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Objective The objective of this review is to trace the evolution of the art and science of allergy immunotherapy (AIT). Data Sources Original reports relating to the evolution of the concept of respiratory allergy and its specific treatment were identified by following references in journal articles, review articles, and allergy textbooks from the mid-20th century to the present. Study Selections Studies highlighting substantial milestones in the evolution of the practice of allergy immunotherapy were included. Results The story of AIT begins with the recognition of hay fever as a distinct entity and subsequent studies that established grass pollen as one of the causes. This knowledge led several investigators, most notable Leonard Noon and John Freeman who worked at St. Mary’s Hospital in London, to attempt to induce tolerance giving grass pollen extract by injection to their patients. After the publication of the work of Noon and Freeman in 1911, the practice of AIT spread rapidly and was applied to many other pollen allergens besides grass and for perennial rhinitis and asthma. The early studies were largely anecdotal, but over the past 60 to 70 years, studies of AIT have been conducted with increasingly sophisticated scientific methods. Nowadays, not only is the practice of AIT based on carefully conducted studies, but the underlying immunologic basis of allergy and the response to AIT have also been and still are being firmly established. Conclusion Both the art and the science behind the practice of AIT have been established by a solid base of clinical and immunologic studies.

BACKGROUND Allergic rhinitis (AR) is a major public health problem and is increasing worldwide. AR affects children's learning efficiency, sleep quality, and other major aspects of life. Sublingual immunotherapy (SLIT) is effective and safe for children with seasonal AR, but for children with perennial allergic rhinitis (PAR) caused by house dust mites (HDM), its effectiveness and safety is less convincing. METHODS Medical literature databases up to 2019 were searched for published and unpublished pieces of evidence. Studies were individually screened by 2 reviewers against the eligibility criteria. Primary outcomes were total nasal symptoms scores (TNSS) and total medication scores (TMS). The secondary outcomes were total ocular symptoms scores and adverse events (AEs). Random effect models and fixed-effect models were used to calculate the standard mean difference (SMD) and risk ratio (RR), respectively. RESULTS We identified 3772 abstracts, of which only 16 studies met our established criteria. SLIT significantly reduced TNSS (SMD -1.73; 95% CI, -2.62 to -0.84; p = 0.0001) and TMS (SMD -1.21; 95% CI, -1.75 to -0.67; p < 0.00001). Compared with children taking placebo, children taking SLIT were 1.08 (95% CI, 1 to 1.17; p = 0.05), 1.15 (95% CI, 0.87 to 1.51; p = 0.32), and 1.68 (95% CI, 0.68 to 4.11; p = 0.26) times more likely to develop mild, moderate, and severe AEs, respectively. CONCLUSION HDM SLIT can effectively alleviate TNSS and TMS in children with PAR, but care should be taken to avoid harm due to possible adverse drug reactions.

Background Asthma and rhinitis are common diseases that often occur concomitantly. However, in patients with asthma, the concurrent assessment of seasonal variation in rhinitis and asthma symptoms has not been comprehensively addressed. We prospectively evaluated seasonal changes in rhinitis and asthma symptoms over one year. Methods Fifty-six patients with asthma were enrolled. Asthma and rhinitis symptoms were assessed by using the State of the Impact of Allergic Rhinitis on Asthma Control (SACRA) questionnaire, developed and validated in Japan by the committee of Global Initiative for Asthma and the committee of Allergic Rhinitis for asthma and its impact on Asthma. Results Fifty-three patients completed the study. Forty-five patients (85%) had nasal symptoms during at least one or more seasons and 15 patients (28%) had perennial rhinitis. The association between asthma symptoms and rhinitis symptoms, assessed by a visual analogue scale (VAS), was significant during each season; seasonal variations of symptoms were synchronous. Uncontrolled asthma was more prevalent in patients with moderate-to-severe rhinitis compared to those with mild rhinitis. The VAS score of asthma symptoms in patients with asthma and perennial rhinitis was significantly higher than that in patients with non-perennial rhinitis or without rhinitis, across every season, except for spring. Correlations were more significantn patients less than 65 years of age than in older patients. Conclusion Rhinitis is common in patients with asthma. Symptoms of rhinitis and asthma often co-exist, and the association between these symptoms may be stronger n younger patients with asthma than older.

