Introduction
Allergic rhinitis is a common, immunoglobulin E (IgE) mediated disease of the nasal mucosa which significantly impairs patients' quality of life.1–3 It is characterised by ocular and nasal symptoms, the latter including obstruction, itching, rhinorrhoea and sneezing.
Treatment efficacy is evaluated by various subjective and objective methods. The grading of nasal symptom severity is crucial in order to guide treatment choice and to facilitate assessment of treatment outcomes. Various subjective scoring systems have been described with which to grade symptom severity. Nasal cytological assessment, an objective evaluation method, may also be used as an adjunct.4–7
This study was designed to assess symptom scores and nasal cytology scores in patients with seasonal allergic rhinitis, before and after treatment with fluticasone proprionate and cetirizine.
Materials and methods
A prospective study was conducted on 29 adult patients with seasonal allergic rhinitis treated in the otolaryngology-head and neck surgery department of a tertiary referral hospital, between June 2007 and June 2008.
All consecutive patients aged 19–67 years with at least a two-year history of moderate or severe seasonal allergic rhinitis (based on the clinical definition and classification criteria of the Allergic Rhinitis and its Impact on Asthma (ARIA) Workshop report) were considered eligible for study inclusion.Reference Bousquet, Van Cauwenberge and Khaltaev8
The protocol was approved by the ethics committee of the research hospital. Written, informed consent was obtained from all patients.
After detailed medical history-taking and otorhinolaryngological examination, nasal specimens were taken using disposable nasal brushes. Patients were also asked to rate the current severity of their nasal and ocular symptoms.
Patients were then prescribed oral levocetirizine dihydrochloride tablets, 5 mg once daily, and mometasone furoate monohydrate nasal spray, two sprays in each nostril (50 µg in each spray) once daily, for 21 days.
At the end of the treatment period, patients were recalled for follow up. They were again asked to rate their current nasal and ocular symptom severity, and further nasal specimens were taken using the same collection technique.
Clinical symptom scores
Before and after treatment, patients rated their nasal symptoms (i.e. nasal stuffiness, rhinorrhoea, sneezing and itching) and ocular symptoms (i.e. eyelid swelling, ocular itching, redness and tearing) using a four-point scale, with 0 = no symptoms, 1 = mild symptoms, 2 = moderate symptoms and 3 = severe symptoms.
Individual and total symptom scores were then calculated. Each patient's total nasal symptom score and total ocular symptom score were calculated by summing that patient's individual nasal and ocular symptom scores, respectively.
Nasal cytology evaluation
Nasal cytology samples were obtained before and after treatment by scraping the surface of the middle third of the inferior turbinate, using disposable nasal brushes, in both nasal cavities. Specimens were spread on microscopy slides and fixed in 95 per cent ethyl alcohol. Preparations stained with haematoxylin and eosin and Giemsa were examined using oil immersion light microscopy (×1000).
All specimens were evaluated by the same pathologist, who was blinded to the patient's identity and clinical features. On each slide, five randomly chosen magnification fields were examined and cell counts (i.e. eosinophils, neutrophils, basophilic cells and goblet cells) recorded and graded on a four-point scale (Table I). The mean cell count per 10 high-power fields was also recorded, for each nasal cavity. Grades higher than 1+ were accepted as positive.
Table I Nasal cytogram grading
*Mean cells per 10 high-power fields (HPF) ×1000.
†Goblet cell count as percentage of epithelial cell count. Adapted with permission.Reference Howarth, Persson, Meltzer, Jacobson, Durham and Silkoff4 No = number
Data analysis
The Statistical Package for the Social Sciences version 16.0 for Windows software was used for statistical analysis. Data were evaluated using McNemar, chi-square and correlation tests. Statistical significance was accepted for p values less than 0.05.
Results and analysis
We enrolled in the study 29 adult patients with documented seasonal allergic rhinitis: 11 men (38 per cent) and 18 women (62 per cent). Patients' mean age ± standard deviation (SD) was 35.55 ± 12.59 years (range, 19–67 years).
