Allergic rhinitis represents a global healthy problem with considerable prevalence especially in children
. The majority of patients in this study were children which is comparable with previous studies done else where
[26–29]. The reason for increased number of children with allergic rhinitis to attend medical services in this study may be due to the fact that allergic rhinits is associated with severe and troublesome symptoms which are exacerbated by recurrent viral infections making parents to seek medical attention while majority of symptoms of allergic rhinitis are ignored by adult patients.
In this study, no gender predilection was observed which is in agreement with other studies
, but at variant with other studies which reported female
[29, 31, 32] and male
 predominance respectively.
The prevalence of allergic rhinitis is increasing in developing countries
 due to the introduction of Western life style
 and environmental factors
 and it differs among countries and even among regions within the same country
. In industrial countries like USA the allergic rhinitis is one among the well documented disease and high prevalence of allergic rhinitis have been reported to be more than 40%
. In the present study the point prevalence of allergic rhinitis at Bugando Medical Centre was 14.7%. This prevalence is comparable to 13.7%,13% found in Kinshasa
 Nairobi Kenya
 respectively. Higher prevalence of allergic rhinitis have been reported in African countries such as 29.6% in Nigeria
 and more than 30% in Cape Town South Africa
. Several theories for the increasing prevalence of allergic rhinitis are climatic factors, increasing in winter and rainy seasons, dietary changes, environmental factors including industrial pollution. These factors may also influence the prevalence in our study and therefore it is recommended that future studies should be done in different periods within a year to determine the variations. The prevalence of allergic rhinitis in our study may actually be underestimate as majority of patients with this condition are treated in the peripheral hospitals and only patients with severe symptoms or associated co-morbidities present to ENT surgeon. A better picture of the magnitude of Allergic rhinitis in this region requires comprehensive data collection including both hospital and population-based study.
Clinically allergic rhinitis is defined as allergen induced inflammation of the nasal membrane and surrounding tissues that results in sneezing, rhinorrhoea, conjunctivitis, nasal congestion, and pruritis of the nose, palate, throat and ears
. Nasal obstruction is associated with sleep disorders, which can have a profound effect on quality of life, mental health, learning, behavior and attention
. Vast majority of respondents in this study had nasal symptoms of which blocked nose was found in many patients and it was found to be the most troublesome symptom. The same observation was also reported in other studies done else where
[40, 41]. The reason for the nasal obstruction was due to the co-existence with adenoid hypertrophy, nasal congestion, inferior turbinate hypertrophy and nasal polyps in majority of our study population. In this study blocked nose showed significant association with adenoid hypertrophy in children.
In the present study, the high proportion of patients had runny nose (rhinorrhoea) compared to other studies found in literature
. The reason for increased proportion of runny nose is the fact that runny nose is common in small children which is commonly associated with viral and bacteria infection especially in under five which were the majority in our study.
The rate of allergic conjunctivitis found in this study is higher as compared to other studies
[26, 43] and majorities of patients had watery eye discharge as compared to eye itching. Ocular symptoms were considered trivial illness by most of our patients and were not complained. The reason for the high proportion of allergic conjunctivitis could be due to dusty environment which causes symptoms in majorities of our study population. The high prevalence of rhinoconjunctivitis was also found in majorities of the centers of Africa and raises number of questions and non allergic factors are found to be responsible
. Further studies are needed to determine the factors responsible for rhinoconjunctivitis.
In the present study it was shown that the allergic rhinitis symptoms could begins as early as one month old child. This is earlier compared to 18 month old reported in Paris
. This could be due to differences in environment between the two countries. The study also shows that the early onset of symptoms of allergic rhinitis is significantly associated with the development of co-morbidities. This explains the needs for public awareness and early medical intervention.