Non-infectious rhinitis can broadly be subdivided into two subclasses, allergic and non-allergic rhinitis, depending predominantly on whether or not an allergic aetiology is implicated. The term 'non-allergic rhinitis' is commonly applied to a diagnosis of any nasal condition in which the symptoms are identical to those seen in allergic rhinitis but an allergic aetiology has been excluded. These non-allergic aetiologic entities can broadly be classified as: idiopathic rhinitis; non-allergic occupational rhinitis; hormonal rhinitis; drug-induced rhinitis; and other forms (non-allergic rhinitis with eosinophilia syndrome (NARES), rhinitis due to physical and chemical factors, food-induced rhinitis, emotion-induced rhinitis, atrophic rhinitis). Idiopathic rhinitis is characterized primarily by symptoms of nasal blockage, rhinorrhoea and sneezing, although the prevalence of sneezing, conjunctival symptoms and pruritis is lower than that in allergic rhinitis. Hormonal rhinitis is often associated with pregnancy in particular, although puberty is also known to induce the symptoms of rhinitis.

Background. Asthma and allergic rhinitis are highly prevalent conditions that cause major illness worldwide. This study aimed to assess the association between allergic rhinitis and asthma control in Peruvian school children.Methods. A cross-sectional study was conducted among 256 children with asthma recruited in 5 schools from Lima and Callao cities. The outcome was asthma control assessed by the asthma control test. A score test for trend of odds was used to evaluate the association between allergic rhinitis severity and the prevalence of inadequate asthma control. A generalized linear regression model was used to estimate the adjusted prevalence ratios of inadequate asthma control.Results. Allergic rhinitis was present in 66.4% of the population with asthma. The trend analysis showed a positive association between allergic rhinitis and the probability of inadequate asthma control (). It was associated with an increased prevalence of inadequate asthma control, with adjusted prevalence ratios of 1.53 (95% confidence interval: 1.19−1.98).Conclusion. This study indicates that allergic rhinitis is associated with an inadequate level of asthma control, giving support to the recommendation of evaluating rhinitis to improve asthma control in children.

Background Allergic rhinitis (AR) is the archetypal allergic disease otolaryngologists encounter. Epidemiologic studies inform providers of the association of rhinitis symptoms and allergy test results in the broader population. Understanding the epidemiological characteristics of AR is important for interpreting both rhinitis symptoms and allergy tests. Methods Articles were selected based on literature review through PubMed and personal knowledge of the author. The largest and highest-quality studies were included. The search selection was not standardized. Results Epidemiological studies demonstrate marked variability globally in the prevalence of both rhinitis symptoms and allergy tests. Self-reported seasonal or perennial rhinitis symptoms significantly overestimate the prevalence of AR defined by a positive history and positive allergy tests. Positive allergy tests are also common in those without self-reported rhinitis symptoms. Conclusion Interpreting rhinitis symptoms and allergy testing is enhanced by an understanding of the epidemiology of AR.

Background Rhinitis is a very common disease with allergies being the most frequent causative factor. It can co-occur together with asthma and eczema in atopic as well as in nonatopic patients. Objectives To assess the prevalence of allergic sensitization within patient groups with rhinitis in consideration of the co-occurring disorders of asthma and eczema. Methods Students of the third year of medical school completed an anonymous questionnaire on age, gender, and clinical symptoms, such as seasonal rhinitis, perennial rhinitis, asthma, and eczema, and underwent an ImmunoCAP Rapid test. We calculated the prevalence of sensitization within subgroups of patients reporting allergic disorders, such as rhinitis, asthma, and eczema. Results Questionnaires and ImmunoCAP Rapid tests of 1513 medical students were analyzed. The participants’ self-reported presence of seasonal/perennial rhinitis, asthma, and eczema was compared to the presence of sensitization. Data of 1467 subjects could be analyzed. Seasonal rhinitis was the most common symptom, followed by eczema, asthma, and perennial rhinitis. The participants were differentiated into 16 subgroups according to the combined clinical manifestations of the different symptoms and association to sensitization within subgroups. The prevalence of sensitization ranged from 18% in subjects reporting only eczema without any other symptom to 100% in those reporting to have asthma, seasonal/perennial rhinitis, and eczema together. In subjects reporting no sign or symptom at all, the prevalence of sensitization was 19%. Seasonal rhinitis was the strongest single predictor for sensitization with the highest proportion of sensitized participants in all symptom combinations (67%–100%), followed by perennial rhinitis (31%–100%), asthma (30%–100%), and eczema (18%–100%). Conclusion Rhinitis most often is associated with allergen sensitization, and the probability of sensitization is substantially enhanced by co-occurrence of asthma. A careful assessment of clinical signs and symptoms is important and enables the selection of patients in whom targeted diagnostic analysis and therapy is appropriate. Trial registration: retrospectively registered by the Cantonal Ethics Committee Zurich on 22.01.2016; Nr: 08-2016.