Prior to treatment, all patients had a total nasal symptom score of 10 or more (mean ± SD 15.69 ± 2.31) and a total ocular symptom score of 7 or more (mean ± SD 13.21 ± 3.83).
Following treatment, the mean ± SD total nasal symptom score was 2.69 ± 3.92. A mean ± SD nasal symptom score decrease of 13 ± 4.13 was observed; this decrease was statistically significant (p < 0.001). Based on improvement in nasal symptoms, treatment success was 75.9 per cent (i.e. 22 patients). Table II shows patients' nasal symptom scores before and after treatment.
Table II Total symptom scores pre- and post-treatment
Data represent means ± standard deviations unless otherwise specified. Rx = treatment; TNS = total nasal symptoms; TOS = total ocular symptoms
Following treatment, the mean ± SD total ocular symptom score was 2.52 ± 3.58. Thus, the mean ± SD decrease in total ocular symptom score over the course of the study was 10.69 ± 5.74; this decrease was also statistically significant (p < 0.001) (Table II). Based on improvement in ocular symptoms, treatment success was 72.4 per cent (21 patients).
There was a statistically significant correlation between the decrease in nasal and ocular symptom scores (p < 0.04).
Nasal cytology examination indicated that eosinophils were present in 17 patients (58.6 per cent) before treatment and four patients (13.8 per cent) after treatment. Neutrophils were present in 26 patients (89.7 per cent) before treatment and 16 patients (55.2 per cent) after treatment. Basophilic cells were present in seven patients (24.1 per cent) before treatment and three patients (10.3 per cent) after treatment. Goblet cells were present in 17 patients (58.6 per cent) before treatment and four patients (13.8 per cent) after treatment (Table III).
Table III Nasal cytology scores pre- and post-treatment
Data represent means ± standard deviations unless otherwise specified. Rx = treatment
Decreases in eosinophils, neutrophils, goblet cells and total cytology scores were statistically significant; the decrease in basophilic cells was not statistically significant. There was a statistically significant correlation between the decrease in total cytology scores and the decrease in eosinophil and neutrophil scores (p < 0.01). However, there was no significant correlation between the decrease in total cytology score and the decrease in basophilic cell and goblet cell scores (p > 0.05).
Discussion
Allergic rhinitis is a ‘symptomatic disorder of the nose, induced after allergen exposure, by an IgE-mediated inflammation of the nasal membranes’.Reference Bousquet, Van Cauwenberge and Khaltaev8
The diagnosis of allergic rhinitis is based on a combination of typical allergic symptoms, physical examination signs and diagnostic test results. Performing nasal smear cytology provides additional support for the diagnosis. Some authors consider an increase in eosinophil count, on nasal smear cytology, to be a diagnostic criterion, but there is no consensus.9–11 The Allergic Rhinitis and its Impact on Asthma initiative has proposed that intermittent allergic rhinitis be diagnosed when symptoms last less than four days a week, or less than four consecutive weeks. Moderate or severe disease is characterised by the presence of one or more of the following: abnormal sleep; impairment of daily activities, leisure and/or sport; impairment of school or work; and troublesome symptoms.Reference Bousquet, Khaltaev, Cruz, Denburg, Fokkens and Togias12
The patients enrolled in our study complained of symptoms in the same months of the year for at least two years, lasting no more than four weeks. They also fulfilled the criteria for the diagnosis of moderate or severe disease.
