Pulsatilla nigricans in chronic rhinosinusitis: characteristics and indications

Dr Sangeeta

 Abstract:
Chronic Rhinosinusitis (CRS), is defined as inflammation of the paranasal sinuses and nasal passages lasting 12 weeks or more, significantly impacts patient’s quality of life and work. This prevalent condition affects at least 11% of the global population, representing a substantial disease burden¹. Homeopathic medicines, known for their efficacy in chronic and recurring respiratory pathologies, offer potential remedies for CRS.

Key words: CRS, Paranasal sinuses, Nasal discharge, Pulsatilla nigricans.

INTRODUCTION:
Sinusitis, particularly chronic forms, stands out as one of the most common respiratory illnesses, ranking fifth in antibiotic prescriptions. Globally, CRS affects at least 11% of the population, with India reporting a prevalence of 5-15% in urban areas¹.

It is characterized by presence of at least two or more of following symptoms Nasal discharge (anterior or posterior nasal dripping) Nasal obstruction, Facial pain or pressure.

Environmental factors, systemic and local host factors, injuries, and infections contribute to CRS pathogenesis. Understanding its multifaceted etiology is crucial for effective management.

Homoeopathic system of medicine with its holistic approach is able to provide safe treatment in CRS. This study is the honest attempt aimed to know about the indications of the homoeopathic medicine Pulsatilla nigricans.

Anatomy of paranasal sinuses: Paranasal sinuses are air-filled spaces present within some bones around the nasal cavities. The sinuses are frontal, maxillary, sphenoidal and ethmoidal. All of them open into the nasal cavity through its lateral wall.

The function of the sinuses is to make the skull lighter, warm up and humidify the inspired air. Depending upon drainage into nasal cavity, the sinuses divided into 2 groups:

• Anterior group
• Posterior group

Anterior group: The sinus structures belonging to the anterior group, which actively channel their drainage into the middle meatus of the nasal cavity, encompass the Frontal sinus, Maxillary sinus, and Anterior ethmoid sinuses.

Posterior group: The drainage route for the Sphenoidal sinus extends into the spheno-ethmoidal recess, while the Posterior ethmoidal sinuses channel their drainage into the superior meatus.

Functions of the paranasal sinuses : The paranasal sinuses are thought to serve the following functions:

• Air-conditioning of the inspired air by providing large surface area over which the air is humidified and warmed.
• To provide resonance to voice.
• To act as thermal insulators to protect the delicate structures in the orbit and the cranium from variations of intranasal temperature.
• To lighten the skull bones.
• To provide extended surface for olfaction; olfactory mucosa is situated in the upper part of nasal cavity and extends over ethmoid as well.
• To provide local immunologic defence against microbes.
• To act as buffers against trauma and thus protect brain against injury, e.g. frontal, ethmoid and sphenoid sinuses³.

DEFINITION:

Chronic rhinosinusitis refers to the persistent inflammation of the nasal and paranasal sinus mucosa lasting for a duration of 12 weeks or more, with incomplete resolution of symptoms. Diagnostic criteria include the manifestation of at least two or more of the specified symptoms:

• Nasal discharge (anterior or posterior nasal dripping)
• Nasal obstruction
• Facial pain or pressure
• Reduction or loss of smell
• Along with endoscopic signs of polyps, edema, swelling, mucopurulent drainage, crusts from the middle meatus
• Or CT scan changes documented by mucosal alterations within the osteomeatal complex (OMC) and/or in the paranasal sinuses⁴.

Aetiology:

1. a) Environmental Factors:

Infection: CRS involves various bacteria, including Haemophilus influenza, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis, other coagulase-negative staphylococci, Corynebacterium species, and anaerobes. Common fungi include Aspergillus, Alternaria, Mucor, or Rhizopus. Viruses such as Adenovirus, Picornavirus, Rhinovirus, Coxsackie virus, and Influenza viruses are also implicated.

Allergy: Immunologic responses to airborne allergens in genetically predisposed individuals contribute to CRS. Two clinical types are recognized: Seasonal (pollens) and Perennial (year-round allergens like dust, molds, cockroaches, and animal dandruff). Genetic predisposition significantly influences childhood allergies.

