A review on disease Nadi Vrana

[Find the meaning and references behind the names: Megha, Kumar, Ranjith]

REVIEW ARTICLE May 2024 Journal of Ayurveda and Integrated Medical Sciences | May 2024 | Vol. 9 | Issue 5 124 A review on disease Nadi Vrana Megha R 1 , Ranjith Kumar 2 1 Post Graduate Scholar, Department of Shalya Tantra, Ayurveda Mahavidyalaya and Hospital, Hubballi, Karnataka, India. 2 Assistant Professor, Department of Shalya Tantra, Ayurveda Mahavidyalaya and Hospital, Hubballi, Karnataka, India. I NTRODUCTION Nadi Vrana is a hollow tube like structure or a blind track, which has excessive pus infiltration where pus burrows deeply. In Nadi Vrana , due to copious flow it is known as Gati and as it flows like a drain, that’s why it is known as Nadi [1] Nadi Vrana is a type of Vrana . Nadi means a track and Vrana means an ulcer. According to Shabdakalpadruma, an ulcer which has track is called Nadi-Vrana [2] According to Amarkosha the word Nadi refers to a deformity where an abnormal track formation occurs, Address for correspondence: Dr. Megha R Post Graduate Scholar, Department of Shalya Tantra, Ayurveda Mahavidyalaya and Hospital, Hubballi, Karnataka, India. E-mail: lodgaaasrvms@gmail.com Submission Date: 14/03/2024 Accepted Date: 23/04/2024 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.9.5.21 which has continuous discharge [3] According to Acharya Sushruta and Acharya Vagbhata , if Vrana-Shopha is not timely drained in Pakvaavastha or if it is neglected at particular stage, then it invades into deeper tissue resulting in formation of Nadi- Vrana [4,5] Nadi-Vrana can be correlated to Sinuses in the modern science. The sinus is defined as a blind tract which leading from surface down into the tissue and lined either by granulation tissue or by epithelium. It persists due to presence of foreign body, non-dependant drainage and infection [6] Ayurvedic classics has described various treatment modalities for Nadi-Vrana such as surgical procedures like Chedana or Vidarana , [7] para-surgical procedures like Kshara Sutra application, [8] other procedures like Lepana , [9] Varti , [10] Prakshalana etc. Ayurvedic perspective Vyutpatti of word Nadi-Varna can be derived from two words Nadi and Vrana . Nadi - any tubular structure and that which has Gamana/Gati , Vrana - discontinuity in the bodily tissue, on combining word Nadi-Vrana , Shabdhakalpadruma says Nadisanglano Vranah which gives the meaning an ulcer with a sinus. A B S T R A C T Nadi-Vrana is a tubular structure which contains pus within it or Nadi-Vrana is a blind tract which has continuous pus discharge from it. According to various Acharyas, if Vranashopha is not timely drained or treated during its Pakvaavastha or neglected at this stage, it traverses into deeper tissues and results in formation of Nadi-Vrana . The disease nature of the Nadi-Vrana can be correlated to Sinuses of the contemporary science, where Sinus is the epithelial lined tubular structures which contain unhealthy granulation tissue. Acharyas have given detailed explanation on different types of Nadi-Vrana along with its treatments, which include Bhaishajya Chikitsa, Kshara Sutra application, Agnikarma and Shastrakarma . Among these various treatment modalities Kshara Sutra application stands out in present days in combating the disease Nadi-Vrana . Shalyaja/Agantuja Nadi-Vrana can be correlated to Pilonidal sinus by its causative factors and clinical features. In this article the compiled explanation of Nadi-Vrana which includes its causes, classification, signs and symptoms, management and many more descriptions according to Ayurveda and modern medicine will be dealt. Key words: Nadi-Vrana, Shalyaja Nadi-Vrana, Sinus, Pilonidal sinus.

