The document discusses Nadivrana or sinus. It defines it as a track formed due to collection of pus from an untreated wound or inflammation that bursts through deep tissues. It describes 5 types based on dosha involvement. Clinical features, treatment and management are explained for each type. Special conditions like involvement of marma or weak patients are also covered. Ksharasutra application is described as an alternative to surgery in some cases. Varti therapy is also mentioned for sinus wound management. In conclusion, a sinus is defined as a chronic non-healing discharging track and fistula is defined as when the track connects two epithelial surfaces.

1. NADIVRANA (SINUS)
Dr. Alok Kumar
PhD Shalya tantra
NEIAH Shillong

2. NIRUKTI
• तामेव नाडीननरुक्ततमाह- नाडीव यद्वहनत तेन मता तु नाडी;
• येन हेतुना नाडीवत् प्रणालीवद्वहनत यानत तेन हेतुना नाडी मतेत्यर्थः| (Dalhana)
• Su.Ni. 10
• Su. Chi 17

3. DEFINITION
• शोफं न पतवममनत पतवमुपेक्षते यो यो वा व्रणं प्रचुरपूयमसाधुवृत्तः |
अभ्यन्तरं प्रववशनत प्रववदायथ तस्य स्र्ानानन पूवथववहहतानन ततः स
पूयः ||९||
तस्यानतमात्रगमनाद्गनतररत्यतश्च नाडीव यद्वहनत तेन मता तु नाडी
|१०|
• The sopha of prolonged duration without Paka or the Pakwa soph
ignored by surgeon collects good amount of pus which percolates in
the deep muscular planes, which later on burst on skin and produces

4. TYPES
•दोषैक्स्त्रमििथवनत सा पृर्गेकशश्च सम्मूक््छथतैरवप च
शल्यननममत्ततोऽन्या ||१०||
•Three from single doshas one tridoshaj and one shalyaj
(due to retain foreign body) total five types.

5. CLINICAL FEATURES
• तत्राननलात् परुषसूक्ष्ममुखी सशूला फे नानुववद्धमधधकं स्रवनत क्षपायाम् |११|
• Rough, pin hole opening, severe pain, frothy excessive discharge.
• तृट्तापतोदसदनज्वरिेदहेतुः पीतं स्रवत्यधधकमुष्णमहःसु वपत्तात् ||११||
• Hot, Throbbing pain, fever, yellow and warm discharge.
• ज्ञेया कफाद्बहुघनार्ुथनवपक््छलास्रा रात्रत्रस्रुनतः क्स्तममतरुतकहिना सकणडूः |१२|
• Thick, white, sticky discharge, more pus discharge in night, hard and itchy.
• दाहज्वरश्वसनमू्छथनवतत्रशोषा यस्यां िवन्त्यमिहहतानन च लक्षणानन |
तामाहदशेत् पवनवपत्तकफप्रकोपाद्धोरामसुक्षयकरीममव कालरात्रत्रम् ||१३||
• Collective feature of all three above include murcha (shock)
• नष्टं कर्क्चचदनुमागथमुदीररतेषु स्र्ानेषु शल्यमधचरेण गनतं करोनत |
सा फे ननलं मधर्तम्छमसृक्ववममश्रमुष्णं स्रवेत सहसा सरुर्ा च ननत्यम् ||१४||
• Frothy, curd like, clear, blood mix warm discharge with pain.

6. TREATMENT OF NADIROGA
• नाडी त्रत्रदोषप्रिवा न मसध्ये्छेषाश्चतस्नः खलु यत्नसाध्याः Su.
Chi 17/17
Sannipataj nadiroga is Asadhya rest are treatable with attempts….
• All type of nadi vrana require Shastra karma for proper healing.
Medicines are used as adjuvant therapy to felicitate good healing.

7. VATAJ NADI
• तत्राननलोत्र्ामुपनाह्य पूवथमशेषतः पूयगनतं ववदायथ |नतलैरपामागथफलैश्च वपष्ट्वा
ससैन्धवैबथन्धनमत्र कु याथत ् ||१८||
प्रक्षालने चावप सदा व्रणस्य योज्यं महद्यत ् खलु पचचमूलम ् | हहंस्रां हररद्ां कटुकां बलां
च
गोक्र्क्ह्वकां चावप सत्रबल्वमूलाम ् ||१९|| संहृत्य तैलं ववपचेद्व्रणस्य संशोधनं पूरणरोपणं
च |२०|
• Use Upnaah or lepa to dilute collection then incised later on above medicines are used

8. PITTAJ NADI
• वपत्ताक्त्मकां प्रागुपनाह्य धीमानुत्काररकामिः सपयोघृतामिः
||२०||
ननपात्य शस्त्रं नतलनागदन्तीयष्ट्याह्वकल्कै ः पररपूरयेत्ताम् |
प्रक्षालने चावप ससोमननम्बा
ननशा प्रयोज्या कु शलेन ननत्यम ् ||२१||
•Upnaah, Utkarika with milk or gruta then incise for
drainage and use different preparation for cleaning and
dressing.

