Abstract: Twelve patients with either chronic allergic or vasomotor rhinitis were treated with only two pairs of acupuncture points. Treatment was kept up in spite of apparent worsening of symptoms or lack of clinical progress. Nine patients obtained essentially total relief, two patients had substantial relief and only one patient did not improve. Clinical effect appeared to be long lasting. Factors contributing to successful therapy are analyzed and the pathophysiological mechanism and implications of rhinitis and its treatments with acupuncture are discussed.

ALLERGIC RHINITIS is a highly prevalent medical problem. It is estimated that 8 to 10% of the population in the United States suffers from this condition.1 Vasomotor rhinitis is probably less common, but clinically practically indistinguishable from the allergic entity. Although rhinitis is hardly disabling, its prominent symptoms such as itching eyes and nose, chain sneezing, rhinorrhea and nasal blockage are often chronic and highly troublesome. Moreover, if left untreated, the condition may progress into bronchial asthma. Presently available modern medical therapies are more palliative than curative. Drug therapy which involves mainly the use of antihistamines often causes drowsiness, a side effect considered by some patients to be worse than the symptoms for which it is intended. Desensitization program with injection of antigens requires prolonged administration and high cost. The therapeutic outcome is unpredictable and generally not well accepted by many patients. Besides it is not entirely without danger of serious systemic reactions such as anaphylactic shock. Recently revived interest in acupuncture has prompted the use of this ancient healing science in the treatment of rhinitis with some degree of success. However, the rate of success does not seem to be as spectacular as in the treatment of other conditions, such as chronic pain. Rhinitis is therefore generally considered as a relatively difficult problem to eliminate with acupuncture. Nevertheless, there are ample references in ancient traditional Chinese medical literature that acupuncture is definitely indicated for this condition. In fact, acupuncture points for the treatment of rhinitis are quite a few. Effective points include Hoku (LI-4), Yinghsiang (LI-20), Shanghsing (Gov-23), Fungch'ih (GB-20), Tienchu (BL-10), Tachuei (Gov-14), Fungfu (Gov-16), Fungmen (BL-12), Holiao (LI-19), Paihui (Gov-20), Laokung (P-8), Chienku (SI-2), Tungtien (BL-7), Funglung (ST-40), Liehchueh (LU-7) and Yintang. Since so many points are available, the permutation and combinations of points can be numerous and the temptation to use as many points as possible in one single treatment session is great. There is a tendency to change the points when the therapist is confronted with lack of clinical progress. In the process of trying to isolate various factors contributing to the successful outcome in the treatment of rhinitis, I have found the persistent use of only two pairs of acupuncture points, namely, Yinghslang (LI-20) and Hoku (LI-4) to be extremely effective, provided the proper techniques are used and an optimal schedule of treatments is selected. The usefulness of this particular approach was first realized while treating a patient whose symptoms fluctuated during the course of therapy despite identical treatments, but subsequently became symptom-free shortly after therapy was terminated. In other words, it appeared that the erratic clinical response during the course of therapy ought to be ignored. Further investigation described in the following report seems to confirm such an impression.

Materials

Twelve patients were included in this study. There were 9 men and 3 women ranging from age 20 to 61. Eight had allergic rhinitis and four had vasomotor rhinitis. Among the 8 pa-tients with allergic rhinitis, 4 of them already had adequate desensitization therapy, but received no significant benefit from it. The duration of symptoms varied from one month to more than 50 years. Two patients suffering from vasomotor rhinitis dated the onset of their problem to an episode of flu-like syndrome. Another patient with the vasomotor variety was a laundryman whose symptoms developed after frequent exposures to hot steam and detergents. Another two patients worked as janitors and developed allergic rhinitis as a result of daily contact with large amounts of dust. All but two patients had rhinitis symptoms perenially. 30-gauge, stainless steel, 11/2-inch traditional Chinese acupuncture needles were used. Electrical stimulation was provided by a model 626 acupuncture apparatus.

Method

1. Selection of Points:
Only two pairs of acupuncture points were used, namely Yinghsiang (LI-20) and Hoku (LI-4). The Yinghsiang point was chosen because this was mentioned most frequently in the traditional Chinese medical literature as a distinctively effective point in the treatment of nasal blockage. In addition, these two paranasal points are consistently sensitive to digital pressure in patients with symptoms of rhinitis. The Hoku points were selected because they are known to be highly effective in treating any physiological disturbance in the facial area. Moreover, both the Yinghsiang and Hoku points are members of the Large Intestine meridian and therefore the simultaneous use of them can enhance the overall therapeutic response.