Objectives and hypothesis:Allergic rhinitis has traditionally been classified into seasonal and perennial rhinitis. However, many subjects with dual sensitisation do not fit neatly into either category. Recently, the Allergic Rhinitis and its Impact on Asthma workshop has proposed a new allergic rhinitis classification, into intermittent and persistent forms. The purpose of the present study was to investigate whether the symptomatic and secretory responsiveness of allergic rhinitis sufferers correlated well with the Allergic Rhinitis and its Impact on Asthma classification, compared with the traditional classification.Study design:Experimental study.Methods:Forty subjects with allergic rhinitis and 13 normal controls underwent a unilateral nasal bradykinin challenge protocol. Symptom scores were recorded and secretion weights measured bilaterally using filter paper disks. The symptomatic and secretory responses of allergic subjects were analysed according to both the traditional and the Allergic Rhinitis and its Impact on Asthma classifications, and the two systems were compared.Results:For both classification systems, the two groups of allergic subjects were clearly demarcated by secretory responses. However, after classification according to the traditional system, there was a lack of clear demarcation between the groups as regards symptomatic response, whereas clear demarcation of symptomatic responses was seen after using the Allergic Rhinitis and its Impact on Asthma classification.Conclusions:In allergic rhinitis subjects, the degree of nasal responsiveness was closely related to their Allergic Rhinitis and its Impact on Asthma classification. Furthermore, this classification was not compromised by the inclusion of subjects with dual sensitisation. Thus, the Allergic Rhinitis and its Impact on Asthma classification may have advantages for future research studies on allergic rhinitis.

Summary Objective The present study was undertaken, to test the hypothesis that schoolchildren on long-term treatment for chronic rhinitis under-report their nasal congestion. Methods Ninety-seven children aged 8.3–15.5 years (median 12.7) with non-purulent perennial rhinitis, for 1.4–8.5 years (median 2.8) self-graded their nasal blockage as “severe” (group-A), “moderate” (group-B), “mild” (group-C) or “absent” (group-D). An additional 48 normal children served as controls (group-E). Subsequently active anterior rhinomanometry for total nasal airway resistance (TNAR) measurement and decongestion test (>20% TNAR fall) were employed as objective means of nasal congestion. Results Mean pre-decongestion TNAR values did not show any significant difference between the group-A, -B and -C; significant differences were observed between group-A and -D (p = 0.04) and between all groups as compared to -E. Positive decongestion test was detected in 57.1%, 53.8%, 48.3%, 32.3% and 10.4% of children in group-A, -B, -C, -D and -E, respectively (group-A, -B, -C versus -E p Conclusions Schoolchildren on long-term treatment for perennial rhinitis frequently under-report their symptom of nasal stuffiness.

Summary Allergic seasonal and perennial rhinitis are common diseases that have a considerable adverse impact on the quality of life of the sufferer. Despite the excellent available treatment, the morbidity of allergic rhinitis remains high, because patients often do not seek medical advice and also because physicians tend to underestimate the disruptive problems caused by the disease. In order to improve patient compliance with medication, the diagnosis of allergic rhinitis should be confirmed and the treatment prescribed should be effective with a simple dosage regimen.

Summary Background Epidemiological studies in the past have focused on meteorological conditions, pollution and pollen and their relationship with symptoms of bronchial hyper-reactivity, however, there are no epidemiological studies which examine a wide range of such factors and determine their role in nasal hyper-reactivity. Objective To investigate whether environmental factors can influence symptomatology in non-allergic non-infectious perennial rhinitis (NANIPER) patients, who suffer primarily from nasal hyper-reactivity symptoms. Methods We studied 16 non-smoking NANIPER patients and seven non-smoking controls during a 218-day study period (March–October) by means of daily symptom scores and visual analogue scales for the subsets patency, secretions and sneezing, and compared them to seven primary factors which affected ‘symptoms’ and 10 secondary factors which affected primary factors only. Results The mean symptom scores in the NANIPER and control groups were 2.17 and 0.13, respectively. In NANIPER, the highest correlations of primary factors with symptomatology were found for symptom scores and sneezing with minimum daytime temperature (r = −0.62 and −0.45, respectively), ozone and NO concentrations. Patency and secretions were associated with minimum daytime temperature (r = −0.39 and 0.32, respectively). Time series analysis, however, correcting for several confounders such as autocorrelated symptomatology, showed that minimum daytime temperature and daytime relative humidity made an independent contribution to symptoms. In the control group, correlations were much lower, though present. Time series analysis was not possible. Conclusions We conclude that in a mild climate with relatively low levels of pollution, minor pollution and meteorological disturbances result in substantial changes in nasal reactivity symptoms in NANIPER patients, but not controls, irrespective of other factors such as allergy or infection.

