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Summary A Wright peak flow meter was used with a special mask for evaluating nasal blockage in a clinical drug study. The effect of beclomethasone dipropionate inhaled nasally was studied with PEFRn measurements twice a day in twenty-seven hospital patients with perennial rhinitis. Thirteen patients also had asthma. A statistically significant improvement in PEFRn values during the first 5 days of the active drug period was noted in both the rhinitis and rhinitis-asthma groups. In the rhinitis-asthma group the nasal blockage index, as calculated from the oral PEFR and PEFRn values, improved significantly during the second period of medication. Patients with rhinitis were found to have a tendency to fluctuating blockage according to the time of the day, the morning generally being poorer than the evening values. The fluctuation partially disappeared at the end of the period of active treatment, which also had a favourable effect on the bronchial obstruction of asthma patients when inhaled nasally, perhaps due to improved nasal respitatory function. The measurement of PEFRn values is, the authors believe, a useful method for measuring changes in nasal blockage of patients with rhinitis and asthma because of its simplicity and rapidity.

Summary Ten patients with either seasonal allergic or perennial rhinitis were treated with intra-nasal beclomethasone dipropionate B.P. (Beconase) and nine comparable patients were treated with sodium cromoglycate B.P. (Rynacrom). The beclomethasone dipropionate was administered as 50 μg per puff into each nostril three times a day and the sodium cromoglycate as one capsule insufflated into each nostril four times a day. Treatments were allocated on a randomized basis and each patient received a course of treatment lasting 2 weeks during the summer of 1973 when the pollen counts were high. Utilizing patient daily symptom diary cards, physician's assessment and by examination of the nasal mucosa prior to and at the end of treatment, it was concluded that both intra-nasal beclomethasone dipropionate and intra-nasal sodium cromoglycate effect a reduction in the symptoms associated with rhinitis. No side effects of importance were noted, nor were there any adverse changes observed in the state of the nasal mucosa.

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.

Beclomethasone dipropionate aerosol (BDA), 50 mug four times daily sprayed into each nostril, was compared with placebo in a double-blind crossover trial in 26 patients with perennial rhinitis. Patients received BDA for 3 weeks and placebo for 3 weeks; the order of administration was randomized. Response was assessed with daily symptom score cards and twice weekly measurements of nasal airway inspiratory resistance at a standard flow rate of 0.4 L/sec. Symptom score and nasal resistance during BDA treatment were significantly lower than those duirng placebo treatment (p less than 0.02 and p less than 0.05, respectively) in the third week. Eighteen of the patients expressed a preference for BDA, 6 for placebo, and 2 for neither (p less than 0.05). Acceptable symptomatic improvement (moderate or marked) was achieved by 54%. Mild side effects were noted by 5 patients; these included nasal irritation and bleeding in 2, aerosol-induced sneezing in 2, and headache in 1. These side effects occurred in 3 patients who used BDA, 1 who used placebo, and 1 who used both. After a 6-mo follow-up period, in which the dose of BDA was adjusted and concurrent initial oral prednisone was administered to patients who were treatment failures, 73% of the patients obtained moderate or marked symptomatic improvement. No further side effects were noted during this time. Results in those in whom a possible allergic component could be identified were not different from those of the whole group. We conclude that BDA is a useful addition to the therapy of perennial rhinitis.

• A flunisolide-containing intranasal spray and matching placebo were used in an eight-week, double-blind parallel study in 67 patients with perennial rhinitis. Seventeen patients who did not benefit from treatment with the placebo then switched to flunisolide for a six-week open trial. Flunisolide-treated patients showed greater improvement in both duration and severity of symptoms, as well as a greater preference for flunisolide; 75% of patients either had "mild" symptoms or were asymptomatic and 67% stated that they experienced "substantial" or "total" control of symptoms. No serious side effects were encountered. Chief side effects in both drug and placebo groups were brief, mild, nasal burning and stinging on spray application. The drug exhibited no adverse effects on adrenal function (morning plasma cortisol levels). ( Arch Otolaryngol 105:649-653, 1979)

Summary Flunisolide nasal spray has been compared with placebo and with beclomethasone dipropionate in the treatment of perennial rhinitis. A double-blind, cross-over study in 26 patients comparing intranasal flunisolide (total dose 300 μg/day) with placebo showed superiority of the active preparation in the relief of sneezing, stuffiness and runny nose. Physicians and patients significantly preferred the active spray. Side-effects on both sprays were mainly confined to transient nasal irritation. Plasma cortisol levels did not change significantly during the trial. A single-blind, cross-over study in 34 patients comparing flunisolide and beclomethasone dipropionate showed relief of sneezing, stuffiness, runny nose and nose-blowing with both medications. There were no differences between the effects of the two preparations. Physicians and patients favoured the drugs equally. Side-effects were minor.

