Wednesday, July 25, 2007

Otitis Media

By John Douillard, DC, PhD


IntroductionIn Western medicine, otitis media (referred to as karnapratinaha in Sanskrit) is defined as an inflammation of the middle ear. The inflammation is usually due to an infection caused by a virus or bacteria that has made its way to the middle ear via the nose, throat, and Eustachian tube. Treatment in Western medicine follows the determination of origin (bacterial versus viral), and hence, which antibiotic, if any, will effectively eradicate the bacterial growth and stop the inflammation. This treatment no doubt works. In fact, it works so well it has lead to a widespread overuse of antibiotics and to antibiotic-resistant strains of bacteria.

In Ayurvedic medicine there are many antibacterial herbs, but they are rarely used as such; the first course of action for recurring conditions, such as otitis media, is prevention. This is primarily performed one or two seasons prior with appropriate seasonal cleansings. The second course of action is the actual treatment. This is accomplished by addressing causative factors in the host that are responsible for the inflammation and infection, rather than by irradiating the symptomatic invaders of an imbalanced physiological medium, i.e., the bacteria and viruses.

Etiology

In Ayurveda ear disorders, called Karna Roga (Cakradatta, Ch LVII), can be caused by one of four imbalances (Caraka, Chikitasthanam , Ch. XXV1, Vi20 121):

Vata: Thin discharge, dried ear wax, severe pain, tinnitus, and deafness.

Pitta: Yellow discharge, swelling, redness, tearing, and burning.

Kapha: White and slimy discharge, abnormal hearing, itching, stable swelling, and mild pain.

Sannipatataja: Characteristics when vata, pitta, and kapha imbalance occur together; the discharge is colored according to the predominant dosha.

Diagnosis

The diagnosis depends on many factors, too numerous for the scope of this article. Here we will discuss those factors that are most important in making a diagnosis.

Age

The age of the individual is commensurate to the ear disorder and is proportionate to the type of disorder experienced. A child (under the age of sixteen) is still in the kapha kala (time) of life. This means that his or her constitution will be made up of, and holding on to, predominantly kapha (earth, water, and phlegm) qualities. It is for this reason that children frequently complain of colds and earaches, and because of this age-related predisposition, certain precautions must be taken to avert frequent ear infections. In general, a kapha-pacifying diet or mucus-free diet should be followed,* particularly during change of seasons and during the spring, which is the kapha season.

Body Type

The prakriti (constitution) of an individual is a factor in diagnosis and predicted frequency:A child with a kapha body type and in the kapha time of life (around eight years old), is susceptible to getting ear infections in the springtime, or other times when kapha’s congestive qualities are increasing in the environment. If the child is eating a kapha-aggravating diet (lots of sweets, wheat, dairy), the chances of an ear infection dramatically increase.

A child with a vata body type will not be at as much of risk for ear infections as a child with a kapha body type is, but when he or she has reached adulthood, in which vata imbalances are common, the individual can become more susceptible. Adult vata types usually complain of chronic colds, having four or five colds each winter.The pitta types are probably the least susceptible all through life, but even they can succumb if they get out of balance.

Season

The seasons play a large role in both the prevention and the treatment of otitis media:

In the vata season, which runs from October through March, the body has a tendency to dry out due to the cold and dry nature of the winter. If accumulated, this dryness excessively dries out the body. This is probably confirmed by a noticeable drying of the sinuses and the skin in the winter. This dryness attacks three srota (channels) systems specifically in the case of otitis media.

First, the Pranavaha srotas (sinuses) dry out, and the mucous membranes are rendered unable to protect against infection. Next, the Udakvaha srotas, or water-carrying channels, dry out, leading to chronic sore and dry throats. Then the Rasavaha srotas (lymph carrying channels) dry out, and lymph flow, which regulates immunity and removes waste, is blocked. The waste subsequently backs up into the Eustachian tube and middle ear, making a perfect place for an opportunistic bacterial or viral infection to settle.

Spring, or kapha season (April through June), is another time when ear infections are frequent. After a long, cold, and dry winter, nature rewards us with a damp and warm spring to balance the extremes of winter. The body’s natural response to being so dry all winter is to make mucus at the first chance. As kapha increases in the environment during the spring, internally its congestive properties can block the Rasavaha Srotas that are needed to remove waste and control immunity.

With these channels compromised, infections are more likely. Regular, seasonal cleansings and a natural foods diet provide the natural antidote for the increasing mucus and congestion of spring. The kapha reducing diet is rich in non-mucus-forming, light, leafy, seasonally-available greens, such as dandelions and asparagus. Look to nature for the antidote to seasonal disorders. Its harvest may hold the keys to both prevention and cure.