Seventy-five children (ages 4 to 14 years) with perennial rhinitis caused by mold allergy (36 had asthma) were enrolled in an air-cleaner study for 2 years. Symptom scores prior to the study were compared with scores 1 and 2 years after placement of air-cleaners in the bedrooms. Forty-two homes were surveyed for mold count in the air in summer and winter, and the results compared with symptom changes. Improvements were found in quality of sleep (96 vs. 99%), sneezing (80 vs. 90%), scratchy throat (75 vs. 80%), night cough (75 vs. 83%), better mood in the morning (65 vs. 80%), postnasal drip (70 vs. 77%), nasal congestion (70 vs. 72%), night wheezing (70 vs. 83%), and sinus infection (50 vs. 55%). Parents reported a decrease in the use of both over-the-counter (76 vs. 80%) and prescription (43 vs. 48%) drugs. When the weekly symptom score sheets were compared, symptom recurrence rates were found to be clustered in the winter. These symptoms were cough (35%), nasal congestion (35%), sinus infection (32%), a...

HRQL is now a fundamental parameter for a global assessment of patients suffering from chronic diseases and it has become a widely accepted outcome in clinical care and research. In addition, HRQL plays an increasing role in the European regulatory documents of pharmaceutical products. Because of its clinical characteristics, Chronic Urticaria deeply interferes with physical and emotional well-being, social relationships and daily-life activities. As it was recently underlined by the guidelines for CU management, research has only recently explored HRQL in urticaria patients. HRQL assessment is now possible by using generic questionnaires or a specific one (Chronic Urticaria Quality of Life Questionnarie - CU-Q2oL). The available studies widely confirm that patients suffering from CU have a reduced HRQL, with considerable limitations in terms of well-being, relationships, daily functioning, sleep, self-image and mood.

The traditional method of classifying perennial rhinitis into eosinophilic and non-eosinophilic is by taking a single nasal smear from one nostril. In the light of personal experience it was felt that this method of sampling may be inadequate. The present study included 20 patients with perennial rhinitis undergoing nasal surgery. Serum total IgE levels were taken and those above 40 IU/ml had allergen specific IgE measured. Nasal smears and biopsies were taken from 5 sites on each side of the nose; middle and inferior turbinates and post nasal space. The smears significantly correlated with the biopsies (rs = 0.446, P < 0.001). The distribution of eosinophils between and within nasal cavities was found to differ. Representative sampling of the nose is important for accurate eosinophil expression. The definition of an eosinophil rich and poor nose requires greater clarification as it has great clinical relevance regarding management.

The effects of azelastine were investigated in 23 patients with perennial and 57 with seasonal allergic rhinitis seen in our institutions between October 1986 and April 1988. The antigen in seasonal allergic rhinitis was identified as Japanese cedar pollen in 45 patients and cock's footgrass in 12.1. In the rating general improvement of the response was classified as moderate or better in 47.8% of those with perennial rhinitis and as slight or better in 82.6%. The corresponding values for seasonal rhinitis were 57.9% and 84.2%. The combined ratings were 55.0% and 83.8%, respectively.2. Treatment reduced the following symptoms: sneezing, nasal secretions, nasal obstruction, disturbances in daily living, and volume of secretion.3. Japanese cedar pollinosis was treated in 25 patients in 1987 and in 20 in 1988. The general improvement ratings were 40.0% and 68.0% in 1987 and 75.0% and 95.0% in 1988. Considering that in 1988 the Japanese cedar pollen count was four times that in 1987 the difference in the general improvement rating between the two years may be due more to the duration of treatment than to the pollen count.4. Drowsiness as an adverse reaction was noted in 4 of the 80 patients, and treatment was discontinued in one.5. In general utility the drug's usefulness was rated as moderate or better in 47.8% of the perennial rhinitis patients and as slight or better in 78.3%. The corresponding values for the seasonal rhinitis patients were 57.9% and 84.2%, respectively. The general utility ratings for both types combined were 55.0% and 82.5%.

Background: Allergic rhinitis is commonly divided into seasonal and perennial rhinitis. The recent Allergic Rhinitis and its Impact on Asthma (ARIA) workshop proposes to replace these terms by intermittent vs persistent rhinitis. Methods: In order to test the new ARIA classification against the classical one used in medical practice in France, we designed two cross-sectional surveys: (i) a spring survey, where 1321 general practitioners enrolled 3026 patients consulting for seasonal allergic rhinitis and (ii) an autumn–winter survey, where 1346 doctors enrolled 3507 patients for perennial allergic rhinitis. Both doctors and patients filled out a specific questionnaire on allergic rhinitis. Results: Focusing on the number of days per week and consecutive weeks per year, the patients described the duration of their symptoms (based on an auto-questionnaire). About 43.7% of the patients, classified by their doctor as seasonal, did in fact have persistent rhinitis, whereas 44.6% classified as perennial had intermittent rhinitis. Conclusions: The proposal of the ARIA expert panel defining the chronology of allergic rhinitis as number of days per week and consecutive weeks per year is likely to change daily physician practice.