II Technique:
The acupuncture points were first sterilized with 75% rubbing alcohol before insertion. The patient was in either sitting or in recumbent position. The Yinghsiang points were first punctured tangentially with the needles pointing upward and obliquely in the direction of the paranasal fold. After the needle has pierced the skin, a steady thrust together with a slight twirling motion was used to advance the needle along the para-nasal fold for a distance of 1 ? to 2 centimeters. Since the bony surface of the maxilla is covered by merely the dermis and a thin layer of subcutaneous fat, care must be taken to avoid touching the very pain sensitive periosteum. Needles were then inserted at the Hoku points bilaterally until there was a sensation of heaviness or congestion radiating from the puncture site towards either the thumb or index finger.

Three variations of acupuncture stimulations can be used. Usually during the first few treatments, needles were left in situ for about 30 minutes without any type of manipulation. The second type of stimulation involved intermittent twirling of the needles for 10-15 seconds every 5 minutes or so for a period of 15-20 minutes. A third mode of stimulation consisted of 15 minutes of electrical stimulation provided by the model 626 electroacupuncture apparatus. The intensity of electrical stimulation was such that the patient would notice a relatively mild sensation in the Yinghsiang points whereas the strength of output for the Hoku points can be adjusted to greater intensity and with more flexibility. The in situ method was usually employed initially. If the therapeutic efficacy appeared to diminish, the second method is used and if progress is still slow, then the third modality would be utilized.

All patients were treated initially on a three times a week schedule which was then tapered down to two treatments per week, once substantial progress had been made.

Results

All but one patient received substantial benefit from above treatment (see Table 1). 9 patients obtained total or almost total relief as a result. 2 patients were greatly relieved from their allergic symptoms despite their poor adherence to the treatment program as prescribed and continuous exposure to the allergens while working as janitors. Only one patient did not respond at all to the treatment. He was a 29-year old man with a history of allergic rhinitis of 20 years duration and had failed to respond to extensive desensitization therapy as well. The minimum number of treatments per patient was one and the maximum was 15. The median number of of treatments per patient was 6.9. Eight patients, or more than half of the patients treated this way experienced a fluctuation of symptoms throughout the course of therapy. In fact, some patients might even feel worse at first, only to be followed by marked progress later. One 19-year old machinist who suffered from excessive rhinorrhea, severe nasal stuffiness and a feeling of congestion in his chest originating from a cold he contracted a month prior to treatment responded completely and instantly to just one single treatment. It is interesting to note that approximately 5 minutes after the insertion of the needles he began to experience the onset of syncope and diaphoresis. The needles were immediately withdrawn and as he recovered from his dizziness, he quickly noticed that his nose and chest became completely clear and he has had no recurrence since. Another 56-year old man who had suffered from allergic rhinitis allegedly all his life responded dramatically to only 6 treatments. This patient's symptoms promptly disappeared after the second treatment, but exacerbated intensely following the third treatment, which was essentially identical with the previous treatments the patient received. By the 6th-which was also the last treatment ? only slight residual symptoms were present. Follow-up in one month revealed that he continued to experience progressive and finally total relief in the interim in spite of continuous and even greater exposure to pollens which he was known to be highly allergic to. Follow-up at six months showed that improvement was retained in all patients and remarkably so in those who suffered from perennial symptoms previously.

Discussion

Although the number of patients in this series is admittedly small, it appears evident that the therapeutic method employed here is highly effective. It has been realized by practitioners of acupuncture therapy and acupuncture anesthesia in China that it is not necessarily true that the more acupuncture points are used, the more effective is the procedure. On the contrary, just a few carefully selected points and the correct amount of stimulation may be the most effective formula. It seems by just using the Hoku and Yinghsiang points, extremely satisfactory clinical results can be achieved in treating either form of rhinitis. One of the reasons why acupuncture has not been acclaimed as a very effective means in treating rhinitis could be due to the fact that clinical investigators in the past did not maintain the effective treatment long enough. The approach outlined in this paper consists of persisting in the treatment using the same acupuncture points with only minor modification of techniques (either by increasing the stimulation manually or electrically), even in the face of obvious therapeutic setbacks. The apparent setback may actually not be clinical failure, but the reactive phase the patient must go through in order to obtain more permanent relief. Sometimes this reactive phase can be prolonged for days or even weeks. If at this point the treatment using the highly effective acupuncture point is given up, then the cumulative therapeutic effect may not be sufficient to carry the body's regulatory response to the fullest extent and as a result relief of symptoms can only be partial. One of the pitfalls former investigators in this field might have encountered is the employment of too many acupuncture points and perhaps chang-ing them too rapidly.

TABLE I. Summary of Clinical Data.