The effectiveness of a topical steroid, flunisolide, was evaluated in patients with perennial rhinitis. Thirty-four patients went through a double-blind cross-over study, comparing flunisolide 200 microgram per day with placebo. The symptoms were assessed over two treatment periods each of 4 weeks, with a 2 weeks' washout period in between. There was a statistically significant difference in favour of flunisolide. About half of the patients complained of mild initial irritation from both active drug and placebo.

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.

Serum samples were obtained from patients with house dust mite–sensitive nasal allergies before and 6 months after immunotherapy, and the level of immunoglobulin (Ig)E, IgG1, and IgG4 antibodies in those sera was determined by the enzyme-linked immunosorbent assay. The present data showed that the mite-specific IgG4 antibodies increased in patients who responded well to immunotherapy but not in those who responded poorly. It was suggested from the present study that IgG4 antibodies seem to act as “blocking antibodies” to reduce the allergic reaction in the target organ, and that an increase of allergen-specific IgG4 antibodies following immunotherapy can be of clinical benefit to patients suffering from mite-specific nasal allergy.

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.

Eighty micrograms of the topically active parasympatholytic ipratropium were applied intranasally 4 times a day to 20 adult patients with perennial rhinitis and severe watery rhinorrhoea in a double-blind placebo controlled cross-over trial. There was a significant reduction in nasal hypersecretion during ipratropium treatment. Fourteen patients preferred the ipratropium period, 3 the placebo period and 3 had no preference. There were no adverse systemic or local effects. Ipratropium was effective also in patients resistant to glucocorticoids, sodium cromoglycate and antihistaminics. As the drug works immediately it can also be used before exposure to known provocating factors. It is concluded that continuous use of this new medication is of value in the management of severe rhinorrhoea in patients with perennial rhinitis, and that the occasional use is helpful in subjects with infrequent attacks of nasal hypersecretion.

Hyposensitization with a tyrosine adsorbed extract of Dermatophagoides pteronyssinus was effective in relieving symptoms in selected patients with perennial rhinitis due to this allergen who had responded poorly to topical application of steroids. There was a significant reduction in the nasal response to allergen after six weekly injections only in the actively treated group, but symptomatic improvement greater than that produced by placebo therapy was only evident after a further 10 months of monthly injections. Significantly more placebo-treated patients considered that therapy was ineffective and withdrew from the study. Only one patient developed significant unwanted effects from the injection therapy and had to be withdrawn from the study. We conclude that hyposensitization with a tyrosine adsorbed extract of Dermatophagoides pteronyssinus can be a safe and effective treatment for adults with perennial rhinitis due to this allergen who have responded poorly to nasal corticosteroids, and that those patients who eventually respond clinically are likely to have a diminished nasal response to allergen after the first 6 weeks of therapy.

The effects of elevated intranasal temperature on symptoms and signs of perennial rhinitis were studied in 78 patients by a double-blind, randomized, placebo-controlled clinical trial. Patients were subjected to two treatments separated by a 1-week interval. Each treatment consisted of three 30-minute sessions, during which the patient's intranasal temperature was raised by inhalation of saturated hot air (42°C to 44°C). Subjective response was recorded on a daily symptom score card during the week following treatment. Nasal patency was determined before and after treatment by measuring maximal nasal expiratory and inspiratory airflow and by measuring the area covered with vapor formed by the exhaled air on a plate. Highly reproducible results were obtained by using these three objective methods. Elevation of intranasal temperature resulted in amelioration of rhinitis symptoms and in objective evidence of increased nasal patency in a significant percentage of patients compared to the placebo-treated group.

The aim of this study was to develop a test for the measurement of nasal reactivity. Different concentrations of methacholine were sprayed intranasally, and the nasal secretion and blockage were measured in normal subjects. The simple collection and measurement of secretion was found to be a valuable parameter of mucosal reactivity, while measurement of nasal airway resistance was unreliable, due in part to the presence of secretion in the nasal cavity. The methacholine test had a fairly good reproducibility when the amount of secretion was used as the only parameter. It caused a significantly stronger reaction in women than in men. Patients with perennial rhinitis had a more vigorous response than the controls. It is concluded that the methacholine test may prove useful as a sign of perennial rhinitis and also for the objective evaluation of medication, but further studies are warranted.

