Comparative Study of Nasal Smear and Biopsy in Patients of Allergic Rhinitis

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1 Indian J Allergy Asthma Immunol 2002; 16(1) : Comparative Study of Nasal Smear and Biopsy in Patients of Allergic Rhinitis Rakesh Chanda, Ajay Kumar Aggarwal, G.S. Kohli, T.S. Jaswal*, and K.B. Gupta** Department of Otolaryngology, Pathology* and Chest**, Pt. B.D.S. PGIMS, Rohtak Haryana, India Abstract Nasal smears and biopsies are easier and far economical alternatives for diagnosis of allergic rhinitis by identifying local inflammatory cells especially eosinophils and mast cells. This study was conducted to compare the results of nasal smears and biopsies in patients of allergic rhinitis and correlate them to age of onset, severity of nasal obstruction, history of allergy to food, inhalant and of other systems eg. skin. GIT etc. Biopsies were found to be better than smears and incidence of eosinophils and mast cells was found to increase with positive history of allergy in family, other organs of body, inhaled or food allergens and severity of obstruction. Key words: Allergic Rhinitis, Nasal Smear, Nasal Biopsy Allergic rhinitis is an IGE-mediated hypersensitivity disease of nasal mucosa characterized by sneezing, itching, watery nasal discharge and a sensation of nasal obstruction. Associated allergic conjunctivitis and bronchial asthma may also occur. Depending on the part of the world the rate of symptoms attributed to allergic rhinoconjunctivitis ranges from % of the population. 1 A characteristic feature of allergic inflammation is local accumulation of inflammatory cells including T lymphocytes, mast cells, eosinophils, basophils and neutrophils. 2 Release of various mediators from these cells is responsible for the symptoms of allergic rhinitis which can be divided into early or delayed (late) phase response. Early phase response is manly due to mediators released from degranulation of mast cells following exposure to an antigen. This antigen binds to mast cell bound IgE. Major mediators released are Address for correspondence: Dr. Rakesh Chanda, 149-R, Model Town, Rohtak (Haryana). IJAAI, 2002, XVI ( I ) p histamine, prostaglandins, thromboxane A2, bradykinin and platelet activation factor etc. Accumulation of additional inflammatory cells such as eosinophils and T cells occurs through chemokine attraction. These cells then release additional mediators such as eosinophil cationic protein and major basic protein, which promote a second inflammatory effect approximately 3-6 hours after allergen exposure and is known as delayed allergic response. 3 These inflammatory cell can be easily identified in nasal mucosa and secretions by performing nasal biopsies and preparing nasal smears respectively confirming the diagnosis of allergic rhinitis. Further these are simple, reproducible, easy to perform and economical as compared to other tests e.g. skin prick test, radioallergosobent test (RAST) etc. The present study was planned to compare the results of nasal smears and nasal biopsies in allergic rhinitis. MATERIAL AND METHODS Twenty five clinically diagnosed patients of nasal

