Manya-vikar- Galaganda, Gandamala, Apachi.pptx

Galaganda, Gandamala, Apachi, Goitre, Cervical Lymphadenitis, Salivary glands infection, Parotitis

1. Manya- vikar Dr Neha Mayekar MS Shalyatantra Assistant professor, Shalyatantra department MES Ayurved Mahavidyalaya

2. MANYA VIKAR APACHI – CERVICAL LYMPHADENITIS GANDAMALA GALAGANDA- GOITRE PASHHANAGARDABHA – DISEASES OF PAROTID GLAND

3. APACHI- LYMPHADENITIS SUSHRUT NIDANSTHAN ADHYAY 11 GRANTHI- APACHI- ARBUDA- GALAGANDA NIDANAM GRANTHI ARBUDA APACHI GALAGANDA VAAT AND OTHER DOSHAS ASSOCIATED WITH KAPHA AGGRAVATION VITIATION OF MUSCLES, BLOOD AND FAT TISSUES PRODUCE ROUND, BULGED AND HARD SWELLING GRANTHI AGGRAVATION OF DOSHAS VITIATION OF MUSCLE TISSUES PRODUCES MUSCULAR SWELLING ANYWHERE IN THE BODY ROUND, STATIC, MILD PAIN, DEEP ROOTED SLOWLY GROWING, NOT RIPENING ARBUDA INCRESED MEDA WITH KAPHA GIVES RISE TO TUMOUR AT HANVASTHI, KAKSHA, AKSHAK, BAHU-SANDHI, MANYA, GALA APACHI VATA + KAPHA + MEDA GETTING LOCALISED IN THE SIDES OF NECK PRODUCING TUMOUR DEVELOPS GRADUALLY GALAGANDA Manya vikara

4. CERVICAL LYMPHADENITIS APACHI (SU. NI. 11/10-12) DOSHA - VITIATED KAPAHA AND MEDA SITES MANDIBLE (HANVASTHI) AXILLA (KAKSHA) CLAVICLE (AKSHA) SHOULDER (BAHU SANDHI) BACK (MANYA) AND FRONT (GALA) OF NECK GANDAMALA (CHA. CHI. 12/79) IF THRE IS A CHAIN OF SWELLINGS AROUND NECK, THEN IT IS CALLED GANDAMALA A CURABLE CONDITION IF ASSOCIATED WITH PINASA ( CHRONIC RHINITIS) PARSHVA SHULA ( PAIN IN THE RIDES OF THE CHEST) BRONCHITIS FEVER AND VOMITING THEN IT IS INCURABLE. INCRESED MEDA WITH KAPHA GIVES RISE TO TUMOUR AT HANVASTHI, KAKSHA, AKSHAK, BAHU-SANDHI, MANYA, GALA APACHI

5. APACHI (CERVICAL LYMPHADENITIS) (SU. NI. 11/10-12) LAKSHANAS/ SIGNS AND SYMPTOMS THE TUMOUR IS STATIC (IMMOVABLE), ROUND, BROAD, UNCTOUS WITH MILD PAIN TUMOURS ARE OF THE SIZE OF AMALAKA SEEDS SPREADS LIKE SHOAL OF THE FISH EGGS (MATSYANDAJAAL) SAME COLOUR AS THAT OF BODY GROWING SLOWLY AND STEADILY- THUS CALLED APACHI ITCHING MILD PAIN DISAPPEARS WHEN PRICKED AND NEW ONES APPEAR DIFFICULT TO CURE PERSISTS FOR MANY YEARS

6. TREATMENT – SU. CHI. AGNIKARMA - BY MAKING THREE LINEAR INCISIONS ABOVE THE WRIST, AT A DISTANCE OF ONE ANGULA BETWEEN EACH AN INCISION IS MADE IN THE LEG, 12 FINGERS AWAY FROM HEEL AVOIDING THE INDRAVASTI MARMA, REMOVE THE RETINACULAM SIMILAR TO THE SPAWN OF FISH AND APPLY DAHAN KARMA DURING HEALING STAGE, KSHARA PREPARED FROM PEACKOCK, CROWS, GODHAS, SNAKES AND TORTOISES SHOULD BE MIXED WITH OIL OF INGUDI IS USED VAIRECHANIK DHUMA REGULAR DIET OF BARLEY AND MUDGA NASYA – KAITRYADI TAILA, SHAKHOTAK TAILA, JYOSHYADI TAILA PAANA- CHANDANAADI TAILA LEPA- SAUBHANJANADI LEPA, SARSHAPADI LEPA SEVANA- NAVAKAARPASIKA MULA _ (SU. CHI. 18/25-26)