1. b) Systemic Host Factors:

Specific hyper reactivity, as seen in asthma and hypersensitivity to aspirin and NSAIDs, plays a role. Immunodeficiency, gastroesophageal reflux disease (GERD), congenital mucociliary dysfunction, and dysfunction of the autonomic nervous system are systemic factors influencing CRS.

1. c) Local Host Factors:

Anatomical abnormalities in the Osteomeatal complex (OMC), such as hypertrophied and pneumatized middle turbinates (concha bullosa), acquired mucociliary dysfunction, and tumors contribute to CRS.

1. d) Injuries:

CRS can result from both trauma and surgical procedures, adversely affecting the overall health of the sinuses.

1. e) Swimming and Diving:

Infections pose a risk when water contaminated with pathogens enters the sinuses through the ostia, a concern notably heightened during activities such as swimming and diving.

1. f) Dental Infections and Extraction of Upper Molars and Premolars:

Dental issues, particularly involving the maxillary sinus, can contribute to CRS, especially following the extraction of upper molars and premolars.

Pathogenesis of Chronic Rhinosinusitis:

Under ordinary circumstances, the sinuses maintain a state of sterility. Sinus secretions, facilitated by ciliary action, flow through the ostia, eventually finding their way into the nasal cavity. In individuals in good health, this flow of sinus secretions is unidirectional, skillfully preventing any risk of back contamination. It is noteworthy that, in the majority of individuals, the maxillary sinus is equipped with a solitary ostium, serving as the exclusive outflow tract for drainage.

Nevertheless, congestion arises when the mucosa at these openings swells due to edema, resulting in potential obstruction of the outflow tract and stasis of secretions. This congestion establishes a favorable environment for bacterial infection. Sinusitis emerges when the retained mucus becomes infected⁵.

Diagnosis⁶:
Accurate patient history is paramount for an accurate diagnosis, and careful consideration of the cause, duration, and progression of various nasal symptoms is essential:

Rhinorrhoea:
Ask whether there is discharge from one nostril (unilateral) or both (bilateral) (rhinorrhoea). Ascertain the characteristics of the discharge, distinguishing between purulent or clear. Identify whether the discharge is located in the front of the nose (anterior) or is a result of postnasal drip.

Blocking of Nose:
Assess if there is unilateral or bilateral obstruction.

Investigate associated symptoms, such as bleeding, swelling, and pain.

Epistaxis: Determine if there is unilateral or bilateral bleeding.

Explore the frequency and duration of episodes, along with provoking factors like trauma, sneezing, or blowing/picking the nose.

Differentiate between bleeding from the front or back of the nose.

Sneezing:Investigate associated symptoms like itchy, red eyes.

Determine if symptoms occur throughout the year, during specific seasons, or upon contact with allergens.

Headache: rule out the causes of headache

Olfaction: Evaluate for a total loss of smell (anosmia) or diminished sense of smell (hyposmia).

Examine reported concerns regarding unpleasant smells (cacosmia) and any linked nasal symptoms, indicating potential issues such as rhinitis or nasal polyps.

Inquire about recent experiences with head injuries or upper respiratory tract infections (URTI).

Deformity or Swelling Complaints: Explore the origins of nasal deformities, especially following trauma, taking into account signs such as swelling, bruising, and deviations in the nose.

Evaluate the consequences of nasal injuries on functionality, including nasal breathing and the sense of smell, as well as on cosmetic appearance.

Delve into the possibility of nasal septal destruction or perforation, resulting in a ‘saddle deformity’ of the nasal bridge. Potential causes encompass granulomatosis with polyangiitis, trauma, cocaine abuse, congenital syphilis, and iatrogenic factors.

Nasal and Facial Pain:

Evaluate the nature of pain, considering descriptors such as throbbing, aching, sharp, stabbing, or tight-band sensations. Ascertain the location of pain, distinguishing between unilateral or bilateral occurrences.

Investigate the duration and frequency of pain, along with any associated nasal symptoms. Inquire about factors that alleviate or intensify the pain, including nausea, photophobia, or the presence of aura (commonly associated with migraines).

On examination:
External nose:

Inspection: The external nose may be deformed developmentally, congenitally or due to trauma. Scars of previous surgery or injury may be seen.

Palpation: Palpation of the nose may detect crepitus in fractured nasal bones.

Nasal cavity:

Inspection:

Assess the external appearance of the nose, noting swelling, bruising, skin changes and deformity.