The pitta season (summer: July through September) is when colds and ear infections should be least frequent. However, if one is out of balance, the increasing amount of heat can rise up into the respiratory tract and dry it, causing the process of Udavarta, the upward movement of vata. As the heat rises, so will the air, or vata, which triggers more drying.

General Discussion

In clinical practice, it is important to put the aforementioned information together to accurately predict the cause of the ear infection as vata, pitta or kapha. A child in kapha kala with a kapha prakriti with excessive mucus will most likely have a kapha imbalance. A vata prakriti with chronic sore throats and frequent colds in the winter will likely have vata type ear infections. The same vata type in the pitta time of life (age 16 50), with colds in the summer and other related pitta symptoms, will probably have to be cooled as well as cleansed to bring about a successful result.

Prevention

Seasonal Cleansing

The most effective way to avoid an ear infection in one season is to cleanse the body at the change of season prior. This is done classically during the months of March, June, and September or October.

In Ayurveda, the most powerful type of seasonal cleansing is as part or a process called Panchakarma. This procedure is quite extensive and is usually done under supervision. Two aspects of this procedure that can easily be performed at home as part of a seasonal cleanse are virechana (intestinal purgation) including a preparatory oleation process, and nasya (nasal cleaning).**

Home Cleansing

Perform the following steps once during the seasons’ changes in March, June, and September. Perform step three once during each of the four days of oleation.

Step One: Oleation (Snehana)

The purpose of oleation (snehana) is to loosen impurities in the body. Drink the following amounts of melted clarified butter (ghee) each morning for 4 days as prescribed (dosages are for individuals older than 16 years of age):***

Day time Ghee Dosage

1 6-7 AM 2 tsp.

2 6 7 AM 4 tsp.

3 6 7 AM 6 tsp.

4 6 7 AM 8 tsp.

Ghee (clarified butter) loosens, dissolves, and mobilizes impurities in the body so they can be easily eliminated during the laxative therapy. Since ghee is heavy to digest, there may be a feeling of slight nausea or dullness during oleation. Ginger tea can remedy this, and once the impurities are flushed out of the system with the laxative therapy, the individual will feel light again.

Ghee should be measured (note: 3 teaspoons = 1 tablespoon) and taken in liquid form on an empty stomach first thing in the morning. To make the ghee more palatable, take it at a lukewarm temperature. Sipping a glass of hot water1/2 hour after taking the ghee is beneficial. Mixing it with 1/2 cup of warm milk followed by a second1/2 cup of warm milk and sugar may help those who have difficulty swallowing plain ghee. If nausea occurs, sip a half to one glass of warm to hot water with fresh lemon juice and grated ginger root.

During this cleansing, eat lightly and follow the prescribed dietary guidelines. Drink copious amounts of water, preferably warm and not cold. It is also advisable to sip hot water every half hour during each day of the cleansing.

Step Two: Laxative Therapy (Virechana)

The purpose of laxative therapy (virechana) is to cleanse the body of impurities which have been loosened by the oleation. The laxative should be taken at bedtime on the evening of the fourth day of ghee. (One may take the laxative early in the morning on an empty stomach on day 5; many people who can stay home find this to be more comfortable.) The evening meal should be very light, and before taking the laxative, take a 15-20 minute hot tub bath to increase the circulation and loosen the impurities in the body. (If a tub bath is not possible, you may substitute a hot shower or a hot water bottle over the lower abdomen for 15 20 minutes).

Castor Oil: Prescription: 6 teaspoons

You can take castor oil by itself or follow the recipe below. You will need two fresh oranges (or lemons) for use in the recipe below. Read the complete recipe, arrange all items conveniently, and then proceed.

Slice open two oranges (or lemons) in quarters. Place the prescribed amount of castor oil (in this case, 6 teaspoons) in1/2 cup hot water. Squeeze the juice from an orange (or lemon) into the cup and stir vigorously. Hold nostrils closed, drink mixture quickly. Bite into the remaining orange (or lemon) for about 5 seconds. Release nostrils.

After taking the laxative, you may awaken during the night with the need to go to the bathroom. The results will normally occur in 1 to 15 hours after taking the laxative (the average is from 4 to 6 hours).

Do not eat or drink anything until after the laxative effect has worn off.