7. TREATMENT – CHA. CHI. SIRAVEDHAN SHARIR- VIRECHAN (ELIMINATION OF DOSHAS FROM BODY BY VAMAN AND VIRECHANA) SHIRO- VIRECHAN (ELIMINATION OF DOSHAS FROM THE HEAD) DHUMA PURANA GHRITA PAAN LANGHANA IF SWELLING IS INSIDE THE MOUTH - PRAGHARSHAN AND KAVALAGHRAHA _(CHA. CHI. 12/80)

8. CERVICAL LYMPHADENITIS DEFINITION- AN INFLAMMATION OF CERVICAL LYMPH NODES LYMPHATIC VESSELS FROM NASAL AND ORAL CAVITY, LARYNX, PHARYNX, EAR, SCALP ETC. DRAINS INTO CERVICAL LYMPH NODES

9. TYPES OF CERVICAL LYMPHADENITIS 1. ACUTE, 2. CHRONIC, 3. TUBERCULOUS ACUTE LYMPHADENITIS CHRONIC LYMPHADENITIS AFFECTED ln ARE ENLARGED AND TENDER PYREXIA GENERAL MALAISE APPROPRIATE ANTIBIOTICS I & D IF ABSCESS IS FORMED PAINLESS IN CHILDREN / ADULTS MAY BE TUBERCULOUS IN ELDERLY MOSTLY DUE TO SECONDARY MALIGNANT METASTASIS

10. TUBERCULOUS LYMPHADENITIS Extrapulmonary tb Common in children, women and young adults Mycobacterium tuberculosis/ Mycobacterium bovis Anterior triangle of the neck Commonly Involved LNs Are Deep Upper Cervical LN Clinical features: Gradually increasing swelling of one or more lymph nodes of a few weeks to few months duration Systemic symptoms such as fever, weight loss, fatigue and night sweats

11. TUBERCULOUS LYMPHADENITIS STAGES Lymphadenitis- Common in young adult between 20-30 years of age, upper anterior deep cervical nodes are enlarged, nontender, discrete, mobile, firm LN and are palpable Peri-adenitis/ mattin g- Results due to involvement of capsule, Nodes move together, firm, non tender, Matting is pathognomonic of tuberculosis Cold abscess- Occurs due to caseating necrosis of LN resulting in fluctuant swelling in the neck. C/F being- No local rise of temperature, no tenderness, no redness, soft, cystic and fluctuant swelling, transillumination is negative, on sternocleidomastoid contraction test, it becomes less prominent (deeps to deep fascia) Collar stud abscess - Results when a cold abscess, which is deep to deep fascia ruptures through the deep fascia and forms another swelling in the subcutaneous plane which is fluctuant. Cross fluctuation may be positive. Sinus - Blind tract leading from the surface down into the tissue, Occurs when collar stud abscess ruptures through the skin. Common in young females. Can be multiple.. Has wide opening. Ulcer with an undermined edges. No induration. Pigmented surrounding skin, occasionally bluish ibn colour.

12. MANAGEMENT INVESTIGATIONS CBC ESR – raised Chest X ray Sputum for AFB FNAC – 75% accuracy LN Biopsy Cold abscess aspiration reveals cheesy material TREATMENT 1. Once diagnosis is confirmed- start with ATT Recommendation of treatment for Extra pulmonary TB by WHO The Three drug regimen Isoniazid (INH) + Rifampicin + Pyrazinamide (HRZ) For two months f/b INH + Rifampicin for another 4 months INH- 6 mg/kg body wt. (usual dose is 300mg/day) Rifampicin - 10 mg/kg body wt. (450-600 mg) HRZ 30 mg/kg body wt. (1500mg/day) 2. Aspiration – A non dependant aspiration of cold abscess, send pus for AFB and ZN stain. 3. LN excision 4. Excision of sinus wall along with the tract Usually negative

13. GALAGANDA (GOITRE) (SU. NI. 11) Vitiation of Vata in combination with the aggravated Kapha and Meda Affects the manya and localises at the anterior part of neck region Producing large swelling Which grows in course of time Characterized by specific symptoms of respective doshas NO POSSIBILITY OF OCCURANCE OF PITTAJA GALAGANDA DOSHA- Vataja and Kaphaja DUSHYA- Mamsa and Meda STROTAS- Medovaha and Rasavaha STROTODUSHTI – Due to Sanga ADHISHTHAN- Gala/ Manyapradesh SADHYASADHYATA- Yapya / Kricchrasadhya AN ELONGATED SWELLING RESEMBLING THE SCROTUM, WHETHER LARGE OR SMALL, OCCURING AT THE REGION OF THE THROAT IS CALLED A GALAGANDA