Background: Allergic rhinitis, asthma or the atopic eczema/dermatitis syndrome (AEDS) may independently impair quality of life in patients. However, although many allergic patients may suffer from more than one disorder, the effect of concomitant disease — in particular, the impact of AEDS — is largely unknown. As part of a large multicenter clinical trial on the efficacy of mattress casings in house-dust mite (HDM) allergy, generic quality of life in a mixed population of 224 subjects with rhinitis (n = 198) and/or asthma (n = 111) and/or AEDS (n = 64) was studied. The study aimed to estimate quality of life impairment in these atopic patients and to address the questionissue of whether one atopic disorder goes beyond other existing allergic diseases, thereby causing further impairment to quality of life. Methods: Generic quality of life was assessed by SF-36. Quality of life in the atopic group was compared with a Dutch norm population. Multiple linear regression was used to determine the effects of disease (i.e. the presence of allergic rhinitis, asthma or AEDS) or disease severity, as assessed by visual analog scores (VAS) for asthma, rhinitis, VAS sleeplessness and VAS itching being considered as major symptoms in AEDS on SF-36 domains. Results: Compared to the norm group, atopic patients were impaired in: physical functioning; role physical functioning; general health; vitality; and social functioning. The diagnosis of asthma was negatively associated with the SF-36 subscales for physical functioning (P = 0.02), and general health (P

Trichophyton was recently reported to be the cause of respiratory allergy in patients with severe bronchial asthma. We describe eight patients with perennial rhinitis in combination with skin or toe-nail infection, in whom Type I hypersensitivity reaction to Trichophyton was confirmed by skin test, RAST and nasal provocation. When treated with oral fungicidal therapy, there was significant improvement in both their skin and nasal symptoms. Local therapy produced only a mild, transient improvement. We emphasize the need for thorough evaluations in patients with respiratory allergies and negative routine skin tests.

Our primary objective in designing the first large-scale nationwide population-based survey in France was to assess the impact of perennial rhinitis on quality of life. Our secondary objective was to describe the use of drug treatment, including histamine H1 antagonists, in that population. A pollbase of 20,000 households was screened for symptoms of rhinitis. 16,786 households responded, including 35,615 patients aged over 15 years, giving an overall response rate of 84%. Using an algorithm, 1367 patients with probable perennial rhinitis were selected for a cross-sectional collection of data about the history of their condition, comorbidity, use of medical resources, sick leave and nasal symptom-related quality of life [according to the Medical Outcomes Study 36-Item Short-Form Questionnaire (SF-36)]. Finally, multivariate regression techniques were used to describe the relationship between quality-of-life scores and treatment subgroups, controlling for some other confounding factors. The point prevalence of perennial rhinitis was estimated to be 4.1% [95% confidence interval (CI): 3.9 to 4.3%]. Association of perennial rhinitis with a history of asthma was highly significant (13.4% in those with perennial rhinitis vs 3.8% in those without; odds ratio 3.26; p0.001). 38% of the patients with perennial rhinitis reported having taken regular medication during the last 3 months. Antihistamine use was associated with use of decongestant or topical nasal products in about one-third of patients. Four SF-36 dimensions (physical functioning, role physical, bodily pain, social functioning) showed significantly higher mean scores (indicating better quality of life) in patients receiving non-anticholinergic histamine H1 antagonist therapy, relative to those receiving other treatments, a difference that was maintained after controlling for gender, age, level of nasal symptoms, medical history of asthma and number of general practitioner visits. These results established the long term impact of perennial rhinitis on quality of life (generic and specific), and raised questions about appropriate therapy, since a positive association between current use of non-anticholinergic antihistamines with improvements on some SF-36 dimensional scores in patients with perennial rhinitis was observed.

This was an open, randomized, cross-over study comparing the efficacy and acceptability of aqueous nasal suspensions of budesonide, 200 micrograms b.i.d. and beclomethasone dipropionate (BDP), 100 micrograms q.i.d., each given for 6 weeks to patients with perennial rhinitis and a history of allergy. Forty men and women aged 18-65 years with perennial rhinitis diagnosed at least 1 year previously, were recruited for study provided they had at least two of the following symptoms of rhinitis--blocked nose, runny nose, itching nose or sneezing. They were requested to record the presence or absence of nasal and ocular symptoms on a severity scale of 0-3 (none, mild, moderate, severe) in daily diary cards. The sum of the nasal scores was calculated to give the total nasal symptom score. Mean individual symptom scores and total symptom score were calculated for each treatment. Thirty-seven patients completed the study. The mean total nasal symptom score was significantly lower during budesonide (2.13) than during BDP (2.75), P = 0.001. There were significantly fewer reports of blocked nose (P = 0.004), runny nose (P = 0.0005) and sore eyes (P = 0.047) during budesonide treatment compared with BDP. Four patients reported adverse events during budesonide treatment (two had nosebleeds and two nasal dryness) and three patients during BDP treatment (two had nasal dryness and one gastric discomfort). A significantly greater proportion of patients stated a preference for budesonide than for BDP on the basis of effect (P = 0.0001), side-effects (P = 0.01), and overall (P = 0.0001).

