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Open Access Full Text Article   Case Reoprt

Integration of Unani Therapy (Ḥijāma bi’l Sharṭ) in Vasomotor Rhinitis: A Case Report

Mo Salman Nagori *¹, Mehmooda Begum ², Mohammad Arif ³, Naseem Ahmad Khan ⁴, Mohd Aadil Khan ⁵, Tabasum Rouf ⁶

1. PG Scholar, Dept. of 'lläj bi'l Tadbir (Regimenal Therapy), College of Hakim Syed Ziaul Hasan Government (Autonomous) Unani Medical College & Hospital, Bhopal, India.

2. Professor and HOD, Dept. of 'llāj bi'l Tadbir (Regimenal Therapy), College of Hakim Syed Ziaul Hasan Government (Autonomous) Unani Medical College & Hospital, Bhopal, India.

3. Assistant Professor, Department of Amraz e Ain, Uzn, Anaf wa Halaq, College of Hakim Syed Ziaul Hasan Government (Autonomous) Unani Medical College & Hospital, Bhopal, India.

4. Assistant Professor, Dept. of Munafeul Aza (Physiology), College of Hakim Syed Ziaul Hasan Government (Autonomous) Unani Medical College & Hospital, Bhopal, India.

5. PG Scholar, Department of Tahaffuzi Wa Samaji Tibb (Preventive & Social Medicine), College of Hakim Syed Ziavi Hasan Government (Autonomous) Unani Medical College & Hospital, Bhopal, India.

6. PG Scholar, Department of Tahaffuzi Wa Samaji Tibb (Preventive & Social Medicine), College of Hakim Syed Ziavi Hasan Government (Autonomous) Unani Medical College & Hospital, Bhopal, India

 

 

Introduction 

The term rhinitis can be used to describe many distinct entities with varying pathogeneses, despite similar presentations. Generally, rhinitis is considered allergic if significant inhalant allergy is diagnosed and non-allergic when symptomatology is perennial or periodic and not IgE-mediated. Thus, non-allergic rhinitis (NAR) comprises a mixed bag of conditions ranging from vasomotor rhinitis (VMR) to hormonally induced rhinitis.¹ Vasomotor rhinitis (VMR) is a non-allergic rhinitis but clinically simulates nasal allergy with symptoms of nasal obstruction, rhinorrhoea and sneezing. One or the other of these symptoms may predominate; the condition usually persists throughout the year and all the tests of nasal allergy are negative^.2 This is a non-infective condition which is due to vasomotor disturbances consequent to autonomic dysfunction. Both parasympathetic and sympathetic fibres supply the nose. Usually, an autonomic balance is maintained, but sometimes alterations occur, producing a clinical condition called vasomotor rhinitis. Various factors may contribute to its causation. Psychogenic instability and emotional conditions, hormonal changes during pregnancy, menstruation, and puberty, climatic conditions like extremes of temperature and humidity, and drugs like antihypertensive agents, local decongestants, and antidepressants are some such factors Autonomic nervous system is under the control of the hypo-thalamus and therefore emotions play a great role in vasomotor rhinitis.³

In Unani medicine, Nazla and Zukām are often used synonymously by many classical scholars, as both involve the falling of Mādda (morbid matter) from the brain (infiltration of fuḍlāt-e-dimāgh). However, some Unani physicians differentiate between the two ^5,8,10. Most of the Unani physicians mentioned that the Balgham (phlegm) dripping into the throat is known as Nazla, and when it goes to the nose is known as Zukām.^{4,5,6,7,8,9,10} Buqrāṭ (Hippocrates) described Zukām as a type of Nazla limited to the nasal mucosa. In contrast, Nazla involves inflammation that may affect the throat and other structures along with excessive nasal discharge. ^11,12 Ibn Sīnā in Al-Qānūn fī al-Ṭibb considered Nazla and Zukām as two distinct disease entities, each with its own pathogenesis and clinical presentation.

He described Nazla Ḥārr as one of the specific types of Nazla, characterized by a hot temperament (ḥār mizāj), with watery, irritating nasal discharge, often accompanied by burning sensations (sozish) in the nose, face, and eyes, lacrimation, and altered olfaction⁵.The madda in Nazla may be hot and thin or cold and viscous, depending on the humoral imbalance⁸. Furthermore, Zakariya al-Rāzī and Jālīnūs (Galen) advised Hijāmah bil Shart (wet cupping) on the Nuqra/Qafa (nape of the neck)/ Faqarāt al-‘Unuq (over the cervical spine) as a treatment, particularly for symptoms like itching in the nose and sneezing, suggesting an effective intervention for such conditions¹⁰. In modern medicine, the clinical picture of Vasomotor Rhinitis which includes sneezing, nasal discharge, and nasal congestion shows remarkable similarity with the classical description of Nazla Ḥārr in Unani texts. However, allopathic management remains largely symptomatic, using antihistamines and decongestants, without addressing the underlying imbalance. Thus, based on clinical similarity, Nazla Ḥārr is considered equivalent to Vasomotor Rhinitis in the present study, reaffirming the relevance of Unani concepts in understanding and managing chronic non- allergic rhinitis through holistic approaches.