Patient	Age & Sex	Type Rhinitis	Duration Sympton	Treatments	Sympton Fluctuations	Results	Remarks
R.J.	M-56	allergic	lifelong	6	yes	essentially cured	adequate desensitization treatment. Asymptomatic despite continued exposure to pollens.
G.W.	M-19	vasomot	1 month	1	no	essentially cured	rhinitis from cold, treatments caused dizziness.
L.B.	M-61	vasomot	13 months	5	no	essentially cured	rhinitis as a sequela to URI.
M.G.	F-31	allergic	2 years	3	no	essentially cured	rheumatoid arthritis concurrently
J.M.	M-25	vasomot	5 years	5	yes	essentially cured	axillary adenopathy concurrently
R.L.	M-37	allergic	2 months	3	no	essentially cured	hyperlipidemia concurrently
M.P.	F-52	allergic	5 years	15	yes	sustained improvement	poor adherence to therapy, cont. exposure to dust
C.R.	M-29	allergic	4 years	10	yes	sustained improvement	poor adherence to therapy, cont. exposure to dust
J.R.	M-20	allergic	19 years	12	yes	essentially cured	adequate desensitization therapy
A.R.	M-28	allergic	20 years	11	yes	no imporvement	previous extensive desensitization therapy
J.L.	M-45	vasomot.	1 year	6	yes	essentially cured	condition resulting form chronic exposure to steam and detergents
S.R.	F-61	allergic	3 yrs.+	6	yes	essentially cured	previous extensive desensitization therapy

The relative deep insertion of needles at the Yinghsiang points may also account for the high degree of clinical efficacy. The author has also found that mild stimulation either manually or electrically seems to be superior to strong stimulation. The frequently spaced treatment sessions are equally important in accomplishing adequate cumulative effect that is necessary to eliminate clinical symptoms on a more permanent basis.

So far, allergic rhinitis has been considered to be basically an immunological disease. However, if the pathophysiology of this condition involves the immune mechanism alone, then how can one account for the marked improvement resulting from acupuncture while the patient continued to be exposed to the same or greater amount of allergens which is thought to be the cause of his disease? One must therefore conclude that the nervous system on which acupuncture acts is equally vital in the pathogenesis of allergic rhinitis, In other words, it takes both the allergen externally and the neurophysiological factors internally to produce the symptoms of nasal allergy. Such a concept seems viable in view of the multitude of evidence indicating the close relationship between the central nervous system and the immune system. Individuals with atopy seem to respond to a large variety of antigens in an exaggerated manner. Modern medicine approaches this problem by desensitizing injections to build up the so-called specific blocking antibodies.3 On the other hand, the traditional Chinese medical approach appears to desensitize the central neurological pathway so that it reduced the intensity with which it responds to the immunological challenge. A hypothesis is therefore proposed as follows to explain this phenomenon.

Frequent contact with an allergen by the nasal mucosa sets up an antigen-antibody reaction which in turn activates specific neurological pathways. With repeated contacts with the allergen, this particular pathway becomes highly reactive or "sensitized" and has a tendency to remain at this habituated state state, producing the series of symptoms. Desensitizing injection treatment prevents the formation of an antibody antigen complex by increasing the circulating blocking antibodies. Acupuncture treatments, on the other hand, actually desensitize or reduce the reactivity of the mediating neurological pathway even though the antigen-antibody complex continue to form abundantly. As a result. the same amount of antigen which normally produces severe symptoms is inadequate to activate this specific neural pathway to complete the physiological events leading to the production of symptoms.

Non-allogenic irritants can also give rise to symptomatology of rhinitis. Here the neurological factors act independently of the immune mechanism, yet they produce practically the same symptoms as allergic rhinitis. Presumably the neurological mechanism may be responsible for the majority of the so-called vasomotor rhinitis. It also explains why acupuncture is effective in treating both conditions, which probably share a common final neurological pathway.

Respiratory infections can cause the nasal mucosa to react as in nasal allergies. But sometimes long after the infection has subsided, symptoms of rhinitis remain. It may be because the neurological pathway initially activated in response to the infection, continued to stay activated or habituated in this active state despite the removal of the cause, resulting in chronic rhinitis. This type of rhinitis can also be ameliorated with acupuncture which deactivate the specific hyperactive neural pathway.

Finally, atopic individuals who possess poorly controlled exaggerated response to foreign substances may signify a weaker and poorly balanced central nervous system and therefore are less healthy than the general population. Conversely, individuals who are in poor health are more likely to develop symptoms simulating allergic rhinitis. Equally noteworthy is the fact that many patients who obtain remarkable relief from acupuncture treatment for their rhinitis frequently report a concurrent sense of well-being and a feeling of being energized.

Naturally, the above hypothesis requires a great deal of research to either confirm or refute. Nevertheless, it is quite clear that the significance of acupuncture is not just another therapeutic modality, but a potential tool to shed new light on the underlying pathophysiological mechanism in many disorders and, in particular, the crucial roles played by the central nervous system in causing disease and healing.

References

1. Sherman, W. B.: "Hayfever and allergic rhinitis." Textbook of Medicine, pp. 434-437. W. B. Saunders, Philadelphia, London, 1967.
2. Shanghai Medical College: Acupuncture, pp. 553-554. People's Hygiene Publisher, Peking, 1974.
3. Loveless, M. H.: Repository Immunization in Pollen Allergy. J. Immune, 79:68, 1957.