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Megha R. et al. A review on disease Nadi Vrana ISSN: 2456-3110 REVIEW ARTICLE May 2024 Journal of Ayurveda and Integrated Medical Sciences | May 2024 | Vol. 9 | Issue 5 125 Nirukti (definition) Tube like structure or tract which is blind in nature where excessive infiltration of pus burrowing deeply [11] Aetiology and pathophysiology of Nadi-Vrana [12] If Vranashopha is treated improperly. Due lack of knowledge about the Avastha of Vranashopha , when a Pakwa Vranashopha is meant to be treated by surgical procedure, if it is left untreated the Puya or pus which is present in it finds its Gati into the deeper tissues of the affected part and forms large tracks resulting in formation of single or multiple tracts called as Nadi- Vrana. Samprapti [13] Vrana Shopha if left untreated or improperly treated in Pakvaavastha ↓ Finds its Gati into deeper tissue at the affected site because of vitiated Vata ↓ Further Pakwatha due to vitiated Pitta ↓ Pus/ Puya formation due to vitiated Kapha ↓ Due to provocation of infection development of Nadi- Vrana (Sinus). Classification SN Sushrut a Samhit a [14] Ashtang a Hridaya [ 15] Bhavaprakas ha [16] Madha va Nidana [ 17] Yogaratnak ara [18] 1. Vataja Vataja Vataja Vataja Vataja 2. Pittaja Pittaja Pittaja Pittaja Pittaja 3. Kaphaja Kaphaja Kaphaja Kaphaj a Kaphaja 4. Vata- Pittaja Sannipat aja Sannipataja Tridosh aja Vata-Pittaja 5. Vata- Kaphaja Shalyaja Shalyaja Shalyaj a Vata- Kaphaja 6. Pitta- Kaphaja Pitta- Kaphaja 7. Tridosh aja Tridoshaja 8. Shalyaj a Shalyaja Lakshanas 1. Vataja Nadi-Vrana According to Acharya Sushruta - Parusha (Rough on touch), Sukshma Mukhi (narrow opening), Sa-Shoola (Painful), Adhika Phenodgham Srava (Frothy discharge), Kshapaya ( Srava during the night) [19] According to Acharya Vagbhata - Vivarna (Discoloration), Ratrau Adhika Srava (Discharge during night) rest other Lakshanas are as per Acharya Sushruta [20] Bhavaprakasha, Madhava Nidana, Yogaratnakara has given same Lakshanas as of Acharya Sushruta. 2. Pittaja Nadi-Vrana According to Acharya Sushruta - Trishna (Thirst), Jwara (associated with fever), Paridaha (Pricking pain), Ushna (Warm on touch), Peetavat Srava (yellowish discharge) [21] According to Acharya Vagbhata - Diva Srava (Discharge during day) rest other Lakshanas are as per Acharya Sushruta [22] Bhavaprakasha, Madhava Nidana, Yogaratnakara has given same Lakshanas as Acharya Sushruta . 3. Kaphaja Nadi-Vrana According to Acharya Sushruta - Bahu Ghana (Hard), Picchila Srava (Viscous discharge), Arjuna Varna/Shweta Varna (whitish or pale in colour), Stabdha (fixed), Kandu (Itching), Aruja (Painless/mild pain) [23] According to Acharya Vagbhata - Adhika Kledata at Nishi (Discharge during night), Kathina (Hard) rest other Lakshanas are as per Acharya Sushruta [24] Bhavaprakasha, Madhava Nidana, Yogaratnakara has given same Lakshanas as Acharya Sushruta .