Various environmental factors were found to increase the risk of allergic rhinitis especially in children. Pollution factors such as environmental tobacco smoke exposure, moulds, road traffic pollution and dusts seem to be important risk factors of allergic rhinitis
. In this study exposure to dust, weather changes, strong perfume order, and smoke were most common self reported triggers for allergic rhinitis where dust reported by majorities of patients. This observation is in agreement with other studies reported elsewhere
The proportion of patients with self-reported allergy to dust was 39.5% which is lower than reported in Nigeria
 and South Africa
. Seventy three percent of respondents noted trouble symptoms inside their houses. The reason for these findings could be due to the plenty of dust in our immediate environment and house dust which mainly consists of dust mite, moulds, insects and animal dander may be the etiological trigger in the study population. In this study dust was found to have statistical significant association with sneezing. Sneezing aims to expel mucus containing irritating allergens and cleanse the nasal cavity.
It was found in the present study that 17.9% and 27.9% of patients were affected by strong perfume and cold weather respectively. This rate is lower compared to 31.1% and 32.4% respectively reported in the literature
. Female patients with allergic rhinitis showed statistical significant association with strong perfume odor. This might be due to the social habits of using strong perfumes which is commonly in female compared to males.
Many patients with allergic rhinitis had their first degree relatives suffering from the disease. Similar findings were reported in other studies
[11, 48, 49]. Unlike in other studies where family history was significant risk factor for allergic rhinitis
[11, 45], in the current study family history of allergic rhinitis did not reach statistical significance. The reason for poor association could be due to small sample as compared to the general population. However family history of allergic rhinitis showed statistical significant association with early onset nasal symptoms, which leads to early development of co-morbidities.
The quality of life is often impaired in patients with allergic rhinitis, due to the classic symptoms of the disease (sneezing, pruritis, rhinorrhoea and nasal obstruction). In addition, the pathophysiology of allergic rhinitis often disrupt sleep, leading to fatigue, daytime sleepiness, irritability and memory deficit
. Sleep disturbance was reported in most of our study population. Similar observation was also reported from other studies
. While 74.2% of our patient had their sleep affected, Machimu at al reported sleep disturbance in 76.6% of the study population. Nasal obstruction and nasal congestion were responsible for the sleep disturbances. In this study nasal obstruction and congestion cause day time sleepiness in more than 70% of respondents especially those who had sleep disturbance during night time. This is in agreement with previous study
. The reason for the nasal obstruction was adenoid hypertrophy in one hand and hypertrophy of inferior turbinate in another hand. Adenoid hypertrophy was complained in majority of patients and it was significantly associated with sleep disturbance in children. Another cause of nasal obstruction was rhinorrhoea triggered by allergens.
Most of our patients 93.3% reported to have interference with their daily activities such as playing, working etc. and thus they have impaired social life. This is in agreement with other studies found in literature
[53, 54] and it is higher than that reported by Bousquet
. The reason for the interference with daily activities is probably due to severe symptoms of nasal blockage and rhinorrhoea which also causes embarrassment to patients.
Besides its direct effect on the quality of life, allergic rhinitis has significant co-morbid disorders such as asthma, sinusitis, otitis media, conjunctivitis and adenoid hypertrophy
. In the present study, more than 90% of patients had associated co-morbidities which is contrary with other studies
. Many other studies reported low incidence of associated co-morbidities. We could not find the reason for these differences, this call for further studies to explain these differences.
Multidisciplinary approach is needed in the treatment of allergic rhinitis and its co-morbidities involving paediatricians, allergists and the otolaryngologists
. Allergen avoidance require aggressive environmental control which is effective but often practically difficult
. Intranasal steroids are the treatment of choice and are more effective than antihistamines for relief of nasal obstruction however surgical therapy is reserved for co-morbidities refractory to medical treatment. Immunotherapy may also be used
With regard to treatment patterns, majority of patients (54.7%) in this study underwent surgical treatment which is at variant with findings from other studies
 where majority of allergic rhinitis patient were treated conservatively and surgical management was reserved for minority of cases who were refractory to medical treatment. The most common indications for surgical treatment in the present study were adenoid hypertrophy, recurrent tonsillitis, nasal obstruction due to hypertrophy of inferior turbinate, nasal polyps and sinusitis. The high rate of surgical treatment found in this study is attributed to high proportion of patients with associated co-morbidities requiring surgical interventions
In agreement with previous report
, conservative treatment in this study was done using mono therapy with steroid nasal spray fluticasone which does not result in complete relief of symptoms and so prolongs the hospital visit and affect compliance with long term use.