All our patients were given an intranasal corticosteroid (mometasone furoate) and an oral H1-antihistamine (levocetirizine). At the end of a three-week course of treatment with these drugs, patients' mean total nasal symptom score had improved by 86.8 per cent, and their mean total ocular symptom score by 80.9 per cent (p < 0.001). These results are consistent with those of Meltzer et al., who found a decrease in mean nasal symptom scores, compared with baseline measurements, in patients with seasonal allergic rhinitis treated with mometasone furoate.Reference Meltzer, Jalowayski, Orgel and Harris7 In another study, patients receiving levocetirizine showed an overall total symptom score improvement of 86 per cent in the first week of treatment and 47 per cent over the entire treatment period, compared with placebo.Reference Potter13 Lee et al. found a 43 per cent decrease in symptom scores in children (aged six to 12 years) with perennial allergic rhinitis treated with oral antihistamine only (levocetirizine).Reference Lee, Sun, Lu, Ku and Lue14 Several studies have shown that mometasone furoate improves the mean total ocular symptom score of patients suffering seasonal allergic rhinitis.15–17
Normal nasal mucosa consists of epithelial cells, goblet cells and basal cells. There are usually no eosinophils or basophilic cells in the superficial layer. A moderate number of neutrophils and a few bacteria may be seen.
In nasal mucosa affected by allergic rhinitis, eosinophils are encountered at all ages.Reference Howarth, Persson, Meltzer, Jacobson, Durham and Silkoff4 In Meltzer and colleagues' multicentre study, nasal eosinophilia was present in 64 to 86 per cent of patients enrolled in seasonal allergic rhinitis studies.Reference Meltzer, Orgel, Rogenes and Field18 In another study assessing adult patients with seasonal allergic rhinitis and a nasal cytology grading of at least 1+, eosinophilia was found in 81 per cent of patients, basophilic cells in 42 per cent, neutrophils in 64 per cent and bacteria in 28 per cent.Reference Meltzer, Orgel, Bronsky, Furukawa, Grossman and LaForce19
In our study, a nasal cytology grading of 1+ or more was considered as eosinophilia, and was found in 58.6 per cent of patients. Nasal eosinophilia was reduced to 13.8 per cent following treatment with oral levocetirizine dihydrochloride (5 mg daily) and mometasone furoate monohydrate (200 µg daily). Compared with pre-treatment values, this decrease in nasal eosinophilia was statistically significant (p < 0.001).
In a study performed by Lee et al., patients' nasal smear eosinophilia was decreased by 23.47 per cent following cetirizine treatment, by 6.5 per cent following levocetirizine treatment and by 2.85 per cent following placebo administration.Reference Lee, Sun, Lu, Ku and Lue14 In Meltzer and colleagues' multicentre study, fluticasone proprionate treatment (100 µg twice daily) resulted in a 33 per cent reduction in the nasal eosinophilia ratio.Reference Meltzer, Orgel, Rogenes and Field18 Ciprandi et al. conducted a double-blind, controlled study of 30 patients with seasonal allergic rhinitis, comparing the efficacy of levocetirizine, desloratadine and placebo treatment.Reference Ciprandi, Cirillo, Vizzaccaro, Civardi, Barberi and Allen20 On completion of two weeks' treatment, the levocetirizine group showed a statistically significant decrease in nasal eosinophilia, while the desloratadine and placebo groups showed no significant decrease. Another study by the same group found a statistically significant decrease in nasal eosinophilia following treatment with mometasone furoate (200 µg daily).Reference Ciprandi, Tosca, Passalacqua and Canonica21
In seasonal allergic rhinitis patients, nasal cytology also reveals a significant increase in neutrophil counts during the pollen season. In the nasal cytological evaluations of both healthy and allergic individuals, a neutrophil predominance (73 per cent ± 10) was present. Nasal cytology specimens from allergic patients reveal significantly more total cells, neutrophils and eosinophils, compared with normal individuals.Reference Lim, Taylor and Naclerio22 In a study of an experimental allergic rhinitis model in guinea pigs, nasal lavage cytology showed increased numbers of eosinophils, neutrophils and mononuclear cells.Reference Yamasaki, Sasaki, Mizutani, Nabe, Sakura and Matsumoto23 Meltzer et al. found baseline nasal neutrophilia in 60–80 per cent of patients with untreated seasonal allergic rhinitis; after two to four weeks' treatment with a topical steroid, the proportion was 50–70 per cent, a statistically significant decrease compared with placebo (p < 0.05).Reference Meltzer, Orgel, Rogenes and Field18 Another study observed a highly significant decrease in neutrophils, in seasonal allergic rhinitis patients treated with mometasone furoate.Reference Meltzer, Jalowayski, Orgel and Harris7 The present study identified nasal neutrophilia in 26 patients (89.7 per cent) before treatment and 16 patients (55.2 per cent) after treatment; this decrease was statistically significant (p = 0.006).