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Megha R. et al. A review on disease Nadi Vrana ISSN: 2456-3110 REVIEW ARTICLE May 2024 Journal of Ayurveda and Integrated Medical Sciences | May 2024 | Vol. 9 | Issue 5 126 4. Vata-Pittaja Nadi-Vrana - combined symptoms of Vataja and Pittaja Nadi-Vrana [25] 5. Vata-Kaphaja Nadi-Vrana - combined symptoms of Vataja and Kaphaja Nadi-Vrana [26] 6. Pitta-Kaphaja Nadi-Vrana - combined symptoms of Pittaja and Kaphaja Nadi-Vrana [27] 7. Sannipataja Nadi-Vrana According to Acharya Sushruta - Daha (burning sensation), Jwara (Fever), Shwasana (difficulty in breathing), Murchana (loss of consciousness), Vaktrashosha (dryness of mouth), combined symptoms of all three Doshas . This type of Nadi-Vrana should be considered as fatal and similar to Kalaratri (god of death) [28] According to Aacharya Vagbhata - Sarva Dosha , Sarvaakruti (Lakshanas of all Ekadoshaja Nadi- Vrana ) [29] Bhavaprakasha , Madhava Nidana , Yogaratnakara has given same Lakshanas as Acharya Sushruta . 8. Shalyaja/Agantuja Nadi-Vrana According to Acharya Sushruta - Shalya (foreign body) will be embedded or hidden in the deeper tissue and this type of Nadi-Vrana formation will be quicker in creating the passage. Phenilavat (Frothy), Ushnavat (warm), Asruk Mishritavat (blood mixed) Srava, Nitya Ruja (Pain) [30] According to Acharya Vagbhata - Phenanuvidha (More of frothy discharge), Tanu (Tender in nature), Alpa Ushna (mild warmth) rest other Lakshanas are as per Acharya Sushruta [31] Madhava Nidana , Yogaratnakara has given same Lakshanas as Acharya Sushruta . Shalyaja / Agantuja Nadi-Vrana can be correlated to contemporary science’s Pilonidal sinus Sadyasadyata [32] ▪ Sannipataja Nadi-Vrana : Asadya ▪ Vataja, Pittaja, Kaphaja, Dwidoshaja, Shalyaja : Krichrasadya or Yatna Sadya. Chikitsa of Nadi-Vrana ▪ Nidana Parivarjana - factors causing Nadi-Vrana i.e., Vranashopha should be treated properly based on the Avastha . ▪ Samprapti Vighatana - Bhaishajya , Ksharasutra application, Agnikarma [33] and Shastra Chikitsa . ▪ Bhaishajya Chikitsa - Acharyas have mentioned various Bhaishajya Chikitsa like Lepa Karma, Upanaha and Varti Prayoga using Dravyas based on Dosha Dushti. ▪ Kshara Sutra application - All the Acharyas have explained Kshara Sutra Chikitsa for Nadi-Vrana , after Eshana of Nadi in cases of Krisha (lean), Durbala (weak), Bhiru (one who is scared of surgery/surgical instruments), and Nadi present at Marma Sthana Kshara Sutra ligation should be done to the Nadi. [34] ▪ Shastra Karma - Patana , Vidarana and Eshana Karma has been mentioned. Chikitsa based of individual type 1. Vataja Nadi-Vrana According to Acharya Sushruta - Upanaha Karma to dilute the Puya and once it gets aggregated at one point, Eshana then Vidarana Karma is done followed by Vrana Shodhana and Ropana by Tilapishta , Apamarga with Saindhava followed by Bandhana Karma . Prakshalana of Vidarita Vrana with Vatahara Dravyas like Panchamoola Kwatha , Bala , Gojihva, Bilva . Taila of Vatahara Dravyas are used for Shodhana , Poorna and Ropana of Vrana [35] According to Acharya Vagbhata and Yogaratnakara - explains the same treatment. 2. Pittaja Nadi-Vrana According to Acharya Sushruta - Upanaha in the form of Ksheera and Ghrita mixed Utkarika , then Shastrakarma . Vrana is created Prakshalana with Somalata, Nimba and Haridra followed by Lepa of Nagadanti and Madhuyashti. [36]

[Find the meaning and references behind the names: Madhu]

