PInasa: Chronic Sinusitus

by Alakananda Devi (Alakananda Ma), M.B., B.S. (Lond.)

An eighteen year old female student from a damp, cold climate presents with chronic greenish nasal discharge, sinus headaches and post nasal drip. The post nasal drip aggravates her allergic asthma, causing her to need more asthma medication and the medications then exacerbate her irritable bowel syndrome and acid reflux (amlapitta). A fifty three year old professional pitta woman complains of dull pain in the face, lack of taste and a pervasive “stale cigarette” smell for the last six months. A sixty year old vata male janitor, residing in a semi-arid climate, has suffered from exhaustion, sinus headaches and greenish nasal discharge for the last six months.

Diverse in gender, age, prakruti, desha or climate zone and profession, all these individuals are suffering from forms of pinasa or chronic sinusitis and are in general turning to Ayurveda “as a last resort.”

According to the Charak Samhita, factors which tend to provoke vata in the sinuses and head include suppression of natural urges, sleeping by day, staying awake at night, loud or excessive talking, excessive sexual intercourse, fasting, and consumption of too much salad and other raw foods. (1). Charak notes that emotional factors play a significant role in the development of vata type sinusitis, particularly too much weeping; suppression of tears; grief, fear and anxiety. Head injury causing fracture of the sinus passages can predispose to vata type sinusitis, while Charak specifically mentions environmental causes, namely exposure to smoke or dust. The factors listed as giving rise to pitta-predominant sinus infections include excessive intake of spicy foods, salt, sour fruits, vinegar and alcohol, excess exposure to the sun, and overly warm indoor environments, while Kapha-type sinus infections are a classic disease of the “couch potato” type. Sedentary habits, excess sleep, and a diet high in oily, sweet and heavy foods, are the main provoking factors.

Patient A, our eighteen year old student, Prakruti V2P3K2, resides in a damp, cottage in a cold, northerly climate. She noted that agantu (external) factors in the form of allergens, chiefly animal dander, would trigger episodes of sneezing accompanied by itching and hives, while among annaja (dietary) factors she became more stuffy following consumption of cow dairy. She was allergic to blue cheese, as were her mother and aunt. She also pointed to an infective factor, with episodes of more acute sinus infections related to flu-like illnesses. She had some important ongoing emotional irritants, as she felt chronically angry due to tensions in the family.

Patient B, our professional pitta woman, Prakruti V2P3K1, was quite healthy until she visited Costa Rica and caught a severe flu while travelling. Following this episode she developed deep orange-brown nasal catarrh— indicative of a combination of pus and blood— and was unable to smell or taste for some months. She felt as if cigarette smoke came out of her nostrils, although she was a lifelong non-smoker. There was a foul smell in her nostrils. All three doshas were provoked and kapha was blocking vata. Her typical breakfast was quite vata provoking—a granola bar and a cup of coffee, while her typical lunch largely consisted of yoghurt, a notably slimy and kaphagenic food. Her situation is thus well described in a sutra from the Chikitsasthanam of Charak, “All types of pinasa, due to unwholesome diet and negligence, get aggravated badly and converted to dushtha pratisyaya (vicious coryza). Thence arise sneezing…foul smell in nostrils, apinasa, inflammation, swelling …pus and blood in nose.” (2) Apinasa is defined by Madhava as: “That person whose nasal passage is obstructed, dried up or very moist, with a feeling as if smoke is coming out of the nostrils, who does not recognize the taste or smell of materials, is considered to be suffering from apinasa.” (3)

Patient C, our vata janitor, had suffered for many years with chronic sinusitis which he controlled by jala neti. This particular long-lasting exacerbation began when he babysat his grand-daughter while she had a cold. Thus he, like our other patients, pointed to an initial infective episode. He noted that he avoided cow dairy as it would cause him to be more mucousy, and also mentioned an agantu factor related to his work, as vacuuming, dusting and changing vacuum cleaner bags exposed him to a considerable amount of dust. His workplace had recently suffered a burst pipe and flood leading to a build up of moulds in the maintenance room, his base of operations at work. He had a history of dust, pollen and mould allergies. He smoked one or two cigarettes daily. He also noted that his current condition arose following a major trauma which had left him affected with unresolved grief and smouldering anger.

A common factor among our diverse patients is their complaint of an initial acute viral upper respiratory infection, leading us to look more deeply into the krumija or infective causation of their conditions. What organisms are involved in their persistent sinus conditions and how important is this understanding in terms of Ayurvedic management?

