D.S. Grewal, M.S., B.K. Sharma, M.S.,
D.D. Shah, M.S. and J.H. Sheode, M.S.,
Department of Otolaryngology and Head and Neck Surgery,
Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Bombay, India.

Allergy is a specifically altered state of the host after contact with a specific allergen. Rhinitis is clinically defined as a condition with one or more symptoms of sneezing, running of the nose and nasal obstruction. If by experimental or clinical evidence, a tissue damaging allergic hypersensitivity process can be inferred as the cause of symptoms, then the rhinitis may be called allergic rhinitis. The common allergens are pollen, house dust, milk, chocolates and drugs like aspirin; even over-use of nasal drops can lead to a type of allergic rhinitis known as rhinitis medicamentosa.

In allergic rhinitis there is a typical history of sneezing, rhinorrhoea and nasal pruritis with nasal obstruction. Nasal examination often reveals oedematous mucosa with bluish colouration; the turbinates may be hypertrophied and in extreme cases can even occlude the nasal cavities. It is frequently associated with nasal polypi and at times, even with bronchial asthma. On blood examination there may be eosinophilia and X-ray of the paranasal sinuses may show thickening of the mucous membrane of the maxillary antra. Skin tests may also be helpful in diagnosis but the results must be correlated with the history in order to be meaningful.

In vasomotor rhinitis there is abnormality of vasomotor control of the nose which is characterised mainly by nasal obstruction, running of the nose and sneezing. The state of the nasal mucous membrane is the resultant of two opposing forces, i.e., the sympathetic and parasympathetic nervous systems. The sympathetic nerve fibres take origin from preganglionic connector cells which lie in the lateral horn of the grey matter of the first and second thoracic segments of the spinal cord. From here they go to the superior cervical ganglion. From there post-ganglionic fibres reach the plexus around the internal carotid artery and then to the deep petrosal nerve and the vidian nerve to reach the sphenopalatine ganglion. From here they go via the palatine and nasopalatine branches to the nasal mucous membrane. The parasympathetic supply comes from the superior secretory nucleus in the pons; from here fibres travel via the pars intermedia of the facial nerve, the geniculate ganglion, the greater superficial petrosal nerve and the vidian nerve to reach the sphenopalatine ganglion. The post-ganglionic fibres from the sphenopalatine ganglion reach the nasal mucous membrane via the palatine and the nasopalatine branches.

Activity of the sympathetic nervous system tends to shrink the nasal mucosa along with dilation of the superficial vessels and hence the nasal mucosa appears pink. Activity of the parasympathetic nervous system tends to congest it, leading to engorgement of the venous sinuses of the nasal erectile tissue, resulting in bluish colouration of the nasal mucous membrane.

Non-specific stimuli can act upon these autonomic nerves to cause reflex changes in the nasal mucosa especially over the turbinates and these stimuli are physical stress, emotional factors and endocrine imbalance which are common during menstruation and pregnancy and perhaps a physical factor like barometer pressure changes. Drugs like reserpine and methyldopa can lead to nasal stuffiness.

The diagnosis of vasomotor rhinitis is made by an increase in symptoms whenever there is stress and strain, absence of positive skin tests and seasonal variation. It is frequently associated with migraine and migrainous neuralgia. The nasal mucous membrane is usually pale or there is bluish colouration with hypertrophy of the inferior turbinates.

Each Septilin tablet contains:

Septilin (Himalaya) is a combination of herbomineral principles with a wide range of pharmacological actions.

Septilin has antibacterial and anti-inflammatory plant principles and is very effective in chronic infections of the upper respiratory tract. It also helps to build up resistance to infection in the mucous membrane. Septilin has marked anti-inflammatory and anti-exudative activity as demonstrated by the granuloma pouch method in experimental rats (Gujral, Sareen, Reddy, Amma and Santha Kumari, 1962). It also has a sterilising effect on the organisms associated with acute rhinosinusitis (Mehta and Naik, 1965). Balsamodendron mukul (Guggul-which is an oleo gum resin) has an action very similar to A.C.T.H. as it raises the general defence mechanism of the body and thus helps to overcome infective and inflammatory processes. It not only builds up resistance to disease but has the capacity to neutralise the causative factors. As an alterative, it is capable of normalising the deranged cellular metabolism. Phyllanthus emblica, another ingredient of Septilin, is the richest natural source of ascorbic acid. This has an effect on the adrenal cortex and helps to build resistance to infection.

The presence of these two ingredients – Guggul and Phyllanthus emblica – in Septilin gave us the idea to use it in allergic and vasomotor rhinitis. Patients who had a history of stress and strain were given Geriforte (also of Himalaya) tablets in addition to Septilin. Geriforte has a mild tranquillising effect and helps to control anxiety and tension, which is at times is associated with vasomotor rhinitis.

Our study comprised 50 cases of allergic and vasomotor rhinitis. All these patients underwent thorough E.N.T. examination and all relevant investigations like:

(i) Blood examination for haemoglobin, total and differential counts and E.S.R. (ii) Urine and stool examination (iii) X-rays of the chest and paranasal sinuses.