We studied the efficacy and side effects of the H 1 -antihistamine astemizole in perennial rhinitis. We also defined subgroups of responders and examined the added effect of a steroid spray. Fifty-five adults completed a 10- to 14-week controlled trial. Astemizole reduced the number of sneezes to 41% ( p p p p p 1 -antihistamine suitable for continuous therapy of perennial rhinitis.

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.

Skin tests were performed on 210 patients with house dust allergy and bronchial asthma or perennial rhinitis using extracts of Dermatophagoides pteronyssinus and of four storage mites most commonly found in house dust in the United Kingdom--Acarus siro, Tyrophagus putrescentiae, Lepidoglyphus (formerly Glycyphagus) destructor and Glycyphagus domesticus. The results of the skin tests were related to certain occupations and living conditions of the patients which could have exposed them to storage mites and some patients were included because their environment seemed especially likely to expose them to these species in order to assess the importance of these conditions. D. pteronyssinus was the most potent of the mite allergens and provoked the largest number of positive tests but a proportion of the storage mite species gave skin reactions which were larger or as large as those of D. pteronyssinus. No significant statistical correlation was found between reactions to D. pteronyssinus and any storage mite but highly significant correlations were found between some storage species. The frequency and strength of reactions to these species were unexpectedly high in view of their irregular occurrence and relative scarcity in house dust. It is suggested that sensitisation to these species occurs through exposure either to localised sources of infestation overlook during the random collection of floor or bedding dust or to infested materials encountered at work or other activities or to infested food or bedding of certain domestic pets. It is concluded that allergy to storage mites is more important and widespread that hitherto realised and is a considerable occupational hazard in farming communities and to those in occupations handling infested materials. Storage mites may also be important allergens for those living in very damp houses where the growth of moulds may encourage the development of Glycyphagus domesticus or other mites.

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.

Fluocortin butyl (FCB) is a new topically active steroid. In this 12-week, parallel, multicenter study, 157 symptomatic patients, aged 12–69 years, with moderate to severe perennial rhinitis were randomized to receive either FCB powder or beclomethasone dipropionate (BDP) aerosol spray intranasally. Four symptoms and four signs were scored at the start of the study and every 2 weeks for 12 weeks. Use of concomitant medications and dosage of intranasal medication were monitored. The nasal cytology and nasal cultures of randomly selected patients were examined. At one center 40 patients had rhinomanometric evaluation. Significant decrease from baseline in symptoms and signs was evident by 2 weeks and then continued at a slower rate for up to 12 weeks with both FCB and BDP. There was also an increase in nasal airflow as shown by rhinomanometry and a decrease in concomitant medications. There was no significant difference in efficacy between the two medications. Both drugs were tolerated with minimal side effects. With a lower incidence of nasal irritation and a simple delivery system, FCB has a definite place in the treatment of rhinitis.

Summary The effectiveness of a new topical steroid, flunisolide, was evaluated for the treatment of patients with perennial rhinitis. The sixty-nine patients in this 8 week double-blind parallel trial received either 300 γg/day of flunisolide or placebo. The flunisolide group showed statistically greater improvement than the placebo group in such symptoms as the duration of sneezing, stuffy nose, runny nose and nose blowing. 63% of the flunisolide group compared with 39% of the placebo group felt the test spray had provided substantial or total control of their nasal symptoms (P= 0·0026). When those patients who were skin test-positive (allergic) were considered separately from those who were skin test-negative (non-allergic), differences in responsiveness were noted. While those patients who had negative skin tests received greater relief of their symptoms with flunisolide than with placebo, patients who had positive skin tests showed a greater responsiveness to flunisolide and reported a higher incidence of significant or total control of their symptoms. Careful monitoring of plasma cortisol levels revealed no evidence of adrenal suppression in any of the patients in this trial. This lack of suppression may be due to two factors: (a) flunisolide is rapidly metabolized into a metabolite with a low degree of activity and (b) a very low dose of corticosteroid is administered.

