This article explains Sushruta Samhita Sutrasthana Chapter 16 “Karna Vyadhabandha Vidhi”- Puncturing the ear and repair of mutilated ear.

Karna Vyadhabandha Vidhi – Puncturing the ear and repair of mutilated ear
Now we shall propound the chapter by name Karnavyadha Bandha Vidhi- procedure of puncturing the ear and repairing the mutilated ear, as revealed by the venerable Dhanvantari.
Read – Ear Piercing Ceremony Karnavedhana Samskara

Karnavyadha

Puncturing the earlobe
Ears of the children are punctured with the purpose of

• protection (from evil) and
• decoration (wearing ornaments)

During the sixth or seventh month, on the day (and time) having an auspicious stellar constellation during the bright fortnight, religious rites, oblations and chanting of hymns of benediction shall be performed. Following this, the child should be placed on the lap of either the wet nurse, or matron. The child should be made happy by giving toys of the choice of the child and such other things so as to draw the attention of the child (and to hold the child in confidence). The physician should also speak to the child in a pleasing voice and with pleasant words (in the language of the child or language which the child understands).

Then the physician should hold the ear of the child with his left hand and pull it down slightly. The ear should be exposed to the sunlight. Now, the physician with his right hand should puncture the earlobe, straight and below the daivakrta chidra – the God made orifice (natural orifice of the ear) slowly. The piercing should be made using a suci (needle) if the earlobe is thin and with an ara (thick needle) if it is thick. In the case of a male child, the right ear should be punctured first. On the other hand, the left earlobe should be punctured first in case of a female child. Following this, a cotton thread / thin wick shall be introduced through the puncture.

Notes: – Dalhana says that counting of the sixth or seventh month, is to be made from the commencement of the year and not from the day of the birth of the child, Magha is the sixth month and Phalguna the seventh.
Read – Ear Discharge – Causes, Symptoms, Ayurvedic Treatment, Remedies

How to know that the earlobe puncture has been done in the right way?
When there is too much bleeding and pain following the earlobe puncture it should be understood that the puncture has been made at another place, different from the exact specified spot (daivakrta chidra). If there are no complications (pain and bleeding are absent after the earlobe puncture) it should be understood that the puncture has been done at the right spot i.e., daivakrta chidra.

Complications caused by wrongly puncturing the earlobe
If an ignorant physician / surgeon, by his choice (or by chance) happens to puncture the Kalika, Marmika and Lohitika veins, without focusing on ‘daivakrta chidra’ (where the puncture needs to be done), then many complications will arise.
When Kalika Sira is punctured – fever, burning sensation, swelling and pain are manifested.
When Marmika Sira is punctured – pain, fever and small cysts / tumors are manifested.
When Lohitika Sira is punctured – rigidity / stiffness of the (nape of the) neck, convulsions, catching pain in the head and pain in the ears are manifested.

These conditions shall be treated suitably.
When rough / ugly (not pointed), crooked and unsuitable needle is used to puncture the earlobe, or when a thick thread is inserted in the orifice made after earlobe has been punctured or when there is severe aggravation of the doshas or when the puncture of the earlobe has not been done properly (inauspicious puncturing) – swelling or pain develops in the ear (at the site of puncture). When this happens, the thread which had been inserted in the orifice following the puncture of the earlobe should be pulled out quickly. On the site, paste made from Madhuka, Erandamula, Manjishta, Yava and Tila made with more honey and ghee should be applied repeatedly, every day until the site has been healed completely. Once the earlobe (at the site of puncture) has been healed properly, puncturing should be done again in the mentioned (proper) site. The method of puncturing the earlobe is as explained above.

Follow up of proper earlobe puncture  
After proper puncturing of the earlobe has been done, the area should be bathed with fresh / raw (un-boiled) oil (of sesame), and thicker and thicker threads should be inserted on every third day and bathed as usual (with uncooked oil).
Read – Oral, Ear And Head Therapy – Ashtanga Hrudaya Sutrasthana 22

Use of Vardhanaka

Dilator
When the aggravation of the Doshas and complications has subsided, light Vardhanaka (dilator) should be used for dilating (the hole).

When the hole is dilated in this manner, the ear may get cut (severed) in two ways – either by aggravated doshas (diseases) or by injury. Now listen to me the method of rejoining them (repairing, sewing).