14. Nidan (Etiological factors) No specific cause has been mentioned, but under various topics few references are available indicating the etiological factors for Galaganda . Galaganda has been described under further rogas: Nidan of Shotha roga (Cha. SU. 18/21) Nidan of Mukha roga (A. H. U. 21/69) Nidan of Kapha prakopa in Nanatmaj Kaphaja rogas (Cha. Su. 20/01) Hima-vata-prabhav rivers might give rise to the occurrence of Galaganda (Su. Su. 45/21):This highlights predominance in hilly areas Excessive use of Madhur Rasa can produce Galaganda (Cha. Su. 26/41) Dushtambu and Krimi dosha Cold, damp with densely grown long trees, water stagnation and heavy rains (Kashyap Kilasthana 25/10) Bheda (Types) Charaka Samhita- Kaphaja Sushruta Samhita- Vataja , Kaphaja, Medoja

15. VATAJA GALAGANDA PRICKING PAIN COVERED BY BLACK OR BLACKISH RED COLOURED VEINS BECOMES COMBINED WITH THE MEDA IN COURSE OF TIME INCREASES IN SIZE, GROWS SLOWLY VERY OILY ABSENCE OF PAIN ROUGH NEVER SUPPURATES TASTELESSNESS IN THE MOUTH DRYNESS OF THROAT AND PALATE Su. Ni. 11/24-25

16. KAPHAJA GALAGANDA FIXED SWELLING SAME COLOUR AS THAT OF SKIN MILD PAIN SEVERE ITCHING COLD TO TOUCH LARGE IN SHAPE GROWS SLOWLY SUPPURATION IS VERY SLOW OCCASSIONAL DULL PAIN SWEET TASTE IN MOUTH THROAT AND PALATE IS SMEARED WITH KAPHA Su. Ni. 11/25-26 26

17. MEDOJ A GALAGAND OILY SWELLING SOFT PALE COLOURED EMITS FETID SMELL SEVERE ITCHING NO PAIN ELONGATED LIKE ALABU SHORT ROOT SIZE IS PROPORTIONATE TO INCREASE OR DECREASE 0F THE BODY MASS ORAL CAVITY FEELS AS IF IT’S ANOINTED WITH OIL CONTINUOUS PECULIAR RUMBLING SOUND IN THROAT Su. Ni. 11/28-29

18. PROGNOSIS INCURABLE CASE OF GALAGANDA HAVING DIFFICULT RESPIRATION EXTREME LETHARGY WEAKNESS ANOREXIA HOARSENESS OF VOICE CHRONICITY FOR MORE THAN ONE YEAR Su. Ni. 11/28

19. GALAGANDA (CHA. CHI. 12/79-80) IF THERE IS A SINGLE SWELLING IN THE RIDE OF THE THROAT, IT IS CALLED GALAGANDA A CURABLE CONDITION IF ASSOCIATED WITH PINASA ( CHRONIC RHINITIS), PARSHVA SHULA ( PAIN IN THE RIDES OF THE CHEST), BRONCHITIS, FEVER AND VOMITING – THEN IT IS INCURABLE. TREATMENT: SIRAVEDHAN SHARIR- VIRECHAN (ELIMINATION OF DOSHAS FROM BODY BY VAMAN AND VIRECHANA) SHIRO- VIRECHAN (ELIMINATION OF DOSHAS FROM THE HEAD) DHUMA PURANA GHRITA PAAN LANGHANA IF SWELLING IS INSIDE THE MOUTH - PRAGHARSHAN AND KAVALAGHRAHA

20. TREATMENT- Vataj Galaganda (SU. CHI. 18/43-47) Nadi sweda with decoction of leaves of Vatahara dravyas boiled in Kanji, various kinds of urines, milks, meat juices and oils. F/B careful drainage of the content of the Galaganda ( Vistravan ) F/B proper purification of the wound F/B application of paste prepared using Shana, Atasi, Mulaka , Sigru , Sesame, Kinva , etc. OR Application of paste composed of Kala, Amruta, Sigru , Punanrnava , Arka, Gajapippali , Madanaphala and Kushta OR with Ekaikshika , Vrukshaka and Tilvaka All of these should be pasted with Sura and Kanjika - And applied hot to the affected part as an UPANAHA Internal use of medicated oil, cooked with Amruta Nimba Hamsahva Vrushaka Pippali Bala Atibala Devdaru

