1. The patient, a 59-year-old male, presented with symptoms including deviation of the mouth towards the right side, inability to fully close the left eye, tearing from the left eye, and slurred speech since August 13. 2. On examination, neurological deficits were observed including loss of forehead frowning and eyebrow raising on the left side consistent with a lower motor neuron lesion of the 7th cranial nerve (facial nerve palsy). 3. The patient was diagnosed with Ardita (facial palsy) based on the involvement of only the left side of the face. He was started on treatments including nasya, herbal Kashaya, and local applications intended

1. Case
presentation
Kamal Kishore
2nd year PG Scholar
Dept. of PG studies in Kayachikitsa
SKAMCH&RC
BENGALURU

2. Name : Mr. P. N. Marilingaiah
Age : 59 Years
Sex : Male
Religion : Hindu
Marital status : Married
Socio economic status : Middle class
Education status : PUC
Occupation : Supervisor in Horticulture Dpt.
Date of admission :16/08/16
Date of discharge :26/08/16 1

3. Ward : Semi Special ward 2
Source of history : Patient
Consultant doctor : Dr. Byresh A.
O.P No : D24757
I.P. No : 3509/16
Case taken on : 17th August 2016
Address : #49, 1st main, 7th cross,
near Gayathri temple,
K.G. nagar, Bangalore.
2

4. Dakshina Mukhardha vakrata /
Deviation of Face towards right side
since 12/08/2016
3

5.  Vaam Akshi nimesha hrasa / Loss of
complete closure of left eye
 Ashru srava from vama netra/
Lacrimation from left eye
 Lalasrava/Dribbling of saliva on left
angle of mouth.
Vaak Aspashtata/ slurred speech
since 13/08/2106
4

6. Patient was apparently normal up to 12/08/2016. After
his post lunch sleep for two hours, when he woke up his
son noticed slight deviation of mouth to Right side/
Dakshina Mukhardha vakrata. Patient did not
experience any difference but was taken to hospital. At
NIMHANS he was advised to take the consultation at
Victoria hospital. In Victoria after initial check up, he
was advised to follow up next day. 5

7. Next day the patient noticed Difficulty in Closure of
left eye/Vaam Akshi nimesha hrasa , Watering from
left eye/Ashru srava from vama netra, Dribbling of
saliva on left angle of mouth/lalasrava, slurred
speech/Vaak Aspashtata & consulted a different
hospital.
6

8. He also approached a folklore practitioner in Andhra
Pradesh. On the advice of his relative he approached
SKAMCH. The patient presented with the following
symptoms at the time of admission on 16/08/2016.
Mukhardha vakrata towards dakshina bhaga, nimesha
hrasa of vama akshi, ashru srava from vama akshi,
lalasrava from vama bhaga of mukha, vak aspastata.
Patient did not c/o shiro ruja, bhrama, karna nada or
drushti hrasa, sparsha hani, rasa gyan hrasa. 7

9. Patient was admitted & treated for acclerated blood
pressure for 6 days from 31st July 2016 as he
presented with features of giddiness, imbalance &
vomiting.
8

10. On 13/08/2016 at Spandana hospital
on OPD basis
1. Tab. Losar H 1 O.D.
2. Tab. Omnacortis 10mg 2-2-0 for 1 week
2-1-0 for 1 week
3. Tab. Sompraz 40mg 2 B.D for 2 weeks
4. Tab. Ecosprin gold 1 O.D for 2 weeks
5. Tab Axovir 800mg 1tid for 1 week
6. Oflox Eye drops 2dros tid for 1 week
7. Inj Rejunex 1amp 1B.D. for 1 week & Physiotherapy for one
week. Patient took 1 – 2 dose of the above & stopped it.
Took folklore treatment after this.
(details of medication – NA) 9

11. HTN from past
11 days
10
All family members are said to be healthy.

12. Diet : Mixed, Non veg
once in a week (chicken, fish)
Appetite : Good
Bowel : once/day (regular)
complete evacuation.
Micturition : 5-7 times/day
once/night
Sleep : Good
Addictions : None
11

13. 12

14. Jatatah: Sadharana
Samvardhitah: Sadharana
Vyadhitah: Sadharana
13

15.  Naadi-78 bpm
 Mootra- 5-7times a day, once at night occasionally.
 Mala- Once a day,
 Jihwa- Alipta
 Shabda- Vikrita (Aspashta vaak)
 Sparsha–Anushnasheeta
 Drik- vaambhaga akshi nimilana Hrasa
 Aakriti - Madhyama 14