• Stand above the seated patient to assess any external deviation.
• Ask the patient to look straight ahead. Elevate the tip of their nose using your non-dominant thumb to align the nostrils with the rest of the nasal cavity.
• Look into each nostril and assess the anterior nasal septum note the mucosal covering, visible vessels in Little’s area, crusting, ulceration and septal perforation. In trauma, a septal haematoma should be excluded

Using an otoscope with a large speculum in an adult, assess the inferior turbinates. Note any hypertrophy and swelling of the turbinate mucosa.

An assessment of the nasal airway or testing of air blast both nostrils⁷:

It is done by using a metallic tongue depressor or using cold glass slide just in front of the nostrils: On expiration, the warm air produces fogging on the surface of tongue depressor. The difference on the two sides is an indication of nasal obstruction.

Anterior rhinoscopy: The anterior rhinoscopy is performed with the help of Thudicum’s speculum. Mucosa, the floor, lateral wall, septum and posterior portions of nasal cavities are viewed.

Posterior rhinoscopy: This procedure is meant for examination of the posterior aspects of nose and nasopharynx using tongue depressor and postnasal mirror. Structures visualised through posterior rhinoscopy.

Palpation: To eliciting tenderness of paranasal sinuses.

• Maxillary sinus: tenderness is elicited on the canine fossa on the cheek.
• Frontal sinus: tenderness is tested by pressing the floor of the frontal sinus in the medial portion, just above the inner canthus of the eye.
• Anterior ethmoidal sinus: tenderness is tested on the sides of the nose midway between the inner canthus of the eye and the nasion.

Investigations:

• Complete blood count
• Absolute eosinophil count
• X ray of Paranasal sinuses
• Nasal endoscopy
• Computed tomography.

Auxillary management of rhinosinusitis

• Drinking adequate amount fluids can help in relieving sinus symptoms.
• Using a humidifier can help in thinning of the mucous production and drain the sinuses. By keeping the mucous moist, it will allow the sinuses to drain more easily.
• Nasal irrigation: by gently flushing out nasal passages with saline solution. We shouldn’t use table salt and instead use sea salt for better results.
• Steam inhalation: is the easiest method that can be adopted. This method is done by introducing warm moist air into the lungs through the nose and throat. We can also add menthol, camphor and eucalyptus oils. Researchers have found that the nasal mucociliary clearance time of patients with rhino sinusitis was shortened after steam inhalation and improvement was seen.
• Warm and cold compresses: rotating warm and cold compress could also help.
• Ginger garlic: the active principle alicin present kills bacteria and gives our immune system a boost.
• Intake of vitamin C rich foods like citrus fruits can be advised.

HOMOEOPATHIC MANAGEMENT
Rhinosinusitis is a condition which has both acute and chronic presentations. According to Hahnemann’s classification of disease rhinosinusitis can be classified as dynamic acute individual disease and dynamic chronic disease with fully developed symptoms miasmatic.

In Aphorism 5 of Organon of medicine, Dr Hahnemann says that in case of chronic disease we need to investigate the physical constitution of the patient, his moral and intellectual character, his occupation, mode of living and habits, his social and domestic relations, his age, sexual function etc.

INDICATIONS OF PULSATILLA NIGRICANS (PULS):

Rubrics from Homeopathic Medical Repertory by Robin Murphy⁷:

• Under chapter NOSE- Coryza- general: PULS is given 4marks
• Under chapter NOSE- Coryza- discharge- fluent with: Puls is given 1 mark
• Under chapter NOSE- Coryza- watery discharge-PULS is given 4marks
• Under chapter NOSE- Coryza- watery discharge- in warm room: PULS given 4marks
• Under chapter NOSE- Sinusitis infection of- PULS is given 4marks
• Under chapter NOSE- Obstruction: PULS 4marks

TEXTBOOK REVIEW:

PULSATILLA NIGRICANS (PULS):

In Pocket Manual of Homoeopathic Materia Medica & Repertory by William Boericke⁸:

• Under the drug Puls, he mentioned under section Nose: All mucous membranes are affected, discharges are thick, bland and yellowish green.
• Coryza, stoppage of Right nostril, Pressing pain at root of nose. Anosmia. Stoppage in the evening, yellow mucus abundant in the morning.
• Bad smells as of old catarrh.