A pointer in Patient A’s history inspired me to look more deeply into this topic. She reported that she had taken several rounds of antibiotics with absolutely no effect, but that Echinacea had been quite effective. Now, antibiotics are designed to work on bacterial infections whereas Echinacea has a much broader spectrum of activity ranging from anti-viral to antifungal. Echinacea has been found to be active against an array of fungal pathogens including Cryptococcus neoformans, Candida albicans, Trichophyton tonsurans, T. mentagrophytes, Microsporum gypseum and Pseudallescheria boydii.(4). Her allergy to the mould cultures in blue cheese and her damp residence corroborated my hunch that she was suffering from a fungal infection. Patient C also reports significant mould exposures and a tendency to atopic reactivity.

According to a study at the Mayo clinic, allergic fungal sinusitis (AFS), better termed chronic eosinophilic rhinosinusitis, was diagnosed in 93 % of 101 consecutive surgical cases with chronic rhinosinusitis (pinasa).(5). Particularly common in atopic individuals such as Patients A and C, AFS is characterized by chronic sinusitis with facial pressure, headache, nasal stuffiness, discharge which is often greenish in colour, and cough.

Understanding that the agantu causes of pinasa typically include fungal infection may be important for the Ayurvedic practitioner in a number of ways. First, we can be aware that antibiotics are unlikely to help this client, whereas there are many Ayurvedic herbs that will be of considerable help. Secondly, we can counsel the client to avoid mould exposure. Patient C, for example, could wear a mask when at work to minimize exposure. Thirdly, since candida albicans was found in nasal mucous in 21% of the patients studied at Mayo clinic (5), we can watch for other symptoms of systemic candidiasis such as gas, bloating and brain fog and can advise the removal of refined starches and sugars from the diet.

Ayurvedic herbs of notable anti-fungal activity include kalmegh (6), Black Pepper (7), Pippali, (8), Turmeric (9), Ginger (10), cardamom (11), Bibhitaki (12), Amalaki (13), Haritaki (14), Elecampane (15), cinnamon (16), and clove (17) as well as neem, well known for its antifungal activity. Thus commonly-used Ayurvedic churnas such as Sitopaladi, Triphala and Avipattikar will be just as effective against AFS as they will against viral colds and flus. Immune Support and Lung Support contain an array of antifungal herbs. Such herbs will be useful as part of a balanced protocol that includes dietary modifications, lifestyle changes, nasal cleansing and yoga.

Patient A benefitted greatly from a pitta-soothing diet that helped her IBS and amlapitta as well as her pranavahasrotas symptoms. She used nasya oil to cleanse her sinuses and was helped by a formula that included Guduchi as dosha pratyanika for pitta, Punarnava as a lung strengthener and anti-allergic, Musta for pitta ama and candidiasis, and Licorice as a lung rejuvenative.

Patient B began making warm, moist breakfasts and stopped using cow yoghurt. She was taught to use a nasal rinse cup with mineral salt in the rinse water and to follow this with vigorous breathing exercises and forward bending yoga poses to allow any excess water to drain from the sinuses. She found that pranayamas such as nadi shodhan and kapala bati helped her taste her food. She began taking sitopaladi churna for her sinus infection and avipattikar churna for pitta ama in the rasa dhatu and was given a custom nasya that included Punarnava, Turmeric, Neem, and Rose. She gradually began to regain her sense of smell and taste. She is currently preparing for home Pancha Karma this spring.

Patient C already had a strong routine of nasal rinses and breathing exercises. Regular spring Pancha Karma protocols with vaman, virechan and basti have also typically helped his chronic sinusitis go into remission. He was advised to stop smoking but has not as yet been compliant in this regard. He would benefit from asanas such as Surya Namaskara, Pavanamukta Asana, Utthan Pada Asana, Simha Asana, Bhujanga Asana, Dhanura Asana, Matsya Asana and Shava Asana. He found that gargles with turmeric and mineral salt were a valuable addition to his daily routine and liked to drink tea containing Ginger, Cardamom and Tulsi. He has entered therapy to help resolve the deep-seated emotions that seem to be driving his persistent sinus condition.

