called
the macula Each macula is covered with a neuroepithelium made up of
neuroepithelium made up of sensory hair cells and support cells these cells
are separated by a basement membrane Fibers of the vestibulo-cochlear
nerve enter the macula and pierce the basement membrane to terminate
at the base of the hair cell or cell bodies The utricle and the saccule with
their macula are called otolith organs Membrane semicircular canals are
the membrane canals of the corresponding bony semicircular canals They
open into the utricle through five openings One end of the opening of each
channel is dilated called the sphere in which the sensory organ of each
channel is located The cross section of the Scala standard looks like a right
angle The base is formed by the basilar membrane Sensory cells are
arranged on the surface of the basilar membrane These sensory cells with
their supporting cells form a complex neuroepithelium called the basilar
papilla or the cortical organ named after an Italian microscopist The
organs of the corti have a gelatinous membrane called the tectorial
membrane and they are supported by the pillar of the corti The cortical
pillars enclose a space called the corti tunnel which contains a fluid called
cortical lymph Vestibule is lies between the medial wall of the middle ear
and lateral to internal acoustic meatus anterior to semicircular canal and
posterior to the cochlea 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 Boney cochlea lies in front of the vestibule It has 275 turns
coiling around boney axis called modiolus Cochlea is approximately 30 mm
in length The hollow center of the modiolus is a spiral canal containing the
fibers and ganglion cells of cochlear nerve A thin boney sheet the osseous
lamina winda around the modiolus This divides the cochlear canal into two
galleries the Scala vestibuli above and the scala tympani below
Page | 37
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 boney labyrinth It is connected
to the bony labyrinth by fibrous trabeculae and is surrounded by perilymph
Endolymph 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 single sensory patch called macula Each
macula is covered by neuroepithelium consist of Neuroepithelium consists
of sensory hair cells and supporting cells these cells are separated by
basement membrane Fibers 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 are referred
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 corti lymph
Page | 38
Fig 5 Inner Ear
Blood supply of labyrinth
Labyrinthine artery
Common cochlear Anterior vestibular Artery
Vestibulocochlear artery Main cochlear artery
Cochlear branch posterior vestibular artery
Page | 39
PHYSIOLOGY OF HEARING [61]
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
bull Mechanical conduction of sound (conductive apparatus)
bull Transduction of mechanical energy to electrical impulses (sensory
system of cochlea)
bull Conduction of electrical impulses to brain (neural
Fig 6 PHYSIOLOGY OF HEARING
Page | 40
Conduction of sound
Under the surface of water we cannot hear the sound made in air because
9995 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 must 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 13 times longer than long process of incus providing
a mechanical advantage of 13
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 beings 211 As the effective
vibratory area of the tympanic membrane is only two- thirds the effective
areal ratio is reduced to 141 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
Page | 41
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 lobe
Page | 42
DISEASES REVIEW
करणसराव
Nirukti - करणसय कणवयोाव ससराा [62]
Nidana- Acharya Sushruta and Vagbhata describe the common etiological
factors for the Karnaroga
अशयाय जलिीडा कणवकणडयन मरत
शमथययोगन शसततरसतय कवपतो अरय च कोपन ||
सउ २० १२
1 Avashaya or Pratishaya
(Excessive exposure to cold)
2 Jalakrida
(Excessive swimming)
3 Karnakandunyanum
(Excessive scracing due to itching)
4 Mithyayogena Shatrasya
(Improper instrumentation during wax removal or foreign body removal)
5Shabdasya
(Louder sound for long durationperverted contact of sound)
6 Abhighata (Trauma)
7 Vitiation of Tridoshas
Page | 43
Samanya Nidana according to different Samhita
Vishesh Nidan of Karnasrava
Acharya Charaka has not mentioned any kind of Nidana regarding Karnaroga
but has described Utapati of Karnaroga from Siroroga in Karnasirasym
Adhyaya[67]
शशरोअशिघातादरा तनमजजतो जल परपकादरा अवप विि
सरतत पय शरणॊ अतनलात स कणवससरा इतत परककतीत
सउ २० १०
असस ३७२५ [68]
1 Shiroabhighatat - Head Injury-Fracture of middle cranial fossa
2 Jala nimajjana - CSF otorrhoea fracture of middle cranial fossa
3 Karnaprapaka
4 Karna Vidhradhi -Puyasrava
Sr
no
Samanya Nidana SU AH[63] AS[64] YR[65] MN[66]
1 Avashaya + + +
2 Pratishaya + +
3 Shabdha
mithyayoga
+
4 Shashtra
mithyayoga
+ + +
5 Karnakandooyan + + + + +
6 Jalkrida + + + + +
7 Abhighata + + +
Page | 44
Samanya samprapti
परापय शरोतरशसरा कयावत शल शरोतशस गान
त कणवगता रोगा अटिावशततरीता
सउ २० १२
Due to common and specific etiology factors the vitiated Doshas gets
Sthanasamshraya in Karna and causes Karnasrava It is the stages of
Samprapti were Doshas gets lodged in Srotas and start processes of Dosh
Dushya Sammurchsna Due to Shiroabhighata Jalanimmajana Karna Paka
Karna Vidhradi vitiated Vata Dosha and Karna becomes Avruta by Vata and
results in Karnasrava Normal physiology of Dosha Dhatus and Malas entirely
depends on the normality of Srotas Dosh Dushya Sammurchana or
manifestation of diseases will not take place if only vitiation of Doshas take
place without deformity of Srotas Here in Karnasrava vitiation of Srotas are
Atipravritti Sanga and Vimargagamana take place Atipravritti is being excess
production of fungus Sanga is obstruction in external acoustic canal
Vimargagamana is the propagation of discharge through ear
Vishesh Samprapti
Karnasrava occurs due to Nij nidana is Pratishaya while Agantuja nidanas are
Avashya Jalkrida and Karnakanduyan Due to etiological factors which are
Vata-Kapha provocative in nature gradual vitiation of Doshas will occur After
vitiation they get accumulated (Sthan samshraya) in external auditory canal
In other hand when patient does Sevana of Agantuj Nidan like water enter in
external ear scratching of ear unsterile instrumentation leads to Dosh
Prakopa These cause Twak and Mamsa Dhatu Dushti which leads to
discontinuity of epithelium of ear canal which creates suitable atmosphere for
fungal pathogen to grow The vitiated Vata will produce symptoms such as
Page | 45
pain hearing impairment and vitiated Kapha causes symptoms like itching
discharge ear blockage By assessing the symptoms it can be said that Kapha
Avrita Vata Dosha is responsible for the manifestation of clinical features like
pain itching discharge Which are seen in Karnasrava that is otomycosis
Acharya Charaka has mentioned while explaining Samanya Chikitsa of
Karnaroga that it should be treated like Vrana when Paka and Srava is present
as a symptom Fungal spores invade in the epithelial layer of EAC In response
to infection inflammatory process is start This is a Paka Avastha After
removing the fungal mass ulceration in external acoustic canal is commonly
seen As a result of infection process exudates was produced which will mix
up- with fungal colonies and appear as discharge As per Dosha involvement
in Vrana Shoola Srava can be differ According to Acharya Sushruta Ruk is
the Samanya Lakshana of Vrana and Vishesha Lakshana of Vrana includes
pain discharge discoloration itching etc according to Dosha involvement
which are also seen in otomycosis In otomycosis mainly watery and purulent
type of discharge is present which indicates Paka avastha If there is Dosha
involve in Vrana is called Dushta Vrana Acharya Sushruta and Acharya
Vagabhata have mentioned verity of Srava in Twak and Mamsa Vranavastu
which is found in otomycosis Based on this description otomycosis can be
correlated with Karnasrava
Page | 46
Representing the Samprapti of Karnasrava
Vishesh Nidana ndash Shiroabhighatat
Jala nimajjana
Prapaka Vidhradhi
Vitited vata
Avarana by kapha
Vimargagamana of Vata
Karnasrava
Samprapti Ghataka
Dosha ndash Kapha and Vata
Dushya ndash Rasa Rakta and Mansa
Strotodushti ndash Vimargagamana and Sang
Adhishthana ndash Karna (Bhayakarna)
Rogmarga ndash Madhyama
Page | 47
Purvarupa
The Purvarupa of Karnasrava are not mentioned separately in any ayurvedic
classics In routine practice cretin Purvarupa are noted
1 Karnakandu
2 Karnagurutwa
3 Alpa karnashoola
4 Discomfort in ear
Rupa
1 Karnashoola
2 Karnakandu
3 Karnasrava
4 karnabadhirya
5 Cotton wool like or wet newspaper like grayish brown or black colored mass
is seen
6 External auditory canal skin appears edematous and red
Upashaya and Anupashaya
Appropriate application of Aushadhi Ahara and Vihara when produces relief in
the symptom is called as Upashaya and when aggravates the symptoms is
called Anaupashaya There is not any reference available in the classics about
the Upashaya and Anupashaya of karnasrava
Sadhyasadhyata
Sushruta has not mentioned specially the Sadhyasadhyata of Karnarogas But
Vagbhata has mentioned Karnasrava as a Sadhyavyadhi[69]
Sadhysadhyatagives the clear picture of prognosis of the disease It depends
on many factors like nature of disease severity of disease Vaya Prakriti Bala
of the patient etc
Page | 48
Upadrava of Karnasrava
In Samhita there is no reference available regarding the Upadrava of
Karnasrava
Samanya Chikitsa ndash
The common treatment principle for all Karnaroga is Ghritapana Use of
Rasayana Bhrahmacharya Avyayama Shirasnana and Atibhashaya
सामरय कणवरोगष घतपान रसयनम
अवयायमो शशराःसतनान बरमहचयवम कतपरनम
स उ२१३
Ghratapana - Ghrita is a Yogavahi and follow Sanskara in addition to these
acquired properties and capable of retaining its own properties So Ghritapana
is effective in Karnasrava
Rasayana - Rasayana represent the basic approach of Ayurveda which
comprise preventive promotive and curative aspect of health
Brahmacharyaapalana -It is like Sadvrittapalana and is equals to Rasayana
effect
Vyayama - It leads to vitiation if Vatas a Karna is a Sthana of vata and
exercise causes Kshayaj Samprapti hence it is important to avoid exercise in
Karnasrava
Shirasnana- In Shirasnana water enters in external acoustic canal it changes
the PH of meatus skin from acid to alkali which favors the growth of pathogens
Atibhashya - Excessive speaking causes Vata Prakopa and Vatapraokopa is
basic Samprapti for Karnasrava as the preventive aspect avoidance of
excessive speaking is necessary
Page | 49
Ghritapana Rasayana and Brahmacharyapalana should be followed for
preservation of dhatu Samyata and restriction of vitiation of Vata Vayayama
Shirasnana and Atibhashaya should be avoided in Karnasrava to protect the
Siras from the affliction of Vata and Kapha
Vishesha Chikitsa ndash
The general treatment principle of Karnasrava described in classics is closely
related to Dushtavrana Chikitsa
शशरोवरचन च ए िपन परण तरा
परमाजवन िान च ीकषय ीकषय़ाचारत [70]
स उ २१४०
कणवसततरा ोददत कयावत पततकशमकणवयो [71]
ाउ १८३५
उपददि च सततरोत साय परात वपचततवशि परमजय
य अगर मदन सघत गगलना ा िपतयतपा मिना परयत [72]
असउ २२४२४३
In addition to that Shirovirechana Karnadhoopana Karnapurana
karnapramarjana Karnadhavana are also indicated
Page | 50
Treatment is also mentioned for Karnasrava
1 Karnaprakshalana Yoga - with Aargawadadi Gana Kashaya and Surasadi
Gana Kashaya [73]
2 Avachurnana Yoga ndash with Aargawadadi Gana Churna and Surasadi Gana
Churna[74]
3 Karnapoorna Yoga ndash
bull Rasanjana Laksha with Sarjachoorna[75]
bull Panchkashaya with Kapittha swarasa and Madhu[76]
bull Jambu AmrapallavShivalaKshuodra Mahavriksha and Madhuki 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 done[77]
bull Sarjatwak Choorna with Karpashiphalarasa and Madhu[78]
bull Abhaya LodraTindukaSamanga(Manjista) Kwatha of this Dravyas mixed
with Madhu and Kapittha Rasa[79]
bull Yogratnakara mention the following drugs for Karnapoorana-
a Samudraphena Churna[80]
b Jambwambpatra Yoga
4 Karnadhoopana Yoga ndash
bull Dhoopana with Churna of Bilvapatra Haridra Palandu[81]
bull Vartak Dhoopana [82]
5 Internal Medications-
bull Rasnadi Guggula [83]
bull Triphala Guggula [84]
bull Sarivadi Vati [85]
bull Gandhaka Rasayana [86]
Page | 51
According to Vagbhata-
Ear should be cleaned with the Pichu and Varti followed by Guggula Dhoopana
and then Karnapoorana with Madhu Followed by Avachurnanana with
Sukshmachootana of Surasadigana
Pathyaapathya ndash Pathya and Apathy mentioned for Samanya Karnaroga is
recommended in Karnasrava also
पथय[87]
सतदो वरको मन नसतय िमाः शशरावयिाः
गोिमाः शालयो मदगााः याशच परतन हवाः 80
लाो मयरो हररणानदसततततरो नकककिाः
पिोल शशगर ातावक सतनषराण कदठललकम
रसायनातन सवणण बरमहचयवमिाषणाम |
उपयकत यरादोषशमद कणावमय दहतम ||81||
िापर २१
Aharaja Upacharaja
bull Godhuma bull Vamana
bull Shala bull Virechana
bull Mudga bull Nasya
bull Yava bull Dhoomapana
bull Puranagitra bull Kavala
bull Lava Harina Tittiramamsa
Page | 52
अपथय[88]
दरत काटठ शशरसतनान वययाम शलटमल गर
कणडयन तषारशच कणवरोगी पररतपयजत
िापर २१
Viharaja
bull Patola ShigruVartaka bull Bhramacharaya
bull Sunishannaka bull Avyayama
bull Katthlika bull Aakthanam
bull All types of Rasayana bull Upacharaja
bull Vamana
Apathyas
bull Abhishyandakara Aharas
bull Shirasnana
bull Karna kandooyana
bull Tushara sevana
bull Guru Kaphakaraka Aaharas
bull Dantdhavana
Page | 53
OTOMYCOSIS
Definition-
Otomycosis is a superficial acute sub-acute or chronic infection of external
ear canal It is mostly unilateral It is characterized by inflammation purities
and scaling Otomycosis is a common condition encountered in ENT practice
more in chronic and persistent ear infection
The Fungal infections are not communicable in the usual sense but the
humans become an accidental host by their introduction into tissue trauma
The virulence factors favoring colonization of fungus in human host are yet to
be identified Ability of the fungus to grow at 37 C and elaboration of a variety
of enzymes and toxins are speculated to contribute to virulence Only 100 to
150 species are generally recognized as a cause of disease in humans[89]
Prevalence-
Otomycosis is a word wide in distribution and in various record stated that 5
to 20 of all cases of infective otitis externa Otomycosis prevalent is more in
warm and humid climates It is one of the commonest manifestations in India
during rainy season It occurs mostly in humid atmosphere otitis externa due
to fungal infection may resembles the desquamative form of diffuse infective
otitis externa The incidence in temperature climates has increased in
proportion to the use of topical antibiotics which have a medium sterilized of
other organism in which the fungus may flourish
Page | 54
Predisposing factors- [90]
1 Environmental factors such as climate contagious and polluting hygiene
more frequently during rainy season as the humidity increases
2 Individual susceptibility ndashGeneral Immunological status of the Individual
eg HIV infection Radiotherapy chemotherapy Diabetes mellitus
3 Self-inflicted trauma that is use of pins to clean the itching ear or use of ear
bud to clean the wax
4 Wide spread of topical antibiotics steroid preparations which have medium
sterilized of other organism in which the fungus may grow
5 Failure of defense mechanism in External auditory canal
6 During swimming or head bath water enters in External acoustic canal
causes quantitative and qualitative change in ear wax It causes change in pH
7 Long term use of hearing aids
Pathophysiology ndash
The life cycle of the average mold encountered in the ear may be reckoned
as two weeks and flare ups may be anticipated at such intervals Swimming is
held responsible for infection in many cases The sequence sequence of
pathogenic changes produced by molds in the external ear is as follows ndash
1 Implantation of the organism in external ear
2 Growth of organism follows the rate depending on condition of temperature
moisture or preexisting irritation
3 Invasion of epithelium occurs with attendant itching and discomfort which
may be quite severe
Page | 55
4 Exfoliation of epithelium occurs as nature attempts to overcome the
infection by casting off upper most cells
5 Denudation occurs from exfoliation as the top layers of epithelium are cast
off and the canal becomes filled with debris
6 Superficial ulceration and lizematoid dermatitis results if the pathologic
process goes for enough The changes do not always proceed through the
entire sequence sometimes the molds produce changes of the mildest
imaginable character which may be overlooked[91]
Clinical features -
Symptoms-
1 Irritation and itching ndash Irritation is mostly found when the infective
organism is aspergillus niger There is sensation of discomfort which is more
diffuse in the ear canal then localized in the deeper part Candida infection
causes marked itching In external ear it is intense and worse at night
2 Discharge through ear- Intermittent scanty colorless discharge through
ear Mucus being a fungal metabolic product appears as discharge Excessive
discharge is associated with mixed infection
3 Pain and discomfort ndash Mild to severe pain in the ear occasionally Mostly
seen in cases where ear is infected with Aspergillus flavus mixed infection
with gram negative organism or mixed infection with candida and aspergillus
Headache is sometimes associated with pain
4 Deafness- Varying degree of mild to moderate conductive deafness
5 A sensation of fullness in ear
6 Tinnitus 7 Vertigo
Page | 56
Signs ndash
1 The external acoustic meatus may contain a mass formed of epithelial
debris exudates cerumen and fungus
2 Erythematous external canal
Fungal appearance
A Niger - The color of the mass which is usually grey or black is mainly
determined by the type of fungus concerned Its appearance is like wet
newspaper or blotting paper or a cotton wool It has a peculiar musty odor In
this infection fruiting heads may be seen as black specks in the debris
Occasionally as inactive form occurs in which the canal is lined by mold giving
a fluffy appearance due to the presence of tiny mycelia
Candida ndash Candida infections generally show as white deposits on magenta
colored skin when the debris is removed it rapidly recovers in 24 hrs
The underlying canal skin is often inflamed and granular due to invasion by
fungal mycelia and be seen in all cases In rare cases excoriation and
ulceration with marked extensive shedding of the epithelium and deep
ulceration can be seen usually associated with a flavus and with pathogenic
bacteria[92]
Otoscope Appearance
1 Aspergillus Niger ndash Black headed
2 Aspergillus Fumigators ndash pale blue or green
3 Candida Albicans ndash White- or cream-colored deposits
Page | 57
4 Auricle is normal in most cases In severe cases small ulceration with crust
formation may be present on lateral surface
5 Tympanic Membrane
In most cases it is normal with normal mobility and normal hearing In a few
cases the surface of the tympanic membrane is congested and scaly There is
erosion or ulceration of the external epithelial layer and the membrane itself
may be edematous
Diagnosis
1 Above mentioned symptoms and signs
2 In the stage at which patient with otitis externa usually first present
themselves mycelia threads conidiophors not visible to naked eye may
sometimes be identified with the microscope
3 Confirmed by culture
Page | 58
Fig7 Aspergillus Niger Fig8 Candida Albicans
Fig9 Aspergillus Fumigators Fig 10 Wet Paper like appearance
Page | 59
Treatment
1 Antibiotic or steroid drops should be discontinued if they are being instilled
since long time
2 Removal of fungal mass epithelial debris and discharge from the external
canal or mastoid cavity repeatedly and thoroughly by forcepa or suction or
syringing or cautiously blow a stream of air into the canal through a fine
cannula and dry thoroughly by swabbing liquid petroleum on swab used in
cleaning the ear lessens the burning sensation when metacresy acetate is to
be employed in the subsequent treatment
Furuncle is developed as a complication if there is no gentleness in cleaning
Cleansing may have to be delayed until local sensitiveness is lessened which
can usually be accomplished within twenty-four hours If there is excessive
epithelial debris along with otomycosis then metacresyl acetate which is a
keratolytic in introduction into the external auditory canal on cotton wick and
is allowed to remain for twenty-four hours After twenty-four hours the cotton
wick is removed at which time the canal can usually be cleansed with little
discomfort as the medication is also anesthetic The epithelium of the canal
was white from contact with the drug The top layer was detached and this
epithelial debris can be easily wiped away The wick is reinserted and wet with
metacresyl acetate
The treatment is employed for three to four days in succession and then a
bland application is substituted Icthyol iodine is of value at this stage Iodine
ointment 2 in combination with Tannic acid 2 is also an excellent local
application following cresatin treatment
Next one of the fungicides may be applied
Page | 60
1 Nystin Effective for candida infection but less active against aspergillus
group Nystatin in boric powder consisting of 100000units of nystatingm of
powder 3 times week for 3 weeks
2 Clotrimazole Available as 11 cream or drops or lotions Phenyl
(zchlorophenyl) 1 ndash imidazole ndash methane is a chlorinated trityl imidazol 1
effective against candida and dermatophytes and for aspergilli infection
3 Amphotericin B Available as cream and as 3 solution and 015 drops
for topical application Very effective for candida infection can be fungistatic
or fungicidal
4 Econazole Available as solution (Econazole nitrate) and as cream (1)
Broad spectrum ndash more effective for Aspergillus Also active against some
gram-positive bacteria (Staphylococci and Streptococci and Dermatophytes)
5 Miconazole Highly effective against dermatophytes and candida infections
used as a 21 cream applied once or twice a day for 10 days
6 Gentian violet 21 Available as drops (recently some evidence of
carcinogenicity) Discolors the ear canal and this interfere with clinical
examination
Other topical antifungal agents are ketoconazole Natamycin Tolciclat Bifonas
zole Fenticonzole Oxiconazole Tioconazole ciclopiroxolomine Tolnafate
Haloprogin Flucytosine Acetic acid Whit field ointment selenium sulfide
undcyclenic acid triacetin etc
Page | 61
Minimal length of treatment
A month of drug treatment is usually required because the antifungal agents
used are not sporicidal and it is necessary that the period of treatment covers
germination time It may be advisable to give short gaps in the period of
treatment to ensure all spores have germinated before deciding to terminate
therapy
Prevention
Accomplished by strict attention to the predisposing causes
1 Water should be prevented from entering the ear
2 Avoidance of external ear trauma
3 Use of alcohol medicated or plain in the ears after swimming mercuric
cyanide (15000) in ethyl alcohol (70) is a satisfactory liquid to use
Ear stoppers do no good unless their use is followed by some antiseptic in the
canal Divers exposed to water for long periods of time may also use acidic
alcohol
4 During Summer months with their high humidity special efforts are needed
to maintain ear dry 5 Indiscriminate use of topical antibiotics steroid
preparations should be avoided
Page | 62
DRUG REVIEW
1 GUGGULA
Fig11 - Guggula
Historical review of Guggula [93]
bull Atharvaveda one of the well-known Vedas of Hindus The earliest
reference given by Atharvaveda medicinal and therapeutic properties of
Guggula Guggula has long history of use in Ayurveda
bull Acharya Charaka Sushruta and Vagbhata describe detail regarding the
actions uses and indication as well as the variety of Guggula
Page | 63
bull Various Nighantus (Medical lexicons) were written between 12th and 14th
centuries AD was based on the Ayurvedic literature also describes
Guggula
bull The explanation of word Guggula is that Gunjo Vyadhegurdti Rakshati
which means to relief against different diseases
bull Guggula is the best medicine because it develops through the rays of
hot sun on specific circumstances
bull Guggula has an aromatic odor
गगलो कणवदौगवररधय िपन शरटठमछयत[94]
स उ २२११२
Latin name- Commiphora mukul
Family ndash Burseraceae
Rasa- Tikta Katu
Guna ndash Laghu Rukshasukshma vishada sara
Veerya ndash Ushna
Vipaka ndash Katu
Action- Rasayana Lekhana
Doshaghanta - Tridoshhara
Page | 64
Chemical composition [95]
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Oleoresin-Z-Guggulsterone E-Guggulsterone
Gum- guggulignans 1 and 2 guggula Tetrols mukulol allylcembrol c
27
Guggulusterol 1 2 ans 3 Z and E ndash guggulusterol
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Parts Used ndash Gum oleoresin
Guggula purity test
1 Yellowish brown emulsion is obtained when Guggula is triturated with
water
2 An ethereal solution of the drug attains reddish colour when treated
with br2 vapors and purple colour when moistened with nitric acid
Biochemical action ndash Antiseptic Anti-inflammatory Disinfectant Diuretic
Immunostimulant stimulating expectorant Ant suppurative Antipyretic
Enhance phagocytosis
Karma- Rasayana cardiovascular disease
Page | 65
2 AGARU-
Fig 12 Agaru
Historical review of Agaru [96]
bull The word Agaru literally means the one which is the heaviest and no
aromatic wood is heavier than it Since thousands of years Agaru lsquoThe
wood of Godrsquo has been used for multiple purpose like commercial
medicinal spiritual aromatic historical
bull The medicinal use of Agaru have been recorded in many pieces of India
Greek Roman Chinese Middle eastern and European since ancient times
bull Acharya Charaka used Agaru and pest of Rasna to counteract the effect of
cold in Agraya Dravyas
bull Acharya Sushruta used Agaru as a Dhoopana Dravya along with Guggula
Ral and Shoma in the treatment of Karnasweda and Vrana
Page | 66
Types-
bull Dhanwantsri Nighantu describes Kaleyaka as a type of Agaru
bull Sodhala Nighantu describes three types of Agaru ndash Agaru Krishna
Agaru Kakatunda Agaru