9. KOSTHGATA NADI
•श्यामात्रत्रिणडीत्रत्रफलासु मसद्धं हररद्यो रोध्रकवृक्षयोश्च |
घृतं सदुवधं व्रणतपथणेन हन्याद्गनतं कोष्िगताऽवप या
स्यात् ||२२||
•Tarpan karma with the above drugs in case of Kosthgata
nadi. It should be try to treat this wth conservative
approach first.

10. KAPHAJ NADI
• नाडीं कफोत्र्ामुपनाह्य सम्यक् कु लत्र्मसद्धार्थकशततुककणवैः |
• मृदूकृ तामेष्य गनतं ववहदत्वा ननपातये्छस्त्रमशेषकारी ||२३||
• दद्याद्व्रणे ननम्बनतलान् सदन्तीन ् सुराष्रर्ासैन्धवसम्प्रयुततान् |
प्रक्षालने चावप करचर्ननम्ब र्ात्यक्षपीलुस्वरसाः प्रयोज्याः ||२४||
सुवधचथकासैन्धवधचत्रके षु ननकु म्ितालीतलरूवपकासु |
फलेष्वपामागथिवेषु चैव कु याथत ् समूत्रेषु हहताय तैलम् ||२५||
• Use Upnaah with above drugs to make soft then assess the track with
Eshani (probe) and then incise to open. Use preparations of these drugs for
sodhana and Ropana of wound. Oil prepared with Apamarga seed and
gomutra for healing of track.

11. AGANTUJ/SHALYAJ NADI
• नाडीं तु शल्यप्रिवां ववदायथ ननहृथत्य शल्यं प्रववशोध्य मागथम् |
संशोधयेत ् क्षौद्घृतप्रगाढैक्स्तलैस्ततो रोपणमाशु कु याथत ् ||२६||
कु म्िीकखर्ूथरकवपत्र्त्रबल्ववनस्पतीनां च शलाटुवगगः |
कृ त्वा कषायं ववपचेत्तु तैलमावाप्य मुस्तासरलावप्रयङगूः ||२७||
सुगक्न्धकामोचरसाहहपुष्पं रोध्रं ववदध्यादवप धातक ं च |
एतेन शल्यप्रिवा तु नाडी रोहेद्व्रणो वा सुखमाशु चैव ||२८||
• After incision remove the retain foreign body and let heal the
wound. To felicitate wound healing various preparation of above
drugs are use.

12. SPECIAL CONDITION OF NADI
• कृ शदुबथलिीरूणां नाडी ममाथधश्रता च या | क्षारसूत्रेण तां क््छन्द्यान्न तु
शस्त्रेण बुद्धधमान ् ||२९||
• The persons which can not afford Shalya karma like emaciated, weak or
afraid from surgery or if the nadi present in marma sthan then Shalya
karma( bhedana/incision) should not be done. In these type of patient
must be treat with Ksharasutra.

13. METHOD OF KSHARSUTRA
APPLICATION
• एषणया गनतमक्न्वष्य क्षारसूत्रानुसाररणीम् | सूचीं ननदध्याद्गत्यन्ते तर्ोन्नम्याशु
ननहथरेत् ||३०||
सूत्रस्यान्तं समानीय गाढं बन्धं समाचरेत् | ततः क्षारबलं वीक्ष्य सूत्रमन्यत् प्रवेशयेत्
||३१||
क्षाराततं मनतमान् वैद्यो यावन्न नछद्यते गनतः |
• Probe with Ksharasutra inserted from one opening and taken out from other and tied
with both ends. Knot should be slightly tight. As kshara looses it’s potency then
replaced with new Ksharasutra by railroad method. These should be continued till
cutting of complete nadi(track).
• िगन्दरेऽप्येष ववधधः कायो वैद्येन र्ानता ||३२|| अबुथदाहदषु चोक्त्क्षप्य मूले सूत्रं
ननधापयेत् |
• सूचीमियथववक्रामिराधचतान् वा समन्ततः | मूले सूत्रेण बध्नीयाक््छन्ने चोपचरेद्व्रणम्
||३३||

14. VARTI FOR NADI
• The various types of varti chikitsha mentioned in dividhvrani
adhyay are for the treatment of NADI VRANA.
• The drug should be choose according to doshaghnta of drug
and involved dosha.
• Gomutra bhavita varti are very effective in treatment of
nadivrana.

