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Diagnostic and monitoring of allergic and non allergic rhinitis: the role of nasal cytology

Indolfi C, Maiello N, Campana G, Galdo F, Coronella A, Allegorico A, Miraglia Del Giudice M.
Department of Women, Child and General and Special Surgery- Second University of Naples, Italy

Abstract

Introduction
Several factors support the development of persistent rhinitis as recurrent viral respiratory tract infections, immune disorders, abnormal respiratory epithelial cilia motion, allergic diseases, and gastrointestinal reflux. Recently, it has been reported that nasal cytological examination of the mucosa give the possibility of non invasive study of cellular changes ongoing within the nasal mucosa. By this analysis, the presence of eosinophils and basophils supports the diagnosis of allergic diseases, whilst an increased percentage of neutrophils supports the diagnosis of bacterical infection. The viral infection can be diagnosed if cilia with separated tufts are visible in the sample. In the present paper we report the role of nasal cytological examination in diagnostic and monitoring of different nasal diseases.
Patients and Methods
Eighty-seven children attended to the Pediatric Department of Second University of Naples were included in this study. The age of patients ranged from 3 to 16 years. All patients were affected by allergic or non allergic rhinitis. All subjects underwent detailed clinical history, and rhinocytogram by nasal cytology examination.
Results
The above mentioned studied group involved 87 patients: 58 with skin prick tests positive and 29 with negative skin prick tests. Among the 29 patients the infectious spots were identified in the 11 (37, 9%) of the patients. Nasal cytology was normal in the remaining patients with skin tests negative. Instead, of the 58 patients with positive skin prick tests the nasal cytological examination allows the diagnosis of allergic rhinitis in 26 (44, 8%) patients, associated to NARNE (non allergic rhinitis with neutrophils) in 14 (24, 1%) children, to NARES (non allergic rhinitis with eosinophis) in 11 (18, 9%), to NARESMA (non allergic rhinitis with eosinophils and mast-cells) in 5 (8, 6%), and to NARMA (non allergic rhinitis with mast-cells) in 2 (3, 4%) patients.
Conclusions
In conclusion, our study confirm that nasal cytological is able to identify the different forms of rhinitis. Nasal cytology may be very important to prevent several collateral effects by an incorrect diagnosis with consequently a wrong therapy.