bull Raj Nighantu describes five types of Agaru ndash Krishna Agaru Kasht
Agaru Daha Agaru Mangalya Agaru and Agurusaar
bull Arthashasstra describes three Agaru wood product
1 Jongaka ndash Black or variegated black in colour and having variegated
spots
2 Dongaka ndash Black in color
3 Parasamudraka- Black in colour and smells like Navamallika
अगर उटण कि तपछय ततकत ततकषण च वपततलम
लघ कणाविरोगघन शीत ात कफपरणत
िापर २१ [97]
Family- Thymelaccensis
Latin name- Aquilaria agallocha
Guna- Laghu Ruksha Tikshan
Rasa- Katu Tikta
Vipaka ndash Katu
Virya ndash Ushna
Karma- Sheetaprasasmana Vranaorasadan Tvachya Pittavardhaka
Shirovirechana Mangalya Sugandhik and Rochaka in properties [100]
Krishna Agaru karma- Katu Tikta rasa Ushna Sheeta when applied externally
and Pittahara when taken orally
Page | 67
Chemical Constituents -
Agaru hardwood is rich in essential oil resins alkaloids saponins Steroids
terpenoids tannins flavonoids and phenolic compound Agaru wood
predominantly contains 2-[-2-phenylethy]-4H-chromen-4-one derivatives and
sesquiterpenes Agaru oil contains selinene dihydroselinene agarnol b-
agarofuran vetispira-2(11)valerianol dihydrokaranone and tetradecanoic
acids[99]
Part Used ndash
Heartwood- Dark resinous wood which is formed when the plant becomes
infected with a type of fungus (ascomycetous mold) Species of Aspergillus
fusarium and penicillium are reported to be associated with the development
of infection Prior to infection the heartwood is odorless relatively light and
pale colored however as the infection progresses the tree produces a dark
aromatic resin in the heartwood The infected resin in response to the attack
which results in accumulation of a very dense dark resin in the heartwood
The infected resin embedded wood is known as Agarwood Infection is more
common on the trunk roots and the area when branches divide The formation
of Agarwood starts when the tree attains the age of 20 years On an average
approximately 30 ml oil is extracted from 100 kg of infected Agarwood[98]
Qualities of best Agaru-
It should be black in color
It should be extremely heavy and aromatic
It should be oily in appearance and test
It should be sink in water
It should burn easily with bright flame with a bright flame giving off a pleasant
smell
Page | 68
3 MADANA
Fig 13 MADANA
Madana consist of dried fruit of Xeromphis spinosa It is a deciduous thorny
shrub or a small tree reaching a high up to 9 m and girth about a meter
branches numerous thick and horizontal found in sub-Himalayan tracts[101]
मदनो मिरनदसततकतो ीयोटणो लखनो लघ
ानदरतिदवििीहर परततशयायवरणारतक
रि कटठकफ़ानाहशोथगलमवरणापह[102]
िा पर १६० १६1
Page | 69
Latin name-Randia dumetorum
Familly ndash Rubiaceae
Rasa - Madhura Tikta
Guna-Laghu Ruksha
Virya- Ushna
Vipaka ndash Katu
Karma- Vamana and Lekhana
Chemical Composition-
Essential Oil Valerianic acid Saponin tannin resin [103]
Page | 70
YAWA [104]
Fig 14 Yawa
1 In Samhitakala Aacharya Charaka Acharya Sushruta explain detail about
medicinal properties of Yawa
2The use of Yawa in Aaharya Dravya mainly described by Dhanwantari
Nighantu Raj Nighantu Bhavprakash Nighantu[105]
Macroscopic Description-
Fruit a caryopsis elliptical oblong Ovoid and tapering at both ends smooth
about 1cm long and 02- 03cm wide dorsally compressed and flattened on
the sides with a shallow longitudinal furrow 3-5 ridges having shallow
depression between them grains tightly enclosed and adhering the lemma
and palea pale greenish yellow odor not distinct taste sweetish acrid
Page | 71
Latin Name ndash Hordenum vulgare
Family- Poaceae
Rasa- Kashaya Madhura
Virya- Sita
Vipaka- Katu
Karma- Vatakrt Pittahara Kaphahara Medahara Balya Visrya
SthairyakaraLekhana
Page | 72
PROCEDURE REVIEW [105]
In Ayurvedic classics there are many references regarding Dhoopana Dravya
Dhoopana is administering Dhuma with the help of Dhoopana Dravya
In Kashyapa Samhita there are 40 types of Dhoopana advised for children
Anesthesia (Mohajananam Dhoopa) is also mentioned For this Dhoopana the
drug used were herbs hairs of animals legs horns old cloths of Buddhist
monks
From the references available regarding Dhoopana we can understand that
Karna can be protected from maggots (krimi) Bactria (Rakshogna) lice etc
References clearly indicate the analgesic and disinfectant effect of Dhoopana
Karma Dhoopana is mentioned for Dushta Vrana Chikitsa It reduces Vedana
Srava Pootigandha of Dushtavrana It also helps in Vranaropana
Dushtavrana Chikitsa is mentioned in the treatment of Karnasrava[106]
Origin of Dhoopana-
In ancient period children of sages were constantly harassed by the
Rakshasas Hence the sages approached lord Agni for shelter Agni in turn
gave them Dhoopana Dravya and asked sages to use the Dhoopana for
protection against Rakshasas bhutas pishachas
Classification of Dhoopana
1 It is classified into Dhupa Anudhupa Pratidhupa
2 On the basis of Origin it is classified into Jangama and Sthavara
Selection of Guggula for Dhoopana
Page | 73
bull Guggul is a best Vatahara
bull It is Krimighana
bull It contains Oleoresin
bull In Ashtang Hrudaya Guggula Dhoopana mentioned for Karnasrava
Selection of Agaru for Dhoopana
bull Agaru is Laghu Ruksha Katu Tikshna
bull Vranaorasadan Tvachya
bull It should burn easily with bright flame with a bright flame giving off a
pleasant smell
Karna Dhoopana Indication
1 Karnaarava
2 Putikarna
3 Krimikarna
4Vataj Karnashula
Contraindications
Especially for Karnadhoopan contraindication is not mentioned in classic texts
But Dhoopana is contraindicated in Pittaj vaydhi Sharad and Grishma Rutu
Page | 74
MATERIAL AND METHOD
Page | 75
For randomize comparative clinical trial to study the effect of Agaruwadi
Karnadhoopana and Guggula Karnadhoopana in Karnasrava following material
and method were required
Source of data
Patient irrespective of gender occupation religion social economic status
signs and symptoms of classical features of Karnasrava (Otomycosis) selected
from the OPD of Shalakyatantra department
Materials ndash
1Patients
2 Drugs-Agaruwadi Dhoopana
Guggula Dhoopana
3Torch
4Otoscope
5 Tuning fork
6Jobson horn probe
7Cotton
8Case record form
DRUG
Group A Trial Group
1Churana of Agaru Yawa Madan
2Ghrita
3Jala
Group B Control Group
1Googula Churna
Page | 76
Properties of Drug
Table no 1 Properties of Drug
Drug
Family
Rasa Veerya Vipaka Effect
on
Dosha
Guna Karma
Agaru
(Aquilegria
Agallocha)
Thymelaca
ceae
Katu
Tikta
Ushna Katu KV Laghu
Ruksha
Tikshna
Shitaprashamana
Shothahara
Vedanasthapak
Durghandhihara
Madan
(Randia
spinosa)
Rubiaceace
Kashaya
Madhur
Tikat
Katu
Ushna Katu KV Ruksha
Laghu
Vatakaphaghana
Shothahara
Vedanasthapak
Vranashodhak
Yawa
Poaceae
Hordeum
Vulgare
Kashaya
Madhur
Sheeta Madhur KP Ruksha
Laghu
Vataghana
Vernashodhana
Raktshodhaka
Guggula
Commiphora
Mukul
Burseracea
e
Tikta
Kashaya
Anushna Katu VPK Laghu
Ruksha
Shothahara
Vedanasthapaka
Kandughna
Ghrita Madhura Sheet Madhur VK Snigdha Vataghana
Shothahara
Vedanasthapaka
Page | 77
METHODOLOGY
SELECTION CRITERIA
1)INCLUSION CRITERIA
1 Patients having signs and symptoms of Karnasrava (Otomycosis) ie करणशल
( pain ) करणकणड ( Itching ) करणसतराव ( Discharge )बाधिरण ( conductive Loss of
hearing )
2 Patient from age group 19 to 70 years
3 Any Gender
2)EXCLUSION CRITERIA
1 Patients suffering from any systemic disease like DM TB HTN
2 Chronic suppurative otitis media (CSOM)
3 Acute supportive otitis media (ASOM)
3 Perforation of Tympanic membrane
4 Chronic otitis media
3)WITHDRAWAL CRITERIA
1If patient develops any adverse effect such as irritation pain burning
sensation in ear loss of hearing and such patients was withdrawn from trial
and receive prompt appropriate medical attention
2If patient shows aggravation in symptoms
3If patient refuses to continue with the treatment
Page | 78
STUDY SETTING
Types of study - Randomized Clinical comparative Trial
Place of work - OPD of Shalakyatantra
Duration of study - 18 months
Study Population - Patients of Karnasrava in Shalakyatantra OPD
SAMPLE SIZE CALCULATION
Sampling Method ndash Purposive sampling followed by random allocation in two
groups
Sample size calculation-
n = z2 p (1-p)
d2
Were
n = sample size
P = prevalence of disease=10
z = standard normal variable ie 196
d = error ie005
desired Sample Size would be
n = Z2 P(1-P)d2
= (196)2x (0021) x(0979)(005)2
= 34
Visiting ENT OPD (ShalakyaTantra) and IPD (ShalakyaTantra) 21 = 34
n raquo34
So one group includes 34patients
Page | 79
Sampling Method
Total 68 patient of Karnasrava are selected by Purposive sampling followed by
random allocation in two groups Written informed consent is taken prior to
commencement of trial They are divided in 2 groups
Group A (Trial Group) 34 patients treated with Agaruwadi Dhoopana for 7
days
Dose 5 minutes twice in a day
Group B (Control Group) 34 patients treated with Guggula Dhoopana for 7
days
Dose 5 minutes twice in a day
STUDY DESIGN ndash
Open labeled Randomized Comparative Clinical trial
STUDY DESIGN
Screening of patient
Inclusion criteria satisfied Exclusion criteria
Initial assessment Excluded
Counseling of patient Treated accordingly
Patient selection by Simple Random Sampling Method
Page | 80
68 Patients were divided in two groups lsquoArsquo and lsquoBrsquo
Trial group A-34 patients were given
Agaruwadi Dhoopana
Control group B- 34 patients were
given Guggul Dhoopana
Informed written consent
Treatment was given for 7 days
Assessment on 1st 4th and 7th day
Post assessments follow up on 15th day
Observation
Data Collection
Statistical analysis of data
Conclusion
Page | 81
(A) Agaruwadi Varti for group A (Trial group)
Table no 2
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
B) Guggula Varti for group B (Control group)
SOP of it is same as above Agaruwadi Varti
Table no 3
Drug Guggula Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
FOLLOW UP
For both groups follow ups were done on 1st 4th and 7th and post
assessment follow up15th day
EXAMINATIONS
Torch for Local examination of ear
Otoscope examination
Tuning fork Test
Page | 82
OBSERVATION TABLE
Table no 4
Sr no Subjective criteria Day 1 Day 4 Day 7 Day 15
1 करणशल
(pain)
2 करणकणड
(Itching)
3 करणसतराव (Discharge )
4 बाधिरण (Conductive Deafness)
OBSERVATIONS
a) करणशल (Pain) -
0 - Absent
1 ndash Present
b) करणकणड (Itching) -
0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
Page | 83
c) करणसतराव (Discharge)
0- Absent
1- Mild -Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाधिरण (conductive Loss of hearing)
0 - Absent
1- Present
Observations were carried out before and after completion of treatment and
during each follow up After observations the data collected and presented in
the form of graphs charts and table
Page | 84
TRIAL DRUG
Authentication and standardization of raw drug material done After
authentication and standardizing of raw drug material Agaruwadi Varti was
prepared by Varti as explained in Ayurvedic classics
Method of Varti preparations
Panchavidh Kashaya Kalpana that is five method of pharmaceutical
preparation constitutes the fundamental process of Ayurvedic pharmaceutics
which is well explained in Sushrut Samhita Varti Kalpana is one among them
which can be included in Kalka Kalpana
तीररसतरपतपतीनामपरककव तीत [106]
स डलहण शरच 151
Medicines are powered triturated and given the Varti shape that is like wick
of lamp so it is called as Varti Kalpana
Drug content Agaru Madan Yawa
Route of Administration Local
Dose Two times a day
Duration 7 days
Page | 85
Methodology
Standard operating procedure (SOP) of Agaruwadi Varti
Agaruwadi Varti is prepared according to the classical text
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization was done as recommended in pharmacy procedure The
raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 mixed together in
equal quantity to make Agaruwadi churn
Quantity of each churn is 4 grams all are mixed when the Varti get dry total
weight of Varti was 10gram
STEP 4 - Agaruwadi churn triturated with appropriate quantity of water or
Ghrita and prepared Varti in GMP Certified Ayurvedic pharmacy Standard
aseptic precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Varti was packed in sterile air packed container
STEP 6 - Agaruwadi Dhoopana was given with the help of Dhoopana yantra
Authentication and Standardization of raw drug of Agaruwadi Varti was done
Sterilization was done as recommended in pharmacy procedure Sterile
preparation packed in sterile container of suitable size Under all aseptic
precaution Karnadhoopana given to infected ear
Page | 86
Containers for packaging and their sterilization-
Sterilization of the containers for storing Varties was done by Ethylene Oxide
(Eto) method
Ethylene Oxide (Eto) procedure-
It includes exposure of materials to ethylene oxide gas under vacuum in a
sealed chamber It consists of four primary variables
1Gas Concentration
2Humidity
3Temperature
4 Time
EtO gas is an alkylating agent which disturbs the DNA of microorganism
preventing them from reproducing It penetrates the breathable packaging
and sterilizes all the accessible surface of the product to render products
sterility by alkylation of essentials proteins for cell reproduction
Most Eto sterilization methods involves three different stages These can be
separated into three different on the size or number of devices to treat
1Preconditioning stage-
First products are passed through a preconditioning phase to make
microorganism grow The batch load goes through a well time under a
controlled environment of temperature and humidity
2Sterilizer stage-
Performed using process phase specially designed to provide the required level
of EtO exposure to assure sterility for a device or family of devices
3Degasser Aerration stage-
Finally products need to go through a degassing phase to remove any residual
particles of Eto The batch load goes over well time under a temperature-
controlled environment
The sterile containers were then used to store Agaruwadi Varti and handed to
patients included in the study
Page | 87
Packing of Agaruwadi Varti
The ETO sterilize plastic container were used for packing of Agaruwadi Varti
Varti was filled into these sterilize containers (7 in each) In an aseptic
environment plugging and capping was done under aseptic precautions In this
way packing of Agaruwadi Varti done These Varti were given to patient and
advise to take two times a day under all hygienic precautions
History and Examination
bull Proper history and presenting complains was recorded on case record form
bull Ear examination with otoscope was done during initial assessment and each
follow up
bull Otoscopic examination was done during initial assessment and each follow
up
bull Systemic Examination that is Blood Pressure Temperature Respiration
rate Pulse was recorded on case record form
Page | 88
Raw material
Fig14 यव चरण Fig15 मदनफळ चरण
Fig16 अगर चरण Fig17 गगगळ चरण
Page | 89
Preparation of Agaruwadi Varti
Fig18 Preparation of Agaruwadi Varti
Fig19 अगरवादी वरती
Page | 90
Fig20 Instruments used for examination of Karnasrava
Fig19 Karnadhoopana Yantra
Page | 91
Karnadhoopana Procedure
Fig 22 Karnadhoopana Procedure
Page | 92
OBSERVATIONS AND RESULTS
Page | 93
BASED ON DRUGS
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 94
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
AUTHENTICATION CERTIFICATE
Page | 95
BASED ON STASTICIAL ANALYSIS OF DEMOGRAPHIC DATA
68 patients of Karnasrava ndash Otomycosis
Table no 5
No of Patients Total
Group A Group B
Registered 38 37 75
Completed 34 34 68
Discontinue 04 03 07
Total 68 patients were enrolled in study 38 patients registered in group A
amongst them 34 patients completed the treatment and04 patients
discontinued the treatment However in group B 37 patients completed the
treatment and 03 patients discontinued the treatment out of 37 registered
patients
Hence the total number of patients registered in the present study was 75
and out of which 68 patients were discontinued the treatment So they
dropped out from the study While 68 patients were successfully completed
the treatment So observations and result of 68 patients were given below
Here we are going to discuss the statistical analysis of the data obtained in
the form of master chart that was prepared in accordance with the data
collected from the patients that had been included in the study The purpose
of statistical analysis was to analyzed the relation between age gender
occupation diet addiction and education
Page | 96
1 Age wise distribution of patients
Table no 6
In trial group 10 (29412) patients were from age group 18-25 years 14
(41176) patients were from age group 25-35 years 8 (23529) patients
were from age group 35-45 years and 2 (58824) patients were from age
group 45-60 yearsIn control group 6 (17647) patients were from age group
18-25 years 14 (41176) patients were from age group 25-35 years 7
(20588) patients were from age group 35-45 years and 7 (20588)
patients were from age group 45-60 years
Fig 23 Age wise distribution of patients
0
2
4
6
8
10
12
14
15 -25 25-35 35-45 45-60
10
14
8
2
6
14
7 7
Age Distribution
Trial Group N Control Group N
Age Distribution
Trial Group Control Group
N N
18 -25 10 29412 6 17647
25-35 14 41176 14 41176
35-45 8 23529 7 20588
45-60 2 58824 7 20588
Total 34 100 34 100
Page | 97
1 Gender wise distribution of patients
Table no 7
Sex
Trial Group Control Group
N N
Female 23 67647 15 44118
Male 11 32353 19 55882
Total 34 100 34 100
In trial group 23 (67647) patients were female and 11 (32353) patients
were male
In Control group 15 (44118) patients were female and 19 (55882)
patients were male
Fig 24 Gender wise distribution of patients
0
5
10
15
20
25
N N
TRIAL GROUP CONTROL GROUP
23
15
11
19
Gender
Female Male
Page | 98
2 Education wise distribution of patients
Table no 8
Education
Trial Group Control Group
N N
Illiterate 4 11765 3 88235
SSC 4 11765 3 88235
HSC 8 23529 9 26471
Graduation 16 47059 10 29412
Primary 1 29412 3 88235
Post-Graduation 1 29412 6 17647
Total 34 100 34 100
In trial group 4 (11765) patients were illiterate 4 (11765) patients were
SSC educated 8 (23529) patients were HSC educated 16 (47059)
patients were graduated 1 (29412) patients were primary educated and
1(29412) patients were post graduated
In control grou 3 (88235) patients were illiterate 3 (88235) patients
were SSC educated 9 (26471) patients were HSC educated 10 (29412)
patients were graduated 3 (88235) patients were primary educated and
6 (17647) patients were post graduated
Page | 99
Fig 25 Education wise distribution of patients
0
2
4
6
8
10
12
14
16
ILLITERATE SSC HSC GRADUATION PRIMARY POST GRADUATION
4 4
8
16
1 1
3 3
910
3
6
Education
Trial Group N Control Group N
Page | 100
3 Occupation wise distribution of patients
Table no 9
Occupation
Trial Group Control Group
N N
Accountant 1 294 2 588
Housewife 11 3235 8 2353
Engineer 1 294 1 294
Job 1 294 4 1176
Labor 1 294 3 882
Mess 1 294 0 000
Naturotherapyst 1 294 0 000
Pharma 1 294 0 000
Shopkeeper 4 1176 2 588
Singer 1 294 0 000
Student 8 2353 4 1176
Tailor 1 294 1 294
Teacher 1 294 1 294
Worker 1 294 3 882
Farmer 0 000 1 294
Lab Tech 0 000 1 294
Page | 101
Daily Collection 0 000 1 294
Fruit seller 0 000 1 294
Bus Driver 0 000 1 294
Total 34 10000 34 10000
In trial group 11 (3235 ) were housewife 8(2353) were students
4(1176) were shopkeeper 1(294) was accountant 1(294) was
engineer 1(294) was doing job 1(294)was labour 1(294) was
catering 1(294) was Naturotherapyst 1(294) was Pharma 1(294)
was Singer 1(294) was Tailor 1(294) was Teacher and 1(294) was
worker
In Control group 8 (2353)were housewife 4(1176) were students
2(588) were shopkeeper 2(588) was accountant 1(294) was
engineer 4( 1176) was doing job 3(882)was labor 1(294) was
Farmer 1(294) was Lab tech 1(294) was Daily collection 1(294)
was Tailor 1(294) was Teacher and 3(882) was worker 1(294) was
Fruit seller and 1(294) Bus driver
Fig 26 Education wise distribution of patients
0
2
4
6
8
10
12
1
11
1 1 1 1 1 1
4
1
8
1 1 10 0 0 0 0
2
8
1
43
0 0 02
0
4
1 13
1 1 1 1 1
Occupation
Trial Group N Control Group N
Page | 102
4 Religion wise distribution of patients
Table no 10
Religion
Trial Group Control Group
N N
Hindu 31 9118 33 9706
Muslim 3 882 1 294
Total 34 10000 34 10000
In trial group 31 (9118) patients were Hindu and 3 (882) patients were
Muslim
In control group 33 (9706) patients were Hindu and 1 (294) patient
were Muslim
Fig 27 Religion wise distribution of patients
0
5
10
15
20
25
30
35
N N
TRIAL GROUP CONTROL GROUP
3133
31
Religion
Hindu Muslim
Page | 103
5 Diet wise distribution of patients
Table no 11
Diet
Trial Group Control Group
N N
Veg 14 4118 20 5882
Non-Veg 20 5882 14 4118
Total 34 10000 34 10000
In trial group 14 (4118) patients were vegetarian and 20 (5882)
patients were Non vegetarian
In control group 20 (5882) patients were vegetarian and 14 (4118)
patients were Non-Veg
Fig 28 Diet wise distribution of patients
0
5
10
15
20
N N
TRIAL GROUP CONTROL GROUP
14
2020
14
Diet
Veg Non Veg
Page | 104
6 Addiction wise distribution of patients
Table no 12
Addiction
Trial Group Control Group
N N
None 30 8824 27 7941
Alcohol 2 588 0 000
Tobacco 1 294 2 588
Mishri 0 000 1 294
Smoking 1 294 4 1176
Total 34 10000 34 10000
In trial group 30 (8824) patients have no addiction 2 (588) patients
have addiction of alcohol 1 (294) patients have addiction of Tobacco 0
(0) patients have addiction of Mishri and 1 (294) patients have addiction
of smoking
In control group 27 (7941) patients have no addiction 0 (0) patients
have addiction of alcohol 2 (588) patients have addiction of Tobacco 1
(294) patients have addiction of Mishri and 11 (1176) patients have
addiction of smoking
Page | 105
Fig 29 Addiction wise distribution of patients
0
5
10
15
20
25
30
NONE ALCOHOL TOBACCO MISHRI SMOKING
30
21
01
27
0
21
4
Addiction
Trial Group N Control Group N
Page | 106
Statistical Analysis and Results
Effect of study on Karnashoola-
Table no 13
Karnashoola
Group A Group B
BT AT BT AT
N N N N
Grade 2 0 000 0 000 0 000 0 000
Grade 1 30 10000 7 2333 32 10667 5 1667
Grade 0 4 1333 27 9000 2 667 29 9667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 30 Effect of study on Karnashoola
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
30
7
32
54
27
2
29
Karnashoola
Grade 2 Grade 1 Grade 0
Page | 107
Table no 14
Karnashoola Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 088 100 033 006
969 2829E-
08 7667 HS
AT 021 000 041 007
Group
B
BT 094 100 024 004
1037 7103E-
11 8438 HS
AT 015 000 036 007
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 31
000010020030040050060070080090100
BT AT BT AT
GROUP A GROUP B
088
021
094
015
Karnashoola
Mean
Page | 108
Table no 15
Karnashoola
Mean SD Effect
Group
A
Group
B Trial Control Trial Control
Day 1 088 094 033 024 000 000
Day 3 065 071 049 046 2667 2500
Day 5 024 038 043 049 7333 5938
Day 14 021 015 041 036 7667 8438
000
010
020
030
040
050
060
070
080
090
100
Day 1 Day 3 Day 5 Day 14
Karnashoola
Mean Group A Mean Group B
Page | 109
Table no 16
Karnashoola N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3250 110500
510000 275 Control group 34 3650 124100
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 110
Effect of study on Karnakandu
Table no 17
Karnakandu
Group A Group B
BT AT BT AT
N N N N
Grade 3 7 2333 0 000 4 1333 0 000
Grade 2 18 6000 0 000 18 6000 0 000
Grade 1 7 2333 7 2333 10 3333 15 5000
Grade 0 2 667 27 9000 2 667 19 6333
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 32 Effect of study on Karnakandu
0
5
10
15
20
25
30
N N N N
BT AT BT AT
GROUP A GROUP B
7
0
4
0
18
0
18
0
7 7
10
15
2
27
2
19
karnakandu
Grade 3 Grade 2 Grade 1 Grade 0
Page | 111
Table no 18
Karnakandu Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 188 200 081 015
1091 3119E-
10 8906 HS
AT 021 000 041 007
Group
B
BT 171 200 076 014
1032 4746E-
09 7414 HS
AT 044 000 050 009
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Page | 112
Fig 33
Table no 19
Karnakandu
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 188 171 081 076 000 000
Day 3 126 118 057 058 3281 3103
Day 5 071 074 046 051 6250 5690
Day 14 021 044 041 050 8906 7414
000
020
040
060
080
100
120
140
160
180
200
BT AT BT AT
GROUP A GROUP B
188
021
171
044
Karnakandu
Mean
Page | 113
Table no 20
Karnakandu N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 4051 137750
373500 006 Control group 34 2849 96850
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is less than
005 Hence we conclude that there is significant difference between Trial
Group and Control Group
000
020
040
060
080
100
120
140
160
180
200
Day 1 Day 3 Day 5 Day 14
Karnakandu
Mean Group A Mean Group B
Page | 114
Effect of study on Karnasrava
Table no 21
Karnasrava
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 11 3667 0 000 8 2667 0 000
Grade 1 23 7667 3 1000 26 8667 2 667
Grade 0 0 000 31 10333 0 000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 34
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
11
0
8
0
23
3
26
20
31
0
32
Karnasrava
Grade 3 Grade 2 Grade 1 Grade 0
Page | 115
Table no 22
Karnasrava Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 132 100 047 009
1122 4356E-
13 9333 HS
AT 009 000 029 005
Group
B
BT 124 100 043 008
1130 9364E-
14 9524 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 35
000
020
040
060
080
100
120
140
BT AT BT AT
GROUP A GROUP B
132
009
124
006
Karnasrava
Mean
Page | 116
Table no 23
Karnasrava
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 132 124 047 043 000 000
Day 3 100 100 025 025 2444 1905
Day 5 047 038 051 049 6444 6905
Day 14 009 006 029 024 9333 9524
000
020
040
060
080
100
120
140
Day 1 Day 3 Day 5 Day 14
Karnasrava
Mean Group A Mean Group B
Page | 117
Table no 24
Karnasrava N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3535 120200
549000 655 Control
group 34 3365 114400
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 118
Effect of study on Karnabadhirya
Table no 25
Karn
Badhirya
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 0 000 0 000 0 000 0 000
Grade 1 13 4333 0 000 16 5333 2 667
Grade 0 21 7000 34 11333 18 6000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 36
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 00 0 0 0
13
0
16
2
21
34
18
32
Karnabadhirya
Grade 3 Grade 2 Grade 1 Grade 0
Page | 119
Table no 26
Karn
Badhirya Mean Median SD SE