Karna Bandha

Techniques and repairing the ear-Otoplasty
Repairing the severed ear is of fifteen kinds in brief. They are –

1. Nemisandhanaka
2. Utpala bhedyaka
3. Valluraka
4. Asangima
5. Gandakarana
6. Aharya
7. Nirvedhima
8. Vyayojima
9. Kapatasandhika
10. Ardhakapata Sandhika
11. Sanksipta
12. Hinakarna
13. Vallikarna
14. Yastikarana and
15. Kakaustaka

Conditions wherein these earlobe repairs are done –

Among these,

Sl No	Name of the Karna Sandhana	When to do it?
1	Nemisandhanaka	when both the parts of the cut ear are thick, broad and even (regular/symmetrical)
2	Utpalabhedyaka	when both the parts are round, long (broad) and even (symmetrical)
3	Valluraka	when both the parts are small, round and even
4	Asangima	when the internal part only is long
5	Gandakarna	when the external part only is long
6	Aharya	when there is absence of lobe on both sides
7	Nirvedhima	when the lobes are torn at the root (attachment) this type of repair should be done by keeping the putrika – tragus and anti-tragus as support
8	Vyayojima	when one portion of the lobe is thick and the other is thin, or when one is regular and the other is irregular
9	Kapadasandhika	when the internal lobe is long and other (external lobe is short
10	Ardhakapatasandhanika	when the external lobe only is long and other (internal)part  of the lobe is short

In this way these ten types of repairing (joining by suturing) are going to be successful. Their shapes are explained generally by their names. Sanksitpa and other (totally five) types of ear lobe repairs are going to be unsuccessful.

Sl No	Name of the Karna Sandhana	When to do it?
11	Sankshipta	when the karnasaskuli (Pinna of the ear) is dry, one part of earlobe is elevated and the other part is very small
12	Hinakarna	when the earlobe is not fixed all around and its muscle is lost (absent / depleted),
13	Vallikarna	when the earlobe is thin, irregular and small (short)
14	Yastikarna	when the earlobe has muscular nodules, static immovable / network of veins and the lobe is small / short
15	Kakaustaka / Kakostaka	when the lobe has no muscles, has constricted tip and little blood in it

The physician / surgeon will not find success in these cases because in spite of doing these properly, the patient would suffer from symptoms including swelling, burning sensation, reddish discoloration, suppuration, eruptions and discharge of pus etc.

Notes: In this context bandhana means ‘joining together by suturing / sewing’ and not ‘bandaging / binding’ as it actually means. Sandhana means joining the mutilated parts together. After doing sandhana, bandhana (bandaging) is also needed. Therefore, the term ‘karna bandha’ means both suturing and bandaging.

From the description of the above said surgical methods (operations) it is not possible to understand them (i.e., know their exact nature). According to Master Dalhana the exact nature of these patterns or procedures can be known and understood by regularly observing (seeing) these procedures being done by any expert followed by regular practice of the same.

He has also tried to throw some light on some of these methods. Examples include –

• Nemi means impression of the wheel, so nemisandhanaka is sewing in a round or circular way.
• Vallura means dried meat. It should be understood that just like dried meat is torn to many pieces, the ear is cut into many pieces. A procedure of joining these pieces is called valluraka.
• Asangima = sewing a big portion when a small portion is not available at the same place.
• Gandakarna = cutting a muscle piece from the neck while maintaining its attachment and turning it over the damaged pinna (as in modern day otoplasty)
• Aharya = fabricating the pinna from the muscle flaps of both cheeks
• Nirvedhima = making the pinna by cutting a muscle piece from the back of the ear.
• Vyayojima = fabricating the pinna by different kinds of cuttings.
• Kapadasandhika = joining by different kinds of suturing just like a hinge at the back.
• Ardhakapata Sandhi = joining the pinna by suturing in its front.

How to suture in different conditions?

When the Pinna (including the lobe) of both ears is not present, then the same should be repaired by cutting the skin at the back of the ears.
When the external ear (Pinna) is long (damaged greatly), joining (suturing) should be done internally (medially), whereas when it is long (damaged greatly) internally (medially), then joining (suturing) should be done externally (posteriorly).
When the external ear (Pinna) only is present (without the lobe) and is big, thick, and static, then it should be cut into two and joined (sutured) above.
(If anyone does not have an earlobe) the physician well learned in science should cut out a flap of the living muscles from the cheek while retaining its connection intact, turn it over to the site of the lobe after scraping the area and thus make up the lobe.
Read – Tinnitus Causes, Ayurvedic Treatment, Herbs, Lifestyle Tips