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

The ancients were well aware of the presence of nasal polyps and of the problems which they presented, and they devised ingenious methods for their removal. The evaluation of the present knowledge of the etiology and treatment of nasal polyps must be viewed with a degree of skepticism engendered by a lack of unanimity of opinion. We do not now know the etiology of polyps. Polyps do not occur solely as the result of allergy; many allergic patients (with seasonal and perennial allergy) do not have them. Polyps represent a hyperplastic change of one portion or all of the nasal or sinal mucosa. Clinicians fail to distinguish between polyps that occur in one person and those that occur in another. This might explain why the same management or procedure is ineffective in one patient and effective in another. A patient with nasal polyps must be distinguished by an additional factor, possibly an inherited structural deficiency of connective tissue. Atopic patients with seasonal and perennial rhinitis associated with extensive nasal polyps may undergo surgery of the nose and/or sinuses. Nonatopic persons, however, are best approached with surgical reluctance, since bronchial asthma develops rapidly in this group. Dissatisfaction with present methods of management arises from failure to control the regrowth of polyps. This applies to those patients whose rate of recurrence of polyps has been prolific and rampant. Attention is directed to the fact that polyps may be a presenting part of underlying tumors, thereby clouding the true nature of the growth pattern. Furthermore, the proliferative nature of polyps may indicate a type of pathologic entity termed "inverting papilloma," erroneously considered to be "merely polyps." An integrated study by the allergist and the rhinologist should be encouraged if the problem is to be solved.

Summary Bronchial asthma is an allergiccondition characterized by wheezing, dyspnea, orthopnea, and cough. It is usually preceded or associated with seasonal or perennial rhinitis. The responsible allergens in childrenare easily discovered in at least 95 per cent of the cases. The history, physical examination, and clinical trials are important. Skin tests should be made in all cases and be done with all protein-containing materials to which the child is exposed. Scratch tests should be done first;intradermal tests are also necessary in about 25 per cent of all cases. Best results are obtained by strictavoidance of causative allergens and by hyposensitization with important inhalant materials. Preventive measures are importantin children of allergic parents. They can definitely delay the onset and lessen the severity of allergic conditions, including asthma. Reassurance, epinephrine, iodides, and ACTH and steroids are the most important symptomatic measures. Attention to complicating infections and to psychic influences are also necessary. Results in asthma in children areusually excellent and they are improving.

The most significant advances in the 1929 literature on hay fever may be enumerated as follows: 1.1. The further increase in percentage of good results in treatment by more general recognition that other sensitizations, such as foods, epidermals, etc., may be complicating, or even the only, factors in seasonal hay fever. 2.2. The admission by some of the most enthusiastic advocates of local therapy or nasal surgery that pollen injections have their place in treatment of hay fever. 3.3. The continued increase in reports of hay fever surveys from various sections of the world, and the addition to our list of hay fever producing pollen. 4.4. More thorough analysis of series of cases, especially from the standpoint of "cures." 5.5. Further chemical studies. 6.6. Extensive studies on atypical cases of hay fever, such as hay fever without positive diagnostic tests, and perennial rhinitis due to pollen harbored in protected places in the home. 7.7. The increasing and more widespread realization of the fact that pollen desensitization, although not a perfect treatment, is the most effective means at our disposal for the treatment of hay fever.

Summary 279 patients, most of whom had perennial asthma or perennial rhinitis, were tested intradermally with extracts of Dermatophagoides pteronyssinus and D. farinae in order to ascertain the incidence of positive skin reactions. The great majority of house dust sensitive patients had positive skin reactions to both mite extracts. However, the concordance between house dust and mite extract positive skin reactions, though statistically significant, did not reach the extent found in other countries. Of the three extracts employed, D. pteronyssinus appeared to contain the most potent allergen while its culture medium extract yielded a low percentage of positive skin reactions. These results suggest that, in italy also, mites seem to represent the most important allergenic source of house dust.

DSCG was tested on 38 patients with perennial rhinitis in the form of a nasal spray (2%) in a double-blind cross-over trial. Few of the investigated parameters in the whole material showed any significant preference of DSCG. A marked drug order effect was shown; in the group receiving placebo first, most of the clinical parameters assessed both by the clinician and the patient were better for DSCG. A therapeutical trial with DSCG is worth trying in perennial rhinitis.

Twenty-seven children with perennial rhinitis entered a double-blind cross-over study comparing nasal sprays of flunisolide---a new topical corticosteroid---and placebo. Symptoms were assessed over two consecutive monthly periods with each treatment. Weekly diary cards, monthly clinical assessments, and end-of-trial preferences all favoured the active drug. At the end of the trial 20 patients preferred the treatment month with flunisolide, four preferred the placebo month, and two rated the periods equally. Side effects were mild, the commonest being transient nasal stinging. Seventeen children who derived benefit from flunisolide continued with the treatment for a six-month open-study period. Many reduced the dosage from three times to twice or once daily without losing benefit. The effect of flunisolide on the pituitary-adrenal axis was assessed in seven children by measuring the 0900 blood cortisol concentrations at two-month intervals over the six months. No effect was observed. The results show that flunisolide is effective and safe for the treatment and prophylaxis of perennial rhinitis in children.

