Development of a Nasya fitness form for clinical practice.

INTRODUCTION: Nasya karma is prime treatment modality for ūrdhvajatrugata vikāra. Though classics clearly mention yogya (arha), ayogya (anarha) criteria for Nasya karma some complications were noticed while practicing. In KLEUS Shri BMK Ayurveda Hospital Belgaum, out of 2867 patients 58 (0.58%) cases reported various complications during and after Nasya karma in the year of 2011 even after taking utmost care in selection of patients as well as drugs. This gave rise to need to develop quick screening criteria to minimize errors.
OBJECTIVE: To develop Nasya fitness form for clinical practice to further minimize unusual complications and thus obtain the maximum result.
MATERIALS AND METHODS: Literature pertaining to Nasya karma, Nāsa śarīra with anatomy of nose, vasculature, innervation, examination of the nose and various anatomical pathologies were considered to develop the fitness form.
RESULTS: On the basis of examination of external nose, nasal cavity, concha, nasopharynx and paranasal sinus by anterior and posterior rhinoscopic examination fitness form was developed.
CONCLUSION: Present fitness format will not only help to assess the nasal pathologies, which are obstacles for drug delivery, but also will help to attain optimum results and avoid unusual complications.

INTRODUCTION

During any disease process, unbalanced doṣas get lodged in the weak parts of the channels of circulation and produce symptoms of the disease. If the channels of circulation are unobstructed and healthy, even the aggravated doṣas cannot accumulate anywhere and lead to disease. To treat the disease, Ayurveda adopts two principles of management: (i) Śodhana (purification therapy) and (ii) Śamana (pacificatory therapy).[2] Śodhana is a unique feature of Ayurveda aimed at the complete expulsion of the unbalanced Doṣas and the purification of the channels of circulation. Śodhana includes karmas such as Vamana, Virecana, Basti, Nasya, Raktamokṣaṇa, as therapeutic procedures.

Nasya (intranasal drug administration) is one of the therapeutic procedures part of Pañcakarma which acts both at local and systemic levels. It is the practitioner's prime duty to consider the patient's fitness prior to any Pañcakarma treatment, as these treatments are similar to any operative procedures used in allopathic medicine. Preanesthetic fitness is a must to avoid complications in surgery and in the same manner prefitness for Pañcakarma procedures has to be considered for imporvement in efficacy and to avoid complications.

The present data collected on Nasya will clearly indicate the need for an approach using a fitness form in the patient's clinical assessment leading up to the Nasya procedure. The database of KLE’U Shri BMK Ayurveda Hospital Belgaum, Karnataka, India documents that 2867 Nasya karmas have been performed in Pañcakarma Department in 2011.[3] These were different types of Nasya like śodhana, śamana and bṛhmaṇa. Despite performing the Nasya karma with due precautions the retrospective data analysis showed the following complications[4] [Table 1].

Table 1

Complications documented following Nasya treatment in 2867 patients

In order to minimize such complications and to achieve optimum results one has to rule out any existing nasal pathologies by proper examination before administering the procedure. This led to the development of a Nasya fitness form for clinical practice in order to further minimize complications.

OBJECTIVE

To develop Nasya fitness form for clinical practice to further minimize unusual complications and thus obtain maximum result.

MATERIALS AND METHODS

Literary sources

This includes study of:

Ayurvedic classics: Includes literature of Nasya karma, Nāsa śarīra, etc

Anatomy of nose, examination of nose and various anatomical pathologies.

Development of format

The above mentioned points from classics and nasal anatomy with its examination were considered for the development of present form to rule out any nasal pathology. They include the examination of external nose, nasal cavity, concha, nasopharynx and paranasal sinus by anterior and posterior rhinoscopic examinations.[4] and this led to the development of a form as seen in Table 2.

Table 2

Nasya fitness form after selection of patient for Nasya karma

RESULTS

On the basis of examination of external nose, nasal cavity, concha, nasopharynx and paranasal sinus by anterior and posterior rhinoscopic examination fitness form was developed.

DISCUSSION

It is well established in Ayurveda classics, that there is a close relationship between the nāsā (nose) and śiras (brain). nāsā is one among the pañcajñānendriyas (five sense organs) whose function is not limited to olfaction and respiration but is also the pathway to śiras. The medicine administered through the nostrils reach up to śṛṅgāṭaka marma, spreads all over ūrdhvajatru and eliminates the deep seated doṣas.[5]

Recent trends in modern science are emphasizing the use of transnasal route for administration of drugs as the nasal mucosa constitute the only site in the body that provides a direct connection between central nervous system and the atmosphere. Drugs administered to the nasal cavity rapidly transfer to the cribriform plate and then to the central nervous system via three routes:

Directly via olfactory neurons

Via supporting cells and the surrounding capillary bed

Directly through cerebrospinal l fluid.[6]

The surface area of the nasal cavity is about 160 cm2 (0.96 m2 if the microvilli are included). The olfactory region, however, is only about 5 cm2 (0.3 m2 when microvilli are included). There are six arterial branches that serve the nasal cavity, making this region, called as Little's area of nose, a very attractive route for drug administration. In particular, the blood flowing in this region is get slightly more reabsorbed in the nasal vein, with any excess draining into the lymph vessels, making this region a very attractive route for drug delivery.[7] The same pathway though may spread any infections directly to the brain if performed without considering safety issues of nasal fitness. The same pathway is also the cause of spreading infection from external to internal parts. Many a time, the administration of Nasya Dravyas (Drugs) without considering the internal existing pathologies such as infected concha etc., will worsen the condition and cause untoward effects. An understanding of the anatomical and histological structure of the nasal cavity is essential and important for nasal drug delivery system and these factors were considered in the development the present fitness form.

The above considerations in ruling out the structural pathology hindering the pathway of a drug administered through the nasal route are better understood by the following example. There was a case diagnosed as Apabāhuka (frozen shoulder)[8] and a nasal examination revealed “S” shaped deviated nasal septum (DNS) with middle turbinate hypertrophy. Though the patient with Apabāhuka is indicated for Nasya karma with Sneha Dravya Prayoga (oil based intranasal drug usage), his DNS makes him unfit for the procedure. With the DNS as a physical obstacle for drug delivery the Nasya karma, if performed will not fully serve its purpose. In addition to this, there is a higher risk of complications in the form of infection like rhinitis and headache in the patient.

Present fitness format will not only help to assess fractures of nasal bones, obstructions like DNS, turbinate hypertrophies, polyps and paranasal sinuses etc., which are obstacles for drug delivery, but also will help to attain optimum results and avoid unusual complications.