Bandhana vidhi

Procedure of joining (suturing)
The surgeon after deciding the kind of joining (suturing to be done) amongst the types described earlier (in this chapter) should collect all the materials required as enumerated in Agropaharaniya (chap.5) especially, scum of sura, milk, water, Dhanyamla (fermented rice wash) and powder of potsherd (powder of piece of / saucer of earthen pot) and keep these nearby. Then, the hair of the head of the woman or man (who is to be operated) is tied into a knot firmly (at the back of the head). The patient should be given light food and made to hold tight by his kith (close relatives dearer to him). Then the physician / surgeon should decide the type of bandhana (joining, suturing) to be done and do the appropriate method and techniques such as excising, dividing, scraping, puncturing, etc. Afterwards he should examine the blood of the ear and decide if it is vitiated or not vitiated. If it is found that the blood is vitiated by vata, the ear should be washed with Dhanyamla (fermented rice-wash) and hot water. If the blood is vitiated by Pitta, then the ear should be washed with cold water and milk. If the blood is vitiated by Kapha then the ear is washed with scum of Sura and water. Then the area (of the ear) should be scraped and joining (sandhana) is affected by placing the parts together, neither too high nor too low, and not irregular and then sutured after the bleeding stops. Afterwards the area should be anointed with honey and ghee, covered with cotton swab or any other suitable pad and fastened with threads, neither too tight nor too loose and sprinkled with powder of potsherd. The patient is then advised on a suitable regimen of food and activities. He should be taken care of as described in the Dvivraniya chapter. (Chapter 1 of Cikitsasthana).

Contraindications during post-operative care

 The person (who has been operated) should avoid –

• movement (of the ear),
• day sleep,
• exercise,
• overeating,
• exposure to fire and
• exertion by talking too much

Sandhana Anarhata

Contra Indications for operation
Sandhana (sewing / joining the damaged ear) should not be done when there is impure blood (blood is found vitiated) in the ear, flowing out greatly (excessive bleeding), or when there is loss of blood (less bleeding).
If sandhana is done-

• when blood is vitiated by vata, paripota i.e., cracking of the skin would occur even after healing
• when blood is vitiated by Pitta, there will burning sensation, suppuration (ulceration), redness and pain;
• when blood is vitiated by Kapha, the area becomes stiff / static and itching;
• when there is too much of bleeding; then the region (of the ear) will become black or blue in color and swelling develops;
• when there is loss of blood or three is little of muscles then the part does not grow

Upadrava chikitsa

Treatment of complication
The area should be bathed with uncooked oil for three days. After three days the swab placed on the wound should be changed / reverted.
When the wound has healed well and is free from complications and when the color of the skin of that region becomes similar to that of the surrounding skin (color of the body), then it (orifice of the earlobe) should be made to grow slowly. Otherwise, it will develop swelling, burning sensation, suppuration (ulceration) and pain or it may get cut (separated) again.

Abhyanga

Massage of the pinna and earlobe with medicated oil
After the complication have subsided and there is no vitiation, then massage (anointing) should be done to promote growth of pinna / earlobe – with oil cooked as follows – muscle fat and marrow of Godha (Iguana lizard), of birds and animals of Pratuda,Viskira, Anupa and Audaka groups, milk, ghee and oil of Gaurasarsapa – as many of these as available, should be collected and boiled with the addition of paste of Arka, Alarka, Bala, Atibala, Ananta, Apamarga, Asvagandha, Vidarigandha, Ksirasukla, Jalasuka, Ksirakakoli, Drugs of Madhura  varga (Drugs of sweet taste) and Payasya. Or Medicated oil prepared with paste of arka etc drugs and stored at a concealed place.
The ear should be given fomentation first and then massaged with this oil; by this the ear grows without any complications and becomes strong.

Use of Yavadi Kalka and Shatavaryadi Taila
Yavadi Kalka – It is beneficial to massage the ear (in the upward direction) with the paste of Yava, Asvagandha, Yastyahva and tila.
Satavaryadi Taila – Oil is cooked with Satavari, Asvagandha, Payasya, Eranda and drugs of Jivaniya gana added with milk. Massage (anointed) with this oil will help in the growth of the earlobe.
If the earlobe does not grow even after doing fomentation and anointing, then pracchana (scraping) should be done at the outer canthus of the eye.  Scraping / incision should not be done on the outer side of the ear. If done, it would lead to complications (due to the presence of sira etc. marmas – vital spots in this region).

Effect of making the earlobe grow immediately after sandhana
If the earlobe is suddenly made to grow after doing the sandhana (sewing, joining, suturing), it becomes swollen (unripe swelling) and breaks off (falls off) quickly since the earlobe will be in an unripe state.

Conditions in which the ear should be made to grow slowly
The ear on which hairs have developed, passages are clear, joint (place of union made) is well adhering, even and stable, well healed and painless, such an ear should be made to grow (elongated) slowly with suitable measures.

Use of suitable method of joining the mutilated ear
Methods of joining the mutilated ear are innumerable and should be learnt from experts. That (method of joining) which is appropriate at the moment should be decided and undertaken.

Karnapali roga- other diseases of the earlobe
Now I am going to describe the diseases of the earlobe, dear Sushruta, listen: –

Pathogenesis – The Tridoshas i.e., Vata Pitta and Kapha – aggravated either separately, or in combination of two or three, getting localized in the earlobe produce different kinds of disorders.
When vata gets aggravated in the earlobe it causes development of eruptions, loss of movement / stiffness and swelling of the lobe.
When pitta gets aggravated in the earlobe it causes burning sensation, eruptions, swelling and suppuration / ulceration.
When kapha gets aggravated in the earlobe it causes itching, swelling, stiffness, and heaviness.