21. TREATMENT- Kaphaja Galaganda (SU. CHI. 18/48-51) Fomentation f/b Poultice f/b Vistravan Ajagandha , Ativisha , Vishalya , Vishanika , Kushhtha , Shukahva , Gunja- Pasted with Palasha bhasmodaka (Alkaline water of Palash) – Hot application to the affected part. Medicated oil cooked with the drugs of Pippalyadi gana and five types of Lavanas – Prashanartha Pracchardana , Murdha virechana by Virechanika dhuma - beneficial In Vataj and Kaphaj types – Suppurating measures in partially suppurated galaganda Diet- Rice, Yava , Mudga yusa with Honey, Trikatu , Gomutra , Fresh ginger, Patola and Nimba .

22. TREATMENT- Medoja Galaganda (SU. CHI. 18/52-55) Snehan f/b Siravedhan Hot plaster of Shyama ( Trivrutta ), Sudha, Mandura ( Loha purisha ), Danti and Rasanjana - pasted together Powders of Sara of Sala tree mixed with cow’s urine can be given every morning As an alternate option- Galaganda should be opened (Patan) f/b complete removal of the fatty content from it, f/b closing the wound by seevan karma OR Cauterizing the content with the application of hot bone marrow, ghee, muscle fat, OR honey. F/B apply Ghee with Honey paste prepared from Kasis , Tuttha and Gorochana. OR after lubricating it with oil, it should be dusted with ashes of Cow dung and of Shalasara Wash daily with the decoction of Triphala f/b Tight bandaging and Yavabhojana .

23. GOITRE A diffused enlargement of thyroid gland is called as Goiter . First endocrine organ to develop Weighs about 15-20 gms in adults, dimensions 4cm (H) x 2cm(w) x 2-2.5 cm (t) 2 lobes connected by isthumus:1-2cm (H), 2cm (w), 0.5cm (t) Superior and inferior thyroid arteries (Branches of external Carotid and Subclavian artery respectively) Superior and Middle thyroid vein drains into Internal Jugular vein Inferior thyroid vein Brachiocephalic vein Vagus and Superior Laryngeal nerve Rt lobe more vascular and larger than the left lobe

24. Histology of Thyroid gland Gland is formed of numerous follicles Lining cells of follicle are Cuboidal when inactive & Columnar when active Around 20-40 follicles are to form a lobule Follicles are filled with proteinaceous colloid Colloid contains – Thyroglobulin molecules Thyroglobulin molecules contains – Thyroid Hormones Parafollicular cells are neuro-endocrine in nature and secrete calcitonin Thyroid gland secretes 2 Iodine containing hormones 1. Tetraiodothyronine (T4) 2. Triiodothyronine (T3)

25. Physiology of Thyroid gland The hypothalamus, pituitary gland, and thyroid gland work together to maintain homeostasis through a self-regulatory circuit called the hypothalamic-pituitary-thyroid axis

26. HYPERTHYROIDISM NORMAL T3-T4 LEVELS IN ADULTS HYPOTHYROIDISM Increased BMR Maintains BMR in resting stage Decreased BMR Hyperthermia, Hyper perspiration (Warm and Moist skin) Maintains body temperature Hypothermia, Hypo perspiration (Rough and Dry skin) Decreased sleep (Insomnia), Mental disturbances Asomnia Psychosis, Fine tremors Maintains sleep Increased sleep – Somnolensce Slowness in thoughts, speech and other activities Tachycardia, Hypertension Maintains Heart rate and Blood pressure Bradycardia, Hypotension Tachypnoea Maintains Respiratory rate Bradypnoea Chronic diarrhoea, Anorexia Maintains GI functions and digestion Chronic constipation Thinning of skin, Easy bruising tendancy Maintains skin thickness by maintaining metaplasia Thickening of skin with hyperpigmented/ blackish skin Myuxoedema Weight loss Maintains weight Weight gain

27. Hyper thyroidism/ Thyrotoxicosis Conditions arising due to hyper secretion of T3 and T4 Etiology - Grave’s disease Oedema on thyroid Multinodular thyroid Multiple endocranial neoplasis syndrome Tumour on anterior pitutory gland secreting an excess of TSH Genetically increased TRH Clinical features- Generalized weakness, reduced ability to work Hyper perspiration and hyperthermia due to increased BMR Disturbances in sleep- insomnia or occ. Asomnia Mental disturbances, restlessness Muscle weakness, hyper motility, producing fine tremors Thinning of skin, may be purpura/ chemosis Intolerance to heat Diarrhoea Wt. loss, indigestion (dyspepsia) Tachycardia, Palpitations Tachypnoea Goitre and exophthalmous , specially in Grave’s disease Investigations - Increased T3, T4 levels CT scan, MRI

