A Multidisciplinary Approach In The Diagnosis Of Allergic And Non Allergic Respiratory Diseases : Nasal Cytology And

Upper and lower airway disease is a common condition. Its prevalence is increasing in different areas of the world, but, at present, non-allergic rhinitis is underestimated. The aim of this study was to investigate FeNO (fractional exhaled nitric oxide) and nasal cytology in allergic and non-allergic patients, in order to reach a correct diagnosis. This study was performed on 120 children with rhinitis and/or asthma, evaluated by an allergist and an otolaryngologist. Skin prick-test and nasal cytology were tested in all patients; FeNO only in the asthmatic ones. The proportion of positive results in nasal cytology was higher in non-allergic than in allergic children: 22 out of 23 patients, vs 91 out of 97 patients. A significant correlation was found between FeNO levels and increase in nasal eosinophil counts. There is compelling evidence of a close relationship between upper and lower airway in asthma and rhinitis. The presence of rhinitis should always be investigated in children with asthma; therefore, FeNO and nasal cytology have clinical benefit both in allergic and non-allergic children. Our finding also supports the use of nasal cytology to evaluate non-allergic rhinitis (NAR). DOI : 10.14302/issn.2379-8572.joa-15-807 Correspondig author: Daniela Simoncini, via Mario Realini 62, 22070, Valmorea, Como. E-mail: daniela_simoncini@libero.it, telephone: 3357023010. Running title: An alarmig problem, a new approach

Dysfunctions of the upper and lower airways frequently coexist: data from epidemiological studies indicate that rhinitis is experienced by as many as 80% of patients with allergic asthma and 75% of patients with nonallergic asthma; while asthma is experienced by as many as 34% of patients with AR and 25% of patients with NAR, [4,5].
Nasal cytology represents a valid method in the differential diagnosis of allergic and non-allergic nasal diseases as it is simple, safe, non-invasive (local anaesthesia is not required), easy to perform and able to detect both the cellular modification of the nasal epithelium (a ciliated pseudo-stratified epithelium) Therefore, the aim of this study was to combine measurements of upper and lower airway inflammation with FeNO and nasal cytology but also to study the clinical benefits of nasal cytology in children.

Materials AND Methods
A total of 120 patients, aged 3-17, coming from our outpatient service of allergic diseases were clinically examined from the 1st of November 2013 to the 31st of March 2014. All participants were interviewed about respiratory symptoms thanks to ACT (Asthma Control Test) or C-ACT (Childhood-Asthma Control Test) and SNOT (Sino-Nasal Outcome Test); lung function and airway inflammation were measured using HyPAIR FeNO and nasal cytology. Furthermore the allergic sensitization to common aeroallergens (birch, core, olive tree, grasses, ragweed, parietaria, dog, cat, house dust mite: DPP and DPF, mould: alternaria) and foods (cow lactalbumin, cow casein, egg white and yolk, peanuts) was evaluated by skin prick-test. Each subject performed no more than a total of 6 exhalations. The interval between exhalations was at least 30 seconds. FeNO was calculated as the mean of 3 correct exhalations. All measurements were performed in parts per billion (ppb).

Nasal Cytology
Eosinophils were found in 80 allergic patients. 6 patients had normal nasal cytology but two of them were sensitized only for grass pollen and the exam was performed out of the pollen season; 2 were on therapy (Fluticasone nasal spray and antihistamine) which could have invalidated the results; 2 were polyallergic.
According to the correlation between symptoms and prick test 6 patients, diagnosed only with allergic rhinitis also had overlapped rhinitis (Table 1a) The  (Table 1b)

Discussion :
Rhinitis   Our research confirmed the role played by eosoniphilia which is able to induce the NO-synthase and the direct correlation between pulmonary and nasal inflammation, [10]: when nasal eosinophils grow, the fraction of exhaled nitric increases as well (Fig. 1).

Conclusion :
According to our experience and to other studies, nasal cytology is a useful, simple and safe technique. Thanks to its non-invasiveness allowing repetition it can be used especially among children, and it is also well accepted by parents who more and more often ask for specific diagnosis and rational approaches.
It can provided an important contribution to identification of new pathological entities such as nonallergic rhinitis (NAR 17%), which are underdiagnosed.
Its association with FeNO is useful in the prevention and management of all allergic and non-allergic respiratory diseases in order to improve patients' quality of life.