The contact to chinchilla in households may lead to sensibilization and allergic rhinitis in children and adults. In nasal provocation tests on 6 sensibilized patients suffering on perennial rhinitis and/or asthma one child and three adults showed positive reactions with chinchilla hair extract. Allergen avoidance is recommended.

In a study group including 2067 adults 20–60 years old who volunteered to get a check up examination in the Public Health Care in Marseille, France, we wanted to evaluate the prevalence of atopy, the prevalence of allergic reactions to hymenoptera venoms and the prevalence of systemic reactions to drugs.

Perennial rhinitis may be defined clinically as an inflammatory condition of the nose characterised by nasal obstruction, sneezing, itching, or rhinorrhoea, occurring for an hour or more on most days throughout the year. In one study in London of adults between the ages of 16 and 65 years, the prevalence of rhinitis was 16%; of these, 8% had perennial symptoms, 6% perennial and seasonal symptoms, and 2% seasonal symptoms alone. As with asthma, both seasonal and perennial rhinitis seem to be increasing. ### Non-allergic, non-infective rhinitis* *Poorly understood and more difficult to identify specific causes Allergic rhinitis —Perennial allergic rhinitis can …

Symptoms of rhinitis in 595 children who attended an allergy clinic over a four-year period were examined to determine the relative frequencies of perennial rhinitis and seasonal rhinitis (hay fever). Perennial rhinitis was much more common than seasonal rhinitis at all ages, and only 12% of children with rhinitis had symptoms restricted to the grass pollen season. The detection of eosinophils in nasal smears from subjects with rhinitis was uncommon (10% of cases), while mast cells were found in one third of cases. Rhinitis was the most common symptom of atopic disease.

Therapeutic trials of intranasal sodium cromoglycate have shown it to be of value in some patients with seasonal or perennial allergic rhinitis and in some with perennial rhinitis of unknown cause. Its use usually enables a reduction in antihistamine requirements thus, sodium cromoglycate should be useful in patients made drowsy by antihistamines. As in trials in asthma, the degree of benefit varies between individuals. Nasal obstruction and rhinorrhoea are relieved more consistently than eye symptoms, and nasal polyps are not reduced in size.

Nasal polyps yielded specimens, which technically were most suitable for study in the scanning electron microscope. A small number of glands and cytoplasm protuberances from the epithelial cells were found. 30% of the total surface was covered by cilia. The cilia looked normal with no signs of destruction. In half of the specimens, areas with widened intercellular spaces were observed. The surface of nasal polyps did not differ essentially from that of the inferior turbinate in patients with perennial rhinitis. It was, however, characteristic of the polyps that cells from a transitional-like epithelium protruded, dome-like, at the surface, resembling cobble-stones. Besides this, a great variation of the surface area of the cells was found, with the occurrence of large cells with a surface area of up to 150 μm2. Another characteristic feature was the occurrence of an irregular surface with an appearance resembling a hilly country, in which every uneveness consisted of several cells.

We examined the nasal responsiveness to topical methacholine application in allergic rhinitis and non-allergic chronic rhinitis patients, and in control subjects. Methacholine responsiveness was significantly higher in allergic rhinitis patients than in non-allergic patients and control subjects. In perennial rhinitis, methacholine responsiveness correlated with the severity of daily nasal symptoms and those provoked by specific allergen challenge tests. Among nasal symptoms, hyper-rhinorrhoea was found to be closely related to methacholine responsiveness. As a result of these findings, the possibility of cholinergic hyper-reactivity in allergic rhinitis patients is discussed.