Wilcoxon
W P-Value
Effect Result
Group
A
BT 038 000 049 009
799 7173E-
05 10000 HS
AT 000 000 000 000
Group
B
BT 047 000 051 009
816 0000138 8750 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 38
000
005
010
015
020
025
030
035
040
045
050
BT AT BT AT
GROUP A GROUP B
038
000
047
006
Karnbadhirya
Mean
Page | 120
Table no 27
Karn
Badhirya
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 038 047 049 051 000 000
Day 3 009 006 029 024 7692 8750
Day 5 003 006 017 024 9231 8750
Day 14 000 006 000 024 10000 8750
000
005
010
015
020
025
030
035
040
045
050
Day 1 Day 3 Day 5 Day 14
Karn Badhirya
Mean Group A Mean Group B
Page | 121
Table no 28
Karn
Badhirya N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3400 115600
561000 806 Control
group 34 3500 119000
Total 68
Page | 122
COMPARISION BETWEEN GROUP A AND GROUP B
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Table no 29
Overall Effect
Trial Group Control Group
N N
Marked Improvement 21 6176 16 4706
Moderate Improvement 8 2353 13 3824
Mild Improvement 4 1176 5 1471
No Change 1 2941 0 0
TOTAL 34 100 34 100
Fig 39
0
5
10
15
20
25
MARKED IMPROVEMENT
MODERATE IMPROVEMENT
MILD IMPROVEMENT NO CHANGE
21
8
41
1613
5
0
Overall Effect
Trial Group N Control Group N
Page | 123
DISCUSSION
Page | 124
Discussion is nothing but the logical reasoning of observations In
every research work discussion part is very important because it brings into
light about the logical analysis which are helpful in filling the research gap in
the scientific world
The discussion is categorized into following ways for the ease of
understanding
1 Discussion on selection of topic
2 Discussion on review of literature
3 Discussion on drugs their mode of action on the disease mode of action
of Karnadhoopana
4 Discussion on observation and results
1 Discussion on selection of topic
Otomycosis is commonly encountered in day-to-day practice Majority
of Indian people affected with this pathology This disease commonly
manifests in developing countries low socio-economic standard and lack
of hygiene Now a days due to busy lifestyle people are not able to follow
the proper instruction of care of ear which may be responsible for the
recurrent nature of disease So for the management of this we use
Karnadhoopana with the help of Agaruwadi Varti Dhoopana is simple
easy cost-effective procedure which can be done even at OPD levelso
for the disease Karnasrava we selected Karna Dhoopana as therapeutic
procedure Karnadhoopana was done with Agaruwadi Varti and Guggula
Varti which was very effective for treatment
Page | 125
2 Discussion on review of literature
Karnasrava is one such disease among 28 Karnarogas mentioned by
Acharya Sushruta in the chapter named Karna Roga Vigyana Acharya
Charaka included Karnasrava as symptom under the four types of
Karnarogas due to vitiation of different doshas Acharya Vagbhata has
not described Karnasrava separately It is a fact that systemic
description of Karnarogas is available in all the ancients of pus from a
Vata afflicted ear may results from head injury or immersion in water
Karnasrava is a clinical entity which can be correlated with Otomycosis
Karnasrava is explained as symptom as well as a disease in Ayurveda
Nidana- Karnasrava occur due to Samanya Nidana and Vishesh Nidana
Vishesh Nidana like Shirobhighata Nimmajato jale Mithyayoga of Shashtra
The exact pathology behind Karnasrava is not understood clearly
Purvarupa ndash No specific Purvarupa are found for Karnasrava in classical
literature Acharya Madhukara describe Purvarupa as expression of
Rupa(lakshana) with less intensity that is less intensity itching sound in ear
may considered as Purvarupa of Lakshana
Samprapti- Aacharya Sushruta not explained the Samprapti of Karnasrava
separately and we must consider the general Samprapti of Karnaroga Due to
various aetiologias as cited above ear afflicted by Vata dosha causes Twak
Rakta Mamsa dushti results in Karnasrava According to Acharya Sushruta
Vata-Kapha dose is dominance in Karnasrava
Page | 126
Nidan
Nija Agantuja
Vata ndash kapha prakopak nidana Shirobhighata Nimmajato-jale
Mithya yoga of Shastra
Vata- kapha Prakopaka(Chaya prakopak) Vata-kapha prakopaka
( Achay prakopak)
Twak Rakta Mamsa dushti
Karnasrava
Page | 127
Chikitsa
The curative aspect and this must be done simultaneously giving due
importance to Nidan Parivarjana that is preventive measures So Nidan
Parivarjana that is avoidance of causative factors like Jalkrida Mithyayogen
shashtrasya Karnakandu Shirasnan Pratishaya is the first step in combating
the disease and form the part of line of treatment
Above Samprapti helps us to proceed towards the treatment of Karnasrava
The main protocol of treatment is removal of fungus and wound management
which include various measures to keep area day clean clear of microbes and
providing ideal condition for healing
Samany Chikitsa- Acharya Sushruta described general treatment for
Karnaroga as Snehapana (Drinking ghee) Rasayana (Rejuvenation therapy)
Bhramacharya Avoid excessive speaking Avoidance of physical exercise and
head bath
Vishesha Chikitsa ndash Acharya Sushruta mentioned some procedures in the
treatment of Karnasrava which is Shirovirechana Karnadhoopana
Karnapurana Karanpramarjana Dhavan Avachurnana Karnapurana Above
various procedures described in Ayurveda for management of fungus growth
in ear discharging ear fulfill these requirements of wound management
Page | 128
Discussion on observation and Result
Out of 68 patients 34 patients included for the trial The incidence of
Karnasrava is observed in trial and control groups
The statistical analysis provided the following data
AGE
Trial group- Maximum no of patients that is 14 (41176) patients were from
age group 25-35 years followed by 29412 patients were from age group
18-25 years 23529patients were from age group 35-45 years and
58824 patients were from age group 45-60 years
Control group - Maximum no of patients that is 14 (41176) patients were
from age group 25-35 years followed by 20588 patients were from age
group 35-45 years and 20588 patients were from age group 45-60 years
17647 patients were from age group 15-25 years
The maximum no of cases of Karnasrava found in age group between 25 to
35 years The reason behind this is repeated use of ear bud or emersed water
in ear More use of earphone or working more in cold environment
GENDER
Trial group ndash A higher prevalence seen in females 6764 and 3235 in
males
Control group - A higher prevalence seen in males 5588 and 4411 in
females
Females and males both are prone to disease
Page | 129
EDUCATION
Trial group-It is observed that amongst 34 patients maximum ie16
(47059) patients were graduated 8 (23529) patients were HSC
educated 4 (11765) patients were SSC educated 4 (11765) patients
were illiterate 1 (29412) patient were primary educated and 1(29412)
patient were post graduated
Control group- It is observed that 10 (29412) patients were graduated 9
(26471) patients were HSC educated 6 (17647) patients were post
graduated 3 (88235) patients were SSC educated 3 (88235) patients
were primary educated3 (88235) patients were illiterate
There is no direct relation between education and Otomycosis
RELIGION
Trial group- The incidence of patients of Hindu religion are 9118 and Muslim
religion are 882
Control group- The incidence of patients of Hindu religion are 9706 and
Muslim religion are 294
There is no probable explanation for this maximum number of patients in
Hindu religion it depends upon the patients attend the hospital and
community residing there
Page | 130
DIET
Trial group It was found that maximum ie5882 patients were taking
mixed diet while 4118 were taking vegetarian diet
Control group It was found that maximum ie5882 were taking
vegetarian diet while 4118 patients were taking mixed diet
The dietary habit of person is based on choice availability and religious
customs of the person
ADDICTION-
Trial group- It was found that maximum ie 30 (8824) patients have no
addiction 2 (588) patients have addiction of alcohol 1 (294) patients
have addiction of Tobacco 1 (294) patients have addiction of smoking and
0 (0) patients have addiction of Mishri
Control group - It was found that maximum ie 27 (7941) patients have
no addiction 4(1176) patients have addiction of smoking 2 (588)
patients have addiction of Tobacco 1 (294) patients have addiction of
Mishri and 0 (0) patients have addiction of alcohol
Very few patients were addicted to Alcohol Smoking Tobacco and Mishri
These factors can be taken as provoking factors for Otomycosis
Page | 131
Discussion based on probable Mode of action of Karnadhoopana
In Ayurveda classics Karna Dhoopana is therapeutic procedure explain for
Karnasrava Dhoopana is administration of Dhooma (Fumes) with the help of
Dhoopan Dravya References indicates that analgesic and disinfectant effect
of Dhoopana karma and mention for Dushta Vrana Chikitsa It reduces
Vedana Srava amp also does Vrana Ropana action
Various Dhoopanas and Dhoopan Dravas for different element in various
Samhitas of Ayurveda but there is a lacuna of availability of reference
regarding how to do it and method of procedure Matra Kala Contraindication
etc
Currently simple modified way of Karnadhoopana according to Yukti Praman
and experience but there is lac of standardization
Karnadhoopana is one among the topical Bahiparimajan type of treatment
Karna Parmarjana is procedure of cleaning ear with the help of cotton or gauze
piece soaked in honey
Page | 132
Dhoopan
The fumes coming out on burning Agaruwadi Varti
Administrated directly into external ear canal
Causes vasodilation
Due to this increase blood supply in external ear canal
It helps in absorption of drug
Fumes dries up Srava and bring the analgesic effect
Karnagata Kapha amp Avrut Vata Dosha Shaman
Decrease in signs and symptoms like karnasrava Karnshool Karnabadhirya amp
Karnandu
Page | 133
3 Discussion based on probable mode of action of Agaruwadi
Dhoopana
Agaru ndash
I Agaru is a fragrant tree aroma is a result of fungal pathogenesis when the
wood of tree is contaminated by fungi at wounds it develops scrap filled
with resin and turn out to be aroma Medicinal use of Agaru have been
recorded in ancient medicinal science in in inflammatory disease and some
infective disease
II Acharya Charaka has referred to Agaru as an Ushna dravya despite having
Tikta Rasa Ashtang Samgraha used Agaru as Dhupana Dravya along with
Madan and Yawa in Karnasrava Nighantu recommended is use as a
Dhoopana
III In various Samhitas and Nighantus Agaru described as Tikta Snighdha
Sheetaprashamana Vranaprasadana Tvachya Due to these properties
Agaru is used in the treatment of Karna-Akashi Roga and Dushta Vrana
Shodhaka
IV Agaru is reported to have Antimicrobial Analgesic Antioxidants
Antihistaminic and anxiolytic properties Its Antihistaminic property gives
relief from itching which is cardinal feature of Otomycosis Due to Katu
Ushna Tikta Guna improves blood circulation Bheda stage develop It is
Niram Awastha of Dosha Karnagata kapha and vata get decrease and
symptoms like karnashoolakarnasrava get decrease Agaru also have a
Antioxidant properties
V Chemically Agaru Contain 2-(2-Phenylethyl) Chromones Terpenoids
Flavonoids
VI Natural Agarwood had inhibitive activities towards Staphylococcus Aures
The chloroform extract of Agarwood prolongs the pain threshold[108]
Page | 134
Madan
I Madanphala have therapeutic properties like Anti-inflammatory
Antiallergic Analgesic and Wound healing
II It is Useful in treatment of disease like Shotha (inflammation) Vidradhi
(Abscess) Pratishaya (Common cold) Kushta(Skin disease)
III Extract of Madanphala mainly contain Glcosides Tritorpenct
Glycosides Saponin
IV Saponin glycosides are act as fire extinguisher This property is helpful
for vartiIt also act as a detergent which clean the surface of fungus
V Tritorpenct act as a anti-inflammatory antimicrobial and
immunomodulator compound Interaction of glycosides with sterol
causes disturbance of selective permeability in plasmic membraneso
exudates and discharge get decrease
VI Pharmacological activity [109]
Antibacterial Activity The preliminary antibacterial activity of Methanolic
extract of Randia D lam was done on some standard and wild pathogenic
strains The inhibition of the bacterial growth was more pronounced on E coli
as compared to the other tested organism This shows the antibacterial action
of Randia D secondary infection can prevent
Anti-Allergic Activity In Ayurveda Randia D Extract and its fraction of milk
induced leukocytosis and eosinophilia in mice
Anti-Inflammatory Activity The crude methanol extract of fruit of Randia D
effectively reduced the carrageenin induced oedema in hind paw of the rats
significant reduction in granular tissue formation was recorded This activity
seems to be significant at various acute phases of inflammation and om
formation of granular tissue This proves action of Madanaphala in shopa
(inflammation)
Page | 135
Analgesic Activity Analgesic activity was tested in mice weighing between 20-
250 with six number of animals in each group Methanlic extract of fruit Randia
d give analgesic activity in both models This proves its Shoolanashaka (pain
killer) action
Immunomodulatory Activity Randia D has immunostimulant activity and
chloroform fraction which strongly affected immune system seems to be
bioactive fraction of this plant
The overall effect of Agaru Mandanphala Yawa having Anti-inflammatory
Antiseptic Antimicrobial Property Active ingredient shows these properties
Agaru Yawa Madanphala
Vatakaphaghna
Act as
Vranashodhak
Vedanasthapaka
Sheetaprashamana
Shothara
Avarana of Vata get decrease so helps to Shaman of Vata dosha
Karnakandu Karnashoola Karnasrava
Prashamana
Page | 136
This fact can be taken into consideration and probably acknowledge that
Karnadhoopana with Agaruwadi Varti had not leave any residue in the ear
Removal of fibrin keratinocyte migration and in growth of epithelial tissue
plays a major role in healing It is technique of fumigation of ear with the
smoke of anti-infective drug In Karnadhoopana Sthanik Swedana increase the
blood supply and helps in absorption of the drug reduce Karnakandu amp
Karnshoola associated with infection
Page | 137
SUMMARY AND CONCLUSION
Page | 138
The dissertation entitled randomize comparative clinical trial to study the
effect of Agaruwadi Karnadhoopan and Guggula Karnadhoopan In Karnasrava
wsr to Otomycosis
The dissertation is divided into fallowing parts
Introduction
Review of literature
Ayurvedic review
Modern Review
Drug review
Procedure review
Material and Method
Observation and result
Discussion
Summary and conclusion
bull INTRODUCTION
It includes importance of Shalakyatantra in Sushrut Samhita Charka
Samhita And Ashtang Samgraha
Common and specific causes of Karnasrava
Karnasrava is a clinical entity which can be corelate with Otomycosis
In Ashtang Samgraha stated the procedure like Karnadhoopana with
Agaru Yawa Madanphala in Karnasrava
Page | 139
bull REVIEW OF LITERATURE
1 Ayurvedic review
2 Modern review
3 Drug review
Ayurvedic review-
It includes Rachana-Sharir and Kriya-Sharir of Karna detail description of
Karnaroga and its types Karnaroga Samanya hetu Poorvaroopa Rupa
Samprapti Upadrava Pathya-Apathya of Karnasrava Vishesh Nidan and
Chikitsa of Karnasrava Detail description of Karnadhoopana according to
various Acharays have been mentioned
Modern review-
It includes anatomy and physiology of Ear brief anatomy of ear anatomy of
External middle and Internal ear Detail description of the disease
Otomycosis mechanism of fungal infection in external canal pathophysiology
investigations diagnosis and management
Drug review-
Detail description of Agaru Yawa Madan Guggula and its synonyms
Ayurvedic properties Karma uses Pharmacological action and their
pharmacodynamic properties
Page | 140
MATERIAL AND METHOD
It includes description regarding materials required for the study Preparation
of Agaruwadi Varti its Standardization Sterilization and packaging
Plan of study
1 Total 68 patients completed the treatment Age criteria was kept
between 18-60 years Patient selection was done by done by simple
random sampling method and divided into two groups A (Trial) and
Group B (Control) 34 patients in each group
2 Patients in Group A were treated with Karnadhoopana with Agaruwadi
Varti for 7 days two times in a day while patients in Group B were treated
with Karnadhoopana with Guggula for 7 days two times in a day
3 Clinical examination done during each follow up ie 0th 4rd 7th and
observation were recorded
Page | 141
OBSERVATIONS AND RESULTS
Page | 142
1 It was observed that higher incidence of disease Karnasrava ie
Otomycosis found in age group 25-35 years
2 Disease otomycosis was equal in both male and female
3 The trial group there was significant relief in Karnakandu (8906)
Karnasrava(9333) Karnashoola(7667) and karnabadhirya(100)
4 In control group there was significant relief in Karnakandu (7414)
Karnasrava(9524) Karnashoola(8438) and
karnabadhirya(8750)
Page | 143
REFERANCES
Page | 144
1 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published byChaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 17 page no
5
2 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 19 page no
6
3 DRNarayan Vidwas Shero-Karna-Nasa and MukhrogaAnand publication
edition 4th 2014 Page no-52
4 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-205
page no 111
5 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 111
6 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Shlok no2012
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 112
8 Dr KBBhargavaDr SK BhargavaDr TMShahaA Short book of ENT
diseases Usha publication edition 10th
9 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 8 Page no -52
Page | 145
10 Research and Review Journal of Ayurvedic science yoga and
Naturopathy 2017 4(3) 1-5 pA Critical review of Otomycosis in cortex to
Karnaroga described in Ayurvedic classic by amisha patel D B Vaghala
Chandani goswami Vol4 no3 (2017)
11 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogpratished Adhaya Shlok no-213
page no127
12 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedh Adhaya Shlok no-
2140 page no 131
13 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyant shirasiya adhaya Shlok no 1712 page no-
258
14 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
15 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
16 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Aupadravik Adhaya Shlok no-15 page no
2
17 Vaidya Jaymini panday Harit Samhita hindi commentaryChaukhamba
vidhyabhartiVaranasiedition 2010 Shlok no- 13-14page no-10
18 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 146
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-20345
page no 112
19 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Karnarogavigyniyam Shlok
no 21 Page no-731
20 Charak
21 Pandit Harigovind Shashtri Namalinganusasana Amarkosha of
Amarsimha hindi commentary published by Chaukhamba Sanskrit
Sansthan page no- 463
22 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
23 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 37
24 Shree Taranath-Trkavachspati-Bhattacharyen Vchaspatym published
by Rashtriya Samskrit Sansthandelhi Volume 4 page no- 5149
25 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
26 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
27 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
28 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Page | 147
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
29 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Indriyaopakramaniya Adhaya Shlok no 811
page no- 125
30 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243
31 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-510 page no56
32 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no3108 page no- 385
33 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no33 page no- 366
34 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sarvabhutachintasharir Adhaya
Shlok no-126 page no9
35 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-522 page no60
36 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-532 page no61
37 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Page | 148
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-521page no58
38 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-527 page no61
39 VdBramhand Tripathi Ashtanghradaya Sharirsthansthan Published by
Chaukhamba prakashana 2005 Shlok no331 page no-372
40 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Siravarnavibhaktisharir Adhaya
Shlok no-725 page no83
41 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Sharirsankhyavykaransharir Adhaya Shlok
no-512
42 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Pratekmarmanirdeshsharir
Adhaya Shlok no-628 page no75
43 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
44 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Marmasharirsthan Shlok no429 page
no- 393
45 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243244
Page | 149
46 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
47 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan pu blished by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711
48 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
49 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
50 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Shlok no 711 page no- 847
51 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Adhaya Shlok no-628 page no- 75
52 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Gandushavidhiadhaya Shlok no2232
page no- 261
53 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Karnavydhbandhvidhi Adhaya Shlok no-
1611 page no- 86
54 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Nidansthan Published by Chaukhamba
Page | 150
Sanskrit SansthanVaranasi Vatvydhinidansa Adhaya Shlok no183 page
no- 304
55 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavaykaransharir
Adhaya Shlok no-532 page no61
56 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Tristaisniya adhaya Shlok no 1120 page no-
163
57 P Hazarika Dr Nayaka R Balkrishnan Textbook of EarNoseThroat and
Head-Neck Surgery CBS Publication Anatomy of Ear
58 DrKB Bhargava DrSKBhargava DrTMShaha A short book of ENT
Diseases Published by Usha Publication 10th edition page no10
59 MrSalah Mansour MrJacques MagnanMr Hassan Haidar MrKaren
Nicolas MRStephan Louryan Comprehensive and clinical anatomy of the
Middle Ear Published by Springer publication Chapter -Middle Ear cavity
Page no 19 to 121
60 DrPLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 7
61 James OPickles An introduction to Physiology of Hearing Published by
Emerald publication 4th edition page no- 1 to 265
62 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
63 VdBramhand Tripathi Ashtanghradaya Uttarsthan Published by
Chaukhamba prakashana 2005 Karnaroga vigyniyam adhaya Shlok
no1713 page no- 998
Page | 151
64 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Shlok no- 212 page no-
730
65 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no
1-2 page no- 309
66 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana
67 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyantshirasiya Adhaya Shlok no 1713 page no-
258
68 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no-
6 page no- 310
69 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Karnarogavigyniym Shlok no- 1725-26 Page no-
1003
70 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2140 page
no 131
71 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Adhyay 18 shlok 35
72 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt
Karnarogapratishedhoadhya Shlok no-2211 Page no- 735
73 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 152
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2141 page
no 131
74 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2142 page
no 131
75 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2144 page
no 131
76 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 34 page no- 649
77 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2145page
no 131
78 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 37 page no- 649
79 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2146page
no
80 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
81 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 153
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2143page
no
82 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publication Krnarogadhikara adhaya page no-
318
83 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary
Madhyamkhand Vatkalpana shlok no- 782-83 page no- 137
84 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 72-77 page no- 651
85 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
86 Vd Shree Laxmipatishastri Yogratnakara
87 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
Karnarogadhikara Shlok no- 808182 page no- 652
88 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 83 page no- 652
89 (PDF) Otomycosis A Comprehensive Review (researchgatenet)
90 httpswwwncbinlmnihgovpubmed24948980
91 A Simon Carney Scott-Browns Otorhinolaryngology Head and Neck
Surgery CRC press 8th publication Otitis externa and otomycosis
92 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no Page no -
93 wwwguggulipidcomtradhtm
Page | 154
94 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
95 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-28 page no-
43
96 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009Agaru page
no726-728
97 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishra chapter Karpuradi varga Shlok no-31-
43 Page no- 116
98 httpswwwthiemeinimagecatlogsample_chapter_GOMPpdf
99 (PDF) Chemical Constituents and Pharmacological Activity of Agarwood
and Aquilaria Plants (researchgatenet)
100 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 4 chapter no-2 page no-4
101 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 chapter no-152 Madanpage
no376-379
102 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