Megha R. et al. A review on disease Nadi Vrana ISSN: 2456-3110 REVIEW ARTICLE May 2024 Journal of Ayurveda and Integrated Medical Sciences | May 2024 | Vol. 9 | Issue 5 127 According to Acharya Vagbhata - Patana followed by Tiladi Pradeha [37] According Yogaratnakara - Patana followed by Lepa of Tila, Manjishta, Nagadanti, Haridra [38] 3. Kaphaja Nadi-Vrana According to Acharya Sushruta - Upanaha of Kulatha, Siddhartaka, Shaktu, Khinva once it attains Mrudutva, Eshana and Shastra Karma is done. Vrana Prakshalana with Kwatha of Karanja, Nimba, Jati, Pilu and Bibhitaka. Lepana of Nimba, Tila, Danti , Saurashtra Mrittika , Saindhava Lavana on the Vrana. Taila prepared of Apamarga and Gomutra is used for Vrana Ropana. [39] Acharya Vagbhata and Yogaratnakara - explains the same treatment. 4. Agantuja Nadi-Vrana According to Acharya Sushruta - Vidarana of Nadi then evacuation of Shalya present in the Nadi-Vrana, Shodhana and Ropana with Taila, Ghrita and Madhu . Taila prepared with Kumbhi, Karanja, Musta, Sarala Priyangu, Sugandhika, Mocharasa, Rodra, Dhataki should be used for Ropana purpose of the Vrana [40] Acharya Vagbhata and Yogaratnakara - explains the same treatment. Modern perspective Sinus The sinus is a blind ending tract connecting a cavity lined with granulation tissue (often an abscess cavity) to an epithelial surface [41,42] Sinus means “hollow” or “a bay” (Latin) [43] Types of Sinus 1. Congenital sinus Causes: arise from remnants of persistent embryonic ducts like preauricular sinus, post auricular sinus [44] ▪ Preauricular sinus: congenital entity occurring due to imperfect fusion of the six tubercle which form ear cartilage. Sinus opening may be seen at the root of helix or on tragus [45] 2. Acquired sinus Causes: results from retained foreign body (ingrowing of hair or suture material), Chronic infection (tuberculosis, osteomyelitis, actinomycosis), chronic inflammation (Chron’s disease), malignancy or inadequate surgical drainage of the cavity. ▪ Median mental sinus - Occurs as a result of tooth abscess (evidence of caries which occurs in the midline just beneath the mentum. Clinical features - recurrent swelling in submental region which bursts open spontaneously discharging at times mucus and seropurulent fluid. Treatment - extraction of caries tooth will heal sinus [46] ▪ Osteomyelitis - Gives rise to sinus discharging pus with or without bony spicules. ▪ Most common sinus in the neck is due to tubercular lymphadenitis. Cheesy material discharge associated with bluish discoloured surrounding skin will be seen. Clinical features of Sinus [47] ▪ Discharge from the opening of sinus. ▪ No floor ▪ Raised indurated edge, indurated base, nonmobile. ▪ Often sprouting granulation tissue over the sinus opening. ▪ Bone thickening in osteomyelitis ▪ Surrounding skin may be erythematous in inflammatory, pigmented in chronic sinus. ▪ Enlargement of regional lymph node ▪ Sinus may be single or multiple. Pilonidal Sinus (Jeep Bottom) [48] Pilonidal sinus means nest of hairs (Greek). ▪ Most common in jeep drivers and in dark people. ▪ It is an acquired condition which appears between age group of 20-30 years, hairy men.

[Find the meaning and references behind the names: Debris, Sri, Ram, Prakashan, Good, Narayan]