Step Three: Home Shirodhara-Abhyanga-Nasya (Head, Neck, and Shoulder Massage with Nasal Cleansing)

The purpose of this treatment is to open, cleanse and lubricate the srotas of the head and neck. When blocked, these srotas allow impurities to back up into the Eustachian tube and middle car, creating a potential ear infection. Follow the next five steps.

1. Massage the head and neck.

2.Take a hot shower.

3. Steam the face and neck: fill a large bowl with freshly boiled water. Add 1 2 drops eucalyptus oil or Vicks Vaporub.™ Drape a clean, large towel over the head, making a tent. Lean over the bowl so that the steam is trapped inside the towel tent. Inhale the steam for 2 3 minutes.

4. Gently apply hot towels to the neck and face.

5. Perform nasal cleansing: using an eye dropper, place two or three drops of sesame oil directly into both nostrils. Sniff the oil into the sinus cavity; then, rapidly closing and opening the nostrils with your thumb and forefinger, breathe in through the nose. Repeat sniffing procedure three times. Repeat as needed. Do not do within two hours of bedtime.

Alternate lubrication method: Place a few drops of the oil in the palm of the left hand. Dip the little finger of the right hand into the oil. Insert the oiled finger into both nostrils until they are well-lubricated. If you use this method, make sure that your hands are clean and that the nail of your little finger is clipped short. Continue with sniffing procedure described above.

General Treatments

Even though vata, pitta, or kapha may cause otitis media, general treatments which are effective in bringing symptomatic relief are helpful. In every kind of ear infection there will be a kind of discharge (mucus that is produced from the virulence of the infection). A kapha-reducing diet is helpful in removing this mucus during the infection itself, and can expedite the healing even if the diagnosis is not 100% accurate. It is indicated when there is low agni (weak digestive power), kapha imbalance, or excessive mucus and a kapha constitutional type.

Cleansing Kapha-Pacifying Diet

Note: Food should be fresh, well-cooked, tasty, and satisfying. It is important to eat only when hungry and to take meals according to a regular schedule. Eat in a settled environment without distractions. Do not overeat.

Grains

Barley, in light preparations such as in soup, crackers, unleavened bread.

Rye, in crackers made from finely ground flour.

Oats, cooked with water to make a light porridge.

Millet, steamed or boiled.

Wheat, in small amounts, and from finely ground whole wheat flour such as that found in crackers, biscuits with low fat and sugar, toasted light bread, unleavened flat breads (chapati, pita bread, tortillas), couscous, semolina and cream of wheat.

Rice, such as Basmati or other white rice, rice flour, puffed rice, and cream of rice.

Suggestion: fry the rice in a pan without oil, then steam or boil it into a soup.

Legumes:Green or yellow mung beans or red lentils (dal). (Mung beans and red lentils are available in health food stores and Indian shops, or by mail order.)

To prepare: boil 1 part legumes in 2 to 3 parts water.

Suggestion: boil legumes with rice and a lot of water to make a thin soup. A pinch of hing (asafoetida) increases the digestibility of lentils.

Vegetables:Vegetables should be well-cooked, and prepared with a high water content (as in soups, stews, casseroles). Green, leafy vegetables (well cooked), white pumpkin, asparagus, artichoke, cabbage, zucchini, eggplant (peeled), celery (not the root), carrots (in small amounts), spinach, chicory, tomato (peeled) and tender white radish (prepared in oil), green papaya.

Dairy Products: Low fat milk, goat’s milk, buttermilk, yogurt mixed with water 1:1 (lassi, or Ayurvedic buttermilk), small amounts of clarified butter (ghee).

Sweeteners: Only honey, in small amounts Do not heat or cook honey.

Oils: All (except coconut oil) in very small amounts for cooking only.

Spices and Condiments: All spices except salt, especially pungent and sharp spices (pepper, ginger, etc.). Lemon juice in small amounts.

Fruits: Fruits should be sweet, ripe and in season: grapes, pomegranates, papayas (small amounts), figs, apples (peeled), guava. The juice of these fruits is also good. Raisins are fine in small amounts, if presoaked and chewed well.

Liquid: Sip hot water every 1⁄2 hour for 1 to 2 weeks.

Specific TreatmentsVata

In vata-based otitis media, the major causative factor is dryness. Drops of medicated oil into the ears can act as an antimicrobial and a lubricant.

Vata Ear Oil

Equal parts garlic oil and ginger juice, with 5% rock salt. Add 30-35 drops to 1 oz. castor oil (a base). Warm and put 10 drops in bath ears t.i.d. for pain and infection. This can be used 1 to 3 times per week in winter months for infection.Tulsi Tea (Ocimum sanctum)For associated fever, drink tea made from basil or tulsi leaves t.i.d.Trikatu (Zingiber officinalis, Piper nigrum, Piper longum)Mix 1 teaspoon with honey to make a paste. Take with warm water t.i.d.Nasya (nasal cleansing treatments) as described above.