103 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-54 page no-
84
104 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 page no697-699
patol-yawa
Page | 155
105 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
106 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
Dhoompanvidhi page no- 252-254
107 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012Chikitasasthan Shlok
no- 151page no-406
108 httpswwwmdpicom1420-3049232342pdf
109 httpswwwijamcoinindexphpijamarticledownload0610201530
0
Page | 156
BIBILOGRAPHY
Page | 157
1 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
2 Scott-Brown WG Diseases of the EarNose and Throat Landon
Botterworth and co(publishers) Ltd1952 Volume 2
3 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012
4 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009
5 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi commantry
Purvakhand and Madhyamkhand
6 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Published by Chaukhamba Sanskrit
SansthanVaranasi
8 The Ayurvedic Pharmacopeia of India Ministry of Health and family welfare
department of Ayush Part 1 and part 4
9 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005
10 Acharya Trivedi Raguveer Prasad Ashtang sangrah published by
Vaidyanath Ayurveda bhavan pvt
11 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition
12 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary published by Chaukhamba
Orientalia
Page | 158
ANNEXURE
Page | 159
ANNEXURE- 1
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
CASE RECORD FORM
RESEARCH PROFORMA FOR MS (AYU) DESSERTATION
DEPARTMENT OF SHALAKYATANTRA
NAME -
ADDRESS -
GENDER - AGE - OCCUPATION-
RELIGION - EDUCATION - MARITAL STATUS-
OPD IPD NO-
DATE OF ADMISSIONCOMMESEMENT-
DATE OF DISCHARGECOMPLITION-
DATE OF COUNSELLING-
TEL NO-
CHIEF COMPLAINTS-
PAST MEDICAL AND SURGICAL HISTORY-
TREATMENT HISTORY-
FAMILY HISTORY-
Page | 160
PERSONAL HISTORY-
a) Ahar(Diet)
b) Vihar
c) History of addiction
GENERAL EXAMINATION
PULSE - MIN BP - mm of hg
TEMP - 0F RR - MIN
ASHATAVIDHA PARIKSHANA
Nadi- Mutra- Mala-
Jivha- Shabda- Sparsha-
Drik- Aakruti-
SYSTEMIC EXAMINATION
RS ndash
CNS-
CVS ndash
Page | 161
LOCAL EXAMINATION (KARNA PARIKSHAN)
OBSERVATION TABLE FOR SUBJECTIVE CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching )
RIGHT EAR LEFT EAR
KARNASHASHUKULI
KARNAPUTRAK
KARNAPALI
KARNAKUHARA -
SRAVA
GANDH
VARNA
SWARUPA
KARNAPATALA (TM)
Page | 162
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
Hearing Test
1Renne Test ndash
2 Weber Test -
Examination of Ear-
Pathological Investigation-
Other Examination-
Nidan Panchak-
1Hetu-
2Purvarup-
3Rupa-
4Upashayanupashaya-
5Samprapti
Signature of Guide Signature of Doctor(Researcher)
Page | 163
ANNEXURE 12
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Dhoopana Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization were done as recommended in pharmacy procedure
The raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 were mixed together
in equal quantity to make Agaruwadi churn
STEP 4 - Agaruwadi churn were triturated with appropriate quantity of water
and prepared Varti in GMP Certified Ayurvedic pharmacy Standard aseptic
precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Dhoopana Varti was packed in sterile air packed
container
STEP 6 - Agaruwadi Dhoopan was given with the help of Dhoopan yantra
TREATMENT DETAIL-
Purvakarma -
1 The patient is asked to sit comfortably on chair having sufficient light and
less amount of dust
2 The EAC is cleaned thoroughly by Pichu Varti (cotton swab) to remove the
discharge and other debris
Pradhankarma -
1 The patient is asked to relax completely on the chair
Page | 164
2 Fumes are passed to the ear with Dhoopana Yantra
3 Dhoopana yantra is funnel shaped and its one end will keep the ear covered
for the passage of Dhooma into the ear canal and other end where Agaruwadi
Dhoopana Varti were placed which produces fumes
4 This Dhoopana was given for 5 min
Pashchat karma -
1 The patient were advised to avoid cold refrigerated food drinks cold water
bath cold wind fog and prevent water from entering the ear
(A) Agaruwadi Dhoopana Varti
B) Guggula Dhoopana Varti SOP of it is same as above Agaruwadi Dhoopana
Varti
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Page | 165
ANNEXURE 21
INFORMED CONSENT DOCUMENT
Study Title
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
Introduction
- You are invited to take part in a research study RANDOMSIED COMPARATIVE
CLINICAL TRIAL TO STUDY THE EFFECT OF AGARUWADI DHOOPANA AND
GUGGULA DHOOPANA IN KARNASRAVA
- Before you decide it is important for you to understand why the
research is being done and what it will involve
- Please take time to read the following information carefully and discuss
it with friends relatives and your doctor if you wish
- Ask us if there is anything that is not clear or if you would like more
information
Purpose amp Nature of Study
- In this research project by examine you and ldquoKarnasravardquo (Otomycosis)
disease were treated
- In the part of treatment Agaruwadi Dhoopana or Guggula Dhoopan were
given
- Dhoopana means medicated drug fumes were given in ear with the help of
Dhoopan Yantra
Page | 166
- Treatment was given for 7 days
Study Duration
7days
Participation
- Your participation is entirely voluntary
- If you do decide to take part you were given this information sheet to keep
and be asked to sign a informed consent form
- If you decide to take part you are still free to withdraw at any time and
without giving a reason This will not affect the standard of current or future
medical care you may receive
Confidentiality
- All information which is collected about you during the research were
kept strictly confidential
- Any information about you which is collected from the center will have
your identity in the form of a code number so that it will remain confidential
Benefits Of Study
- The results obtained from this study would be helpful for providing better
quality of treatment amp other essential facilities for Karnasrava (Discharge)
patients
- You will get clinical benefit from the study
Page | 167
Risks Of Study
- In this treatment there are few chances of Irritation of Ear Nose and
congestion at EAC if any of these happens then treatment were given
Results Of Study
- If the Results obtained are profitable then they may get published
without disclosing your details
Signature of patient
Date
Time
Phone no of Researcher
Page | 168
रण मादहती पतरक
सशोिनाच शीषवक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE
EFFECT OF AGARUWADI DHOOPANA AND GUGGULA DHOOPANA
IN KARNASRAVA
परसतताना
- आपणास या सशोिनातपमक अभयासात सहिागी होणय़ाच आाहन करणयात यत आह
- सशोिनातील सहिाग तननदशचत करणयापी सशोिनाच उददश समजन घया
- खालील मादहती काळजीपवक ाचा आणण आशयक ािलयास आपलया डॉकिराशी कका
दहतशरचतकाशी चचाव करा
- काही सददिता असलयास कका आणखी मादहती ही असलयास आमछयाशी चचाव करा
सशोिनाच उददीटि सतरप
- सदर सशोिन परकलपामरधय आपलयाला तपासणी करन कणवसरा या वयाशरिची शरचककतपसा दणयात
यणार आह
- सदर वयाशरिची शरचककतपसा महणन आपणास अगरादी िपन कका गगल िपन
दणयात यणार आह
- सदर औषि आपणास 7 ददस घयायाच आह
Page | 169
कालािी
- 7 ददस
सहिाग
- आपला सहिाग हा पणवपण ऎनदछिक आह
- आपला सहिाग तननदशचत असलयास आपणास ही मादहती पतरतरका दणयात यईल आपणास यातील
समती पतरकार सही कराी लागल
- सहिाग तननदशचत असनही आपण कोणतपयाही ळस कोणतही कारण न दता माघार घ शकता
याचा आपलया दयकीय सविर कोणताही पररणाम होणार नाही
गोपनीयता
- सशोिना दरमयान गोळा कलली आपलया वषयाची सव मादहती गोपनीय ठणयात यईल
- आपली यनदकतक मादहती साकततक सतरपात गोपनीय ठणयात यईल
सशोिनाच फ़ायद
- सशोिनाच तनटकषव कणवसरा बाशरित रणाछया दयकीय इतर सविाचा दजाव सिारणयास
फायदशीर ठरतील
सशोिनातील जोणखम
- य़ा शरचककतपसमरधय कान दखण डॊळय़ातन नाकातन पाणी य़ण नाकात जळजळण डोक जड
होण ही लिण ददस शकतात यापकी लिण तनमावण झालयास तपयाची शरचककतपसा कली जाईल
Page | 170
सशोिनाच तनटकषव
सशोिनाच तनटकषव फ़ायदशीर ठरलयास आपली मादहती गोपनीय ठन परकाशशत करणय़ात यईल
रण सतािरी-
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
Page | 171
ANNEXURE 31
INFORMED CONSENT FORM
Patient OPD no __________
Subjectrsquos Identifier
Date of Birth Age Gender
I _____________________________________ age___________ years
exercising my free power of choice hereby give my consent to be included
as a participant in the clinical study entitled
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
1 I confirm that I have read have been read and understood the information
sheet for the above study and can ask questions
2 I understand that my participation in the study is voluntary and that I am
free to withdraw at any time without giving any reason without affecting my
medical care or legal rights
3 I understand that the Ethics Committee members investigators and study
doctors will not need my permission to look at my health records both in
respect of the current study and any further research that may be conducted
in relation to it even if I withdraw from the trial I agree to his access
However I understand that my identity will not be revealed in information
released to third parties or published
4I agree not to restrict the use of any data or results that arisefrom this study
provided such a use only for scientific purpose
5 I agree to take part in the above study
Page | 172
signature with Date-
Left hand thumb impression
Name amp signature of the witness ndash
Name amp signature of the student ndash
Page | 173
ANNEXURE 32
समतीपतरक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
वयकतीच य
ददनाक जरमददनाक
1) मी ह तननदशचत कररत आह ककसदर सशोिन परकलपाबाबतची सपणव मदहती मी ाचली असनमला ती
समजली आहतपयाबददल मला परशन वचारणयाची पणव मिा आह सदर मादहतीन माझ समािान झाल
आह
2) मी सदर सशोिनातन माझया मजीनसार किीही बाहर पड शकतो या माझया अशरिकाराची मला कलपना
आह
3) माझी दयककय मादहती तपासणयाची कागदपतर कळ सशोिनाकररता ापरली जाणार आहत याची
मला मादहती आहसदर सशोिन परकलपातील सबशरित घिकाना माझी दयककय मादहती पाहणयाची मी
समती दत आहतरावप या सदिावतील माझी ओळख दशववणारी मादहती कोणासही ददली जाणार नाहीयाची
मला कलपना दणयात आली आह
4) सदर अभयासातन शमळणारी मादहती अरा तनटकषव कळ शासततरीय हतसाठी ापरल जाणयासाठी माझी
समती आह
5) रील अभयासात सहिागी होणयास माझी समती आह
रण सतािरी-
Page | 174
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
ASSESSMENT CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching)
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
a) कणवशल ( pain )- 0 - Absent
1 ndash Present
Page | 175
b) कणवकणड (Itching)- 0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
c) कणवसततरा ( Discharge )
0- Absent
1-Mild- Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाशरियव ( conductive Loss of hearing )
0 - Present
1 - Absent
Page | 176
Page | 177
Page | 178
Page | 179
Page | 180
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
Page | 181
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 182
AUTHENTIFICATION CERTIFICATE
Page | 11
3 There are several prayers mentioned for normal functioning of sense
organs (Yajurveda)
4 Structures and functions of Mastishka are described (Atharveda)
5 Mantras having reference to disease of Eye Ear Oral cavity etc are
found (Atharvaveda)
Upanishada Period ndash
1 Samhita Period
a) Sushrut Samhita ndash
bull Explanation regarding Netra Nasa and Shirorogas (Uttartantra 1-
26th chapter)
bull Details regarding Mukha and Karna Roga Nidan and
Chikitsa(Nidansthan 16th and Chikitsasthan 22nd chapter)
bull Description regarding Karna Chedana Sandhana Nasa
Ostasandhana Sutra Sthan 16th chapter
b) Charaka Samhita -
bull Explanation regarding Shirorogas (Sutrasthan 17th chapter)
bull Explanation of Gala rogas like Upajivika Galshundi and Rohini
bull Nasa Shiro Mukha Karna and Netra Chikitsa (Chikitsa sthan 26th
chapter)
bull Description regarding Lakshana and Chikitsa of Shankhaka
Ardhavbhedaka Shirovirechana and Shiro basti (siddhi sthan 9th
chapter)
c)Ashtnga Sangraha ndash
bull Detailed description regarding Shalakyatantara (Uttartantra 11-28
chapter)
bull Description of Kriyakalpa (Sutrasthan 32nd and 33rd)
Page | 12
d)Ashtang Hrudayam
bull Detailed description on Shalakya Tantra (Uttar tantra 8-24 chapters)
bull Kriyakalpas (Sutrasthan 23rd and 24th chapter)
e) Bhela Samhita
bull Chakshushya Vaisheshik and Buddhi Vaisheshik Alochaka pitta
f) Harita Samhita- Branch of Medical science offering elaborating
information about the procedure like Nasya Anjan Gandusha etc
comprehended with their applications in disease of Head Eyes Ears
Eyebrows Throat Temporal region and cervical spine is known as
Shalakyatantara
शशरोरोगा नतररोगा कणवरोगा वशषताः भरकरठशङकमरयास य रोगा समिनदरत दह १३
तषा परततकारकम व नसतयतपयवणजनातन च अभयङगमखगणडषकियााः शालकयसशमतााः १४
इतत शालाकयनाम [17]
Documentation of different ancient literature gives various references
regarding all aspects of Karnasrava in various periods It is very much
important to know the history of Karnasrava from Vedic Pauranic Samhita
and Samgraha period
Vedic period ndash The Vedas being the oldest source of knowledge have no
direct mentioning of Karnasrava
Page | 13
Samhita and Samgraha period ndash
Aacharya Sushruta described about Karnaroga Karnasrava Nidan
Roopa and Chikitsa The detail description is available in Sushrut
Samhita Uttartantra 20 and 21st chapters
Aacharya Charaka did not specify Karnasrava but mentioned 4 types
of Karnarogas that is Vataj Pittaj Kaphaja and Sannipataja and their
treatment in 26th chapter of Chikitsasthan
In Ashtang Hrudaya karnasrava is not explained as a separate disease
but Chikitsa is mentioned in 18th chapter of Astanga Hrudaya
uttartantra
In Ashtang Samgraha Chikitsa is mentioned in 22nd chapter of Astang
Samgraha Uttartantra
The details about Karnasrava are explained in Bhavprakasha
Madhyamakhanda 64th chapter
Madhavakara has explained about Karnasrava in 57th chapter of
Madhymakhanda
Karnasrava is also explained in Sharangadara Samhita Uttarkhand 11th
chapter
The reference for treatment of Karnasrava is available in
Yogaratnakara
In Gadhnigraha Karnasrava and its treatment is mentioned in
Karnarogadhikara Adhaya
Vangasena had mentioned about the disease and treatment in 69th
chapter
Chakradatta explained Karnasrava in 57th chapter
Dalhana has given commentary on Sushrut Samhita Uttartantra 20th
and 21st chapter
Sankhya Samprapti of Karnasrava ndash
Aachary Sushruta explains 28 Karnaroga in Uttaratantra Karnaroga
Vigyniyam Aadhaya Aacharya charaka explain 4 Karnaroga in
Page | 14
Karnarohvigyniyam Adhaya based on doshas Acharya Vagabhata in
Ashtang Hrudaya explain 25 Karnaroga in Adhyaya
कणवशल परणादशरच बाशरियव कषड ए च
कणवसरााः कणवकणडाः कणव चवसतततर च
कशमकणवपरततनाहौ विशरिदवविसततरा
कणवपाकाः पततकणवसततराशवशरचतवविम
कणावबवद सपतवि शोफशरचावप चतवविाः
ऎत कणवगता रोगा अटिावशततरीररतााः
स उ २०- ३ त ५[18]
ातकणवरोग वपततकणवरोग कफकणवरोग
रकतकणवरोग सनदरनपातकणवरोग कणवनाद
बशरिरतप परततनाह कणडाः शोफ पततकणवक
किशमकणवक उियरपविरधयअशो अबवद
कशरचकणवक वपपपली वदाररका पाळीशोष
ततिका पररपोिो उतपपातो उरमरर दाःखिवन
शलहाखयााः परचवशनदरतकणवरोगा उकतााः
इदिीका अ स उ २१ [19]
चतपाराः कणवरोगााः
च स [20]
Page | 15
KARNA
Karna ndash करोतत शबद गरहण [21]
The organ of hearing
Karnasrava- कणवसतय कणवयोाव ससराा [22]
Discharge from the ear is referred as Karnasrava
KARNA SHAREERA
bull Nirukti
कणयवत अकणयवत अनन इती [23]
It means reception and conduction of sound waves
These are the functions of external and middle ear
bull Nirukti of Sravanam
शरयत अनन इती शरणम[24]
It means perception of sound
It can be attributed to the internal ear function
bull Karna Utpatti-
Karna is an organ formed by Akash Mahabhuta[25]
The fundamental characteristic is as follows
Indriya ndash Srotram [26]
Indriya Adhisthan ndash Karna [27]
Indriya Dravy ndash Akasha [28]
Indriya Arth ndashShabdha [29]
Indriya buddhi ndash Srotobyddhi
Page | 16
bull Paryaya of Karna- Shabdapatha Srotrapatha Sravanam shruti
Kuhuram Dwanigraham etc
bull Definition of Karna-
कणवशटकलयनदछिरनमिटिोपगरदहत शरोतरमछयत [30]
मा तन ५७१
The definition of Karna is stated in Madhav Nidanam Indriya which is not
seen with naked eye along with Shashkuli is called Shrotra that is Karna
Indriya is so minute that it is not perceived with any sense organ
In Charak Samhita the word Karna explain as the Indriya Adhisthan of
Shabdha Karna is described as one of the Prathyangas of the body He
emphasizes that all Indriyas manifest during the 3rd month of gestation
period
Acharya Sushruta while describing formation of Purusha from Prakriti or
Avyakta narrated that all Indriyas are developing from the Vikarika and
Taijas Ahankara Both Vagabhata and Sushruta stated that Karna as one of
the Bahirsrotas
शरण नयन दन घराण गदमढराणण न सततरोताशसराणा बदहमवखातन [31]
स शा ५-१०
In Ashtang Hradaya Vagbhata has states that all Indriyas are Atmaja
According to him lower lobule elevated helix projected posterior portion
fleshy and adherent ear are indications of long span of life[32]
ततरखातखातन दह अनदसतमन शरोतर शबद ववकतता [33]
ा शा ३-३
शबदाः शबदनदरिय सवनदछििसमहो ववकतता [34]
स शा १-२६
Page | 17
Ear has the prominence of Akash Mahabhuta The prominent dosha of ear
is Vata It is important seat of Vata The prominent Dhatus are Asthi and
Mamsa Karna is one of the Panchgnanendriyas and it meant for hearing
Sushruta narrated that Karnasthita Asthi and Sandhi
घराणकणवगरीाकषिकोषष तरणातन [35]
सशा ५-२२
शरोतरशरगािकष शखाताव [36]
सशा ५-३२
गडकणवशखटककम [37]
स शा ५-२२
One Sandhi and one Tarunasthi in ear
Sandhi ndash Karna contain two Sandhi one in each ear Type of Sandhi is
Shankhavartha which is present in Shringataka
Mansapeshi ndash 2[38]
Siras ndash 10 [39]
Vataj Sira - 4
Pittaj sira - 2
Kaphaj sira - 2
Raktaj Sira - 2
Avedhya sira-
कणवयोदवश तासा शबदादहनीनामकका पररहरत
सशा ७-२५[40]
Amongst above mentioned ten Siras each Karna lodges one Shabdavaha
Sira It is Avedhya
Page | 18
Dhamani -2
Length of ear is 4 Angula
Karna moola ndash 2 Angula
कणाविरतर चतदवशअगलम
स शा ३५-१४[41]
The distance between two ears through the back of the neck is 14 Angula
bull Marmas of Karna-
1 Vidhuras-
कणवपटठतो अिाःसशरशरत विर ततर बशरियवम
सशा ६-३७[42]
कणतपयादद सतनायममवणी ककनदचचनदरनममनाकर कलयकररणणच
डलहणाचयव[43]
अिसततात कणवयोतनवमन विर शरततहाररणण
ा शा ४-२९[44]
Sankhya-2
Vistara- frac12 Angula
Type- Snayumarma (Susha)
- Dhamanimarma(AH)
- Vaikalykar
Sthana- It is situated in the depressed portion in the back of the ear
Injury to them causes loss of hearing
Page | 19
2 Shringataka marma-
नदजवहाकषिनाशसकाशरोतरखचतटियसरमम
तालरयासतयातन चतपारर सरोतसा तष ममवस
वदि शरगातकाखयष सददसततपयजतत जीवतम
मा तन ५७१ [45]
Sankhya- 4
Type- Siramarma
Sthana- It is in head that is amidst Siras (blood vessels) nursing sense
organ
A palm size area near Talu
Injury to this Marma causes death
In modern anatomy ear divides into Bhayakarna or External ear Mdhyakarn
or Middle ear Antahkarna or Internal ear This is extremely appropriate
Even though the ear is divided into three divisions in the point of modern
anatomy Ayurveda denotes ear organ is one Ayurveda treats disease by
way of assessing Dosha and Dushya Here Dushya is one that is Karnendria
Dosha difference will call for different treatment for different disease Hence
treating the vitiated Dosha will cure the disease irrespective whether it is in
external middle or internal ear The thought is based on different
fundamental principle from Ayurveda
bull Parts of Karna
In Ayurveda classics detailed description about anatomy of ear is not
available But the various parts are mentioned as follows
Bhayakarna- External ear
Mdhyakarna ndash Middle ear
Antahkarna- Internal ear
Page | 20
द कणवशटकशलक दॊ कणवपतरकौ
च शा 7-11[46]
कणवशटकशलक कणवगतातवकौ कणवपतरकौ त बाहयकणा
चिदतत च शा 7-11[47]
शटकली बाहयपालयाशरिटिानम
डलहन- स शरच 25-1 12[48]
Karna Shashkulika ndash It is also called as Karna Shashakuli Charaka has
mentioned this term while describing different Pratyngas of the body
Acharaya Gananatha sen has given the clarification for it as a pinna or
auricle[49]
Karnapali ndash It is popularly known as lobule of the ear Daivakrita Chidra is
present in it
Karnaputrika- Ayurvedic scholars accepted two terms in this cortex They
are Karnaputrika and Karnaputrika The former is considered as Tragus and
antitragus[50]
Karna Prushtha- It can be taken as the cranial surface of mastoid or
auricle[51]
Karnapeetha- Aacharaya Sushruta firstly mention the term Karnapeetha
It is mentioned first by Sushruta while describing the procedure of
Karnavyadana Vagbhata has mentioned that it is Adhobhaga of Karna
Dalhana has clarified that it is the region above the Karnaputrika that is the
region which is at the bottom of the concha
Karnamoola ndash It can be considered as parotid region[52]
Karna lathika ndashAcharaya Dalhana mentioned lobule as a Karna Lathika
Page | 21
Karnaavatu ndashThis term is used by Sushruta while describing the
measurements of different Angapratyangas where he has mentioned that
the distance between the Karnaavatu is 14 Angul Dalhana has comments
that it can be taken as the distance between two ears from behind[53]
Shabdhavahasrotas ndash It also called as Shabdapatha or Srotapatha The
whole passage through which the sound waves pass can be taken as
Shabdavahasrotas[54]
Shrotashringataka ndash It can be taken as the labyrinth of ear[55]
bull Dosha in context to Karna-
Karna is principal location of Vayu
1 Prana Vayu- Prana Vayu circulating in oral cavity is responsible for
Dehadhruka that is keeping all body parts active Indriyadruka that is
keeping all Dnyanendriya healthy by proper nourishment (Purana) helps in
deglutition of food material and convey the stimulation of Indriyabuddhi
and atma
2 Udana Vayu- Bala(strength) Varna speech singing are its function It
is responsible for facial expressions due to pleasure sorrow anger love
frustration etc in general its circulation and actions are just opposite to
Pranavayu
3 Vyana Vayu- Its principal functions are circulation of Rasa and Rakta
through body and various movements Its main location is Hrudaya Five
types of movements for which it is responsible are expansion contraction
upward downward and oblique other activities are opening closure of
eyelid yawning perspiration During circulation if it gets obstructed due
to Srotodushti it generates disease of that Srotas Vyana Vayu gets vitiated
by disease of Rasa Rakta Oja and Chetanadhatu
Page | 22
4 Samana Vayu- It is circulating in the vicinity of stomach and intestine
and helps in keeping the Jatharagni (digestive juices and enzymes) in
equilibrium Disturbance in Jatharagni precipitates disease
5 Tarpaka Kapha- Entire body functions movements are controlled and
executed by various centers in the brain Sensation perceived by sense
organs is conveyed to Mann and Aatma residing in Hrudaya The motor
signals from them are then conveyed to the functioning
organsKarmendriya through Prana Vayu Shira head is therefore a
location of continuous activities motions of Vata All these centers are in
unctuous Majjadhatu in the Shira For stabilizing this ever-active Vata and
to nourish the Majja dhatu very unctuous Tarpaka Kapha situated in Shira
plays an important role
bull Ayurvedic aspect of sound perception [56]
According to Ayurveda Pratyaksha Dnyan or Perception of any sensation
including Shabda occurs due to interaction of the Karnendriya and the
Indriya- Arth -Karma resulting in Sravana
External Environmental acquaintance with living body is executed by five
sense organs namely Netra Karna Nasa Jivha and Twaka All
Dnyanendriya that is sense organ are Panchmahabhautic combination
Despite this fact every Indrya sense organ perceives object Tanmatra of
that Mahabhuta only from which it is originated from Akash Mahabhuta and
hence perceives Shabd only that is audio perception Shrotrendriya is one
of the principal locations of Vata and its function is to perceive Shabda that
is sound waves This sensation is conveyed through Shabdavahi Dhamanis
to Mana and Atma through Pranavayu and the sequence is responsible for
perception of sound in this way external sound is perceived and interpreted
when Atma is linked with Mann Mann is linked with Indriyabuddhi that is
minute virtual Dnyanendriya located in brain Indriyabuddhi is linked with
Adhishthana with prominent Mahabhuta and lastly with Indriya
ArthShabdatanmatra that is sense object Once this sequence is completed
Page | 23
the meaning of a particular sound is interpreted and understood In this
entire process of perception and interpretation of sound waves Pranavayu
and Tarpaka Kapha located in Shira play extremely important role Hence
the healthy status of all the sense organ depends upon the normal
physiologically homeostatic condition of Pranavayu and Tarpaka Kapha
MANAS
ATAMA
BUDDHI
AHANKARA
ARTHA
Page | 24
EAR ANATOMY
bull Embryology of the Ear [57]
1 The sound conducting apparatus develops from the branchial apparatus
whereas the sound perceptive apparatus from the ectodermal otocyst
2 The pinna develops from the six hillocks around the 1st branchial cleft
3 External auditory canal develops from 1st branchial cleft
4 The outpouching of the 1st pharyngeal pouch gives rise to a proximal
narrow part that forms the eustachian tube and distal dilated part that
forms the middle ear cavity
5 Prussakrsquos space is a potential space lateral to the Shrapnellrsquos membrane
and medically by the neck of malleus that can be involved during the
extension of cholesteatoma
6 Development starts in the 3rd week of the intrauterine life and is
completed by 16th week of intrauterine life Membranous and boney
labyrinth develops from the otic capsule
The Ear is divided into
1 External Ear
2 Middle Ear
3 Internal Ear or the labyrinth
Page | 25
Fig 1 Ear Anatomy
EXTERNAL EAR [58]
The outside ear contains pinna and lobule
Pinna is the noticeable piece of outer ear made from single sheet of yellow
flexible ligament covered by subcutaneous tissue and skin It has two
surfaces average and parallel It is intently disciple to perichondrium on its
sidelong surface while it is somewhat free on average surface Pinna
incorporates tragus helix against helix fossa three-sided scaphoid fossa
incisura terminalis
External auditory Canal ndash It extends from the bottom of the conchea to
the tympanic membrane and measures about 24 mm along its posterior
wallit is S shaped
Parts 1 Cartilaginous part
2 Bony part
Page | 26
Cartilaginous part ndash The outer one third is cartilaginous consist of fibro
cartilage is directed first inward backward and upward It has Fissure of