16. Prakriti :- Vata Kapha Prakriti
Saara :- Madhyama
Samhanana: Madhyama
Pramana : Madhyama Ht: 1.67m, Wt: 55 kg
Saatmya : Madhyama
Satva : Madhyama
Aahara Shakti :
Abhyavaran Shakti : Madhyama
Jarana Shakti : Madhyama
Vyayama Shakti : Madhyama
Vaya :Madhyama 15

17. Vikriti :- Madhyama
Hetu:- Aaharaja & viharaja nidaana.
Dosha:- kapha (bodhak,tarpak)
Vaata (prana & udana,vyan),
Dooshya:- Meda, Rakta, sira, snayu.
Desha:- Sadharana
Bala:- Madhyama
Kaala:- Ritusandhi (Varsha-Sharat)
Prakriti:- vikriti vishama Samasamveta
16

18. Patient conscious, alert, oriented to time, place and
Person.
Built : Moderate
Nourishment : Moderate
Pallor : Absent.
Cyanosis : Absent.
Nail : Normal
Icterus : Absent
Oedema : Absent
Lymphadenopathy : Absent.
17

19. Temperature: 98.6 degree Fahrenheit
BP :130/90 mm of Hg.
R/R :20 cycles/minute.
Tongue : Uncoated.
Height : 1.67m
Weight : 55Kg
BMI : 19.72
18

20. Respiratory System Examination
Shape of chest -bilaterally symmetrical.
Trachea -centrally placed
Normal vesicular breath sounds heard.
No added sounds.
Cardiovascular System Examination
S1 S2 heard, no murmurs.
19

21. Per Abdomen Examination
Inspection –
Scaphoid
Umbilicus – Inverted
 Auscultation -Peristaltic sounds heard,
 Palpation –
Soft, No tenderness.
No organomegaly
 Percussion – dull over liver area, Resonant
otherwise.
20

22. Local Examination
Inspection
Deviation of mouth towards right
Left eyeball moves upwards and inwards when the
patient attempts to close it along with incomplete
closure of eyelid. (Bells phenomenon)
Lacrimation from left eye.
Dribbling of saliva on left angle of mouth & food
contents during eating.
Nasolabial fold loss on left side.
21

23. Central nervous system Examination
1. Higher Motor Functions
Consciousness- Conscious
Orientation to- Time, place, person- Intact
Memory - Recent -not affected
Remote- not affected
Intelligence- Intact
Hallucination & Delusion - Absent
Speech - Slow and words are mumbled
Handedness - Right
22

24. 2. Cranial Nerve Examination
 CN1 – Smell sensation - Intact
 CN II- Optic –
a)Visual acuity - Not Affected
b)Visual field - Not affected
c)Light reflex - Not affected
d)Drooping of eye lids (Ptosis)-Absent
23

25.  CN III Occulomotor , CN IV Trochlear , CN VI
Abducens Nerve –
Pupil - position , size, shape, symmetry- no
abnormality detected
Eyeball movement - Possible in all directions
CN V Trigeminal Nerve
Sensory –Touch, pain and pressure sensation – intact
Motor - Clenching of teeth – Possible
Jaw movement against resistance decreased
Jaw jerk- Normal24

26. CN VII Facial Nerve
a) Forehead frowning - not possible on left side
b) Eyebrow raising - not possible on left side
c) Eye closure - not possible in left eye
d) Teeth showing - not possible in left side denture
e) Blowing of cheek - not Possible in left side
25

27. f) Nasolabial fold - decreased on left side
g) Taste perception - not affected
h) Dribbling of saliva – left corner of mouth present.
i) Bells phenomenon – present on left side.
26

28. CN VIII Vestibulocochlear nerve
Rhinne’s test - AC > BC
Weber’s test -Equal on both sides
CN IX, CN X Glossopharyngeal and Vagus nerve
Speech – no Dysarthria or Dysphonia noted
Position of uvula - Centrally placed
Taste sensation -Intact
Gag reflex - normal
27

29. CN XI Accessory Nerve
Shrugging the shoulder - Possible against
resistance
Neck movement -Possible against
resistance
CN XII Hypoglossal Nerve
Protrusion of tongue - Possible
Tongue movements - Possible
28

30. 3. Motor system
Muscle Bulk
Right (in cms ) Left (in cms)
Upper limb
Arm 24 25
Forearm 17.5 18
Lower limb
Thigh 46.5 45
Leg 29.5 29
29

31. Muscle tone
B/L Upper limb and lower limb- Normal
Muscle power
Rt Lt
Upper limb 5/5 5/5
Lower limb 5/5 5/5
 Reflexes
Biceps jerk- ++, Triceps jerk- ++
Supinator jerk- ++, Knee jerk- ++
Ankle jerk- ++, Plantar reflex- ++
30