Allergen exposure in atopic individual activates mast cells resulting in the release of mediators and cytokines capable of inducing inflammatory cell recruitment including eosinophils, neutrophils and basophils at the target organ level. Eosinophils in the nasal smear has shown to display the best correlation with clinical allergic rhinitis
, and can be used not only to establishes the diagnosis of allergic rhinitis but also useful in the follow up of patients with this condition
. In this study oesinophils were found in 73.2% of patients and were significantly associated with female sex and family history of allergic rhinitis. The reason for this association was not known
Polymorpho-nuclear cells were found in 77.4% of our patients. Since the presence of neutrophils provides evidence substantiating the diagnosis of nasal infections, high rate of nasal neutrophils in this study indicate that nasal infections is common in these groups.
Nasal smears for oesinophils, basophils and neutrophils were negative in 9.7% of the slides. Unlike observation from other studies that nasal mucosa scrapings in allergic rhinitis patients had large numbers of basophilic metachromatic cells
 in this studies no basophils was found. The reason could be due to the fact that basophil cells are found predominately in the nasal mucosa
, where proper nasal curettes (rhino-probe) are required for acquisition of a large number of intact cells to interpret. In contrary neutrophils and oesinophils are present in both nasal secretion and within the nasal mucosa.
The overall average length of hospital stay for in patients was 4.6 days. However for the patient underwent adenotonsillectomy the average hospital stay was 3 days. This was in contrary with other studies done in Malaysia where adenotonsillectomy was done safely as day care surgery
While gender was not found to be a risk factor, younger age group was significantly associated with increased length of hospital stay post adenotonsillectomy. Same observation was also reported in the literature
. This is contrary with other studies
. The reason for increased length of hospital stay was mostly due to delay in conduction of the procedure, where patients stayed in the ward for days awaiting surgery.
Patients who had chronic sinusitis were found to have statistical significant association with increased length of hospital stay. The reason for this is that during post operative period, most of patients had associated oedema and prolonged catheter placed for sinus drainage.
In the present study post operative bleeding was the most post surgical complication. This is consistent with other study
. The rate of post operative bleeding of 2.88% in the present study was in agreement to the rate of 2.4% found in other studies
. The low rate of post tonsillectomy bleeding was attributed to the suture tie techniques used to arrest bleeding during tonsillectomy at Bugando Medical Centre and also weekly follow up post surgery was found to be effective in early detection of delayed and episodic bleeding which can be corrected before the development of life-threatening anaemia.
Majority of patients were discharged against medical advice in the current study was caused by long hospital stay especially before surgery. This is attributed to inadequate operating days for ENT patients despite of high number of patients demanding surgical services. Further more lack of essential surgical equipments such as oxygen, gauze and surgical gowns during the study period led to delay of surgical procedures.
AR is not common to cause death but it may occur from its co-morbid conditions as 1.5% mortality rate reported in a study done in Sweden
 or as a result of surgical complications. In the current study death rate post adenotonsillectomy was 1.6%. High mortality rate was previously reported
 although there was no postoperative deaths reported in study done in Germany
. In our study death occurred within the first 24 hours post adenotonsillectomy in younger children who had severe obstructive symptoms. Aspiration and respiratory arrest may probably be the cause of death. This calls for improvement of pediatric post operative care.
There was no death caused by bleeding in this study. The reason was careful inspection of the nasopharynx before performing surgery and curettage in a piecemeal fashion under visual control which was done during each adenoidectomy in order to prevent direct injury to aberrant arteries.
The potential limitations of this study include the absence of allergy testing, short study period, presence of neutrophils in the nose and failure of estimating the measure of quality of life based on a standardized and validated (generic or disease-related) questionnaires. However, despite these limitations, the study has provided local data that can help health care workers develop guideline for early detection and proper treatment of allergic rhinitis and so reduce development of co-morbidities.