Santorium The skin of this part of the canal contains hair follicles
sebaceous gland and cruminous gland
Bony part ndash The inner two third part is boney It goes forward downward
and medially skin lined in this part is very thin Isthmus is the narrowest
part of the canal lying medial to junction of bony and cartilaginous part
nearly 5 mm lateral to tympanic membrane
The roof and posterior wall of the external auditory canal shorter than floor
and anterior wall The skin lining the tympanic membrane and boney canal
has a self-cleansing property due to migration of keratin layer of epithelium
from drum towards the cartilaginous portion
Relations- Anteriorly- Temporomandibular joint and parotid gland
Superiorly- Middle cranial fossa
Inferiorly- parotid gland
Posterior- Mastoid antrum mastoid air cells and facial nerve
Nerve supply ndashSensory nerve supply of the external ear The auricle
supplied by fibers of the great auricular nerve (C2 and C3) and lesser
occipital nerve (C2) Auriculo temporal branch of the 5th cranial nerve and
auricle branch of the vagus (Arnoldrsquos nerve) supply external canal Facial
nerve has small sensory contribution on posterior-inferior wall
Tympanic Membrane -It is the partition between EAC and middle ear It
is a thin semitranslucent membrane pearly white in colored lying obliquely
in the medial end of EAC with the angle of 55 It is forming major part of
lateral wall of middle ear Annulus tympanicus is attached at its
circumference to the sulcus The TM is oval shape It measures
approximately 10 mm in vertical diameter and 90 mm in horizontal
diameter
Page | 27
Layers ndash Tympanic membrane consist of three layers
1 Outer Epithelium or cuticular layer which is continuous with skin of
external ear
2 Middle fibrous layer has both circular and radial fibers middle layer
missing in upper part
3 Inner layer- Inner mucosal layer which is continuous with middle ear
mucosa
Parts ndash Tympanic membrane consist of two parts
1 Pars tensa -It is largest part below the malleolar folds The inner
surface at the center attached to the handle of malleus Angle of cone
is most illuminated part in the pars tensa at anteroinferior part of pars
tensa
2 Pars flaccida Sharpnells membrane -it is triangular area above the
malleolar folds which are thin and devoid of fibrous tissue and
annulus It fits into notch of Rivinous
Nerve supply 1 Anterior half of lateral surface Auriculotemporal V3
2 Posterior half of lateral surface Auricular branch of vagus cn 10
3 Medial Surface Tympanic branch of CN 9 (Jacobsons nerve)
Fig 2 Tympanic membrane of ear
Page | 28
MIDDLE EAR [59]
The middle ear or tympanic cavity is an irregular laterally compressed
space within the temporal bone It is filled with air that is supplied to you
from the nasal part of the throat through the ear canal It contains a chain
of mobile bones that connect its side with the medial wall and serve to
transmit vibrations transmitted to the eardrum through the cavity to the
inner ear Including the parapet the vertical and anteroposterior diameters
of the cavity are each approximately 15 mm The transverse diameter
measures about 6mm at the top and 4mm at the bottom Compared to the
eardrum it is only about 2mm The eardrum is limited laterally by the
eardrum medially by the lateral wall of the inner ear It communicates
behind with the tympanic antrum and through it with the air cells of the
mastoid and in front with the auditory canal The middle ear together with
the Eustachian tube aditus antral and mastoid air cells is called the
middle ear cleft It is lined by mucus membrane and filled with air
It is divided into 3 parts
1 Mesotympanum (located in front of the pars tensa)
2 Epitympanum or attic (located above the pars tensa but medial to
Sharpnells membrane and the lateral bony wall of the attic)
3 Hypotympanum (located under pars tensa) The middle ear is like a
hexagonal box with a roof
Carotid or Anterior wall- It separates middle ear cavity from internal
carotid artery The various structure passing through anterior wall of
tympanic cavity
bull Canal of chorda tympani nerve
bull Canal of tensor tympani muscle
bull Eustachian tube
bull Anterior malleolar ligament
bull Anterior tympanic artery
Page | 29
Posterior or mastoid wall ndash The upper part of the back wall shows the
opening of the auditorium Below the auditory is a triangular bony
projection known as the pyramidalis processors The stapedial tendon is
transmitted through the apex of the pyramidalis processes The vertical
portion of the facial nerve descends along the posterior wall until it opens
into the stylomastoid foramen
Roof or Tegmental wall (Pars terminalis)- It is formed by a thin bone
plate called the tegman tympanum that separates the skull and tympanic
cavities It is located on the anterior surface of the rocky part of the
temporal bone near the junction with the temporal shell it extends back to
the roof in the tympanic membrane and anteriorly to cover the half canal
of the tensor tympanic muscle The lateral border corresponds to the
remains of the Petro scaly suture
Floor ndash It is formed by a thin plate of bone which separate middle ear from
the bulb of the internal jugular vein lodged in the jugular fossa
Lateral wall ndash It is formed by tympanic membrane and partly by a portion
of squamous part of the temporal bone It separates the middle ear from
external ear
Medial wall- It separates the middle ear from the inner ear
bull The promontory is the most prominent and convex part formed by the
basal rotation of the cochlea
bull The bony lateral semicircular canal is postero-superior to the promontory
above the oval window
bull The oval window is located between the middle ear and the vestibular
slope of the cochlea It is closed by the stirrup footrest and the annular
ligament
Page | 30
bull The round window is located under and behind the cape The round
window recess is directed to the rear It is closed by the secondary eardrum
and separates the middle ear of the Scala tympani from the cochlea
bull The facial nerve passes through the bony fallopian tube above the oval
window
Mastoid Antrum ndash It is a large space with air in the upper part of the
mastoid and communicates with the attic through the aditus The roof is
formed by the antri tegmen which extends and separates the tympani
tegmen from the middle cranial fossa The lateral wall of the antrum is
formed by a bony plate that is on average 15 cm thick in adults It is
marked externally on the surface of the mastoid by the suprameatal triangle
(MacEwen)
Aditus and Antrum- Aditus is a gap through which the attic communicates
with the antrum The boney prominence of the horizontal canal lies on its
medial aspect even as the fossa incudes to thats attaches the quick system
of incus lies laterally Facial nerve publications simply underneath the
aditus
The mastoid and its air cell system-
The mastoid consists of bone cortex with a honeycomb of air cell
underneath Depending on development of air cell three types of mastoids
have been described
1Well-pneumatized or cellular- Mastoid cells are well developed and
intervening septa are thin
2Diploetic- Mastoid consist of marrow spaces and a few air cells
3Sclerotic or acellular ndash There are no cells or marrow spaces
With any type of mastoid pneumatization antrum is always present In
sclerotic mastoids antrum is usually small and the sigmoid sinus is
anteposed
Page | 31
Depending on the location mastoid air cells are divided into
1 Zygomatic cells (In the root of zygoma)
2 Tegman cell (Extending into tegmen tympani)
3 Perisinus cells (overlying the sinus plate)
4 Retrofecial cells (round the facial nerve)
5 Peri labyrinthine cells (located above below and behind the
labyrinthine some of them pass through the arch of superior
semicircular canal These cells may communicate with the petrous
apex)
6 Peritubal (around the Eustachian tube Along with hypotymoanic
cells they also communicate with the petrous apex)
7 Tip cells (which are quite large and lie medial and lateral to the
digastric ridge in the tip of mastoid)
8 Marginal cells (Lying behind the sinus plate and may extend into
the occipital bone)
9 Squamosal cells (Lying in the squamous part of temporal bone)
Development of Mastoid ndash
The mastoid develops from the scaly petrous bone The petrosquamosal
suture may persist in the form of a bone plate - Korners septum which
separates the superficial squamosal cells from the deep rock cells Korners
septum is surgically important because it can cause problems locating the
antrum and deeper cells and thus lead to incomplete removal of the disease
during mastoidectomy The mastoid antrum can only be reached if Korners
septum is removed
Page | 32
Fig 3 Cross section of Mastoid
Contents of the middle ear
Ossicles ndash Three tiny bones which conduct the sound from eardrum to oval
window
Malleus ndash It is the largest and most lateral ossicle measuring 8 mm in
length It has head neck handle anterior and lateral processes The head
is situated in the epitympanum A lateral process project laterally from the
neck while the handle is firmly fixed to the pars tensa of the ear drum
Incus- It has a body short process and long process The body short
process and long process The body articulate with the head of mallelus in
the attic and the short process project into the attic The long process
projects downwards behind the handle of malleus running parallel to it and
articulate with the head of the stapes via the lenticular process
Stapes ndash It is the smallest ossicle measuring about 35 mm and consist of
head neck footplate and anterior and posterior curcura The footplate of
stapes is held to the oval window by the annular ligament
Page | 33
Muscles ndash
1Tensor tympani ndash It is inserted is a branch of the facial nerve which carries
the sense of taste It is first arch muscle supplied by branch of mandibular
nerve V3
2 Stapedious muscles ndash It is inserted to the neck of stapes It is the second
arch muscle supplied by branch of facial nerve that is nerve to stapedius
Fig 4 Contents of the middle ear
Blood supply of Middle Ear
bull Anterior tympanic branch of maxillary artery which supplies tympanic
membrane
bull Stylomastoid branch of posterior auricular artery which supplies middle
ear and mastoid air cells
Page | 34
Four minor vessels are
bull Petrosal branch of middle meningeal artery runs along greater petrosal
nerve
bull Superior tympanic branch of middle meningeal srtery traversing along
the canal for tensor tympanic muscle
bull Branch of artery of pterygoid carotid
bull Tympanic branch of internal carotid
Lymphatic Drainage of Ear
Lymphatics from the middle ear drain into retropharyngeal and parotid
nodes while those of the Surgical Importance ndash Eustachian tube drain into
retropharyngeal group
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 middle is likely to pass to
middle ear
2 Moreover middle ear suppurative disease may spread to adjacent organs
and produce complication eg Labyrinthitis meningitis facial nerve palsy
etc
3 Lenticular process is vulnerable in suppurative ear diseases and causes
ocular disruption
4 Prussac space is the site of primary acquired cholesteatoma
Page | 35
INNER EAR [60]
Inner ear is divided into two parts
1 Bony Labyrinth
2 Membranous labyrinth
Anatomy of bony labyrinth
It is divided into two parts
1 Vestibule
2 Cochlea
3 Semicircular canal
The vestibule is located between the medial wall of the middle ear and the
lateral to internal acoustic meatus anterior to the semicircular canal and
posterior to the cochlea The vestibule is the central part of the inner ear
On its side is the oval window opening which is closed by the bracket foot
plate The bony cochlea is located in front of the vestibule It has 275 turns
wound around a bony axis called a modiolus The cochlea is about 30 mm
long The hollow center of the modiolus is a spiral canal that contains the
fibers and ganglion cells of the cochlear nerve A thin bony sheet the bony
lamina winda around the modiolus This divides the cochlear duct into two
galleries the Scala vestibuli above and the scala tympani below
There are three semicircular canals superior posterior and lateral They
are semicircular in shape and open into the vestibule One end of the
semicircle is enlarged and is known as the sphere
The membranous labyrinth is in the bony labyrinth It is connected to the
bony labyrinth by fibrous trabeculae and is surrounded by perilymph The
endolymph is located in the membranous labyrinth
Page | 36
The utricle is in the upper part of the vestibule while the saccule is found
below Both the utricle and saccule contain a single sensory patch called
the macula Each macula is covered with a neuroepithelium made up of
neuroepithelium made up of sensory hair cells and support cells these cells
are separated by a basement membrane Fibers of the vestibulo-cochlear
nerve enter the macula and pierce the basement membrane to terminate
at the base of the hair cell or cell bodies The utricle and the saccule with
their macula are called otolith organs Membrane semicircular canals are
the membrane canals of the corresponding bony semicircular canals They
open into the utricle through five openings One end of the opening of each
channel is dilated called the sphere in which the sensory organ of each
channel is located The cross section of the Scala standard looks like a right
angle The base is formed by the basilar membrane Sensory cells are
arranged on the surface of the basilar membrane These sensory cells with
their supporting cells form a complex neuroepithelium called the basilar
papilla or the cortical organ named after an Italian microscopist The
organs of the corti have a gelatinous membrane called the tectorial
membrane and they are supported by the pillar of the corti The cortical
pillars enclose a space called the corti tunnel which contains a fluid called
cortical lymph Vestibule is lies between the medial wall of the middle ear
and lateral to internal acoustic meatus anterior to semicircular canal and
posterior to the cochlea 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 Boney cochlea lies in front of the vestibule It has 275 turns
coiling around boney axis called modiolus Cochlea is approximately 30 mm
in length The hollow center of the modiolus is a spiral canal containing the
fibers and ganglion cells of cochlear nerve A thin boney sheet the osseous
lamina winda around the modiolus This divides the cochlear canal into two
galleries the Scala vestibuli above and the scala tympani below
Page | 37
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 boney labyrinth It is connected
to the bony labyrinth by fibrous trabeculae and is surrounded by perilymph
Endolymph 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 single sensory patch called macula Each
macula is covered by neuroepithelium consist of Neuroepithelium consists
of sensory hair cells and supporting cells these cells are separated by
basement membrane Fibers 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 are referred
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 corti lymph
Page | 38
Fig 5 Inner Ear
Blood supply of labyrinth
Labyrinthine artery
Common cochlear Anterior vestibular Artery
Vestibulocochlear artery Main cochlear artery
Cochlear branch posterior vestibular artery
Page | 39
PHYSIOLOGY OF HEARING [61]
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
bull Mechanical conduction of sound (conductive apparatus)
bull Transduction of mechanical energy to electrical impulses (sensory
system of cochlea)
bull Conduction of electrical impulses to brain (neural
Fig 6 PHYSIOLOGY OF HEARING
Page | 40
Conduction of sound
Under the surface of water we cannot hear the sound made in air because
9995 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 must 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 13 times longer than long process of incus providing
a mechanical advantage of 13
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 beings 211 As the effective
vibratory area of the tympanic membrane is only two- thirds the effective
areal ratio is reduced to 141 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
Page | 41
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 lobe
Page | 42
DISEASES REVIEW
करणसराव
Nirukti - करणसय कणवयोाव ससराा [62]
Nidana- Acharya Sushruta and Vagbhata describe the common etiological
factors for the Karnaroga
अशयाय जलिीडा कणवकणडयन मरत
शमथययोगन शसततरसतय कवपतो अरय च कोपन ||
सउ २० १२
1 Avashaya or Pratishaya
(Excessive exposure to cold)
2 Jalakrida
(Excessive swimming)
3 Karnakandunyanum
(Excessive scracing due to itching)
4 Mithyayogena Shatrasya
(Improper instrumentation during wax removal or foreign body removal)
5Shabdasya
(Louder sound for long durationperverted contact of sound)
6 Abhighata (Trauma)
7 Vitiation of Tridoshas
Page | 43
Samanya Nidana according to different Samhita
Vishesh Nidan of Karnasrava
Acharya Charaka has not mentioned any kind of Nidana regarding Karnaroga
but has described Utapati of Karnaroga from Siroroga in Karnasirasym
Adhyaya[67]
शशरोअशिघातादरा तनमजजतो जल परपकादरा अवप विि
सरतत पय शरणॊ अतनलात स कणवससरा इतत परककतीत
सउ २० १०
असस ३७२५ [68]
1 Shiroabhighatat - Head Injury-Fracture of middle cranial fossa
2 Jala nimajjana - CSF otorrhoea fracture of middle cranial fossa
3 Karnaprapaka
4 Karna Vidhradhi -Puyasrava
Sr
no
Samanya Nidana SU AH[63] AS[64] YR[65] MN[66]
1 Avashaya + + +
2 Pratishaya + +
3 Shabdha
mithyayoga
+
4 Shashtra
mithyayoga
+ + +
5 Karnakandooyan + + + + +
6 Jalkrida + + + + +
7 Abhighata + + +
Page | 44
Samanya samprapti
परापय शरोतरशसरा कयावत शल शरोतशस गान
त कणवगता रोगा अटिावशततरीता
सउ २० १२
Due to common and specific etiology factors the vitiated Doshas gets
Sthanasamshraya in Karna and causes Karnasrava It is the stages of
Samprapti were Doshas gets lodged in Srotas and start processes of Dosh
Dushya Sammurchsna Due to Shiroabhighata Jalanimmajana Karna Paka
Karna Vidhradi vitiated Vata Dosha and Karna becomes Avruta by Vata and
results in Karnasrava Normal physiology of Dosha Dhatus and Malas entirely
depends on the normality of Srotas Dosh Dushya Sammurchana or
manifestation of diseases will not take place if only vitiation of Doshas take
place without deformity of Srotas Here in Karnasrava vitiation of Srotas are
Atipravritti Sanga and Vimargagamana take place Atipravritti is being excess
production of fungus Sanga is obstruction in external acoustic canal
Vimargagamana is the propagation of discharge through ear
Vishesh Samprapti
Karnasrava occurs due to Nij nidana is Pratishaya while Agantuja nidanas are
Avashya Jalkrida and Karnakanduyan Due to etiological factors which are
Vata-Kapha provocative in nature gradual vitiation of Doshas will occur After
vitiation they get accumulated (Sthan samshraya) in external auditory canal
In other hand when patient does Sevana of Agantuj Nidan like water enter in
external ear scratching of ear unsterile instrumentation leads to Dosh
Prakopa These cause Twak and Mamsa Dhatu Dushti which leads to
discontinuity of epithelium of ear canal which creates suitable atmosphere for
fungal pathogen to grow The vitiated Vata will produce symptoms such as
Page | 45
pain hearing impairment and vitiated Kapha causes symptoms like itching
discharge ear blockage By assessing the symptoms it can be said that Kapha
Avrita Vata Dosha is responsible for the manifestation of clinical features like
pain itching discharge Which are seen in Karnasrava that is otomycosis
Acharya Charaka has mentioned while explaining Samanya Chikitsa of
Karnaroga that it should be treated like Vrana when Paka and Srava is present
as a symptom Fungal spores invade in the epithelial layer of EAC In response
to infection inflammatory process is start This is a Paka Avastha After
removing the fungal mass ulceration in external acoustic canal is commonly
seen As a result of infection process exudates was produced which will mix
up- with fungal colonies and appear as discharge As per Dosha involvement
in Vrana Shoola Srava can be differ According to Acharya Sushruta Ruk is
the Samanya Lakshana of Vrana and Vishesha Lakshana of Vrana includes
pain discharge discoloration itching etc according to Dosha involvement
which are also seen in otomycosis In otomycosis mainly watery and purulent
type of discharge is present which indicates Paka avastha If there is Dosha
involve in Vrana is called Dushta Vrana Acharya Sushruta and Acharya
Vagabhata have mentioned verity of Srava in Twak and Mamsa Vranavastu
which is found in otomycosis Based on this description otomycosis can be
correlated with Karnasrava
Page | 46
Representing the Samprapti of Karnasrava
Vishesh Nidana ndash Shiroabhighatat
Jala nimajjana
Prapaka Vidhradhi
Vitited vata
Avarana by kapha
Vimargagamana of Vata
Karnasrava
Samprapti Ghataka
Dosha ndash Kapha and Vata
Dushya ndash Rasa Rakta and Mansa
Strotodushti ndash Vimargagamana and Sang
Adhishthana ndash Karna (Bhayakarna)
Rogmarga ndash Madhyama
Page | 47
Purvarupa
The Purvarupa of Karnasrava are not mentioned separately in any ayurvedic
classics In routine practice cretin Purvarupa are noted
1 Karnakandu
2 Karnagurutwa
3 Alpa karnashoola
4 Discomfort in ear
Rupa
1 Karnashoola
2 Karnakandu
3 Karnasrava
4 karnabadhirya
5 Cotton wool like or wet newspaper like grayish brown or black colored mass
is seen
6 External auditory canal skin appears edematous and red
Upashaya and Anupashaya
Appropriate application of Aushadhi Ahara and Vihara when produces relief in
the symptom is called as Upashaya and when aggravates the symptoms is
called Anaupashaya There is not any reference available in the classics about
the Upashaya and Anupashaya of karnasrava
Sadhyasadhyata
Sushruta has not mentioned specially the Sadhyasadhyata of Karnarogas But
Vagbhata has mentioned Karnasrava as a Sadhyavyadhi[69]
Sadhysadhyatagives the clear picture of prognosis of the disease It depends
on many factors like nature of disease severity of disease Vaya Prakriti Bala
of the patient etc
Page | 48
Upadrava of Karnasrava
In Samhita there is no reference available regarding the Upadrava of
Karnasrava
Samanya Chikitsa ndash
The common treatment principle for all Karnaroga is Ghritapana Use of
Rasayana Bhrahmacharya Avyayama Shirasnana and Atibhashaya
सामरय कणवरोगष घतपान रसयनम
अवयायमो शशराःसतनान बरमहचयवम कतपरनम
स उ२१३
Ghratapana - Ghrita is a Yogavahi and follow Sanskara in addition to these
acquired properties and capable of retaining its own properties So Ghritapana
is effective in Karnasrava
Rasayana - Rasayana represent the basic approach of Ayurveda which
comprise preventive promotive and curative aspect of health
Brahmacharyaapalana -It is like Sadvrittapalana and is equals to Rasayana
effect
Vyayama - It leads to vitiation if Vatas a Karna is a Sthana of vata and
exercise causes Kshayaj Samprapti hence it is important to avoid exercise in
Karnasrava
Shirasnana- In Shirasnana water enters in external acoustic canal it changes
the PH of meatus skin from acid to alkali which favors the growth of pathogens
Atibhashya - Excessive speaking causes Vata Prakopa and Vatapraokopa is
basic Samprapti for Karnasrava as the preventive aspect avoidance of
excessive speaking is necessary
Page | 49
Ghritapana Rasayana and Brahmacharyapalana should be followed for
preservation of dhatu Samyata and restriction of vitiation of Vata Vayayama
Shirasnana and Atibhashaya should be avoided in Karnasrava to protect the
Siras from the affliction of Vata and Kapha
Vishesha Chikitsa ndash
The general treatment principle of Karnasrava described in classics is closely
related to Dushtavrana Chikitsa
शशरोवरचन च ए िपन परण तरा
परमाजवन िान च ीकषय ीकषय़ाचारत [70]
स उ २१४०
कणवसततरा ोददत कयावत पततकशमकणवयो [71]
ाउ १८३५
उपददि च सततरोत साय परात वपचततवशि परमजय
य अगर मदन सघत गगलना ा िपतयतपा मिना परयत [72]
असउ २२४२४३
In addition to that Shirovirechana Karnadhoopana Karnapurana
karnapramarjana Karnadhavana are also indicated
Page | 50
Treatment is also mentioned for Karnasrava
1 Karnaprakshalana Yoga - with Aargawadadi Gana Kashaya and Surasadi
Gana Kashaya [73]
2 Avachurnana Yoga ndash with Aargawadadi Gana Churna and Surasadi Gana
Churna[74]
3 Karnapoorna Yoga ndash
bull Rasanjana Laksha with Sarjachoorna[75]
bull Panchkashaya with Kapittha swarasa and Madhu[76]
bull Jambu AmrapallavShivalaKshuodra Mahavriksha and Madhuki 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 done[77]
bull Sarjatwak Choorna with Karpashiphalarasa and Madhu[78]
bull Abhaya LodraTindukaSamanga(Manjista) Kwatha of this Dravyas mixed
with Madhu and Kapittha Rasa[79]
bull Yogratnakara mention the following drugs for Karnapoorana-
a Samudraphena Churna[80]
b Jambwambpatra Yoga
4 Karnadhoopana Yoga ndash
bull Dhoopana with Churna of Bilvapatra Haridra Palandu[81]
bull Vartak Dhoopana [82]
5 Internal Medications-
bull Rasnadi Guggula [83]
bull Triphala Guggula [84]
bull Sarivadi Vati [85]
bull Gandhaka Rasayana [86]
Page | 51
According to Vagbhata-
Ear should be cleaned with the Pichu and Varti followed by Guggula Dhoopana
and then Karnapoorana with Madhu Followed by Avachurnanana with
Sukshmachootana of Surasadigana
Pathyaapathya ndash Pathya and Apathy mentioned for Samanya Karnaroga is
recommended in Karnasrava also
पथय[87]
सतदो वरको मन नसतय िमाः शशरावयिाः
गोिमाः शालयो मदगााः याशच परतन हवाः 80
लाो मयरो हररणानदसततततरो नकककिाः
पिोल शशगर ातावक सतनषराण कदठललकम
रसायनातन सवणण बरमहचयवमिाषणाम |
उपयकत यरादोषशमद कणावमय दहतम ||81||
िापर २१
Aharaja Upacharaja
bull Godhuma bull Vamana
bull Shala bull Virechana
bull Mudga bull Nasya
bull Yava bull Dhoomapana
bull Puranagitra bull Kavala
bull Lava Harina Tittiramamsa
Page | 52
अपथय[88]
दरत काटठ शशरसतनान वययाम शलटमल गर
कणडयन तषारशच कणवरोगी पररतपयजत
िापर २१
Viharaja
bull Patola ShigruVartaka bull Bhramacharaya
bull Sunishannaka bull Avyayama
bull Katthlika bull Aakthanam
bull All types of Rasayana bull Upacharaja
bull Vamana
Apathyas
bull Abhishyandakara Aharas
bull Shirasnana
bull Karna kandooyana
bull Tushara sevana
bull Guru Kaphakaraka Aaharas
bull Dantdhavana
Page | 53
OTOMYCOSIS
Definition-
Otomycosis is a superficial acute sub-acute or chronic infection of external