Pinasa, or chronic rhinosinusitis, has been found to be due, in a majority of instances, to fungal infections with eosinophilic reactivity. Ayurvedic herbs and formulations traditionally used for pinasa are inherently antifungal and hence likely to prove effective in the context of a balanced protocol which addresses annaja and agantu causes. Diet modifications, lifestyle changes and shodhan practices such as Pancha Karma are essential parts of such a protocol, as are asana and pranayama and specific nasal therapies, jala neti (nasal rinses) and nasya. This condition is hard to treat but typically will show at least some improvement with Ayurvedic therapies.

  1. Charak Samhita Sutrasthana xvii v 8-2
  2. Charak Samhita, Chikitsasthanam, ch. xxvi, v 100-102 tr. PV Sharma, Chaukhambha Orientalia.
  3. Madhava Nidhanam Ch 58 v 1, Tr Prof Srikantha Murthy, Chaukhambha Orientalia.
  4. Merali S.; Binns S et. al, .lAntifungal Activity of Echinacea, Pharmaceutical biology ISSN 1388-0209
  5. Ponikau JU, Sherris DA et .al. The diagnosis and incidence of allergic fungal sinusitis. Mayo Clin Proc. 1999 Sep;74(9):877-84
  6. M Nazrul Islam Bhuiyan, TIMA Mozmader et al Growth Inhibition and Mutagenesis of Neurospora crassa and the Same Organism by Leaf Extracts of Andrographis paniculata Burm. f. Bangladesh J. Sci. Ind. Res. 43(2), 173-182, 2008
  7. Gurdip Singh, Marimuthu, P.,et. Al. Chemical, antioxidant and antifungal activities of volatile oil of black pepper and its acetone extract. Journal of the Science of Food and Agriculture 2004 Nov., v. 84, issue 14 p. 1878-1884.
  8. Sung-Eun Lee Byeoung-Soo Park et a lFungicidal activity of pipernonaline, a piperidine alkaloid derived from long pepper, Piper longum L., against phytopathogenic fungi Crop Protection Volume 20, Issue 6, July 2001, Pages 523-528
  9. Amphawan Apisariyakul, Nongnuch Vanittanakom et. al. Antifungal activity of turmeric oil extracted from Curcuma longa Journal of Ethnopharmacology Volume 49, Issue 3, 15 December 1995, Pages 163-169
  10. Hexiang Wang and Tzi Bun Ng. An antifungal protein from ginger rhizomes, Biochemical and Biophysical Research Communications Volume 336, Issue 1, 14 October 2005, Pages 100-104
  11. Kapoor, I.P.S.; Singh, B.; Chemistry, antifungal and antioxidant activities of cardamom (Amomum subulatum) essential oil and oleoresins International Journal of Essential Oil Therapeutics, Volume 2, Number 1, March 2008 , pp. 29-40(12)
  12. Valsaraj, R. et al. 1997. New anti-HIV-1, antimalarial, and antifungal compounds from Terminalia bellerica. J Nat Prod. Jul;60(7):739-42
  13. S. Satish, D.C. Mohana et .al. Antifungal activity of some plant extracts against important seed borne pathogens of Aspergillus sp Journal of Agricultural Technology
  14. Vonshak , O. Barazani et. al. Screening South Indian medicinal plants for antifungal activity against cutaneous pathogens Phytotherapy Research Volume 17 Issue , Pages 1123 – 1125 Published Online: 27 Oct 2003
  15. Canadanovic-Brunet,-J.M.; Djilas,-S.M.; et. al. ESR studies of antioxidative activity of different elecampane (Inula helenium L.) extracts Acta-Periodica-Technologica (Serbia and Montenegro). (2002). v. 33(APTEFF, 33) p. 127
  16. Quale J. M. ; Landman D. In vitro activity of Cinnamomum zeylanicum against azole resistant and sensitive Candida species and a pilot study of cinnamon for oral candidiasis The American journal of Chinese medicine ISSN 0192-415X CODEN AJCMBA
  17. Lidia Núñez; Miguel D'Aquino; Jorge Chirife Antifungal Properties Of Clove Oil (Eugenia Caryophylata) In Sugar Solution Braz. J. Microbiol. Vol.32 No.2 São Paulo Apr./June 2001

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Alakananda Devi (Alakananda Ma) is director of Alandi Ayurvedic Clinic in Boulder, Colorado, and principal teacher of Alandi School of Ayurveda, a traditional ayurvedic school and apprenticeship program. She can be reached at 303-786-7437 or by email at: info@alandiashram.org.

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