Special importance was given to their history of stress and strain. A detailed interrogation of all the patients was done as regards stress and strain in their professional, family and married lives. The personality traits of the patients were also observed. All the patients with a history of stress and strain were given Geriforte tablets in addition to Septilin.

Dosage : (i) Septilin 2 tablets t.i.d. for 1 month or more depending on the response to the therapy. (ii) Geriforte 1 tablet t.i.d. for 1 month or more depending on the response to the therapy.

In our study we had 50 patients of allergic and vasomotor rhinitis. Seventeen patients gave a history of stress and strain. Hence they were given Geriforte in addition to Septilin.

(1) Age and Sex (Table 1). Allergic and vasomotor rhinitis are common during the third decade of life. We had 28 cases (56%) in this category; this was followed by the second and fourth decades with 11 cases each (22%).

Males were more affected than females (32 males, 18 females).

(2) Clinical Presentation (Table2 and 3). Nasal discharge was the most common symptom (48 cases, 96%). Nasal obstruction was present in 46 cases (92%) and sneezing in 43 (86%) cases. Seventeen patients (34%) gave a history of stress and strain. Eight patients (16%) complained of headache and two patients (4%) complained of pain in the nose.

On clinical examination all the patients had characteristic bluish allergic nasal mucosa. Besides this, inferior turbinate hypertrophy was present in 35 cases (70%) and nasal discharge in 34 cases (68%). Of these 34 patients, 29 patients (58%) had post-nasal drip. Nasal septum was deviated in 41 patients (82%) and one patient had septal perforation due to a previous S.M.R. operation.

(3) Investigations — On examination of the blood, eosinophilia — more than 5% - was present in 46 cases (92%). Stool examination showed presence of ova of thread or round worms in 9 cases (18%), which were treated accordingly, as it is important to treat the worm infestation, if any, before starting the therapy.

X-rays of the paranasal sinuses showed haziness of both the maxillary sinuses in 4 cases (8%). These patients also had mucopurulent discharge in the nose with post-nasal drip; hence they underwent atrum puncture before starting the therapy.

(4) Results [Table 4, Figures (1a) and (1b) and Figures (2a) and (2b)]. These were judged after therapy on the following criteria: (i) Symptomatic improvement – in sneezing nasal obstruction, nasal discharge. (ii) Clinical appearance of the nasal mucosa – change in colour of mucosa from bluish to pink. (iii) Change in colour of nasal mucosa from bluish to normal pink along with symptomatic improvement was taken as a good response.

 

Thirty-nine cases (78%) were cured 100% and they had total disappearance of symptoms and change in colour of the nasal mucosa from bluish to pink. Eight patients (16%) had about 75% improvement and 3 patients (6%) had only 50% improvement. These 11 patients were advised to continue the drug for a longer time, i.e., 6-8 weeks and of these patients, 4 patient showed further improvement.

(5) Side-effects—Initially for a week after therapy there was an increase in symptoms in 18 patients (36%). However, they were encouraged to continue the drug and then they responded to the therapy. One of these 18 patients complained of temporary giddiness lasting for 2-3 days at the start of Septilin therapy. We feel that the cause of giddiness may be blockage of the Eustachian tubes, as this patient had a temporary increase in nasal stuffiness with all the signs of Eustachian tube blockage.

Balsamodendron mukul (Guggul) is an important constituent of Septilin and is excreted by the skin, mucous membranes and kidneys. In the course of its excretion, it stimulates them and disinfects their secretions (Chopra, Chopra, Handa and Kapur, 1958). Because it is excreted through the genitourinary tract, at times it may bring on the first menstrual period much earlier than expected. For this reason and for safety’s sake, Septilin which contains a large percentage of Guggul is contraindicated in pregnancy. However, the effect is only on the first period after commencing the drug. Thereafter, even periods which tend to be irregular, become regular.

Our study comprised 50 patients of allergic and vasomotor rhinitis. Seventeen patients gave a history of stress and strain, hence they were given Geriforte in addition to Septilin. The results of therapy were judged on the following criteria: (I) Symptomatic improvement. (ii) Appearance of nasal mucosa before and after the therapy.

Thirty-nine patients (78%) were cured 100% as they had total relief from symptoms along with change of the nasal mucosa from bluish to pink. Eight patients (16%) had about 75% improvement and 3 patients (6%) had only 50% improvement. These patients were advised to continue the therapy for a longer time (6-8 weeks). Of these, 4 patients showed further improvement. In our opinion. Septilin has proved very useful in cases of allergic and vasomotor rhinitis. Those patients who have a history of stress and strain may also need Geriforte in addition to Septilin.

We are grateful to our Dean for allowing us to publish this paper and Dr. N.L. Hiranandani, Hon. Professor and Head, Department of Otolaryngology and Head and Neck Surgery, for his guidance.

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