ear canal It is mostly unilateral It is characterized by inflammation purities
and scaling Otomycosis is a common condition encountered in ENT practice
more in chronic and persistent ear infection
The Fungal infections are not communicable in the usual sense but the
humans become an accidental host by their introduction into tissue trauma
The virulence factors favoring colonization of fungus in human host are yet to
be identified Ability of the fungus to grow at 37 C and elaboration of a variety
of enzymes and toxins are speculated to contribute to virulence Only 100 to
150 species are generally recognized as a cause of disease in humans[89]
Prevalence-
Otomycosis is a word wide in distribution and in various record stated that 5
to 20 of all cases of infective otitis externa Otomycosis prevalent is more in
warm and humid climates It is one of the commonest manifestations in India
during rainy season It occurs mostly in humid atmosphere otitis externa due
to fungal infection may resembles the desquamative form of diffuse infective
otitis externa The incidence in temperature climates has increased in
proportion to the use of topical antibiotics which have a medium sterilized of
other organism in which the fungus may flourish
Page | 54
Predisposing factors- [90]
1 Environmental factors such as climate contagious and polluting hygiene
more frequently during rainy season as the humidity increases
2 Individual susceptibility ndashGeneral Immunological status of the Individual
eg HIV infection Radiotherapy chemotherapy Diabetes mellitus
3 Self-inflicted trauma that is use of pins to clean the itching ear or use of ear
bud to clean the wax
4 Wide spread of topical antibiotics steroid preparations which have medium
sterilized of other organism in which the fungus may grow
5 Failure of defense mechanism in External auditory canal
6 During swimming or head bath water enters in External acoustic canal
causes quantitative and qualitative change in ear wax It causes change in pH
7 Long term use of hearing aids
Pathophysiology ndash
The life cycle of the average mold encountered in the ear may be reckoned
as two weeks and flare ups may be anticipated at such intervals Swimming is
held responsible for infection in many cases The sequence sequence of
pathogenic changes produced by molds in the external ear is as follows ndash
1 Implantation of the organism in external ear
2 Growth of organism follows the rate depending on condition of temperature
moisture or preexisting irritation
3 Invasion of epithelium occurs with attendant itching and discomfort which
may be quite severe
Page | 55
4 Exfoliation of epithelium occurs as nature attempts to overcome the
infection by casting off upper most cells
5 Denudation occurs from exfoliation as the top layers of epithelium are cast
off and the canal becomes filled with debris
6 Superficial ulceration and lizematoid dermatitis results if the pathologic
process goes for enough The changes do not always proceed through the
entire sequence sometimes the molds produce changes of the mildest
imaginable character which may be overlooked[91]
Clinical features -
Symptoms-
1 Irritation and itching ndash Irritation is mostly found when the infective
organism is aspergillus niger There is sensation of discomfort which is more
diffuse in the ear canal then localized in the deeper part Candida infection
causes marked itching In external ear it is intense and worse at night
2 Discharge through ear- Intermittent scanty colorless discharge through
ear Mucus being a fungal metabolic product appears as discharge Excessive
discharge is associated with mixed infection
3 Pain and discomfort ndash Mild to severe pain in the ear occasionally Mostly
seen in cases where ear is infected with Aspergillus flavus mixed infection
with gram negative organism or mixed infection with candida and aspergillus
Headache is sometimes associated with pain
4 Deafness- Varying degree of mild to moderate conductive deafness
5 A sensation of fullness in ear
6 Tinnitus 7 Vertigo
Page | 56
Signs ndash
1 The external acoustic meatus may contain a mass formed of epithelial
debris exudates cerumen and fungus
2 Erythematous external canal
Fungal appearance
A Niger - The color of the mass which is usually grey or black is mainly
determined by the type of fungus concerned Its appearance is like wet
newspaper or blotting paper or a cotton wool It has a peculiar musty odor In
this infection fruiting heads may be seen as black specks in the debris
Occasionally as inactive form occurs in which the canal is lined by mold giving
a fluffy appearance due to the presence of tiny mycelia
Candida ndash Candida infections generally show as white deposits on magenta
colored skin when the debris is removed it rapidly recovers in 24 hrs
The underlying canal skin is often inflamed and granular due to invasion by
fungal mycelia and be seen in all cases In rare cases excoriation and
ulceration with marked extensive shedding of the epithelium and deep
ulceration can be seen usually associated with a flavus and with pathogenic
bacteria[92]
Otoscope Appearance
1 Aspergillus Niger ndash Black headed
2 Aspergillus Fumigators ndash pale blue or green
3 Candida Albicans ndash White- or cream-colored deposits
Page | 57
4 Auricle is normal in most cases In severe cases small ulceration with crust
formation may be present on lateral surface
5 Tympanic Membrane
In most cases it is normal with normal mobility and normal hearing In a few
cases the surface of the tympanic membrane is congested and scaly There is
erosion or ulceration of the external epithelial layer and the membrane itself
may be edematous
Diagnosis
1 Above mentioned symptoms and signs
2 In the stage at which patient with otitis externa usually first present
themselves mycelia threads conidiophors not visible to naked eye may
sometimes be identified with the microscope
3 Confirmed by culture
Page | 58
Fig7 Aspergillus Niger Fig8 Candida Albicans
Fig9 Aspergillus Fumigators Fig 10 Wet Paper like appearance
Page | 59
Treatment
1 Antibiotic or steroid drops should be discontinued if they are being instilled
since long time
2 Removal of fungal mass epithelial debris and discharge from the external
canal or mastoid cavity repeatedly and thoroughly by forcepa or suction or
syringing or cautiously blow a stream of air into the canal through a fine
cannula and dry thoroughly by swabbing liquid petroleum on swab used in
cleaning the ear lessens the burning sensation when metacresy acetate is to
be employed in the subsequent treatment
Furuncle is developed as a complication if there is no gentleness in cleaning
Cleansing may have to be delayed until local sensitiveness is lessened which
can usually be accomplished within twenty-four hours If there is excessive
epithelial debris along with otomycosis then metacresyl acetate which is a
keratolytic in introduction into the external auditory canal on cotton wick and
is allowed to remain for twenty-four hours After twenty-four hours the cotton
wick is removed at which time the canal can usually be cleansed with little
discomfort as the medication is also anesthetic The epithelium of the canal
was white from contact with the drug The top layer was detached and this
epithelial debris can be easily wiped away The wick is reinserted and wet with
metacresyl acetate
The treatment is employed for three to four days in succession and then a
bland application is substituted Icthyol iodine is of value at this stage Iodine
ointment 2 in combination with Tannic acid 2 is also an excellent local
application following cresatin treatment
Next one of the fungicides may be applied
Page | 60
1 Nystin Effective for candida infection but less active against aspergillus
group Nystatin in boric powder consisting of 100000units of nystatingm of
powder 3 times week for 3 weeks
2 Clotrimazole Available as 11 cream or drops or lotions Phenyl
(zchlorophenyl) 1 ndash imidazole ndash methane is a chlorinated trityl imidazol 1
effective against candida and dermatophytes and for aspergilli infection
3 Amphotericin B Available as cream and as 3 solution and 015 drops
for topical application Very effective for candida infection can be fungistatic
or fungicidal
4 Econazole Available as solution (Econazole nitrate) and as cream (1)
Broad spectrum ndash more effective for Aspergillus Also active against some
gram-positive bacteria (Staphylococci and Streptococci and Dermatophytes)
5 Miconazole Highly effective against dermatophytes and candida infections
used as a 21 cream applied once or twice a day for 10 days
6 Gentian violet 21 Available as drops (recently some evidence of
carcinogenicity) Discolors the ear canal and this interfere with clinical
examination
Other topical antifungal agents are ketoconazole Natamycin Tolciclat Bifonas
zole Fenticonzole Oxiconazole Tioconazole ciclopiroxolomine Tolnafate
Haloprogin Flucytosine Acetic acid Whit field ointment selenium sulfide
undcyclenic acid triacetin etc
Page | 61
Minimal length of treatment
A month of drug treatment is usually required because the antifungal agents
used are not sporicidal and it is necessary that the period of treatment covers
germination time It may be advisable to give short gaps in the period of
treatment to ensure all spores have germinated before deciding to terminate
therapy
Prevention
Accomplished by strict attention to the predisposing causes
1 Water should be prevented from entering the ear
2 Avoidance of external ear trauma
3 Use of alcohol medicated or plain in the ears after swimming mercuric
cyanide (15000) in ethyl alcohol (70) is a satisfactory liquid to use
Ear stoppers do no good unless their use is followed by some antiseptic in the
canal Divers exposed to water for long periods of time may also use acidic
alcohol
4 During Summer months with their high humidity special efforts are needed
to maintain ear dry 5 Indiscriminate use of topical antibiotics steroid
preparations should be avoided
Page | 62
DRUG REVIEW
1 GUGGULA
Fig11 - Guggula
Historical review of Guggula [93]
bull Atharvaveda one of the well-known Vedas of Hindus The earliest
reference given by Atharvaveda medicinal and therapeutic properties of
Guggula Guggula has long history of use in Ayurveda
bull Acharya Charaka Sushruta and Vagbhata describe detail regarding the
actions uses and indication as well as the variety of Guggula
Page | 63
bull Various Nighantus (Medical lexicons) were written between 12th and 14th
centuries AD was based on the Ayurvedic literature also describes
Guggula
bull The explanation of word Guggula is that Gunjo Vyadhegurdti Rakshati
which means to relief against different diseases
bull Guggula is the best medicine because it develops through the rays of
hot sun on specific circumstances
bull Guggula has an aromatic odor
गगलो कणवदौगवररधय िपन शरटठमछयत[94]
स उ २२११२
Latin name- Commiphora mukul
Family ndash Burseraceae
Rasa- Tikta Katu
Guna ndash Laghu Rukshasukshma vishada sara
Veerya ndash Ushna
Vipaka ndash Katu
Action- Rasayana Lekhana
Doshaghanta - Tridoshhara
Page | 64
Chemical composition [95]
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Oleoresin-Z-Guggulsterone E-Guggulsterone
Gum- guggulignans 1 and 2 guggula Tetrols mukulol allylcembrol c
27
Guggulusterol 1 2 ans 3 Z and E ndash guggulusterol
Volatile oils- Phenol eugenol cuminic aldehyde-2 pinine Limonene and
Sesquiterpines
Parts Used ndash Gum oleoresin
Guggula purity test
1 Yellowish brown emulsion is obtained when Guggula is triturated with
water
2 An ethereal solution of the drug attains reddish colour when treated
with br2 vapors and purple colour when moistened with nitric acid
Biochemical action ndash Antiseptic Anti-inflammatory Disinfectant Diuretic
Immunostimulant stimulating expectorant Ant suppurative Antipyretic
Enhance phagocytosis
Karma- Rasayana cardiovascular disease
Page | 65
2 AGARU-
Fig 12 Agaru
Historical review of Agaru [96]
bull The word Agaru literally means the one which is the heaviest and no
aromatic wood is heavier than it Since thousands of years Agaru lsquoThe
wood of Godrsquo has been used for multiple purpose like commercial
medicinal spiritual aromatic historical
bull The medicinal use of Agaru have been recorded in many pieces of India
Greek Roman Chinese Middle eastern and European since ancient times
bull Acharya Charaka used Agaru and pest of Rasna to counteract the effect of
cold in Agraya Dravyas
bull Acharya Sushruta used Agaru as a Dhoopana Dravya along with Guggula
Ral and Shoma in the treatment of Karnasweda and Vrana
Page | 66
Types-
bull Dhanwantsri Nighantu describes Kaleyaka as a type of Agaru
bull Sodhala Nighantu describes three types of Agaru ndash Agaru Krishna
Agaru Kakatunda Agaru
bull Raj Nighantu describes five types of Agaru ndash Krishna Agaru Kasht
Agaru Daha Agaru Mangalya Agaru and Agurusaar
bull Arthashasstra describes three Agaru wood product
1 Jongaka ndash Black or variegated black in colour and having variegated
spots
2 Dongaka ndash Black in color
3 Parasamudraka- Black in colour and smells like Navamallika
अगर उटण कि तपछय ततकत ततकषण च वपततलम
लघ कणाविरोगघन शीत ात कफपरणत
िापर २१ [97]
Family- Thymelaccensis
Latin name- Aquilaria agallocha
Guna- Laghu Ruksha Tikshan
Rasa- Katu Tikta
Vipaka ndash Katu
Virya ndash Ushna
Karma- Sheetaprasasmana Vranaorasadan Tvachya Pittavardhaka
Shirovirechana Mangalya Sugandhik and Rochaka in properties [100]
Krishna Agaru karma- Katu Tikta rasa Ushna Sheeta when applied externally
and Pittahara when taken orally
Page | 67
Chemical Constituents -
Agaru hardwood is rich in essential oil resins alkaloids saponins Steroids
terpenoids tannins flavonoids and phenolic compound Agaru wood
predominantly contains 2-[-2-phenylethy]-4H-chromen-4-one derivatives and
sesquiterpenes Agaru oil contains selinene dihydroselinene agarnol b-
agarofuran vetispira-2(11)valerianol dihydrokaranone and tetradecanoic
acids[99]
Part Used ndash
Heartwood- Dark resinous wood which is formed when the plant becomes
infected with a type of fungus (ascomycetous mold) Species of Aspergillus
fusarium and penicillium are reported to be associated with the development
of infection Prior to infection the heartwood is odorless relatively light and
pale colored however as the infection progresses the tree produces a dark
aromatic resin in the heartwood The infected resin in response to the attack
which results in accumulation of a very dense dark resin in the heartwood
The infected resin embedded wood is known as Agarwood Infection is more
common on the trunk roots and the area when branches divide The formation
of Agarwood starts when the tree attains the age of 20 years On an average
approximately 30 ml oil is extracted from 100 kg of infected Agarwood[98]
Qualities of best Agaru-
It should be black in color
It should be extremely heavy and aromatic
It should be oily in appearance and test
It should be sink in water
It should burn easily with bright flame with a bright flame giving off a pleasant
smell
Page | 68
3 MADANA
Fig 13 MADANA
Madana consist of dried fruit of Xeromphis spinosa It is a deciduous thorny
shrub or a small tree reaching a high up to 9 m and girth about a meter
branches numerous thick and horizontal found in sub-Himalayan tracts[101]
मदनो मिरनदसततकतो ीयोटणो लखनो लघ
ानदरतिदवििीहर परततशयायवरणारतक
रि कटठकफ़ानाहशोथगलमवरणापह[102]
िा पर १६० १६1
Page | 69
Latin name-Randia dumetorum
Familly ndash Rubiaceae
Rasa - Madhura Tikta
Guna-Laghu Ruksha
Virya- Ushna
Vipaka ndash Katu
Karma- Vamana and Lekhana
Chemical Composition-
Essential Oil Valerianic acid Saponin tannin resin [103]
Page | 70
YAWA [104]
Fig 14 Yawa
1 In Samhitakala Aacharya Charaka Acharya Sushruta explain detail about
medicinal properties of Yawa
2The use of Yawa in Aaharya Dravya mainly described by Dhanwantari
Nighantu Raj Nighantu Bhavprakash Nighantu[105]
Macroscopic Description-
Fruit a caryopsis elliptical oblong Ovoid and tapering at both ends smooth
about 1cm long and 02- 03cm wide dorsally compressed and flattened on
the sides with a shallow longitudinal furrow 3-5 ridges having shallow
depression between them grains tightly enclosed and adhering the lemma
and palea pale greenish yellow odor not distinct taste sweetish acrid
Page | 71
Latin Name ndash Hordenum vulgare
Family- Poaceae
Rasa- Kashaya Madhura
Virya- Sita
Vipaka- Katu
Karma- Vatakrt Pittahara Kaphahara Medahara Balya Visrya
SthairyakaraLekhana
Page | 72
PROCEDURE REVIEW [105]
In Ayurvedic classics there are many references regarding Dhoopana Dravya
Dhoopana is administering Dhuma with the help of Dhoopana Dravya
In Kashyapa Samhita there are 40 types of Dhoopana advised for children
Anesthesia (Mohajananam Dhoopa) is also mentioned For this Dhoopana the
drug used were herbs hairs of animals legs horns old cloths of Buddhist
monks
From the references available regarding Dhoopana we can understand that
Karna can be protected from maggots (krimi) Bactria (Rakshogna) lice etc
References clearly indicate the analgesic and disinfectant effect of Dhoopana
Karma Dhoopana is mentioned for Dushta Vrana Chikitsa It reduces Vedana
Srava Pootigandha of Dushtavrana It also helps in Vranaropana
Dushtavrana Chikitsa is mentioned in the treatment of Karnasrava[106]
Origin of Dhoopana-
In ancient period children of sages were constantly harassed by the
Rakshasas Hence the sages approached lord Agni for shelter Agni in turn
gave them Dhoopana Dravya and asked sages to use the Dhoopana for
protection against Rakshasas bhutas pishachas
Classification of Dhoopana
1 It is classified into Dhupa Anudhupa Pratidhupa
2 On the basis of Origin it is classified into Jangama and Sthavara
Selection of Guggula for Dhoopana
Page | 73
bull Guggul is a best Vatahara
bull It is Krimighana
bull It contains Oleoresin
bull In Ashtang Hrudaya Guggula Dhoopana mentioned for Karnasrava
Selection of Agaru for Dhoopana
bull Agaru is Laghu Ruksha Katu Tikshna
bull Vranaorasadan Tvachya
bull It should burn easily with bright flame with a bright flame giving off a
pleasant smell
Karna Dhoopana Indication
1 Karnaarava
2 Putikarna
3 Krimikarna
4Vataj Karnashula
Contraindications
Especially for Karnadhoopan contraindication is not mentioned in classic texts
But Dhoopana is contraindicated in Pittaj vaydhi Sharad and Grishma Rutu
Page | 74
MATERIAL AND METHOD
Page | 75
For randomize comparative clinical trial to study the effect of Agaruwadi
Karnadhoopana and Guggula Karnadhoopana in Karnasrava following material
and method were required
Source of data
Patient irrespective of gender occupation religion social economic status
signs and symptoms of classical features of Karnasrava (Otomycosis) selected
from the OPD of Shalakyatantra department
Materials ndash
1Patients
2 Drugs-Agaruwadi Dhoopana
Guggula Dhoopana
3Torch
4Otoscope
5 Tuning fork
6Jobson horn probe
7Cotton
8Case record form
DRUG
Group A Trial Group
1Churana of Agaru Yawa Madan
2Ghrita
3Jala
Group B Control Group
1Googula Churna
Page | 76
Properties of Drug
Table no 1 Properties of Drug
Drug
Family
Rasa Veerya Vipaka Effect
on
Dosha
Guna Karma
Agaru
(Aquilegria
Agallocha)
Thymelaca
ceae
Katu
Tikta
Ushna Katu KV Laghu
Ruksha
Tikshna
Shitaprashamana
Shothahara
Vedanasthapak
Durghandhihara
Madan
(Randia
spinosa)
Rubiaceace
Kashaya
Madhur
Tikat
Katu
Ushna Katu KV Ruksha
Laghu
Vatakaphaghana
Shothahara
Vedanasthapak
Vranashodhak
Yawa
Poaceae
Hordeum
Vulgare
Kashaya
Madhur
Sheeta Madhur KP Ruksha
Laghu
Vataghana
Vernashodhana
Raktshodhaka
Guggula
Commiphora
Mukul
Burseracea
e
Tikta
Kashaya
Anushna Katu VPK Laghu
Ruksha
Shothahara
Vedanasthapaka
Kandughna
Ghrita Madhura Sheet Madhur VK Snigdha Vataghana
Shothahara
Vedanasthapaka
Page | 77
METHODOLOGY
SELECTION CRITERIA
1)INCLUSION CRITERIA
1 Patients having signs and symptoms of Karnasrava (Otomycosis) ie करणशल
( pain ) करणकणड ( Itching ) करणसतराव ( Discharge )बाधिरण ( conductive Loss of
hearing )
2 Patient from age group 19 to 70 years
3 Any Gender
2)EXCLUSION CRITERIA
1 Patients suffering from any systemic disease like DM TB HTN
2 Chronic suppurative otitis media (CSOM)
3 Acute supportive otitis media (ASOM)
3 Perforation of Tympanic membrane
4 Chronic otitis media
3)WITHDRAWAL CRITERIA
1If patient develops any adverse effect such as irritation pain burning
sensation in ear loss of hearing and such patients was withdrawn from trial
and receive prompt appropriate medical attention
2If patient shows aggravation in symptoms
3If patient refuses to continue with the treatment
Page | 78
STUDY SETTING
Types of study - Randomized Clinical comparative Trial
Place of work - OPD of Shalakyatantra
Duration of study - 18 months
Study Population - Patients of Karnasrava in Shalakyatantra OPD
SAMPLE SIZE CALCULATION
Sampling Method ndash Purposive sampling followed by random allocation in two
groups
Sample size calculation-
n = z2 p (1-p)
d2
Were
n = sample size
P = prevalence of disease=10
z = standard normal variable ie 196
d = error ie005
desired Sample Size would be
n = Z2 P(1-P)d2
= (196)2x (0021) x(0979)(005)2
= 34
Visiting ENT OPD (ShalakyaTantra) and IPD (ShalakyaTantra) 21 = 34
n raquo34
So one group includes 34patients
Page | 79
Sampling Method
Total 68 patient of Karnasrava are selected by Purposive sampling followed by
random allocation in two groups Written informed consent is taken prior to
commencement of trial They are divided in 2 groups
Group A (Trial Group) 34 patients treated with Agaruwadi Dhoopana for 7
days
Dose 5 minutes twice in a day
Group B (Control Group) 34 patients treated with Guggula Dhoopana for 7
days
Dose 5 minutes twice in a day
STUDY DESIGN ndash
Open labeled Randomized Comparative Clinical trial
STUDY DESIGN
Screening of patient
Inclusion criteria satisfied Exclusion criteria
Initial assessment Excluded
Counseling of patient Treated accordingly
Patient selection by Simple Random Sampling Method
Page | 80
68 Patients were divided in two groups lsquoArsquo and lsquoBrsquo
Trial group A-34 patients were given
Agaruwadi Dhoopana
Control group B- 34 patients were
given Guggul Dhoopana
Informed written consent
Treatment was given for 7 days
Assessment on 1st 4th and 7th day
Post assessments follow up on 15th day
Observation
Data Collection
Statistical analysis of data
Conclusion
Page | 81
(A) Agaruwadi Varti for group A (Trial group)
Table no 2
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
B) Guggula Varti for group B (Control group)
SOP of it is same as above Agaruwadi Varti
Table no 3
Drug Guggula Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose Two times a day
Duration 7 days
FOLLOW UP
For both groups follow ups were done on 1st 4th and 7th and post
assessment follow up15th day
EXAMINATIONS
Torch for Local examination of ear
Otoscope examination
Tuning fork Test
Page | 82
OBSERVATION TABLE
Table no 4
Sr no Subjective criteria Day 1 Day 4 Day 7 Day 15
1 करणशल
(pain)
2 करणकणड
(Itching)
3 करणसतराव (Discharge )
4 बाधिरण (Conductive Deafness)
OBSERVATIONS
a) करणशल (Pain) -
0 - Absent
1 ndash Present
b) करणकणड (Itching) -
0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
Page | 83
c) करणसतराव (Discharge)
0- Absent
1- Mild -Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाधिरण (conductive Loss of hearing)
0 - Absent
1- Present
Observations were carried out before and after completion of treatment and
during each follow up After observations the data collected and presented in
the form of graphs charts and table
Page | 84
TRIAL DRUG
Authentication and standardization of raw drug material done After
authentication and standardizing of raw drug material Agaruwadi Varti was
prepared by Varti as explained in Ayurvedic classics
Method of Varti preparations
Panchavidh Kashaya Kalpana that is five method of pharmaceutical
preparation constitutes the fundamental process of Ayurvedic pharmaceutics
which is well explained in Sushrut Samhita Varti Kalpana is one among them
which can be included in Kalka Kalpana
तीररसतरपतपतीनामपरककव तीत [106]
स डलहण शरच 151
Medicines are powered triturated and given the Varti shape that is like wick
of lamp so it is called as Varti Kalpana
Drug content Agaru Madan Yawa
Route of Administration Local
Dose Two times a day
Duration 7 days
Page | 85
Methodology
Standard operating procedure (SOP) of Agaruwadi Varti
Agaruwadi Varti is prepared according to the classical text
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization was done as recommended in pharmacy procedure The
raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 mixed together in
equal quantity to make Agaruwadi churn
Quantity of each churn is 4 grams all are mixed when the Varti get dry total
weight of Varti was 10gram
STEP 4 - Agaruwadi churn triturated with appropriate quantity of water or
Ghrita and prepared Varti in GMP Certified Ayurvedic pharmacy Standard
aseptic precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Varti was packed in sterile air packed container
STEP 6 - Agaruwadi Dhoopana was given with the help of Dhoopana yantra
Authentication and Standardization of raw drug of Agaruwadi Varti was done
Sterilization was done as recommended in pharmacy procedure Sterile
preparation packed in sterile container of suitable size Under all aseptic
precaution Karnadhoopana given to infected ear
Page | 86
Containers for packaging and their sterilization-
Sterilization of the containers for storing Varties was done by Ethylene Oxide
(Eto) method
Ethylene Oxide (Eto) procedure-
It includes exposure of materials to ethylene oxide gas under vacuum in a
sealed chamber It consists of four primary variables
1Gas Concentration
2Humidity
3Temperature
4 Time
EtO gas is an alkylating agent which disturbs the DNA of microorganism
preventing them from reproducing It penetrates the breathable packaging
and sterilizes all the accessible surface of the product to render products
sterility by alkylation of essentials proteins for cell reproduction
Most Eto sterilization methods involves three different stages These can be
separated into three different on the size or number of devices to treat
1Preconditioning stage-
First products are passed through a preconditioning phase to make
microorganism grow The batch load goes through a well time under a
controlled environment of temperature and humidity