28. Hyper thyroidism/ Thyrotoxicosis Complications- Amennorhoea , infertility in females due to suppressed oestrogen secretion due to increased T3-T4 Impotency, Gyanaecomastia in male due to suppressed Testosteron Hypertension, CCH, CCF Hyperglycemia and DM Psychosis Osteoporosis Corneal ulceration and Visual loss Pressure symptoms on trachea Treatment 1. TSH antagonist Carbimazole , it supresses thyroid and decreases T3, T4 secretions Carbimazole 30-40 mg/day 2. Surgical Subtotal thyroidectomy – 2 to 3 gms of tissue is kept in situ, removing rest of the gland

29. Hypo-thyroidism A condition arising due to reduced secretion of T3 T4 hormones Etiology - Iodine deficiency Hashimoto’s thyroiditis (Autoimmune) Biosynthetic defect ( Euthyroidism ) Genetical lack of Thyroid releasing hormone Genetical or acquired lack of TSH Genetical lack of T3-T4 Infective thyroiditis Investigations - Increased T3, T4 levels CT scan, MRI Complications- Mental retardation Hypotension Obesity with decreased intake (Anorexia) of food Pressure symptoms of trachea In female- Menstrual cycle disturbance, infertility, galactorrhoea In males- Impotency Clinical features- Generalized weakness Hypoperspiration , Hypothermia Sleepiness, Somnolence Slowness in thoughts Hypokinesia Thickening of skin (Myxoedema) Indigestion and Constipation Intolerance to cold Easy weight gain Bradycardia Bradypnoea

30. Hypo thyroidism Hypothyroid mother: Cretinism- Neurological disorder Babies with delayed milestones, Enlarged face, protruded tongue, excessive salivation Squint like appearance Mental retardation Late responses, like crying, slow movements, etc. Protruded abdomen (due to unused fat) Dwarfism Myxoedema- Similar features as that of neurological ones along with thickening of skin Treatment: Iodine therapy: Mostly used in infant or children in the form of drops Dose- 125 to 250 microgram/day Tab Thyroxine Orally on empty stomach

31. CLASSIFICATION 1. Simple goitre Puberty goitre (Diffused hyperplastic) - Physiological (Puberty, pregnancy and menopause) No signs of thyroid imbalance get’s smaller without any treatment Enough iodine in diet to prevent Colloid goitre (Iodine deficiency goitre)- Benign, non cancerous enlargement, filled with colloid (A glycoprotein that stores thyroid hormones) Endemic/ simple goitre: to compensate for an inability to produce enough thyroid hormones May be asymptomatic Mass in the neck or signs of slowness in activities, tightness at throat, difficulty in breathing hoarsness of voice frequent coughing Multinodular goitre - An enlarged thyroid caused by multiple thyroid nodules can be toxic (makes excessive thyroid hormones- hyperthyroidism) OR Non-toxic (Does not make excessive hormones) Occasionally can cause pain/ discomfort from rapid growth in size SOS may require Surgical removal

32. CLASSIFICATION 2. Toxic goitre Grave’s disease (Diffuse toxic goitre) An autoimmune disorder Most common cause of hyperthyroidism in iodine replete parts of the world Diffused toxic goitre, Infiltrative ophthalmopathy and infiltrative dermopathy : A characterized triad Plummer’s disease (Toxic multinodular goitre) A hormonally active multinodular goitre with hyperparathyroidism Ranges from subclinical hyperthyroidism to severe thyrotoxicosis c. Toxic nodule A benign growth in the thyroid gland that produces too excessive thyroid hormone Leads to hyperthyroidism

33. PASHANAGARDABHA हनुसन्धौ समुद्भुतं शोफमल्परुजं स्थिरम पाषाणगर्दभं विद्याद्बलासपवनात्मकम II Su. Ni. 13/13 Kapha and Vaata dosha dushti Lakshanas Slightly painful Non shifting Swelling that appears on the joint of jaw bones Hard Treatment Swedana Application of paste of Manashila , Hartal, Kusha and Devdaru In Pakwawastha - Bhedan f/b lekhan

34. Parotiditis Inflammation of one or both Parotid glands