Pitta

With pitta-based otitis media the primary concern is the removal of the yellowish discharge and the heat from the middle ear, Eustachian tube, and blood.

Pitta Ear Oil

Equal parts neem oil and ginger juice. Add 40 drops to this combination to 1 oz. castor oil. Warm and put 10 drops in each ear t.i.d. This can also be used for prevention.

Neem Leaf Fomentation

Boil neem leaves in water for 10 minutes. Massage neck and cervical lymph channels with castor oil and sandalwood oil combination. Then apply warm neem leaves on sides of neck. Keep replacing with warm leaves and continue for 20 minute t.i.d.FeverEqual parts mahasudarshan, neem and kutki. Take 1/2 teaspoon in capsules every four hours.Nasya treatments as mentioned, using neem: add 15 drops neem oil to 1 oz. sesame oil.

Kapha(Also see Neti, below.)

Kapha-based otitis media is caused by congestion and mucus.

Kapha Ear Oil

Equal parts ginger juice, garlic juice and mustard seed oil. Make juices by squeezing ginger and garlic in a clove press. Add 1/2 part honey and1/4 part rock salt. Add to castor oil, such that the kapha ear oil is 10% of this mixture and 90% is castor oil. Heat. Place 10 drops in each ear t.i.d.Internal

Kapha Treatment

Mix 1⁄2 teaspoon sitopladi with honey to make a paste and take 1 teaspoon q.i.d. For severe conditions, add 1⁄4 teaspoon trikatu to 1⁄2 teaspoon sitopladi. Make a paste with honey and take 1 teaspoon q.i.d.Note: These treatments can be combined as needed. Many ear infections will stem from a combination of imbalances.

Neti Practice

For kapha conditions, the treatment of choice in nasal cleansing is called neti. This is a rinsing of the nasal passages with a mild, salt water solution, which effectively removes accumulated kapha or phlegm. There are times when neti and nasya can be used in conjunction. Nasya, a lubricating treatment, is typically more effective for vata and pitta imbalances: it lubricates the sinus to address the underlying cause of excess mucus, which is dryness of the nasal mucosa, caused by vata and sometimes pitta.

A special, small, pot with an extended spout, is used for neti. If one is not available, a tea pot works well. Fill the pot with lukewarm water, preferable body temperature. Add about 1 teaspoon salt per half liter of water. Make sure all the salt is dissolved.

Technique

Insert the spout gently into the left nostril. Slowly, tilt the head to the right, so the water runs into the left nostril. The mouth should be open so that you can breathe through the mouth instead of the nose. The water should flow in through the left nostril and out through the right nostril. This will happen automatically, provided that the position of the head is correct. Allow the water to freely flow through the nostrils for 20 seconds. Then remove the pot and clean the nostrils by blowing through the nose with some force but with no strain. Repeat the process through the right nostril. Perform neti in both nostrils two times each for 20 seconds.Drying the NoseBend at the waist and blow vigorously through the nose five times. Then stand erect, and gently pressing one nostril, breathe in and out vigorously 20 times in quick succession, emphasizing the exhalation to expel the maximum amount of moisture. Repeat the process with the other nostril, then with both nostrils open.

Precaution

A slight burning sensation may be felt as the water passes over sensitive mucous membranes. This sensation usually abates after a few practices. If nasal passages are acutely or chronically irritated, the first attempt with neti should be with half the amount of salt (1/2 teaspoon per liter).* Scott Gerson, M.D. notes that for children, milk should continue to be given, as it is an important food for children (according to Ayurveda). However, in Kapha season, milk is generally decocted with kapha-reducing herbs before consumption: sunthi (Zingiber officinalis), devadaru (Cedrus deodara), haritaki (Terminalia chebula), tvak (Cinnamomum zeylanicum), or marica (Piper nigrum).** Scott Gerson, M.D. notes that most ancient scholars opine that panchakarma not be administered to children. Caraka allows administration if the vitality of the child and mental capacity is normal (CS Ci 8/56).*** Scott Gerson, M.D. further offers that Sushruta states oleation is given to children only in the summer season and not to those under age three, because the diet of the very young is made up mainly of milk, which is already unctuous (SS Ci 17, 24-27).

Further Information

http://www.lifespa.com/article.asp?art_id=38

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