2Sterilizer stage-
Performed using process phase specially designed to provide the required level
of EtO exposure to assure sterility for a device or family of devices
3Degasser Aerration stage-
Finally products need to go through a degassing phase to remove any residual
particles of Eto The batch load goes over well time under a temperature-
controlled environment
The sterile containers were then used to store Agaruwadi Varti and handed to
patients included in the study
Page | 87
Packing of Agaruwadi Varti
The ETO sterilize plastic container were used for packing of Agaruwadi Varti
Varti was filled into these sterilize containers (7 in each) In an aseptic
environment plugging and capping was done under aseptic precautions In this
way packing of Agaruwadi Varti done These Varti were given to patient and
advise to take two times a day under all hygienic precautions
History and Examination
bull Proper history and presenting complains was recorded on case record form
bull Ear examination with otoscope was done during initial assessment and each
follow up
bull Otoscopic examination was done during initial assessment and each follow
up
bull Systemic Examination that is Blood Pressure Temperature Respiration
rate Pulse was recorded on case record form
Page | 88
Raw material
Fig14 यव चरण Fig15 मदनफळ चरण
Fig16 अगर चरण Fig17 गगगळ चरण
Page | 89
Preparation of Agaruwadi Varti
Fig18 Preparation of Agaruwadi Varti
Fig19 अगरवादी वरती
Page | 90
Fig20 Instruments used for examination of Karnasrava
Fig19 Karnadhoopana Yantra
Page | 91
Karnadhoopana Procedure
Fig 22 Karnadhoopana Procedure
Page | 92
OBSERVATIONS AND RESULTS
Page | 93
BASED ON DRUGS
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 94
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
AUTHENTICATION CERTIFICATE
Page | 95
BASED ON STASTICIAL ANALYSIS OF DEMOGRAPHIC DATA
68 patients of Karnasrava ndash Otomycosis
Table no 5
No of Patients Total
Group A Group B
Registered 38 37 75
Completed 34 34 68
Discontinue 04 03 07
Total 68 patients were enrolled in study 38 patients registered in group A
amongst them 34 patients completed the treatment and04 patients
discontinued the treatment However in group B 37 patients completed the
treatment and 03 patients discontinued the treatment out of 37 registered
patients
Hence the total number of patients registered in the present study was 75
and out of which 68 patients were discontinued the treatment So they
dropped out from the study While 68 patients were successfully completed
the treatment So observations and result of 68 patients were given below
Here we are going to discuss the statistical analysis of the data obtained in
the form of master chart that was prepared in accordance with the data
collected from the patients that had been included in the study The purpose
of statistical analysis was to analyzed the relation between age gender
occupation diet addiction and education
Page | 96
1 Age wise distribution of patients
Table no 6
In trial group 10 (29412) patients were from age group 18-25 years 14
(41176) patients were from age group 25-35 years 8 (23529) patients
were from age group 35-45 years and 2 (58824) patients were from age
group 45-60 yearsIn control group 6 (17647) patients were from age group
18-25 years 14 (41176) patients were from age group 25-35 years 7
(20588) patients were from age group 35-45 years and 7 (20588)
patients were from age group 45-60 years
Fig 23 Age wise distribution of patients
0
2
4
6
8
10
12
14
15 -25 25-35 35-45 45-60
10
14
8
2
6
14
7 7
Age Distribution
Trial Group N Control Group N
Age Distribution
Trial Group Control Group
N N
18 -25 10 29412 6 17647
25-35 14 41176 14 41176
35-45 8 23529 7 20588
45-60 2 58824 7 20588
Total 34 100 34 100
Page | 97
1 Gender wise distribution of patients
Table no 7
Sex
Trial Group Control Group
N N
Female 23 67647 15 44118
Male 11 32353 19 55882
Total 34 100 34 100
In trial group 23 (67647) patients were female and 11 (32353) patients
were male
In Control group 15 (44118) patients were female and 19 (55882)
patients were male
Fig 24 Gender wise distribution of patients
0
5
10
15
20
25
N N
TRIAL GROUP CONTROL GROUP
23
15
11
19
Gender
Female Male
Page | 98
2 Education wise distribution of patients
Table no 8
Education
Trial Group Control Group
N N
Illiterate 4 11765 3 88235
SSC 4 11765 3 88235
HSC 8 23529 9 26471
Graduation 16 47059 10 29412
Primary 1 29412 3 88235
Post-Graduation 1 29412 6 17647
Total 34 100 34 100
In trial group 4 (11765) patients were illiterate 4 (11765) patients were
SSC educated 8 (23529) patients were HSC educated 16 (47059)
patients were graduated 1 (29412) patients were primary educated and
1(29412) patients were post graduated
In control grou 3 (88235) patients were illiterate 3 (88235) patients
were SSC educated 9 (26471) patients were HSC educated 10 (29412)
patients were graduated 3 (88235) patients were primary educated and
6 (17647) patients were post graduated
Page | 99
Fig 25 Education wise distribution of patients
0
2
4
6
8
10
12
14
16
ILLITERATE SSC HSC GRADUATION PRIMARY POST GRADUATION
4 4
8
16
1 1
3 3
910
3
6
Education
Trial Group N Control Group N
Page | 100
3 Occupation wise distribution of patients
Table no 9
Occupation
Trial Group Control Group
N N
Accountant 1 294 2 588
Housewife 11 3235 8 2353
Engineer 1 294 1 294
Job 1 294 4 1176
Labor 1 294 3 882
Mess 1 294 0 000
Naturotherapyst 1 294 0 000
Pharma 1 294 0 000
Shopkeeper 4 1176 2 588
Singer 1 294 0 000
Student 8 2353 4 1176
Tailor 1 294 1 294
Teacher 1 294 1 294
Worker 1 294 3 882
Farmer 0 000 1 294
Lab Tech 0 000 1 294
Page | 101
Daily Collection 0 000 1 294
Fruit seller 0 000 1 294
Bus Driver 0 000 1 294
Total 34 10000 34 10000
In trial group 11 (3235 ) were housewife 8(2353) were students
4(1176) were shopkeeper 1(294) was accountant 1(294) was
engineer 1(294) was doing job 1(294)was labour 1(294) was
catering 1(294) was Naturotherapyst 1(294) was Pharma 1(294)
was Singer 1(294) was Tailor 1(294) was Teacher and 1(294) was
worker
In Control group 8 (2353)were housewife 4(1176) were students
2(588) were shopkeeper 2(588) was accountant 1(294) was
engineer 4( 1176) was doing job 3(882)was labor 1(294) was
Farmer 1(294) was Lab tech 1(294) was Daily collection 1(294)
was Tailor 1(294) was Teacher and 3(882) was worker 1(294) was
Fruit seller and 1(294) Bus driver
Fig 26 Education wise distribution of patients
0
2
4
6
8
10
12
1
11
1 1 1 1 1 1
4
1
8
1 1 10 0 0 0 0
2
8
1
43
0 0 02
0
4
1 13
1 1 1 1 1
Occupation
Trial Group N Control Group N
Page | 102
4 Religion wise distribution of patients
Table no 10
Religion
Trial Group Control Group
N N
Hindu 31 9118 33 9706
Muslim 3 882 1 294
Total 34 10000 34 10000
In trial group 31 (9118) patients were Hindu and 3 (882) patients were
Muslim
In control group 33 (9706) patients were Hindu and 1 (294) patient
were Muslim
Fig 27 Religion wise distribution of patients
0
5
10
15
20
25
30
35
N N
TRIAL GROUP CONTROL GROUP
3133
31
Religion
Hindu Muslim
Page | 103
5 Diet wise distribution of patients
Table no 11
Diet
Trial Group Control Group
N N
Veg 14 4118 20 5882
Non-Veg 20 5882 14 4118
Total 34 10000 34 10000
In trial group 14 (4118) patients were vegetarian and 20 (5882)
patients were Non vegetarian
In control group 20 (5882) patients were vegetarian and 14 (4118)
patients were Non-Veg
Fig 28 Diet wise distribution of patients
0
5
10
15
20
N N
TRIAL GROUP CONTROL GROUP
14
2020
14
Diet
Veg Non Veg
Page | 104
6 Addiction wise distribution of patients
Table no 12
Addiction
Trial Group Control Group
N N
None 30 8824 27 7941
Alcohol 2 588 0 000
Tobacco 1 294 2 588
Mishri 0 000 1 294
Smoking 1 294 4 1176
Total 34 10000 34 10000
In trial group 30 (8824) patients have no addiction 2 (588) patients
have addiction of alcohol 1 (294) patients have addiction of Tobacco 0
(0) patients have addiction of Mishri and 1 (294) patients have addiction
of smoking
In control group 27 (7941) patients have no addiction 0 (0) patients
have addiction of alcohol 2 (588) patients have addiction of Tobacco 1
(294) patients have addiction of Mishri and 11 (1176) patients have
addiction of smoking
Page | 105
Fig 29 Addiction wise distribution of patients
0
5
10
15
20
25
30
NONE ALCOHOL TOBACCO MISHRI SMOKING
30
21
01
27
0
21
4
Addiction
Trial Group N Control Group N
Page | 106
Statistical Analysis and Results
Effect of study on Karnashoola-
Table no 13
Karnashoola
Group A Group B
BT AT BT AT
N N N N
Grade 2 0 000 0 000 0 000 0 000
Grade 1 30 10000 7 2333 32 10667 5 1667
Grade 0 4 1333 27 9000 2 667 29 9667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 30 Effect of study on Karnashoola
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
30
7
32
54
27
2
29
Karnashoola
Grade 2 Grade 1 Grade 0
Page | 107
Table no 14
Karnashoola Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 088 100 033 006
969 2829E-
08 7667 HS
AT 021 000 041 007
Group
B
BT 094 100 024 004
1037 7103E-
11 8438 HS
AT 015 000 036 007
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 31
000010020030040050060070080090100
BT AT BT AT
GROUP A GROUP B
088
021
094
015
Karnashoola
Mean
Page | 108
Table no 15
Karnashoola
Mean SD Effect
Group
A
Group
B Trial Control Trial Control
Day 1 088 094 033 024 000 000
Day 3 065 071 049 046 2667 2500
Day 5 024 038 043 049 7333 5938
Day 14 021 015 041 036 7667 8438
000
010
020
030
040
050
060
070
080
090
100
Day 1 Day 3 Day 5 Day 14
Karnashoola
Mean Group A Mean Group B
Page | 109
Table no 16
Karnashoola N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3250 110500
510000 275 Control group 34 3650 124100
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 110
Effect of study on Karnakandu
Table no 17
Karnakandu
Group A Group B
BT AT BT AT
N N N N
Grade 3 7 2333 0 000 4 1333 0 000
Grade 2 18 6000 0 000 18 6000 0 000
Grade 1 7 2333 7 2333 10 3333 15 5000
Grade 0 2 667 27 9000 2 667 19 6333
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 32 Effect of study on Karnakandu
0
5
10
15
20
25
30
N N N N
BT AT BT AT
GROUP A GROUP B
7
0
4
0
18
0
18
0
7 7
10
15
2
27
2
19
karnakandu
Grade 3 Grade 2 Grade 1 Grade 0
Page | 111
Table no 18
Karnakandu Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 188 200 081 015
1091 3119E-
10 8906 HS
AT 021 000 041 007
Group
B
BT 171 200 076 014
1032 4746E-
09 7414 HS
AT 044 000 050 009
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Page | 112
Fig 33
Table no 19
Karnakandu
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 188 171 081 076 000 000
Day 3 126 118 057 058 3281 3103
Day 5 071 074 046 051 6250 5690
Day 14 021 044 041 050 8906 7414
000
020
040
060
080
100
120
140
160
180
200
BT AT BT AT
GROUP A GROUP B
188
021
171
044
Karnakandu
Mean
Page | 113
Table no 20
Karnakandu N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 4051 137750
373500 006 Control group 34 2849 96850
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is less than
005 Hence we conclude that there is significant difference between Trial
Group and Control Group
000
020
040
060
080
100
120
140
160
180
200
Day 1 Day 3 Day 5 Day 14
Karnakandu
Mean Group A Mean Group B
Page | 114
Effect of study on Karnasrava
Table no 21
Karnasrava
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 11 3667 0 000 8 2667 0 000
Grade 1 23 7667 3 1000 26 8667 2 667
Grade 0 0 000 31 10333 0 000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 34
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 0
11
0
8
0
23
3
26
20
31
0
32
Karnasrava
Grade 3 Grade 2 Grade 1 Grade 0
Page | 115
Table no 22
Karnasrava Mean Median SD SE Wilcoxon
W P-Value
Effect Result
Group
A
BT 132 100 047 009
1122 4356E-
13 9333 HS
AT 009 000 029 005
Group
B
BT 124 100 043 008
1130 9364E-
14 9524 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 35
000
020
040
060
080
100
120
140
BT AT BT AT
GROUP A GROUP B
132
009
124
006
Karnasrava
Mean
Page | 116
Table no 23
Karnasrava
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 132 124 047 043 000 000
Day 3 100 100 025 025 2444 1905
Day 5 047 038 051 049 6444 6905
Day 14 009 006 029 024 9333 9524
000
020
040
060
080
100
120
140
Day 1 Day 3 Day 5 Day 14
Karnasrava
Mean Group A Mean Group B
Page | 117
Table no 24
Karnasrava N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3535 120200
549000 655 Control
group 34 3365 114400
Total 68
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Page | 118
Effect of study on Karnabadhirya
Table no 25
Karn
Badhirya
Group A Group B
BT AT BT AT
N N N N
Grade 3 0 000 0 000 0 000 0 000
Grade 2 0 000 0 000 0 000 0 000
Grade 1 13 4333 0 000 16 5333 2 667
Grade 0 21 7000 34 11333 18 6000 32 10667
TOTAL 34 11333 30 10000 34 11333 34 11333
Fig 36
0
5
10
15
20
25
30
35
N N N N
BT AT BT AT
GROUP A GROUP B
0 0 0 00 0 0 0
13
0
16
2
21
34
18
32
Karnabadhirya
Grade 3 Grade 2 Grade 1 Grade 0
Page | 119
Table no 26
Karn
Badhirya Mean Median SD SE
Wilcoxon
W P-Value
Effect Result
Group
A
BT 038 000 049 009
799 7173E-
05 10000 HS
AT 000 000 000 000
Group
B
BT 047 000 051 009
816 0000138 8750 HS
AT 006 000 024 004
Since observations are on ordinal scale (gradations) we have used Wilcoxon
signed Rank Test to test efficacy in Trial Group and Control Group From above
table we can observe that P-Value for Trial Group and Control Group is less
than 0001 Hence we conclude that effect observed in Trial Group and Control
Group is highly significant
Fig 38
000
005
010
015
020
025
030
035
040
045
050
BT AT BT AT
GROUP A GROUP B
038
000
047
006
Karnbadhirya
Mean
Page | 120
Table no 27
Karn
Badhirya
Mean SD Effect
Group A Group B Trial Control Trial Control
Day 1 038 047 049 051 000 000
Day 3 009 006 029 024 7692 8750
Day 5 003 006 017 024 9231 8750
Day 14 000 006 000 024 10000 8750
000
005
010
015
020
025
030
035
040
045
050
Day 1 Day 3 Day 5 Day 14
Karn Badhirya
Mean Group A Mean Group B
Page | 121
Table no 28
Karn
Badhirya N
Mean
Rank
Sum of
Ranks
Mann-
Whitney U
Asymp Sig
(2-tailed)
Trial group 34 3400 115600
561000 806 Control
group 34 3500 119000
Total 68
Page | 122
COMPARISION BETWEEN GROUP A AND GROUP B
We have used Mann Whitney U-Test for comparison between Trial Group and
Control Group From above table we can observe that P-Value is greater than
005 Hence we conclude that there is no significant difference between Trial
Group and Control Group
Table no 29
Overall Effect
Trial Group Control Group
N N
Marked Improvement 21 6176 16 4706
Moderate Improvement 8 2353 13 3824
Mild Improvement 4 1176 5 1471
No Change 1 2941 0 0
TOTAL 34 100 34 100
Fig 39
0
5
10
15
20
25
MARKED IMPROVEMENT
MODERATE IMPROVEMENT
MILD IMPROVEMENT NO CHANGE
21
8
41
1613
5
0
Overall Effect
Trial Group N Control Group N
Page | 123
DISCUSSION
Page | 124
Discussion is nothing but the logical reasoning of observations In
every research work discussion part is very important because it brings into
light about the logical analysis which are helpful in filling the research gap in
the scientific world
The discussion is categorized into following ways for the ease of
understanding
1 Discussion on selection of topic
2 Discussion on review of literature
3 Discussion on drugs their mode of action on the disease mode of action
of Karnadhoopana
4 Discussion on observation and results
1 Discussion on selection of topic
Otomycosis is commonly encountered in day-to-day practice Majority
of Indian people affected with this pathology This disease commonly
manifests in developing countries low socio-economic standard and lack
of hygiene Now a days due to busy lifestyle people are not able to follow
the proper instruction of care of ear which may be responsible for the
recurrent nature of disease So for the management of this we use
Karnadhoopana with the help of Agaruwadi Varti Dhoopana is simple
easy cost-effective procedure which can be done even at OPD levelso
for the disease Karnasrava we selected Karna Dhoopana as therapeutic
procedure Karnadhoopana was done with Agaruwadi Varti and Guggula
Varti which was very effective for treatment
Page | 125
2 Discussion on review of literature
Karnasrava is one such disease among 28 Karnarogas mentioned by
Acharya Sushruta in the chapter named Karna Roga Vigyana Acharya
Charaka included Karnasrava as symptom under the four types of
Karnarogas due to vitiation of different doshas Acharya Vagbhata has
not described Karnasrava separately It is a fact that systemic
description of Karnarogas is available in all the ancients of pus from a
Vata afflicted ear may results from head injury or immersion in water
Karnasrava is a clinical entity which can be correlated with Otomycosis
Karnasrava is explained as symptom as well as a disease in Ayurveda
Nidana- Karnasrava occur due to Samanya Nidana and Vishesh Nidana
Vishesh Nidana like Shirobhighata Nimmajato jale Mithyayoga of Shashtra
The exact pathology behind Karnasrava is not understood clearly
Purvarupa ndash No specific Purvarupa are found for Karnasrava in classical
literature Acharya Madhukara describe Purvarupa as expression of
Rupa(lakshana) with less intensity that is less intensity itching sound in ear
may considered as Purvarupa of Lakshana
Samprapti- Aacharya Sushruta not explained the Samprapti of Karnasrava
separately and we must consider the general Samprapti of Karnaroga Due to
various aetiologias as cited above ear afflicted by Vata dosha causes Twak
Rakta Mamsa dushti results in Karnasrava According to Acharya Sushruta
Vata-Kapha dose is dominance in Karnasrava
Page | 126
Nidan
Nija Agantuja
Vata ndash kapha prakopak nidana Shirobhighata Nimmajato-jale
Mithya yoga of Shastra
Vata- kapha Prakopaka(Chaya prakopak) Vata-kapha prakopaka
( Achay prakopak)
Twak Rakta Mamsa dushti
Karnasrava
Page | 127
Chikitsa
The curative aspect and this must be done simultaneously giving due
importance to Nidan Parivarjana that is preventive measures So Nidan
Parivarjana that is avoidance of causative factors like Jalkrida Mithyayogen
shashtrasya Karnakandu Shirasnan Pratishaya is the first step in combating
the disease and form the part of line of treatment
Above Samprapti helps us to proceed towards the treatment of Karnasrava
The main protocol of treatment is removal of fungus and wound management
which include various measures to keep area day clean clear of microbes and
providing ideal condition for healing
Samany Chikitsa- Acharya Sushruta described general treatment for
Karnaroga as Snehapana (Drinking ghee) Rasayana (Rejuvenation therapy)
Bhramacharya Avoid excessive speaking Avoidance of physical exercise and
head bath
Vishesha Chikitsa ndash Acharya Sushruta mentioned some procedures in the
treatment of Karnasrava which is Shirovirechana Karnadhoopana
Karnapurana Karanpramarjana Dhavan Avachurnana Karnapurana Above
various procedures described in Ayurveda for management of fungus growth
in ear discharging ear fulfill these requirements of wound management
Page | 128
Discussion on observation and Result
Out of 68 patients 34 patients included for the trial The incidence of
Karnasrava is observed in trial and control groups
The statistical analysis provided the following data
AGE
Trial group- Maximum no of patients that is 14 (41176) patients were from
age group 25-35 years followed by 29412 patients were from age group
18-25 years 23529patients were from age group 35-45 years and
58824 patients were from age group 45-60 years
Control group - Maximum no of patients that is 14 (41176) patients were
from age group 25-35 years followed by 20588 patients were from age
group 35-45 years and 20588 patients were from age group 45-60 years
17647 patients were from age group 15-25 years
The maximum no of cases of Karnasrava found in age group between 25 to
35 years The reason behind this is repeated use of ear bud or emersed water
in ear More use of earphone or working more in cold environment
GENDER
Trial group ndash A higher prevalence seen in females 6764 and 3235 in
males
Control group - A higher prevalence seen in males 5588 and 4411 in
females
Females and males both are prone to disease
Page | 129
EDUCATION
Trial group-It is observed that amongst 34 patients maximum ie16
(47059) patients were graduated 8 (23529) patients were HSC
educated 4 (11765) patients were SSC educated 4 (11765) patients
were illiterate 1 (29412) patient were primary educated and 1(29412)
patient were post graduated
Control group- It is observed that 10 (29412) patients were graduated 9
(26471) patients were HSC educated 6 (17647) patients were post
graduated 3 (88235) patients were SSC educated 3 (88235) patients
were primary educated3 (88235) patients were illiterate
There is no direct relation between education and Otomycosis
RELIGION
Trial group- The incidence of patients of Hindu religion are 9118 and Muslim
religion are 882
Control group- The incidence of patients of Hindu religion are 9706 and
Muslim religion are 294
There is no probable explanation for this maximum number of patients in
Hindu religion it depends upon the patients attend the hospital and
community residing there
Page | 130
DIET
Trial group It was found that maximum ie5882 patients were taking
mixed diet while 4118 were taking vegetarian diet
Control group It was found that maximum ie5882 were taking
vegetarian diet while 4118 patients were taking mixed diet
The dietary habit of person is based on choice availability and religious
customs of the person
ADDICTION-
Trial group- It was found that maximum ie 30 (8824) patients have no
addiction 2 (588) patients have addiction of alcohol 1 (294) patients
have addiction of Tobacco 1 (294) patients have addiction of smoking and
0 (0) patients have addiction of Mishri
Control group - It was found that maximum ie 27 (7941) patients have
no addiction 4(1176) patients have addiction of smoking 2 (588)
patients have addiction of Tobacco 1 (294) patients have addiction of
Mishri and 0 (0) patients have addiction of alcohol
Very few patients were addicted to Alcohol Smoking Tobacco and Mishri
These factors can be taken as provoking factors for Otomycosis
Page | 131
Discussion based on probable Mode of action of Karnadhoopana
In Ayurveda classics Karna Dhoopana is therapeutic procedure explain for
Karnasrava Dhoopana is administration of Dhooma (Fumes) with the help of
Dhoopan Dravya References indicates that analgesic and disinfectant effect
of Dhoopana karma and mention for Dushta Vrana Chikitsa It reduces
Vedana Srava amp also does Vrana Ropana action
Various Dhoopanas and Dhoopan Dravas for different element in various
Samhitas of Ayurveda but there is a lacuna of availability of reference
regarding how to do it and method of procedure Matra Kala Contraindication
etc
Currently simple modified way of Karnadhoopana according to Yukti Praman
and experience but there is lac of standardization
Karnadhoopana is one among the topical Bahiparimajan type of treatment
Karna Parmarjana is procedure of cleaning ear with the help of cotton or gauze
piece soaked in honey
Page | 132
Dhoopan
The fumes coming out on burning Agaruwadi Varti
Administrated directly into external ear canal
Causes vasodilation
Due to this increase blood supply in external ear canal
It helps in absorption of drug
Fumes dries up Srava and bring the analgesic effect
Karnagata Kapha amp Avrut Vata Dosha Shaman
Decrease in signs and symptoms like karnasrava Karnshool Karnabadhirya amp
Karnandu
Page | 133
3 Discussion based on probable mode of action of Agaruwadi
Dhoopana
Agaru ndash
I Agaru is a fragrant tree aroma is a result of fungal pathogenesis when the
wood of tree is contaminated by fungi at wounds it develops scrap filled
with resin and turn out to be aroma Medicinal use of Agaru have been
recorded in ancient medicinal science in in inflammatory disease and some
infective disease
II Acharya Charaka has referred to Agaru as an Ushna dravya despite having
Tikta Rasa Ashtang Samgraha used Agaru as Dhupana Dravya along with
Madan and Yawa in Karnasrava Nighantu recommended is use as a
Dhoopana
III In various Samhitas and Nighantus Agaru described as Tikta Snighdha
Sheetaprashamana Vranaprasadana Tvachya Due to these properties
Agaru is used in the treatment of Karna-Akashi Roga and Dushta Vrana
Shodhaka
IV Agaru is reported to have Antimicrobial Analgesic Antioxidants
Antihistaminic and anxiolytic properties Its Antihistaminic property gives
relief from itching which is cardinal feature of Otomycosis Due to Katu
Ushna Tikta Guna improves blood circulation Bheda stage develop It is
Niram Awastha of Dosha Karnagata kapha and vata get decrease and
symptoms like karnashoolakarnasrava get decrease Agaru also have a
Antioxidant properties
V Chemically Agaru Contain 2-(2-Phenylethyl) Chromones Terpenoids
Flavonoids
VI Natural Agarwood had inhibitive activities towards Staphylococcus Aures
The chloroform extract of Agarwood prolongs the pain threshold[108]
Page | 134
Madan
I Madanphala have therapeutic properties like Anti-inflammatory
Antiallergic Analgesic and Wound healing
II It is Useful in treatment of disease like Shotha (inflammation) Vidradhi
(Abscess) Pratishaya (Common cold) Kushta(Skin disease)
III Extract of Madanphala mainly contain Glcosides Tritorpenct
Glycosides Saponin
IV Saponin glycosides are act as fire extinguisher This property is helpful
for vartiIt also act as a detergent which clean the surface of fungus
V Tritorpenct act as a anti-inflammatory antimicrobial and
immunomodulator compound Interaction of glycosides with sterol
causes disturbance of selective permeability in plasmic membraneso
exudates and discharge get decrease
VI Pharmacological activity [109]
Antibacterial Activity The preliminary antibacterial activity of Methanolic
extract of Randia D lam was done on some standard and wild pathogenic
strains The inhibition of the bacterial growth was more pronounced on E coli
as compared to the other tested organism This shows the antibacterial action
of Randia D secondary infection can prevent
Anti-Allergic Activity In Ayurveda Randia D Extract and its fraction of milk
induced leukocytosis and eosinophilia in mice
Anti-Inflammatory Activity The crude methanol extract of fruit of Randia D
effectively reduced the carrageenin induced oedema in hind paw of the rats
significant reduction in granular tissue formation was recorded This activity
seems to be significant at various acute phases of inflammation and om