Megha R. et al. A review on disease Nadi Vrana ISSN: 2456-3110 REVIEW ARTICLE May 2024 Journal of Ayurveda and Integrated Medical Sciences | May 2024 | Vol. 9 | Issue 5 128 Sites of Pilonidal sinus: Midline over coccyx, umbilicus, interdigital in barbers [49, 50] Pathogenesis The hair follicle is never demonstrated in the wall of the pilonidal sinus but hair is the content of pilonidal sinus. Hair accumulates due to vibration and friction causing shedding of the hair. Thus, it accumulates in the gluteal cleft and enters the opening of the sweat glands. Contents: mainly Hair, granulation tissue, epithelial scales and debris [51] Clinical features ▪ External Opening of the sinus seen just above the anal verge in the midline over the coccyx. ▪ History of discharge of pus. ▪ History of recurrent abscesses which rupture, discharging pus Treatment Excision - Open method and closed method ▪ Open method - wound left open. ▪ Closed method - wound closed by ‘Z’ plasty, ▪ Karydakis procedure - through a semi-primary procedure is to remove all the sinus tracts and branches till sacral bone. Semilateral incision is made around the sinuses and flap mobilised to excise all the sinuses and their branches. Then the tension free closure is done. This procedure decreases the chances of skin necrosis [52] ▪ Bascom’s procedure - incision is given laterally, not midline. After raising the flaps, wide excision of infected sinuses and tracts is done followed by closure of the midline openings. Lateral wound is left open [53] ▪ Lahey and Cattell’s relaxing skin incisions [54] ▪ Davies and Starr buttock skin flap rotation [55] ▪ Buie’s marsupialisation of the sinus track [56] Complication [57] 1 Abscess formation 2 Recurrent inflammation 3 Recurrence of sinus formation 4 Very malignant degeneration may occur in the lesion Note: Based on the clinical features, among various types of Nadi-Vrana, Shalyaja/Agantuja Nadi-Vrana can be correlated to Pilonidal sinus. CONCLUSION Nadi-Vrana is a tubular structure which contains pus and which enters the underlying structures making a track. In classics, Achrayas have mentioned the pathogenesis of Nadi-Vrana , when the Pakva Shotha is not treated it traverses into the deeper tissues creating the tract which is called as Nadi-Vrana , this shows that Nadi-Vrana is a complication of Pakva Shotha or Vidradhi. Nadi-Vrana is correlated to sinuses of the modern science as it has same clinical features. Acharyas have mentioned various types of Nadi-Vrana based on the aetiology, the similar aetiological classification is also there in modern science as that of Sinuses. If the underlying disease in the tissue is not treated at proper time it leads to formation of hollow tubular structure which contains pus/unhealthy granulation tissues in it. The same pathogenesis holds good for Sinus and Nadi-Vrana , hence it can be correlated to each other. In contemporary science, medical management to treat the underlying disease and surgical management for sinus proper has been stated. In Ayurveda, Acharyas have mentioned various treatment modalities, such as Aushadha Prayoga (Medical management), Kshara Prayoga , Agnikarma and Shastra Karma (Surgical approach), that which provides a holistic approach in the management of the Nadi-Vrana , in turn which restrains to be good in present era by providing relief and preventing from recurrence of the condition. REFERENCES 1 Sushruta; Sushruta Samhita; with Nibandhasangraha Commentary of Sri Dalhanacharya; Edited by Yadavji Trikamji and Narayan Ram Acharya Kavyatirtha; Chaukambha Surbharati Prakashan, Varnasi; nidana sthana 10/9; page no. 307.

[Find the meaning and references behind the names: Shri, Raja, Deva, Sitaram, Anna, Krishna, Hari, Radha, Sagar]

Megha R. et al. 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Megha R. et al. 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[Find the meaning and references behind the names: Williams, Sriram, Joshua, Love, Anitha, Prakash, Roman, Norman, Nil, Andrew, Rao, Med]