• In allergic rhinitis, both objective and subjective measures are used for diagnosis and evaluation of treatment efficacy
• Nasal smear cytology may be a useful additional, objective assessment method for patients with allergic rhinitis, as an adjunct to symptom scoring systems
Nasal mucosa contains approximately 200–400 basophilic cells per cubic millimetre. Most of these cells are located in the lamina propria. Three types of basophilic cells are present in the nasal mucosa: basophil leukocytes and two different types of mast cell.Reference Howarth, Persson, Meltzer, Jacobson, Durham and Silkoff4 In patients with allergic rhinitis, basophilic cell distribution on the nasal mucosal surface has been shown to increase within 5 to 24 hours of allergen exposure. This increase has been found to correlate with nasal symptom scores.Reference Borres, Irander and Björkstén24, Reference Saito, Howie, Wattie, Denburg, Ellis and Inman25 Meltzer et al. found a basophilic cell percentage of 29–57 per cent in seasonal allergic rhinitis patients pre-treatment, falling to 8–31 per cent after treatment with various doses of fluticasone proprionate (50–800 µg).Reference Meltzer, Orgel, Rogenes and Field18 In our study, nasal basophilic cells were present in seven patients (24.1 per cent) before treatment and three patients (10.3 per cent) after treatment; this decrease was statistically insignificant (p = 0.289).
In an experimental allergic rhinitis model, Nakaya et al. have reported goblet cell hyperplasia and submucosal collagen deposition.Reference Nakaya, Dohi, Okunishi, Nakagome, Tanaka and Imamura26 In contrast, Berger et al. reported that the increased mucus secretion observed on the inferior turbinates of patients with perennial allergic rhinitis was dependent upon increased goblet cell functional activity, rather than increased goblet cell numbers.Reference Berger, Moroz, Marom and Ophir27 Meltzer et al. found no significant difference in nasal goblet cell counts before and after treatment with fluticasone proprionate aqueous nasal spray.Reference Meltzer, Orgel, Rogenes and Field18 In the present study, goblet cells were present in 17 patients (58.6 per cent) before treatment and four patients (13.8 per cent) after treatment; this decrease was statistically significant (p = 0.001).
In the present study, the total cytology score was defined as the sum of the eosinophil, basophil, neutrophil and goblet cell scores. Our patients' mean ± SD total cytology score was 4.48 ± 1.68 before treatment and 2.19 ± 1.79 after treatment. There have been no previous reports evaluating these four cell groups together in seasonal allergic rhinitis patients; therefore, we could not compare our total cytology scores with other authors' findings. However, our internal comparison of total cytology scores before versus after treatment revealed a significant decrease (p < 0.001). Moreover, there was a significant correlation between the decrease in total cytology scores and the decrease in eosinophil and neutrophil scores (p < 0.01). There was no significant correlation between the decrease in total cytology scores and the decrease in basophilic cell and goblet cell scores (p > 0.05).
Conclusion
In the present study of patients with seasonal allergic rhinitis, we found a correlation between nasal cytological parameters and nasal and ocular symptoms before and after treatment. On completion of seasonal allergic rhinitis therapy, we observed significant improvements both in nasal and ocular symptoms and in nasal inflammatory cell counts. Symptom scoring and nasal cytological evaluation provided significant information both for diagnosis and for assessment of treatment efficacy.
The collection of nasal smears (for cytologic evaluation) is simple and well tolerated by patients. However, such smears are not commonly used in clinical trials. Nasal cytology may potentially be a useful additional investigation for the standard evaluation and diagnosis of allergic rhinitis. However, studies with larger patient series would be required in order to assess this.