In A dictionary of practical Materia medica by J.H Clarke: vol III⁹,

• Under the drug Puls, he mentioned under section, Nose: Nasal catarrh accompanied by special discomfort in the house, cannot breathe well in warm room, great amelioration by going out into open air. Obstruction of nose and dry coryza principally in evening. Tickling in nose and frequent sneezing principally in morning and evening. Constant smell before nose as from a coryza of long standing. Old Catarrh.
• Face: Painful sensitiveness of skin and face, boring pain in malar bone, alternating with heat and redness of cheek.
• Mouth: Discharge of foetid and greenish yellowish discharge from nose. Offensive smell and putrid foetor from mouth.

In Keynotes and characteristics with comparison of some of the leading remedies of the materia medica with bowel nosodes by H.C Allen¹⁰

• Under the drug Puls, he mentioned that, Secretion from all mucous membranes are thick, bland, and yellowish green, bad taste in mouth, unable to breathe well or is chilly in a warm room.

Lectures on homoeopathic materia medica by J. T Kent¹¹:

• Under the drug Puls he mentioned that, Mucous membranes are in a state of thickening and suppuration with formation of crusts and ulcers.
• Pain in face through the nose, watery discharge with sneezing, stuffing up of nose in evening with thick yellow green discharge.
• Loss of smell and taste with acute and chronic catarrh. Violent headache- throbbing and congestive in character.

Lotus materia medica by Robin Murphy¹²:

• Under the drug Puls, he mentioned as, Mucous membranes are all affected.
• Mucus discharges are profuse, bland &thick yellowish green.
• Nose: Sinusitis with thick yellow green nasal discharge, worse in-doors, better open air.
• Head: Head seems heavy, can’t hold upright, and cannot raise it, Frontal & Supraorbital pains.

 References:

1. Singla, G., Singh, M., Singh, A., Kaur, I., Harsh, K., & Jasmeen, K. (2018). Is sino-nasal outcome test-22 reliable for guiding chronic rhinosinusitis patients for endoscopic sinus surgery? Nigerian Journal of Clinical Practice, 21(9), 1228–1233. [Accessed on 2023 May 13] Available from: https://doi.org/10.4103/njcp.njcp_429_17

2. Chaurasia, B. D. (2019). BD chaurasia’s human anatomy, volumes 3 & 4: Regional and applied dissection and clinical: Head and neck, and brain-neuroanatomy (8th ed.). CBS Publishers & Distributors.
3. Dhingra, P. L., Shruthi, D., & Deeksha, D. (n.d.). Diseases of Ear, Nose and Throat & Head and Neck Surgery,6 th edition. Elsevier India Private Limited.
4. Piromchai, P., Kasemsiri, P., Laohasiriwong, S., & Thanaviratananich, S. (2013). Chronic rhinosinusitis and emerging treatment options. International Journal of General Medicine, 6, 453–464.[Accessed on 2023 June 10] Available from: https://doi.org/10.2147/IJGM.S29977
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7. Robin Murphy (Iind Ed.). B. Jain Publishers(P)Ltd (Ed.). (n.d.). Homoeopathic Medical Repertory A Modern Alphabetical and Practical Repertory by.
8. William Boericke M.D B. Jain publishers(P)Ltd (Ed.). (n.d.). Boericke’s new manual of Homoeopathic Materia medica with Repertory by.
9. Dictionary of practical materia medica by John Henry Clarke M.D B Jain publishers(P)Ltd 32nd impression. (2015).
10. Keynotes and Characteristics with comparisons of some of the leading remedies of the materia medica with Bowel Nosodes H. C Allen B Jain publishers(P)Ltd. (2002).
11. Lectures on homoeopathic Materia Medica: together with Kent’s” New Remedies” Incorporated and arranged in one alphabetical order by James Tyler Kent . B. Jain Publishers(P)Ltd; 2003.
12. Robin Murphy ND. B. Jain Publishers(P)Ltd (Ed.). (2010). Lotus materia medica 1,400 homoeopathic and herbal remedies by.

Dr. Sangeeta
MD part II
Dept. of practice of medicine
Under the guidance
Dr. Veerabhadrappa . C
Professor, Dept. of practice of medicine
Govt. Homeopathic Medical College & Hospital, Bengaluru