Megha R. et al. A review on disease Nadi Vrana ISSN: 2456-3110 REVIEW ARTICLE May 2024 Journal of Ayurveda and Integrated Medical Sciences | May 2024 | Vol. 9 | Issue 5 131 Chaukambha Surbharati Prakashan, Varnasi; Chikitsa sthana 17/23-25; page no. 468 40 Sushruta; Sushruta Samhita; with Nibandhasangraha Commentary of Sri Dalhanacharya and the Nyayachandrika Panjika of Sri Gayadasacharya on Nidanasthana; Edited by Yadavji Trikamji and Narayan Ram Acharya Kavyatirtha; Chaukambha Surbharati Prakashan, Varnasi; Chikitsa sthana 17/26-28; page no. 468 41 Bailey & Love’s Short Practice of surgery; Edited by Professor Sir Norman Williams, Professor P. Roman O’Connell, Professor Andrew W. McCaskie; 27 th edition; Part-6, Skin and Subcutaneous tissue; Chapter 40; Page no 616 42 A concise textbook of surgery; Dr Somen Das;11 th edition;Dr S Das; chapter 11, page 165. 43 SRB’s Manual of Surgery’ Sriram Bhat M; Forewords by Prakash Rao, Thangan Verghese Joshua; 5 th edition; Jaypee Brothers Medical Publishers(P) ltd; Chapter 1 (C); Page No 31. 44 Manipal Manual of Surgery; K Rajgopal Shenoy, Anitha Shenoy (Nileshwar); 4 th edition; CBS Publishers & Distributors Pvt ltd; Chapter 2; Page no 28. 45 SRB’s Manual of Surgery’ Sriram Bhat M; Forewords by Prakash Rao, Thangan Verghese Joshua; 5 th edition; Jaypee Brothers Medical Publishers(P) ltd; Chapter 1 (C); Page No 35. 46 Manipal Manual of Surgery; K Rajgopal Shenoy, Anitha Shenoy (Nileshwar); 4 th edition; CBS Publishers & Distributors Pvt ltd; Chapter 27; Page no 295. 47 SRB’s Manual of Surgery’ Sriram Bhat M; Forewords by Prakash Rao, Thangan Verghese Joshua; 5 th edition; Jaypee Brothers Medical Publishers (P) ltd; Chapter 1 (C); Page No 35. 48 Manipal Manual of Surgery; K Rajgopal Shenoy, Anitha Shenoy (Nileshwar); 4 th edition; CBS Publishers & Distributors Pvt ltd; Chapter 31; Page no 804. 49 A concise textbook of surgery; Dr. Somen Das;11 th edition; Dr S Das; chapter 46, page 1102. 50 Manipal Manual of Surgery; K Rajgopal Shenoy, Anitha Shenoy (Nileshwar); 4 th edition; CBS Publishers & Distributors Pvt ltd; Chapter 31; Page no 804. 51 A concise textbook of surgery; Dr. Somen Das;11 th edition; Dr S Das; chapter 46, page 1102. 52 Manipal Manual of Surgery; K Rajgopal Shenoy, Anitha Shenoy (Nileshwar); 4 th edition; CBS Publishers & Distributors Pvt ltd; Chapter 31; Page no 805. 53 Manipal Manual of Surgery; K Rajgopal Shenoy, Anitha Shenoy (Nileshwar); 4 th edition; CBS Publishers & Distributors Pvt ltd; Chapter 31; Page no 805. 54 SRB’s Manual of Surgery’ Sriram Bhat M; Forewords by Prakash Rao, Thangan Verghese Joshua; 5 th edition; Jaypee Brothers Medical Publishers(P) ltd; Chapter 25; Page No 968. 55 SRB’s Manual of Surgery’ Sriram Bhat M; Forewords by Prakash Rao, Thangan Verghese Joshua; 5 th edition; Jaypee Brothers Medical Publishers(P) ltd; Chapter 25; Page No 968. 56 SRB’s Manual of Surgery’ Sriram Bhat M; Forewords by Prakash Rao, Thangan Verghese Joshua; 5 th edition; Jaypee Brothers Medical Publishers(P) ltd; Chapter 25; Page No 968. 57 A concise textbook of surgery; Dr Somen Das;11 th edition; Dr S Das; chapter 46, page 1103. ******************************* How to cite this article: Megha R, Ranjith Kumar. A review on disease Nadi Vrana. J Ayurveda Integr Med Sci 2024;5:124-131. http://dx.doi.org/10.21760/jaims.9.5.21 Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2024 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and perform the work and make derivative works based on it only for non-commercial purposes, provided the original work is properly cited

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