2 28 allergy were selected from the outpatient department of Otolaryngology PGIMS, Rohtak. Twenty five age and sex matched healthy subjects with no evidence of allergic rhinitis acted as controls. Complete allergic work up was carried out in each case which included history with special stress on allergens, allergic symptoms and examination. In the study group both nasal smears as well as biopsy was performed while in the control group only nasal smears were prepared. Two slides each were prepared for both nasal smears as well as biopsies. One was stained with hematoxylin and eosin (H&E) while in other Giemsa staining was carried out. In H&E preparation only eosinophils could be made out but in Giemsa staining both eosinophils and mast cells could be differentiated. Smear slides were examined by the set zig zag method. Grading of both smears and biopsies was done using method of Shioda and Mishima. 5 In smears for eosinophils, criteria adopted were 0 : No cell, + : few eosinophils or small clumps, ++ : moderate number or large clumps, +++ : still larger clumps but did not cover the entire field, ++++ : large clumps covering the entire field. For mast cells, 0 - No cell, ± : <15, + : 15-25, ++ : , +++ : > 100 cells in whole slide. In biopsy cellular grading was done as follow: ± : Occasional cells, + : few natural cells, ++ : moderate number of cells, +++ : clumps. After grading, these observations were correlated with the clinical findings. OBSERVATIONS AND RESULTS In the control group out of 25 patients 20 were males and five were females, while in study group 10 were males and 15 were females. All the patients in both groups were between the age of years. 13 INDIAN J ALLERGY ASTHMA IMMUNOL 2002; 16(1) patients in control group and 15 in study group were less than 30 years old. In the control group, nasal smears showed eosinophils and mast cells in 2 patients each. In study group eosinophils were present in 10 smears only, out of which 7 were +, 2 were ++, 1 was ++++ whereas 17 biopsies revealed eosinophils. Out of 10 smears which showed eosinophils, 8 were positive in biopsies also. As far as mast cells are concerned 4 smears and 6 biopsies showed mast cells. Out of 10 positive smears for eosinophils, one was showing mast cells also. While in 17 biopsies positive for eosinophils, mast cells were presents in four. In rest 8 biopsies which were negative for eosinophil, 2 had mast cells. In 15 patients of stud group with age of onset <30 years, 7 smears (47%) and 10 biopsies (70%) were having eosinophils while only 3(20%) smears and 4 biopsies (27%) were having mast cells while in rest 10 patients with age of onset >30 years only 3 smears (30%) and 7 biopsies (70%) showed eosinophils and one smear, and 2 biopsies were having mast cells. There appeared to be a tendency to find eosinophils and mast cells more frequently in patients with onset of disease below 30 year of age. Incidence of both eosinophils and mast cells was found to increase both in smears and biopsies with increasing severity of nasal obstruction (Table 1). It was significantly higher in patients with complaints of continuous as compared to intermittent nasal obstruction (p<0.5) Incidence of eosinophils and mast cells was also studied with respect to history of allergic symptoms in other organs and systems e.g. eye, skin respiratory system and GIT (Table II). Both eosinophils and Table I. Correlation of eosinophils and mast cells in nasal smears and biopsies in patients of allergic rhinitis with severity of nasal obstruction

3 NASAL SMEAR AND BIOPSY IN ALLERGIC RHINITIS 29 Table II. Correlation of eosinophils and mast cells in patients of allergic rhinitis with the adjuvant allergy of eye, respiratory system, gastrointestinal system and skin mast cells in biopsies and smears were more in patients having eye symptoms as compared to those with no eyes symptoms. Incidence of eosinophils in nasal smears was found to be more in patients with positive skin allergy as compared to patients with no skin allergy. However difference in mast cells was not significant (p>0.1). Different in eosinophils and mast cells in biopsy was even less significant vis a vis the smear with respect to skin allergy (p>0.1). Higher incidence of both mast cell and eosinophils was found in smears of patient with respiratory symptoms. However eosinophils were high in biopsies of these while mast cells did not increase. Results of smears appeared to be more significant than biopsies (p<0.05). In patients with GIT symptoms, higher incidence of only mast cells was presented both in smears and biopsies. Incidence of eosinophils in smears and mast cells in biopsies was found to increase with family history of allergy, while both eosinopils as well as mast cells were found in patients with positive history of inhalant allergen. Positive history of food allergen was found to have higher incidence of eosinophils in biopsy with no effect on mast cells (Table III). DISCUSSION Although the onset of allergic rhinitis can occur at any time of life, 70% of these develop it before 30 years of age. 6 In our study 60% patients were <30 years of age. Although allergic rhinitis is considered Table III. Correlation of eosinophils and mast cells on smears and biopsies with allergy in family and history of food and inhalant allergen