Summary As part of a study of the effectiveness of beclomethasone dipropionate in perennial rhinitis five immunologically related parameters were measured. These included skin tests, total IgE, specific IgE, nasal and peripheral blood eosinophil counts. In addition, nasal biopsies were obtained in twenty out of sixty patients. It was apparent that patients with perennial rhinitis formed a heterogeneous group who could be divided into three groups based on the extent of immunological abnormality detected. Group 1 consisted of twenty patients who displayed no abnormality in any of the five parameters studied. Group 2 consisted of twenty-six patients in whom specific IgE was not detected but who had varying degrees of abnormal findings in the other laboratory parameters. The remaining fourteen patients formed a third group in whom specific IgE was detected in addition to abnormalities in other parameters. In general, patients with detectable specific IgE had a higher frequency of abnormal parameters, including abnormal histology of their nasal biopsy, than patients in whom no specific IgE was detected. The heterogeneous nature of perennial rhinitis is discussed. Despite the heterogeneous nature of the total patient group, the majority of patients (80%) treated with beclomethasone dipropionate improved compared to 20% improved in the placebo group. There was no difference in the drug effect between the three groups of patients.

Although propylene-and-polyethylene-glycol and saline have been used in clinical studies as placebos, their possible therapeutic role as wetting agents in the treatment of perennial rhinitis was investigated. Clinical and laboratory response to these agents was measured in eighteen patients during a 2-week baseline period and with 4 weeks of active treatment in a double blind randomized study. After 2 and 4 weeks there was a significant improvement compared to baseline in nasal function (P less than 0.05) and blockage index (P less than 0.01) combining both groups, with no difference between treatments. Patients had less sneezing at 2 and 4 weeks (P less than 0.01), and less stuffiness at 4 weeks (P less than 0.01). There was a significant correlation between improvement in blockage index and nasal biopsies when both were judged independently of the other. This study has demonstrated that wetting agents offer both subjective and objective improvement in the treatment of perennial rhinitis and merit consideration prior to (or along with) other agents with known systemic side effects.

Summary Children with allergic perennial rhinitis had a four-fold greater likelihood of having had an ear, nose and throat (ENT) operation than children with orthopaedic problems. Whilst the patients who had ENT operations had significantly lower serum IgA and IgE levels than the non-operated patients, there was no difference in clinical features of atopy or allergy skin-test responses between the two groups of rhinitic patients. Forty per cent of the perennial rhinitics had an improvement in symptoms following ENT operations, whereas 90% improved on medical therapy. Thus, patients with perennial rhinitis should have allergy investigations and the benefit of medical treatment prior to consideration for surgery.

In this investigation, a double-blind, cross-over trial of sodium cromoglycate in 23 patients with perennial rhinitis was carried out. An improvement in symptoms was found in actively-treated patients, and a greater preference was expressed for active treatment. There was no relationship between response to sodium cromoglycate and the results of allergological investigation. It is conclcuded that therapeutic trial of sodium cromoglycate is worth considering in patients with perennial rhinitis, irrespective of the results of RAST and intracutaneous skin tests.

The efficacy and safety of beclomethasone dipropionate (BD), 0.05 mg three times daily, sprayed in each nostril was studied in 39 adult patients with perennial rhinitis in a 12 wk, double-blind, vehicle controlled trial. Parameters of IgE-mediated reactivity, including epicutaneous skin testing, total serum IgE, specific serum IgE, and nasal eosinophilia, were assessed. All adverse reactions, including changes in serum cortisol and nasal and pharyngeal Candida infections, were monitored. Sixty-three percent of BD patients achieved total or substantial control of nasal symptoms compared with 25% of controls (p = 0.04). Eighty-three percent of BD-treated, skin test-positive patients improved, while only 14% of BD nonatopics improved (p less than 0.05). All BD patients with nasal eosinophilia improved compared with 38% without eosinophilia. Adverse reactions were frequent, minor, and equal in both groups. Serum cortisols were stable and no nasal Candida infections were documented. This study demonstrates the efficacy and safety of BD in treatment of perennial rhinitis, particularly in atopic patients with nasal eosinophilia.

The effect of a combined pediatric preparation of brompheniramine maleate and phenylpropanolaminehydrochloride (Lunerin mite) was studied in 17 children (aged 4-14 years) with allergic rhinitis. A double-blind cross-over technique was used, and a score system was used for evaluation of symptoms and signs. The results show that the drug had a good effect with statistical differences on the 1 per cent level between the active preparation and the placebo. The effect was less pronounced in children aged more than 10 years, for whom a higher dose of the drug is recommended. The frequency of side-effects was negligible.