A panel of human CD4+ T cell clones specific for the house dust mite was isolated from an atopic individual with perennial rhinitis. Soluble antigen specificity was defined using proliferation assays and subsequently the antigenic determinants recognized by some of these clones were mapped using nitrocellulose immunoblots of fractionated Dermatophagoides spp. Both cross-reactive and species-specific T cell clones were identified and in some instances their specificity could be mapped to the serologically defined Der f l, Der p I and Der f II allergens. In comparison, the serum antibody response showed additional specificity for Der f lll. The antigen recognition by six of these clones was found to be restricted by HLA-DR gene products.

Twenty-five patients with perennial rhinitis completed a double-blind cross-over trial of intranasal beclomethasone dipropionate 200 mug daily and placebo. Of these patients 19 preferred the active drug and two preferred placebo. There were significant reductions in symptom scores for nasal obstruction and rhinorrhoea and in the use of decongestant nasal drops when using the active drug. No changes in morning plasma cortisol levels occurred during the three-week treatment period.

Summary Tissues from patients with allergic asthma or perennial rhinitis have been examined and normal mast cell ultrastructure described. Degranulating mast cells are shown in nasal and bronchiolar tissue, with attention focused on granules, microfilaments and labyrinth and pore formations. Five stages of degranulation are described: (1) disappearance of granule lamellae; (2) swelling of area within perigranular membrane; (3) fusion of perigranular membranes or fusion of perigranular and plasma membranes; (4) perforation of fused perigranular and plasma membranes; (5) extrusion of granules.

• Nasal smears for eosinophils obtained by nose blowing and/or posterior nasopharyngeal swabbing were stained with Wright's or Hansel's stains and read in three groups of children aged 4 to 15 years: 65 with seasonal allergic rhinitis, 42 with perennial rhinitis and negative skin tests, and 70 nonallergic controls. Of smears obtained by either or both methods, 69%, 11%, and 7% were positive (≥4%) in the three groups, respectively. Almost identical results were obtained using only the nose-blowing method. In children with seasonal nasal symptoms, the nasal smear for eosinophils appears to be a reliable diagnostic test with moderately high sensitivity and high specificity. ( Am J Dis Child 1982;136:1009-1011)

Conventional treatments for non-allergic perennial rhinitis have proven somewhat unsuccessful in the control of rhinorrhoea when it is the predominant symptom. Hence, a double-blind cross-over trial of Ipratropium, a parasympatholytic, and placebo were carried out over a 12-week period. There was a significant reduction in rhinorrhoea during active treatment, with the most noticable effect being in the moderate-to-severe rhinorrhoea group. No significant effect was noted on nasal obstruction or sneezing and no serious side-effects were seen. A carry-on effect was noted when active treatment was used initially. However, the group given active treatment following placebo had a better result overall. A strong placebo effect was also noted in both groups, in keeping with a trial of this order.

The investigation of a recently synthesized non-halogenated steroid with a high local anti-inflammatory effect and low systemic glucocorticoid effect, on 36 patients with perennial rhinitis was carried out using a double-blind, cross-over technique, where the patients were treated with an aerosol spray containing a concentration corresponding to 200 micrograms/day and 400 micrograms/day of the active compound Budesonide, as well as placebo. There was a significantly better effect from the active compound than from placebo. A dosage-dependent effect was demonstrated for the symptoms nasal blockage and nasal discharge, while this was not so for sneezing bouts. No effect was observed on the function of the suprarenal glands. Local side effects were few and of no importance.

Seventy-eight patients with perennial rhinitis underwent a double-blind, placebo-controlled. 12-wk trial with flunisolide nasal spray, a new potent topical steroid. Eighteen of these patients were followed in an open study and evaluated at intervals for side effects and dosage of spray used. Baseline and plasma cortisol concentrations were performed before and at the end of the 12-wk, double-blind period. Adrenocorticotropic hormone (ACTH) stimulation testing was performed on six patients after 1 yr of flunisolide therapy at 300 micrograms/day or less. Flunisolide was found to be safe and effective over a short period. Over a 2-yr follow-up there were no serious side effects or evidence of adrenal suppression. Ten patients with perennial rhinitis continue to obtain subjective benefit after 2 yr of therapy with flunisolide nasal spray.

A double-blind crossover trial comparing the clinical efficacy of intranasal beclomethasone dipropionate and intranasal sodium cromoglycate was carried out in fourteen patients with perennial rhinitis due to animal danders. Intranasal beclomethasone dipropionate was significantly more effective than intranasal sodium cromoglycate in relieving nasal obstruction, nasal discharge and sneezing. Eleven patients reported preference for beclomethasone dipropionate and three had no preference for either drug.