Case report

A 28-year-old female presented to the OPD of Amrāz-e-Ain, Uzn, Anaf wa Halaq (ENT) at Hakim Syed Zia-ul-Hasan Government Unani Medical College and Hospital, Bhopal, with a chief complaint of profuse runny nose, frequent sneezing, and nasal congestion for the past 2 years. She also reported diffuse headache and right ear fullness. The intensity of the symptoms was more severe in the morning, just after waking up from sleep, and after exposure to Cold air. Mizaj of the patient was Balghami. Mizaj was assessed by adopting the mizaj assesment chart based on ajnas e ashaarah prescribed by the CCRUM. The patient had been using nasal decongestant (Otrivin nasal drops) and antihistaminic medication (Tablet Levocetirizine) for symptom relief for the past one year. Her past medical history was unremarkable for hypertension, hypercholesterolemia, diabetes mellitus and hypothyroidism. A Review of systems was negative for trauma, weight loss, night sweats, shortness of breath, chest pain, nausea, vomiting or diarrhea but positive for, diffuse headaches, recurrent colds and sneezing. On presentation, the patient’s Total Nasal Symptom Score (TNSS) was 11/12, indicating moderate to severe rhinitis symptoms, with the breakdown as given in the table no.1

On physical exam her vital signs were: BP 110/80mmhg, Pulse 89 bpm, Respiratory rate 18, Temperature 36.2 C, Weight 73 kgs. Generally, she presented to us holding a rag over her nose but not in distress. She had a normocephalic/atraumatic head, tympanic membranes were clear, and conjunctivae were clear. She had watery nasal discharge from the right naris with a continual drip. The nasal mucosa was otherwise moist and mildly erythematous; with a Bilateral inferior turbinate hypertrophy. There was no chest deformity. The lungs were clear to auscultation without wheezes, rubs or rhonchi. Cardiovascularly, she had a regular rate and rhythm without murmurs, rubs or gallops. The abdomen was soft, non-tend and no masses were palpated. Skin exam revealed no lesions. Extremity examination did not reveal any cyanosis, clubbing or oedema. Lastly, she had no enlarged cervical lymph nodes.

Diagnostic Assessment

Before starting the treatment, some lab investigations were conducted, which included CBC, Absolute Eosinophil Count, BT, CT, BSL, HIV, HBSAG, and VDRL. PT and INR to make Diagnosis & to exclude allergic rhinitis, and to prepare for further procedures. Based on the Medical history, clinical findings, examination and investigation reports of the patient, it was diagnosed as vasomotor rhinitis distinct to allergic rhinitis there are no specific diagnostic tests for non-allergic rhinitis, and diagnosis is made based on rhinitis symptoms in the absence of identifiable allergy (by allergy testing), structural abnormality, immune deficiency, sinus disease or other causes.

Intervention:

After a thorough history, clinical evaluation, and diagnostic assessment, the patient was diagnosed with vasomotor rhinitis and was advised to undergo wet cupping therapy at the nape of the neck administered once for three consecutive weeks. The primary goal of therapy was symptomatic relief, particularly reduction in rhinorrhea, nasal congestion, sneezing and headache along with prevention of recurrence.

Methodology

The following Standardized Wet Cupping therapy protocol was followed

Pre-procedure Preparation

1. Written informed consent was taken from the patient briefing him the entire procedure and the duration of therapy.
2. The required materials are (Hijama Cups), 11 no. surgical blade, kidney tray, gauze pieces and drapes were kept ready
3. All the essential vitals temperature, pulse, respiration and blood pressure were recorded prior to the procedure

Procedure

• Patient was positioned comfortably in a prone position, exposing the nape of the neck.
• The skin over the Nape was cleansed using betadine solution and allowed to dry
• Three Cups was applied on the nape of the neck. The suction was well created and maintained there for at least 10 minutes to induce hyperemia.
• After 10 minutes, all the cups were removed and using 11 no. Surgical blade, multiple minute incisions were made in the demarcated sites to facilitate bloodletting.
• Again, cups were reapplied to the same area for 5 minutes to allow the extraction of stagnant blood and interstitial fluid.
• Then all cups were removed when the blood stopped oozing, and clots were formed

 

 

 

Post-procedure Instructions and Follow-up

• A sterile gauze was used to clean the impure blood and clots.
• The sterile gauze soaked with betadine solution was applied over the incised circular area after the Cupping procedure.
• Follow up every week.
• DOs: Patient was advised to take a light diet and do light work.
• Patient was advised to take a bath after 24 hours
• DO N'TS: Do not sit in an air-conditioned room.