formation of granular tissue This proves action of Madanaphala in shopa
(inflammation)
Page | 135
Analgesic Activity Analgesic activity was tested in mice weighing between 20-
250 with six number of animals in each group Methanlic extract of fruit Randia
d give analgesic activity in both models This proves its Shoolanashaka (pain
killer) action
Immunomodulatory Activity Randia D has immunostimulant activity and
chloroform fraction which strongly affected immune system seems to be
bioactive fraction of this plant
The overall effect of Agaru Mandanphala Yawa having Anti-inflammatory
Antiseptic Antimicrobial Property Active ingredient shows these properties
Agaru Yawa Madanphala
Vatakaphaghna
Act as
Vranashodhak
Vedanasthapaka
Sheetaprashamana
Shothara
Avarana of Vata get decrease so helps to Shaman of Vata dosha
Karnakandu Karnashoola Karnasrava
Prashamana
Page | 136
This fact can be taken into consideration and probably acknowledge that
Karnadhoopana with Agaruwadi Varti had not leave any residue in the ear
Removal of fibrin keratinocyte migration and in growth of epithelial tissue
plays a major role in healing It is technique of fumigation of ear with the
smoke of anti-infective drug In Karnadhoopana Sthanik Swedana increase the
blood supply and helps in absorption of the drug reduce Karnakandu amp
Karnshoola associated with infection
Page | 137
SUMMARY AND CONCLUSION
Page | 138
The dissertation entitled randomize comparative clinical trial to study the
effect of Agaruwadi Karnadhoopan and Guggula Karnadhoopan In Karnasrava
wsr to Otomycosis
The dissertation is divided into fallowing parts
Introduction
Review of literature
Ayurvedic review
Modern Review
Drug review
Procedure review
Material and Method
Observation and result
Discussion
Summary and conclusion
bull INTRODUCTION
It includes importance of Shalakyatantra in Sushrut Samhita Charka
Samhita And Ashtang Samgraha
Common and specific causes of Karnasrava
Karnasrava is a clinical entity which can be corelate with Otomycosis
In Ashtang Samgraha stated the procedure like Karnadhoopana with
Agaru Yawa Madanphala in Karnasrava
Page | 139
bull REVIEW OF LITERATURE
1 Ayurvedic review
2 Modern review
3 Drug review
Ayurvedic review-
It includes Rachana-Sharir and Kriya-Sharir of Karna detail description of
Karnaroga and its types Karnaroga Samanya hetu Poorvaroopa Rupa
Samprapti Upadrava Pathya-Apathya of Karnasrava Vishesh Nidan and
Chikitsa of Karnasrava Detail description of Karnadhoopana according to
various Acharays have been mentioned
Modern review-
It includes anatomy and physiology of Ear brief anatomy of ear anatomy of
External middle and Internal ear Detail description of the disease
Otomycosis mechanism of fungal infection in external canal pathophysiology
investigations diagnosis and management
Drug review-
Detail description of Agaru Yawa Madan Guggula and its synonyms
Ayurvedic properties Karma uses Pharmacological action and their
pharmacodynamic properties
Page | 140
MATERIAL AND METHOD
It includes description regarding materials required for the study Preparation
of Agaruwadi Varti its Standardization Sterilization and packaging
Plan of study
1 Total 68 patients completed the treatment Age criteria was kept
between 18-60 years Patient selection was done by done by simple
random sampling method and divided into two groups A (Trial) and
Group B (Control) 34 patients in each group
2 Patients in Group A were treated with Karnadhoopana with Agaruwadi
Varti for 7 days two times in a day while patients in Group B were treated
with Karnadhoopana with Guggula for 7 days two times in a day
3 Clinical examination done during each follow up ie 0th 4rd 7th and
observation were recorded
Page | 141
OBSERVATIONS AND RESULTS
Page | 142
1 It was observed that higher incidence of disease Karnasrava ie
Otomycosis found in age group 25-35 years
2 Disease otomycosis was equal in both male and female
3 The trial group there was significant relief in Karnakandu (8906)
Karnasrava(9333) Karnashoola(7667) and karnabadhirya(100)
4 In control group there was significant relief in Karnakandu (7414)
Karnasrava(9524) Karnashoola(8438) and
karnabadhirya(8750)
Page | 143
REFERANCES
Page | 144
1 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published byChaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 17 page no
5
2 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Vedotaptti Adhaya Shlok no- 19 page no
6
3 DRNarayan Vidwas Shero-Karna-Nasa and MukhrogaAnand publication
edition 4th 2014 Page no-52
4 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-205
page no 111
5 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 111
6 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Shlok no2012
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-203
page no 112
8 Dr KBBhargavaDr SK BhargavaDr TMShahaA Short book of ENT
diseases Usha publication edition 10th
9 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 8 Page no -52
Page | 145
10 Research and Review Journal of Ayurvedic science yoga and
Naturopathy 2017 4(3) 1-5 pA Critical review of Otomycosis in cortex to
Karnaroga described in Ayurvedic classic by amisha patel D B Vaghala
Chandani goswami Vol4 no3 (2017)
11 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogpratished Adhaya Shlok no-213
page no127
12 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedh Adhaya Shlok no-
2140 page no 131
13 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyant shirasiya adhaya Shlok no 1712 page no-
258
14 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
15 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
16 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Aupadravik Adhaya Shlok no-15 page no
2
17 Vaidya Jaymini panday Harit Samhita hindi commentaryChaukhamba
vidhyabhartiVaranasiedition 2010 Shlok no- 13-14page no-10
18 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 146
Sanskrit SansthanVaranasi Karnarogvigyniya Adhaya Shlok no-20345
page no 112
19 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Karnarogavigyniyam Shlok
no 21 Page no-731
20 Charak
21 Pandit Harigovind Shashtri Namalinganusasana Amarkosha of
Amarsimha hindi commentary published by Chaukhamba Sanskrit
Sansthan page no- 463
22 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
23 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 37
24 Shree Taranath-Trkavachspati-Bhattacharyen Vchaspatym published
by Rashtriya Samskrit Sansthandelhi Volume 4 page no- 5149
25 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
26 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
27 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 77 page
no- 847
28 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Page | 147
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 716 page
no- 850
29 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Indriyaopakramaniya Adhaya Shlok no 811
page no- 125
30 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243
31 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-510 page no56
32 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no3108 page no- 385
33 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Shlok no33 page no- 366
34 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sarvabhutachintasharir Adhaya
Shlok no-126 page no9
35 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-522 page no60
36 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-532 page no61
37 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Page | 148
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-521page no58
38 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavykaransharir
Adhaya Shlok no-527 page no61
39 VdBramhand Tripathi Ashtanghradaya Sharirsthansthan Published by
Chaukhamba prakashana 2005 Shlok no331 page no-372
40 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Siravarnavibhaktisharir Adhaya
Shlok no-725 page no83
41 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Sharirsankhyavykaransharir Adhaya Shlok
no-512
42 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Pratekmarmanirdeshsharir
Adhaya Shlok no-628 page no75
43 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
44 VdBramhand Tripathi Ashtanghradaya Sharirsthan Published by
Chaukhamba prakashana 2005 Marmasharirsthan Shlok no429 page
no- 393
45 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana571 page no- 243244
Page | 149
46 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
47 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan pu blished by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711
48 Vaidya Yadavaji trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri Dalhanacharya Published by-
Chaukhamba Sanskrit sansthanEdition reprinted 2012
49 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sharirsthan published by
Chaukhamba Orientalia Sharirsankhyasharir Adhaya Shlok no 711 page
no- 847
50 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Shlok no 711 page no- 847
51 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Adhaya Shlok no-628 page no- 75
52 VdBramhand Tripathi Ashtanghradaya Sutrasthan Published by
Chaukhamba prakashana 2005 Gandushavidhiadhaya Shlok no2232
page no- 261
53 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sutrasthan Published by Chaukhamba
Sanskrit SansthanVaranasi Karnavydhbandhvidhi Adhaya Shlok no-
1611 page no- 86
54 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Nidansthan Published by Chaukhamba
Page | 150
Sanskrit SansthanVaranasi Vatvydhinidansa Adhaya Shlok no183 page
no- 304
55 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Sharirsthan Published by
Chaukhamba Sanskrit SansthanVaranasi Sharirsankhyavaykaransharir
Adhaya Shlok no-532 page no61
56 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Tristaisniya adhaya Shlok no 1120 page no-
163
57 P Hazarika Dr Nayaka R Balkrishnan Textbook of EarNoseThroat and
Head-Neck Surgery CBS Publication Anatomy of Ear
58 DrKB Bhargava DrSKBhargava DrTMShaha A short book of ENT
Diseases Published by Usha Publication 10th edition page no10
59 MrSalah Mansour MrJacques MagnanMr Hassan Haidar MrKaren
Nicolas MRStephan Louryan Comprehensive and clinical anatomy of the
Middle Ear Published by Springer publication Chapter -Middle Ear cavity
Page no 19 to 121
60 DrPLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no 7
61 James OPickles An introduction to Physiology of Hearing Published by
Emerald publication 4th edition page no- 1 to 265
62 Raja Radhakantadeva Shabdakalpadruma Naga PublicationsDelhi 3rd
edition -2006 Volume 2 Page no 42
63 VdBramhand Tripathi Ashtanghradaya Uttarsthan Published by
Chaukhamba prakashana 2005 Karnaroga vigyniyam adhaya Shlok
no1713 page no- 998
Page | 151
64 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt Shlok no- 212 page no-
730
65 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no
1-2 page no- 309
66 Shree Yadunandanopadhyaya Madhavnidan with madhukosh
teekapublished by Chaukhamba Prakashana
67 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary Sutrasthan published by
Chaukhamba Orientalia Kiyantshirasiya Adhaya Shlok no 1713 page no-
258
68 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya Shlok no-
6 page no- 310
69 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Karnarogavigyniym Shlok no- 1725-26 Page no-
1003
70 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2140 page
no 131
71 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005 Adhyay 18 shlok 35
72 Acharya Trivedi Raguveer Prasad Ashtang sangrah uttartantra
published by Vaidyanath Ayurveda bhavan pvt
Karnarogapratishedhoadhya Shlok no-2211 Page no- 735
73 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 152
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2141 page
no 131
74 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2142 page
no 131
75 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2144 page
no 131
76 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 34 page no- 649
77 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2145page
no 131
78 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 37 page no- 649
79 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2146page
no
80 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
81 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-
Tatva-Sandipika hindi commentary Uttartantra Published by Chaukhamba
Page | 153
Sanskrit SansthanVaranasi Karnarogapratishedho Shlok no-2143page
no
82 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publication Krnarogadhikara adhaya page no-
318
83 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary
Madhyamkhand Vatkalpana shlok no- 782-83 page no- 137
84 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 72-77 page no- 651
85 Vd Shree Laxmipatishastri Yogratnakara with Vidyodini tika hindi
commentary Chaukhamba publicationKrnarogadhikara adhaya page no-
316
86 Vd Shree Laxmipatishastri Yogratnakara
87 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
Karnarogadhikara Shlok no- 808182 page no- 652
88 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
KarnarogadhikaraShlok no- 83 page no- 652
89 (PDF) Otomycosis A Comprehensive Review (researchgatenet)
90 httpswwwncbinlmnihgovpubmed24948980
91 A Simon Carney Scott-Browns Otorhinolaryngology Head and Neck
Surgery CRC press 8th publication Otitis externa and otomycosis
92 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition Diseases of external ear
Chapter no Page no -
93 wwwguggulipidcomtradhtm
Page | 154
94 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
95 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-28 page no-
43
96 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009Agaru page
no726-728
97 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishra chapter Karpuradi varga Shlok no-31-
43 Page no- 116
98 httpswwwthiemeinimagecatlogsample_chapter_GOMPpdf
99 (PDF) Chemical Constituents and Pharmacological Activity of Agarwood
and Aquilaria Plants (researchgatenet)
100 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 4 chapter no-2 page no-4
101 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 chapter no-152 Madanpage
no376-379
102 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
103 The Ayurvedic Pharmacopeia of India Ministry of Health and family
welfare department of Ayush Part 1 Volume 1 chapter no-54 page no-
84
104 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009 page no697-699
patol-yawa
Page | 155
105 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi
commantry Purvakhand Mishr Chapter Karpuradi varga Shlok no-31-43
Page no- 117
106 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
Dhoompanvidhi page no- 252-254
107 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012Chikitasasthan Shlok
no- 151page no-406
108 httpswwwmdpicom1420-3049232342pdf
109 httpswwwijamcoinindexphpijamarticledownload0610201530
0
Page | 156
BIBILOGRAPHY
Page | 157
1 Shree Govindadasvirachita Pandit Shree Lalachandraji Vaidya
Bhaishajyaratnawai Banarasidas prakashana-8th edition
2 Scott-Brown WG Diseases of the EarNose and Throat Landon
Botterworth and co(publishers) Ltd1952 Volume 2
3 Vaidya Yadavaji Trikamji Acharya Sushrut Samhita of Sushruta with
Nibandhasangraha commentary of Shri DalhanacharyaPublished by-
Chaukhamba Sanskrit sansthanedition reprint 2012
4 Acharya Priyavat Sharma Dravyaguna Vijnaanavol 2
Chaukhamba Bharati Academyreprint 2009
5 Vaidy Purushottm Ganesh Nanal Sarth Bhavprakash Marathi commantry
Purvakhand and Madhyamkhand
6 Dr Bramhanand Tripathi Sharandhar Samhita containing Anjananida of
Maharshi Agnivesha an noted with Dipika Hindi commentary Uttarkhand
7 Kaviraj Ambikadatta shashtri Sushrut Smhita edited with Ayurveda-Tatva-
Sandipika hindi commentary Published by Chaukhamba Sanskrit
SansthanVaranasi
8 The Ayurvedic Pharmacopeia of India Ministry of Health and family welfare
department of Ayush Part 1 and part 4
9 Vd Bramhanand Tripathi Ashtangridhyam Uttartantra published by
Chaukhamba2005
10 Acharya Trivedi Raguveer Prasad Ashtang sangrah published by
Vaidyanath Ayurveda bhavan pvt
11 Dr PLDhingra and DrShruti Dhingra Diseases of Ear Nose Throat
published by ELSEVIER Publication 6th edition
12 Vd Harish chandra singh Kushwaha Charak Samhita edited with
Ayurved Dipikarsquos Ayusi Hindi Commentary published by Chaukhamba
Orientalia
Page | 158
ANNEXURE
Page | 159
ANNEXURE- 1
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
CASE RECORD FORM
RESEARCH PROFORMA FOR MS (AYU) DESSERTATION
DEPARTMENT OF SHALAKYATANTRA
NAME -
ADDRESS -
GENDER - AGE - OCCUPATION-
RELIGION - EDUCATION - MARITAL STATUS-
OPD IPD NO-
DATE OF ADMISSIONCOMMESEMENT-
DATE OF DISCHARGECOMPLITION-
DATE OF COUNSELLING-
TEL NO-
CHIEF COMPLAINTS-
PAST MEDICAL AND SURGICAL HISTORY-
TREATMENT HISTORY-
FAMILY HISTORY-
Page | 160
PERSONAL HISTORY-
a) Ahar(Diet)
b) Vihar
c) History of addiction
GENERAL EXAMINATION
PULSE - MIN BP - mm of hg
TEMP - 0F RR - MIN
ASHATAVIDHA PARIKSHANA
Nadi- Mutra- Mala-
Jivha- Shabda- Sparsha-
Drik- Aakruti-
SYSTEMIC EXAMINATION
RS ndash
CNS-
CVS ndash
Page | 161
LOCAL EXAMINATION (KARNA PARIKSHAN)
OBSERVATION TABLE FOR SUBJECTIVE CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching )
RIGHT EAR LEFT EAR
KARNASHASHUKULI
KARNAPUTRAK
KARNAPALI
KARNAKUHARA -
SRAVA
GANDH
VARNA
SWARUPA
KARNAPATALA (TM)
Page | 162
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
Hearing Test
1Renne Test ndash
2 Weber Test -
Examination of Ear-
Pathological Investigation-
Other Examination-
Nidan Panchak-
1Hetu-
2Purvarup-
3Rupa-
4Upashayanupashaya-
5Samprapti
Signature of Guide Signature of Doctor(Researcher)
Page | 163
ANNEXURE 12
PREPARTION OF DRUG
Standard Operating Procedure (SOP) of Agaruwadi Dhoopana Varti
STEP 1 - Agaru Madan and Yawa these raw drugs were purchased from
authentic source
STEP 2 - Sterilization were done as recommended in pharmacy procedure
The raw drugs were authentified and standardize from certified lab
STEP 3 - Powder of above drugs having mesh size of 100 were mixed together
in equal quantity to make Agaruwadi churn
STEP 4 - Agaruwadi churn were triturated with appropriate quantity of water
and prepared Varti in GMP Certified Ayurvedic pharmacy Standard aseptic
precaution was taken during preparation of Varti
STEP 5 - Agaruwadi Dhoopana Varti was packed in sterile air packed
container
STEP 6 - Agaruwadi Dhoopan was given with the help of Dhoopan yantra
TREATMENT DETAIL-
Purvakarma -
1 The patient is asked to sit comfortably on chair having sufficient light and
less amount of dust
2 The EAC is cleaned thoroughly by Pichu Varti (cotton swab) to remove the
discharge and other debris
Pradhankarma -
1 The patient is asked to relax completely on the chair
Page | 164
2 Fumes are passed to the ear with Dhoopana Yantra
3 Dhoopana yantra is funnel shaped and its one end will keep the ear covered
for the passage of Dhooma into the ear canal and other end where Agaruwadi
Dhoopana Varti were placed which produces fumes
4 This Dhoopana was given for 5 min
Pashchat karma -
1 The patient were advised to avoid cold refrigerated food drinks cold water
bath cold wind fog and prevent water from entering the ear
(A) Agaruwadi Dhoopana Varti
B) Guggula Dhoopana Varti SOP of it is same as above Agaruwadi Dhoopana
Varti
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Drug Agaruwadi Varti
Route of administration Local
Kriyakalpa Karna Dhoopana
Dose two times a day
Duration 7 days
Page | 165
ANNEXURE 21
INFORMED CONSENT DOCUMENT
Study Title
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
Introduction
- You are invited to take part in a research study RANDOMSIED COMPARATIVE
CLINICAL TRIAL TO STUDY THE EFFECT OF AGARUWADI DHOOPANA AND
GUGGULA DHOOPANA IN KARNASRAVA
- Before you decide it is important for you to understand why the
research is being done and what it will involve
- Please take time to read the following information carefully and discuss
it with friends relatives and your doctor if you wish
- Ask us if there is anything that is not clear or if you would like more
information
Purpose amp Nature of Study
- In this research project by examine you and ldquoKarnasravardquo (Otomycosis)
disease were treated
- In the part of treatment Agaruwadi Dhoopana or Guggula Dhoopan were
given
- Dhoopana means medicated drug fumes were given in ear with the help of
Dhoopan Yantra
Page | 166
- Treatment was given for 7 days
Study Duration
7days
Participation
- Your participation is entirely voluntary
- If you do decide to take part you were given this information sheet to keep
and be asked to sign a informed consent form
- If you decide to take part you are still free to withdraw at any time and
without giving a reason This will not affect the standard of current or future
medical care you may receive
Confidentiality
- All information which is collected about you during the research were
kept strictly confidential
- Any information about you which is collected from the center will have
your identity in the form of a code number so that it will remain confidential
Benefits Of Study
- The results obtained from this study would be helpful for providing better
quality of treatment amp other essential facilities for Karnasrava (Discharge)
patients
- You will get clinical benefit from the study
Page | 167
Risks Of Study
- In this treatment there are few chances of Irritation of Ear Nose and
congestion at EAC if any of these happens then treatment were given
Results Of Study
- If the Results obtained are profitable then they may get published
without disclosing your details
Signature of patient
Date
Time
Phone no of Researcher
Page | 168
रण मादहती पतरक
सशोिनाच शीषवक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE
EFFECT OF AGARUWADI DHOOPANA AND GUGGULA DHOOPANA
IN KARNASRAVA
परसतताना
- आपणास या सशोिनातपमक अभयासात सहिागी होणय़ाच आाहन करणयात यत आह
- सशोिनातील सहिाग तननदशचत करणयापी सशोिनाच उददश समजन घया
- खालील मादहती काळजीपवक ाचा आणण आशयक ािलयास आपलया डॉकिराशी कका
दहतशरचतकाशी चचाव करा
- काही सददिता असलयास कका आणखी मादहती ही असलयास आमछयाशी चचाव करा
सशोिनाच उददीटि सतरप
- सदर सशोिन परकलपामरधय आपलयाला तपासणी करन कणवसरा या वयाशरिची शरचककतपसा दणयात
यणार आह
- सदर वयाशरिची शरचककतपसा महणन आपणास अगरादी िपन कका गगल िपन
दणयात यणार आह
- सदर औषि आपणास 7 ददस घयायाच आह
Page | 169
कालािी
- 7 ददस
सहिाग
- आपला सहिाग हा पणवपण ऎनदछिक आह
- आपला सहिाग तननदशचत असलयास आपणास ही मादहती पतरतरका दणयात यईल आपणास यातील
समती पतरकार सही कराी लागल
- सहिाग तननदशचत असनही आपण कोणतपयाही ळस कोणतही कारण न दता माघार घ शकता
याचा आपलया दयकीय सविर कोणताही पररणाम होणार नाही
गोपनीयता
- सशोिना दरमयान गोळा कलली आपलया वषयाची सव मादहती गोपनीय ठणयात यईल
- आपली यनदकतक मादहती साकततक सतरपात गोपनीय ठणयात यईल
सशोिनाच फ़ायद
- सशोिनाच तनटकषव कणवसरा बाशरित रणाछया दयकीय इतर सविाचा दजाव सिारणयास
फायदशीर ठरतील
सशोिनातील जोणखम
- य़ा शरचककतपसमरधय कान दखण डॊळय़ातन नाकातन पाणी य़ण नाकात जळजळण डोक जड
होण ही लिण ददस शकतात यापकी लिण तनमावण झालयास तपयाची शरचककतपसा कली जाईल
Page | 170
सशोिनाच तनटकषव
सशोिनाच तनटकषव फ़ायदशीर ठरलयास आपली मादहती गोपनीय ठन परकाशशत करणय़ात यईल
रण सतािरी-
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
Page | 171
ANNEXURE 31
INFORMED CONSENT FORM
Patient OPD no __________
Subjectrsquos Identifier
Date of Birth Age Gender
I _____________________________________ age___________ years
exercising my free power of choice hereby give my consent to be included
as a participant in the clinical study entitled
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
1 I confirm that I have read have been read and understood the information
sheet for the above study and can ask questions
2 I understand that my participation in the study is voluntary and that I am
free to withdraw at any time without giving any reason without affecting my
medical care or legal rights
3 I understand that the Ethics Committee members investigators and study
doctors will not need my permission to look at my health records both in
respect of the current study and any further research that may be conducted
in relation to it even if I withdraw from the trial I agree to his access
However I understand that my identity will not be revealed in information
released to third parties or published
4I agree not to restrict the use of any data or results that arisefrom this study
provided such a use only for scientific purpose
5 I agree to take part in the above study
Page | 172
signature with Date-
Left hand thumb impression
Name amp signature of the witness ndash
Name amp signature of the student ndash
Page | 173
ANNEXURE 32
समतीपतरक
RANDOMSIED COMPARATIVE CLINICAL TRIAL TO STUDY THE EFFECT OF
AGARUWADI DHOOPANA AND GUGGULA DHOOPANA IN KARNASRAVA
वयकतीच य
ददनाक जरमददनाक
1) मी ह तननदशचत कररत आह ककसदर सशोिन परकलपाबाबतची सपणव मदहती मी ाचली असनमला ती
समजली आहतपयाबददल मला परशन वचारणयाची पणव मिा आह सदर मादहतीन माझ समािान झाल
आह
2) मी सदर सशोिनातन माझया मजीनसार किीही बाहर पड शकतो या माझया अशरिकाराची मला कलपना
आह
3) माझी दयककय मादहती तपासणयाची कागदपतर कळ सशोिनाकररता ापरली जाणार आहत याची
मला मादहती आहसदर सशोिन परकलपातील सबशरित घिकाना माझी दयककय मादहती पाहणयाची मी
समती दत आहतरावप या सदिावतील माझी ओळख दशववणारी मादहती कोणासही ददली जाणार नाहीयाची
मला कलपना दणयात आली आह
4) सदर अभयासातन शमळणारी मादहती अरा तनटकषव कळ शासततरीय हतसाठी ापरल जाणयासाठी माझी
समती आह
5) रील अभयासात सहिागी होणयास माझी समती आह
रण सतािरी-
Page | 174
ददनाक-
ळ-
सशोिकाचा दररधतन िमाक
ASSESSMENT CRITERIA
Sr no Subjective
criteria
Day 1 Day 4 Day 7 Day 15
1 कणवशल
(pain)
2 कणवकणड
(Itching)
3 कणवसततरा
(Discharge
)
4 बाशरियव
(conductiv
e
Deafness)
a) कणवशल ( pain )- 0 - Absent
1 ndash Present
Page | 175
b) कणवकणड (Itching)- 0 - Absent
1 - Mild- Intermittent or occasionally
2 - Moderate-frequently
3 - Severe-continuous
c) कणवसततरा ( Discharge )
0- Absent
1-Mild- Scanty secretion near Tympanic membrane Brownish Blackish
White
2 - Moderate - secretion irrigating in ear canal BrownishBlackishwhite
3- Severe - secretion coming out of ear canal BrownishBlackishwhite
d) बाशरियव ( conductive Loss of hearing )
0 - Present
1 - Absent
Page | 176
Page | 177
Page | 178
Page | 179
Page | 180
CERTIFICATE OF ANALYSIS OF AGARUWADI VARTI
Page | 181
CERTIFICATE OF ANALYSIS OF GUGGULA VARTI
Page | 182
AUTHENTIFICATION CERTIFICATE