32. Co-ordination
Upper limb
• Dysdiadokinesia- absent
• Finger to nose test- possible
• Pronator Drift- Possible
• Fine movements- No abnormality detected
Lower limb
• Tandem walking- Possible
• Heel shin test- Possible
• Heel walk- Possible
31

33. • Toe walk- Able to do
• Rhomberg’s sign- negative
• Pronator drift - negative
4. Sensory system
Superficial
a) Touch - Intact
b) Temperature - Intact
c) Pain - Intact
32

34. Deep
Vibration sense- intact
Joint position sense- intact
Cortical
a)One point localization - intact
b) Two point discrimination - intact
c) Stereognosis - Present
d) Graphesthesia - Present
33

35. FINDINGS OF CNS EXAMINATION :-
 Peripheral lesion (LMN) of 7th Cranial nerve.
34

36. 135

37. Nidana –
? Diwaswapna, Sheetala vayu sevana.
136

38. Nidana
Sevana
Kapha prakopa and rakta
dushti
Aavarana to
vaata
Vaata prakopa
Sthana samshraya in
vaama mukhardha bhaaga
Mukhardha vikriti
Vyaktavastha
Ardita
137

39. Purvaroopa - Mukhardha vikriti.
Roopa – Dakshina Mukhardha vakrata / Deviation
of Face towards right side , Vaam Akshi nimesha
hrasa of / Loss of complete closure of left eye.
Ashru srava from vama netra/ Lacrimation
from left eye.
Lalasrava/Dribbling of saliva on left angle
of mouth.

138

40. Dosha – Vaat pradhana kapha
Dushya – Rasa, Rakta, Meda, .
Srotas –Rasavaha, Raktavaha, Medovaha.
Sroto dushti - Sanga,vimargagamana.
Agni - Jatharagni and Dhatvagni mandya
139

41. Udbhavasthana – Aamashaya,Pakwashaya
Sancharasthana – Rasayani
Vyaktasthana – Mukhaarda
Adhishtana – Shiras, Indriya
Rogamarga – Madhyama
Sadhya-Asadhyata – Kricchra Sadhya
140

42. 141

43. Disease Inclusion Exclusion
Pakshavadha Dakshina mukhardha ardhakaya akarmanyo
Pakshaghaata Vaakstambha,
mukhardha cheshta
nivritti.
Cheshta nivritti in
ardhakaya, ruja in
sharirardha, hastpada
sankocha
Ardita
(charak&vaghb
hataokta)
Mukha vikruthi. sareerardha vikruthi.
Ardita
(Sushrutokta)
Mukhardha vikruthi
42

44. 43

45. Disease Inclusion Exclusion
CVA Loss of functions of
face
Loss/ reduced
strength of half of
body is generally seen
Facial palsy
(UMN)
Loss of functions of
lower half of face of
affected side
Intact functions of
upper half of face of
affected side
Facial Palsy
(LMN) / Bell’s
Palsy
Loss of functions of
half of face of affected
side
44

46. Ardita (Sushrutokta)
Facial Palsy/Bell’s palsy
145

47.  Kricchra Saadhya
46

48. DATE TREATMENT
GIVEN
OBSERVATIONS
16/8/16 1. Nasya Karma
Mukhabhyanga
with ksheerbala
taila followed by
bala moola
saadhita ksheer
dhooma
Nasya with
maha masha
taila 15 drops to
each nostril
2.
•Deviation of mouth
towards right.
• Left eyeball moves
upwards and
outwards when the
patient attempts to
close it along with
incomplete closure
of eyelid. (Bells
phenomenon)
• Slurred speech
47

49. DATE TREATMENT GIVEN OBSERVATIONS
2.Dhandhanyadi
kashayam
3tsp with 9 tsp
water at 7am &
6pm.
3.Ashwagandha
choorna
(mix with water to
apply to left half of
face once daily)
4.Idli prepared out
of Masha with
navneeta for
breakfast.
•Lacrimation from
left eye.
•Forehead
frowning not
possible on left
side.
•Dribbling of
saliva on left
angle of mouth &
food contents
during eating.
•Nasolabial fold
loss on left side.
48

50. DATE TREATMENT
GIVEN
OBSERVATIONS
17/8/16 –
18/8/16
CST 1-4
5. Vacha
Choorna
Mix ¼ tsp
powder with ½
tsp honey &rub
over tongue for
3-5 min (twice
daily)
6. Cap.
Palsineuron
(one Cap. Tid)
• Deviation of mouth
towards right.
• Left eyeball moves
upwards and outwards
when the patient
attempts to close it along
with incomplete closure
of eyelid. (Bells
phenomenon)
• Slurred speech.
49