Treatment for these is administration of purificatory therapies appropriate to the Dosa, fomentation, massage / anointing, bathing (showering with medicated liquids), applying pastes as anointments (poultices), bloodletting etc.
Apart from this, all mild therapies / measures shall be administered. The patient is encouraged to consume nourishing (bulk promoting) foods.
He who understands the conditions of the Dosas, will be able to adopt suitable treatments.

Complications occurring in the earlobe
Further, I will describe the diseases of the earlobe which occur in the form of complications along with their names, symptoms and treatment. These diseases are ten in number and include Utpataka, Utputaka, Syava, Kandu, Avamantha, Kanduka, Granthika, Jambula, Sravi and Dahava. Now listen now to their respective treatment.

Treatment of complications of earlobe
For utpataka, the paste of Apamarga, Sarjarasa, barks of Patala and Lakuca twak should be applied or oil cooked with the paste of these herbs may be anointed.
For Utputaka, paste of Sampaka, Sigru, Putika, fat, muscle fat and Pitta (bile) of iguana lizard, boar, cow and antelope, added with ghee should be applied or oil cooked with these may be anointed.
For Syava, paste of Gauri, Sugandha,Syama, Ananta and Tanduliyaka should be used or oil cooked with these may be used.
 For Sakanduka, Paste of Patha, Rasanjana, honey and warm Kanjika(rice gruel) may be applied or oil prepared from these may be anointed.
If it (earlobe) has become ulcerated (along with other complications), oil is cooked with Madhuka, Ksirakakoli, Jivaka etc. (Jivakadi gana) should be applied. If the lobe is emaciated then application of muscle fat of Iguana lizard, boar and snake is beneficial for stouten it.
 For Avamanthaka, the site should be first showered / bathed (to cleanse) and then the paste of Prapaudarika, Madhuka, Samanga and Dhava should be applied or oil cocked with these may be anointed.
For Kandu, the paste of Sahadeva, Visvadeva, Ajaksira (goats’ milk) and Saindhava should be applied or oil cooked with these may be anointed.
In Granthika, the tumor (cystic swelling) should be punctured / cut open and the contents drained out first. Later the region shall be rubbed with powder of saindhava (rock salt) following which the paste of the same (saindhava) made with water shall be applied.  
In Jambula, it should be scraped and squeezed (drained) first and then rubbed with the powder of lodhra. Later milk should be sprinkled on it and when the wound becomes cleansed, healing measures should be adopted.
In Sravi, paste of Madhuparni, Madhuka, Madhuka added with honey should be applied or oil cooked with these may be applied.
In Dahavan, paste of Pancavalkala and Madhuka made into a paste and added with ghee or the drugs of Jivakadi Gana made into a paste and mixed with ghee, should be applied.

Sanskrit Verses

Nasa Sandhana

Joining the mutilated nose: – Rhinoplasty
Now, I will describe the method of joining the mutilated nose – A leaf of a tree should be taken and cut to the shape (and size) of the nose. Now this leaf is placed on the cheek. The cheek muscle is cut to the same size (of the measurement of the leaf carrying the measure of the nose), raising a flap of it and maintaining the connection with the live muscles. Now the mutilated nose (damaged portion) is scraped (causing bleeding) and the flap of the cheek skin with the muscle attachment is placed quickly on the mutilated nose, sutured with a needle and a suitable bandage tied.

Following these two tubes of Eranda are inserted into the nose (one in each nostril) and the nostrils elevated and observed if both are joined together in a proper way just as a normal nose and after confirming that it shall be bandaged. Later, powder of Patanga, Yastimadhuka and Anjana (Rasanjana according to Dalhana) should be sprinkled on the site. A white cotton swab (pad) is placed on it, and tila taila (sesame oil) should be sprinkled on it frequently. The patient is made to drink ghee and after the digestion of previously taken food. After proper oleation purgation should be administered as stipulated.  After the union has healed, the flap of muscles should be cut at its half-length allowing the remainder intact. If the repaired nose is short, an attempt should be made to augment its growth and if there is excess growth (of muscle), it should be made even (to the normal size by cutting or scraping).

Osthasandhaa

Joining the mutilated lip – Otoplasty

Joining of the mutilated lips should be done in the same way as joining of the mutilated nose but without the insertion of tubes.
The physician / surgeon who performs these (operations) becomes fit to treat the king.
Thus ends the sixteenth chapter by name Karnavyadha Bandha Vidhi in Sutra Sthana of Susruta Samhita.