Result 

The patient was assessed weekly using the Total Nasal Symptom Score (TNSS) as a standardized tool for measuring rhinitis symptom severity. The baseline TNSS was 11/12, indicating severe symptoms. Following a series of 4 weekly sessions of wet cupping. significant improvements were observed. Initially, the patient’s TNSS was 11 out of 12. After the first session, the TNSS 8. After the third session, the TNSS had further reduced to 5 and at the final session the TNSS had reduced to 1. Throughout the treatment course, no adverse events were reported. By the end of the treatment cycle, the patient's pain had reduced. The patient reported an 80% improvement in symptoms and resumed normal activities.

 

 

Table 1: Total Nasal Symptom Score (TNSS) 

	Day 0		Day 7		Day 14		Day 21
Symptom	BF	AF	BF	AF	BF	AF	BF	AF
Rhinorrhoea	3	3	3	3	3	2	2	1
Nasal Congestion	3	3	3	2	2	1	1	0
Sneezing	3	3	3	2	2	1	1	0
Nasal Itching	2	2	2	1	1	1	1	0
TNSS Total	11/12		8/12		5/12		1/12

By the end of the third session (Day 21), complete resolution of all symptoms was achieved (TNSS: 1/12).

 

 

Discussion

Vasomotor rhinitis (VMR) is a form of non-allergic, non-infectious rhinitis characterized by chronic nasal congestion, rhinorrhoea, sneezing, and postnasal drip, often exacerbated by environmental or emotional stimuli. In contrast to allergic rhinitis, it lacks IgE-mediated hypersensitivity and identifiable allergens, making diagnosis largely clinical and based on exclusion. In this case, the patient presented with moderate to severe VMR, unresponsive to conventional pharmacotherapy (nasal decongestants and antihistamines). The application of Ḥijāma bi’l Sharṭ was chosen as an Unani-based therapeutic intervention, supported by its historical use for balancing humours (Tanqiya’-i-Akhlāṭ) and relieving local congestion and inflammation. the classical medical texts, including “Kitab al-Ghinā Munā” both Jālīnūs (Galen) and al-Rāzī, Abū Bakr Muḥammad ibn Zakariyyā (Rhazes) have noted that performing Ḥijāma bi’l Sharṭ at the Faqarāt al-‘Unuq (nape of the neck)—corresponding to the upper cervical vertebrae—is therapeutically effective in cases of Nazla Ḥārr, especially for alleviating symptoms such as sneezing and nasal pruritus (itching). Furthermore, Ḥijāma bi’l Sharṭ is hypothesized to Improve local blood circulation, promote lymphatic drainage, remove metabolic waste products, modulate autonomic nervous system function, and reduce proinflammatory cytokines. The patient's TNSS reduced from 11/12 to 1/12, demonstrating significant improvement across all parameters, including rhinorrhoea, nasal blockage, sneezing, and nasal itching. The sustained effect at one-month follow-up suggests a long-lasting benefit without recurrence or adverse effects.

This aligns with growing evidence that Ḥijāma bi’l Sharṭ may offer relief in chronic inflammatory and idiopathic conditions. In this case, it served as an effective complementary therapy, particularly valuable for patients with suboptimal response to conventional medications or who seek alternative modalities.

Conclusion

The observed patient's clinical symptoms of vasomotor rhinitis showed a significant improvement after using Ḥijāma bi’l Sharṭ, or wet cupping therapy. After several sessions, the patient reported a notable decrease in rhinorrhoea, sneezing frequency, and nasal congestion without experiencing any serious side effects. This implies that hijamas may lessen nasal mucosal hyperreactivity and control autonomic nerve activity, two important elements in the pathophysiology of vasomotor rhinitis. Larger controlled studies are advised to further establish the effectiveness, mechanism, and safety of Ḥijāma bi’l Sharṭ in the treatment of non- allergic rhinitis, even though this single case suggests possible therapeutic benefit. 

Author contributions: Mo Salman Nagori and Mehmooda Begum: Conceptualization, Validation, Visualization, writing of original draft, Methodology; Mohammad Arif and Naseem Ahmad Khan: Supervision, writing review, and final editing; Mohd Aadil Khan and Tabassum Rouf: Resources, software, and data extraction.

Financial support: None

Declaration of Competing Interest: The authors have no conflicts of interest to declare.

Acknowledgements: None 

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