15. SINUS/FISTULA
• A chronic, non-healing, discharging, blind track lined with
unhealthy granulation tissue which may be epithelialized,
called sinus. It May have a cavity which connects to skin.
• When a sinus track open between two epithelial surfaces either
an organ to skin (external) or organ to organ(internal) then it is
called fistula.

17. CLINICAL FEATURE
•Recurrent discharge (usually pus)
•Pain (on/off)
•Fever (on/off)
•Common site: neck, axilla, inter-gluteal cleft, inter
digital area, umbilicus, inguinal area.

18. CLASSIFICATION
•Congenital (urachal, umblical, pre-auricular, trachea-oesophageal)
•Acquired/traumatic (perianal, arterio-venous, inter-digital,
post surgical)
•Inflammatory (osteomyilitis)
•Neoplastic ( feacal-fistula, watercane perineum)
•Miscellaneous (Pilonidal sinus)

19. CONTRIBUTING FACTORS
• Presence of foreign body
• Absence of rest
• Inadequate drainage
• Specific chronic infection
• Epithelialization of track
• Dense fibrosis and chronic empyema
• Presence of malignant diseases

20. DIAGNOSIS
• History taking
• Physical examination
• General appearance
• Location
• Number
• Opening (sprouting if foreign body, undermine edges in
tuberculosis)
• Mobility

21. LOCAL EXAMINATION
• Discharge
• White watery- tuberculosis
• Yellow – staph.
• Faecal – faecal fistula
• Yellow granules - Actinomycosis
• Thin mucous- bronchial fistula
• Urine- urinary fistula
• Surrounding skin
• Red – inflammatory
• Bluish –tuberculosis
• Pigmentation- chronic nonspecific
• Skin excoriating- faecal fistula

22. •Palpation
• Temperature and tenderness in acute inflammation of
sinus- PNS
• Discharge after applying pressure- Active collection
• Induration/ fixity – present in Ch. Nonspecific sinus, OM,
Actinomycosis and absent in tubercular sinus
• Probing under anesthesia

23. INVESTIGATION
•Routine blood/urine
•Examination of discharge
•X-Ray/Sino-gram
•MRI scan
•Biopsy

24. TREATMENT
•Surgical treatment for nonspecific.
• Removal of foreign body.
• Remove the causative agents.
• Clean the cavity and let it heal correctly.
• Repair the defect
•Specific treatment for specific sinus/fistula.

25. PILONIDAL SINUS (PNS)
• Made from Latin words for hair (pilus)
and nest (nidus) i.e. nest of hairs.
• Also called as “jeep” disease ,was
commonly found in jeep driver of
Germany at the time of World War II.
• Common in young adults and hairy
people both male and female. Male
suffers more frequently.
• Most common site in inter gluteal
region but also may present in axilla
and inter digital area in (babours).

27. CAUSATIVE FACTORS
• Excessive hairs
• Long time sitting/driving
• Heavy buttock

28. CLINICAL FEATURES
• Patients present with pain/ discomfort in sitting , swelling,
itching and recurrent pus discharge from the affected area.
• On inspection there is and opening with hyper-granulation.
• Condition present with chronicity, so there may be no
generalized symptoms.
• On palpation swelling may be tender and pus comes out on
press may have few induration.

29. DIFFERENTIAL DIAGNOSIS
•Infected Post anal Dermoid
•Infected Dermoid cyst
•Sacrococcygeal teratoma
•Hydroadenitis suppurativa

30. MANAGEMENT
• Acute condition antibiotic/anti-inflammatory drugs.
• Surgical excision of complete sinus with all hairs.
• Z-Plasty/ Bascom’s technique for deep and wide sinus cavity.
• Antibiotics after culture and sensitivity
• If sinus is small heal with secondary intension.
• Cleaning and dressing daily
• Ksharsutra/ ksharvarti is a good option.

31. PROCEDURE OF EXCISION
• After all pre-operative preparation take patient in decubitus or left lateral position,
draping after cleaning of hairs.
• After anesthesia probe insert in sinus to assess the length and direction of track.
• Either Excise complete track around the probe or just laid open the cavity and
remove hairs, debride the cavity surgically as well as chemically with hydrogen
peroxide.
• If cavity is very deep/wide Z platy require to close the wound if track is small
packing with antiseptic dressing. Continue dressing until wound heal.
• dressing is very important to reduce recurrence

32. Z-PLASTY

33. BASCOM’S TECHNIQUE
• Incision in lateral side of midline
• Raise the flap drain the cavity.
• Close in interrupted suture

35. KSHARSUTRA /KSHAARVARTI
• After cleaning the cavity make an external opening at dependent part and place Ksharsutra.
• Replace Ksharsutra till complete track heals.
• After Opening and cleaning of the cavity and place the ksharvarti and change accordingly to
felicitate healing.
• Kshara karma in this disease take little longer time but reduce the chance of recurrence.