4 30 INDIAN J ALLERGY ASTHMA IMMUNOL 2002; 16(1) to be a male predominant disease 3, our study group had male: female ratio of 2:3. In our study two patients (8%) had increased number of eosinophils in control group. This is in agreement with Mygind 7 and Murray et al 8 who reported increased eosinophils in 11% and 17% of their controls respectively. Two patients (8%) in control group also showed mast cells also reported by Mygind and Thomson. 9 However, no satisfactory explanation is found for this in literature. Nasal smear of 40% patents, in study group showed eosinophils which is in agreement with study by Lans et al. 10 However some studies have shown higher positive rates of 81% and 69.2%. 11,12 The cause for lower incidence of eosinophils in present study could be that we might have missed the eosinophil peak in some of our cases as Shioda and Mishima concluded that eosinophil peak in nasal smears occur at 12 hours after provocation and fell by 36 hours. 5 Our study showed 17(68%) biopsies to have eosinophils and this incidence was higher in comparison to other studies which showed it to be 26%. 13 So in the present study biopsies proved to be better than smears for the detection of eosinophils though smears were also significant (p<0.05). However results of our study were in contrary to that of Mygind which showed smears to be better than biopsies. 7 On the other hand 16% of smears and 24% of biopsies of study group showed mast cells. Similar results were shown by Sasaki. 14 In our study biopsy appears to have an edge over smears as also reported by McKenna. 15 Though the incidence of mast cells was higher as compared to controls but definitely not as high as that of eosinophils and hence it was not found to be that much reliable indicator of allergy. Our study showed a trend towards direct proportion of eosinophilia and inverse proportion of mastiphilia with severity of nasal obstruction. Higher incidence of eosinophils and mast cells was found in patients having associated allergic symptoms of eyes and respiratory system. However in cases with associated symptoms of skin and GIT higher incidence of only eosinophils and mast cells respectively was found. Our study showed increased eosinophils but not mast cells smears and mast cells in biopsy in patients with positive family history of allergy. Incidence of eosinophils increased with history of both inhalant and food allergens but there was no significant difference between the level of eosinophils in inhalant and food allergy i.e. 43% and 42% respectively in smears and 71% and 75% respectively in biopies. Mast cells increased only with inhalant allergen with no significant change with history of food allergen (p>0.1). Incidence of mast cells in patients with inhalant allergy was more as compared to patients with food allergy. Our findings about correlation of eosinophils with inhalant allergens and that of mast cells with food allergens coincide with those of Johnson 16 but differ from the findings of Shioda and Mishima. 5 REFERENCES 1. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis and atopic eczema : ISAAC. The international study of asthma and allergies inchildhood (ISAAC) steering committee. Lancet 1998; 351: Varney VA, Jacobson MR, Sudderick RM, Robinson DS, Irani AMA, Schwartz LB et al. Immunohistology of the nasal mucosa following allergen - induced rhinitis: Identification of activated T lymphocytes, eosinophils and neutrophils. Am Rev Respir Dis 1992; 146 : Durham SR. Mechanism and treatment of allergic rhinitis. In : Mackay IS, Bull TR, editors. Scott Brown's Otolaryngology, Vol 4. 6th ed. Oxford: Butterworth Heinemann; 1997; p.6 : Jirapongrananuruk O, Vidhyanand P. Nasal cytology in the diagnosis of allergic rhinitis in children. Ann Allerg Asthma Immunol 1998;80: Shioda H, Mishima T. Significance of mast cells in nasal smears from patietns with food allergy. J. Allergy 1966; 37 : Bellonti JA, Wallerstedt DB. Allergic rhinitis update : Epidemiology and nature history. Allergy Asthma Proc 2000; 21 : Mygrind N, Weeks B, Dirksin A, Johnson NJ. Perenial rhinitis: An analysis of skin testing, serum IgE and blood and smear eosinophilla in 201 patients. Clin Otolaryngol 1978; 3 : Murray AB, Anderson DO. The epidemiologic relationship of clinical nasal allergy to eosinophils and to goblet cells in the nasal smears. J Allergy 1969; 43 : Mygind N, Thomson J. Cytology of the nasal mucosa. Arch Klin Exp Chru Kehik Heilk 1973; 204 : Lans DM, Alfano N, Rocklin R. Nasal eosinophilia in allergic and non allergic rhinitis usefulness of the nasal smear in the

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