Introduction
Several factors support the development of persistent rhinitis as recurrent viral respiratory tract infections, immune disorders, abnormal respiratory epithelial cilia motion, allergic disease, and gastrointestinal reflux. The last decade has resulted in numerous studies, the aim of which was to assess the methods to determining the nature of chronic rhinitis in children. Recently, it has been reported that nasal cytological examination of the mucosa gives the possibility of non invasive study of cellular changes ongoing within the nasal mucosa. By this analysis, the presence of eosinophils and basophils supports the diagnosis of allergic disease, whilst an increased percentage of neutrophils supports the diagnosis of bacterical infection. The viral infection can be diagnosed if cilia with separated tufts are visible in the sample. Recently, it has been reported that nasal cytology in light microscopy can identify biofilms which appear as cyan-stained “infections Spots”. (1) Moreover, it is reported that nasal exfoliative cytology can be a complementary tool in diagnostics of allergic and non allergic rhinitis. Till now cytological examination has been most commonly performed in patients with allergic rhinitis. This group of patients showed an increase of eosinophils after allergen challenge and a correlation was found between the number of eosinophils and symptoms such as nasal congestion, sneezing, and rhinitis. In the present paper we report the role of nasal cytological examination in diagnostic and monitoring of different nasal disease.
Patients and Methods
Eight-seven children were included in this study. The age of patients ranged from 3 to 16 years. All patients were affected by allergic and non allergic rhinitis and observed to the Pediatric Department, Second University of Naples. All subjects underwent detailed clinical history, and rhinocytogram by nasal cytology examination. Nasal cytology was performed by anterior rhinoscopy, and consisted of scrapings from the middle portion of the inferior turbinate, using a Rhino-Probe (2) . The scraped material was transferred on a glass slide, air-dried and stained by May-Grunwald Giemsa. The slides were examined by a light microscope and 50 microscopic fields were read at a magnification of 1000x, to assess the presence of normal and abnormal cellular elements. A semi-quantitative grading was used, according to Meltzer (3) . We considered as abnormal those cytograms were neutrophils represented more than 50%, eosinophils more than 20% and mast cells more than 10% of total cells recovered (3, 4) .
Results
The above mentioned studied group involved 87 patients: skin prick tests to assess allergic rhinitis were carried out according to guidelines, with a panel of commercial pneumoallergens extracts and resulted positive in 58 patients (negative skin prick tests in 29 patients) . Among the 29 patients affected by non allergic rhinitis (negative prick tests) the infectious spots (expression of biofilm) characterized by presence of bacteria and neutrophils, reduction of number of cilia, gain of metaplasic cells and macrofagic cells was identified in the 11 (37.9%) of the patients. Nasal cytology was normal in the remaining patients (18=62%) where no infectious spot was detectable. Instead, of 58 patients with skin prick tests positive the nasal cytological examination allows the diagnosis of allergic rhinitis in 26 (44.8%) patients, associated to NARNE (non allergic rhinitis whit neutrophils) in 14 (24.1%) children, NARES (non allergic rhinitis with eosinophils) in 11 (18.9%), NARESMA (non allergic rhinitis with eosinophils and mast-cell) in 5 (8.6%), and NARMA (non allergic rhinitis with mast-cell) in 2 (3.4%) patients.
Discussion
Over the years the nasal cytology has become a diagnostic method of growing usefulness in rhino-allergy field (5, 6) . It was already proved that this method is capable of detecting changes in cell epithelium of the nasal mucosa to distinguish between physical and chemical irritation or viral, fungin, and parasitic inflammation (7) . Gelardi et al demonstrated that the cytological study of the nasal mucosa, especially in allergic and non allergic vasomotor rhinitis, resulted in a significant contribution to the clarification of the pathophysiological mechanisms underlying the different rhinitis (8-10) . In the 1996 Chapelin et al showed that the nasal diseases of childhood were characterized by reshuffling of the epithelium of the hair cells mucosa in favour of globet cells (metaplasia mucipara) (11) . In the pediatric age the sino-nasal diseases most frequently encountered are the infettive rhinopaties although in our study the presence of the biofilm was detected only in 37.9% of patients with non allergic rhinitis. Gelardi et al show that the biofilm not is found only in infectious rhinitis, but also in inflammatory and/or immune-mediated diseases (1) . Recently, Madry Bozek et al in a study of 64 patients with chronic rhinosinusitis have confirmed the importance of nasal cytology in such diseases (12) . The nasal cytology has demonstrated its value also in allergic rhinitis. In these pathologies the stimulation nasal, natural or not, it is capable of developing an immediate reaction nasal, early phase and a tardive reaction, late phase (13, 14) . The nasal cytology in the allergic patients show an increase of eosinophils and a correlation between the number of eosinophils and the severity of specific symptoms, such as nasal congestion, rhinorrhea, sneezing, and lacrimation. In these patients Gelardi et al demonstrated through the nasal cytology that subjects with persistent rhinitis present different aspects of the immune-inflammatory concentration and the nasal resistance to rhino-manometric method (15) . Among the chronic rhinitis should not be overlooked that the non allergic vasomotor rhinitis are characterized by a clinical-diagnostic-therapeutic approach not unique. This group included the NARNE (16), the NARES, the NARMA, and the NARESMA, described by Gelardi et al in 2008 (17) . The most important contribution given by nasal cytology to these rhinitis is the possible diagnosis of layering multiple nasal diseases (18) . Even in our study it is confirmed this concept: in subjects positive skin prick tests, allergic rhinitis isolated was diagnosed in the 44.8% of patients whereas in the 55.2% of cases the allergic rhinitis was associated with other types of non allergic rhinitis. The possibility of recognizing these clinical conditions allows to set therapeutic approaches diversified and personalized. The analysis of our data associated to the findings of the literature allow us to confirm the importance of nasal cytology in the early diagnosis, in the different follow-up, and in a correct therapeutic approach of allergic and non allergic rhinitis. These objectives are very important to prevent serious complications secondary to an incorrect diagnosis.

References
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