Summary The efficacy of a 2% solution of sodium cromoglycate has been assessed in the treatment of chronic perennial rhinitis by a double-blind group comparative trial over a period of 4 weeks. The solution was administered to the nose as a fine spray delivered by a metered device at a frequency of six times a day; thus the daily dose of active drug was approximately 31.2 mg. The patients' response was measured by both subjective and objective parameters; in addition nasal smears were examined for eosinophils before and after treatment. Analyses of the subjective data demonstrated a significant difference between the active and placebo solutions at the end of the trial. The objective data was obtained by measurement of nasal resistance and flow at weekly intervals; there was a highly significant difference between the two treatment groups compared to the baseline measurements after only 1 week's treatment. There was a reduction of eosinophils in the nasal smears in those patients allocated the SCG solution, there was virtually no change in those who received placebo; the difference was significant. This study has demonstrated that a 2% solution of SCG is effective in the treatment of perennial rhinitis. It has been shown that measurements of nasal airways resistance and flow are sensitive indices of changes in the mucous membrane of the nose and that beneficial effects of SCG solution can be detected after 7 days treatment.

Summary Ten patients with allergic perennial rhinitis completed a 3-month course of treatment with flunisolide nasal spray†. Biopsy of the nasal mucosa was carried out before the initiation of treatment and at the end of the treatment period. The flunisolide was administered as a 0.025% solution twice daily at a total daily dose of 200μg. No histological abnormalities which could have been attributed to the effects of the drug were found in the post-treatment biopsies. Comparison of the pre- and post-treatment histological features showed either that there had been no apparent changes or that there had been a reduction in the oedema and/or cellular infiltration which had been present initially. All except one patient improved clinically and in this case the pre-treatment nasal biopsy demonstrated features of atrophic rhinitis.

1. Five years' experience in the use of beclomethasone dipropionate aerosol (BDA) in the treatment of 315 patients with upper respiratory tract allergy is reviewed. 2. A total of 223 patients with perennial rhinitis was treated. In 23, where the nasal allergy had recurred after oral corticosteroid therapy for asthma was withdrawn, BDA was effective in 69% of cases. A similar success rate (68%) was recorded in 169 patients suffering from perennial allergic rhinitis alone, but a satisfactory response was observed in only 45% of 31 patients with nasal polypi. 3. In 92 patients with seasonal allergic rhinitis freedom from symptoms was achieved in 80%. 4. A total of approximately 534 patient-years of treatment has been recorded without any evidence of side-effects either clinically or on nasal biopsy.

The present investigation evaluated dentoalveolar morphology in 49 children between 6 and 16 years of age with bronchial asthma and perennial allergic rhinitis, and in 49 control children matched with respect to age and sex. Dentoalveolar morphology was measured on study casts and fourteen variables were recorded. No statistically significant differences were found in dentoalveolar morphology between asthmatic children and controls (p 0.05). Correlations between asthma severity and morphology within the asthma group did not show any significant associations (p < 0.2). The results from this study indicate that the average asthmatic children in countries where close control is habitual are not specifically at risk of developing a malocclusion.

A double-blind crossover study has compared intra-nasal sodium cromoglycate (SCG) with beclomethasone dipropionate (BDP), and both drugs with placebo, in fifty-two chronic perennial rhinitis patients. BDP was significantly more effective in relieving symptoms than SCG (76.9% and 50% of the patients improved respectively, P < 0.01). Both drugs were more active than placebos but while BDP was very clearly more effective (P < 0.0005) SCG was only marginally better than its placebo (P < 0.05, Fisher; P = 0.068, chi 2). BDP was selected by 56% of the patients as the best agent for continuing therapy at the end of the trial. By contrast SCG was preferred by the same number of patients as chose the two placebos (11.5%).

Nasal biopsies of patients with perennial rhinitis were performed at baseline and compared with biopsies performed 4 wk after active flunisolide, 50 μg four times per day, or placebo. An effort was made to relate histologic findings to other subjective and objective parameters as an indication of response to treatment. Although patients admitted to the study had severe subjective nasal symptoms, biopsies varied considerably. Some resembled biopsies from normal individuals, and others showed marked edema and inflammation; the latter findings were more typically present in the biopsies of patients with the most severe disease. A decrease in edema and loss of inflammatory cells on biopsy as well as a corresponding decrease in eosinophils on the nasal smear usually accompanied clinical improvement, which occurred in both the active and placebo groups.

THE OTOLARYNGOLOGIST needs an adequate method of treatment for those patients who suffer with vasomotor rhinitis so severe that it defies conventional forms of therapy. It is frequently impossible to differentiate in a patient with a perennial problem, whether he suffers from true allergic vasomotor rhinitis. The diagnosis and management of seasonal allergic rhinitis is fairly satisfactory. The cause of perennial rhinitis is frequently elusive. If the physician and patient cooperatively discover the offending allergens or irritants, control of the disorder is possible. All too often, however, despite extensive allergic testing and food elimination tests no cause is found. In such instances one has to resort to less rational forms of therapy, such as the administration of drugs and performance of various intranasal procedures to produce a larger nasal airway. In this discussion we are concerned, then, with the patient who has chronic or frequently recurring nasal obstruction, watery rhinorrhea