51. DATE TREATMENT GIVEN OBSERVATIONS
•Lacrimation from left eye.
INCREASES WHILE
MUKHABHYANGA.
•Forehead frowning not
possible on left side.
•Dribbling of saliva on left
angle of mouth & food
contents during eating.
•Nasolabial fold loss on left
side.
50

52. DATE TREATMENT
GIVEN
OBSERVATIONS
19/8/16 CST 1-6 • Deviation of mouth
towards right.
DECREASED BY 10
PERCENT.
• Left eyeball moves
upwards and outwards
when the patient
attempts to close it along
with incomplete closure
of eyelid. (Bells
phenomenon)
• Slurred speech.
51

53. DATE TREATMENT GIVEN OBSERVATIONS
•Lacrimation from left eye.
DECREASED.
•Forehead frowning not
possible on left side.
•Dribbling of saliva on left
angle of mouth & food
contents during eating.
•Nasolabial fold loss on left
side.
52

54. DATE TREATMENT GIVEN OBSERVATIONS ON
22/8/16
20/8/16 to
22/8/16
CST • Deviation of
mouth towards
right.
DECREASED BY
25 PERCENT.
• Left eyeball
moves upwards
and outwards
when the patient
attempts to close
it along with
incomplete
closure of eyelid.
(Bells
phenomenon)
IMPROVED.
• Slurred speech.
MILDY
IMPROVED
53

55. DATE TREATMENT GIVEN OBSERVATIONS ON
22/8/16
•Lacrimation from
left eye.
DECREASED.
•Forehead
frowning not
possible on left
side.
•Dribbling of
saliva on left
angle of mouth &
food contents
during eating.
ABSENT
•Nasolabial fold
loss on left side.
54

56. DATE TREATMENT GIVEN OBSERVATIONS
23/8/16 CST • Deviation of
mouth towards
right.
DECREASED BY
50 PERCENT.
• Left eyeball
moves upwards
and outwards
when the patient
attempts to close
it along with
incomplete
closure of eyelid.
(Bells
phenomenon)
MODERATELY
IMPROVED.
• Slurred speech.
MODERATELY
IMPROVED
55

57. DATE TREATMENT GIVEN OBSERVATIONS
•Lacrimation from
left eye.
DECREASED.
•Forehead
frowning
possible MILDLY
on left side.
•Dribbling of
saliva on left
angle of mouth &
food contents
during eating.
ABSENT
•Nasolabial fold
VISIBLE on left
side.
56

58. DATE TREATMENT GIVEN OBSERVATIONS ON
26/8/16
24/8/16 TO
26/8/16
CST • Deviation of
mouth towards
right.
DECREASED BY
75 PERCENT.
• Left eyeball
moves upwards
and outwards
when the patient
attempts to close
it along with
incomplete
closure of eyelid.
(Bells
phenomenon)
IMPROVED.
• Slurred speech.
IMPROVED57

59. DATE TREATMENT GIVEN OBSERVATIONS ON
26/8/16
24/8/16 TO
26/8/16
CST • Lacrimation from
left eye.
REDUCED
COMPLETELY.
•Forehead
frowning
possible
MODERATELY on
left side.
•Dribbling of
saliva on left
angle of mouth &
food contents
during eating.
ABSENT
•Nasolabial fold
VISIBLE on left
side.58

60. BEFORE TREATMENT AFTER TREATMENT
Deviation of mouth towards right
side.
Bells phenomenon present.
Deviation of mouth reduced by
75%.
Dribbling of saliva on left side of
mouth.
Dribbling of saliva stopped.
Watering of left eye. Watering of left eye stopped.
Not able to close Left eye. Able to close left eye.
Nasolabial fold not present on left
side.
Nasolabial fold visible on
left side.
59

61. Rx
 Dhanyanadi kashayam
3tsp with 9 tsp water at 7am & 6pm.
 Cap. Palsineuron
(one Cap. Tid)
 Pratimarsha nasya with maha masha taila
2 drops to each nostril.
 L/A of ashwagandha choorna lepa on face
 L/A of vacha choorna on tongue
Review in OPD after 15days.
60
for 15 days

62. 61

63. Pathyas
 Milk
 Meat soups
 masha
 Navaneetha
63
62

64. Varjas by arditha rogi
 Sheeta jala Snana
 Dantha dhaavana
 Vata prakopakara ahara and viharas
63

65. Thank you !