eISSN: 2299-0046
ISSN: 1642-395X
Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii
Current issue Archive Manuscripts accepted About the journal Editorial board Reviewers Abstracting and indexing Subscription Contact Instructions for authors Ethical standards and procedures
SCImago Journal & Country Rank
vol. 39
Original paper

Nasal cytology can predict clinical efficacy of subcutaneous immunotherapy in intermittent allergic rhinitis

Edyta Jura-Szołtys
Radosław Gawlik
Olga Branicka
Grażyna Stryjewska-Makuch
Joanna Glück

Clinical Department of Internal Diseases, Allergology and Clinical Immunology, Medical University of Silesia, Katowice, Poland
Department of Laryngology and Laryngological Oncology, Upper Silesian Medical Centre, Independent Public Research Hospital No. 7 of Silesian Medical University, Katowice, Poland
Adv Dermatol Allergol 2022; XXXIX (6): 1110-1115
Online publish date: 2022/07/10
Article file
- Nasal cytology.pdf  [0.15 MB]
Get citation
JabRef, Mendeley
Papers, Reference Manager, RefWorks, Zotero


Allergic diseases are one of the most serious health problems worldwide. According to the latest European Academy of Allergy and Clinical Immunology (EAACI) report from 2016, it is estimated that by 2025 over 50% of all Europeans will be patients with at least one type of allergic disease [1]. The most common problem in clinical practice, apart from bronchial asthma, is allergic rhinitis (AR). AR is an inflammatory disease of the nasal mucosa, induced by an IgE-mediated reaction [2]. The costs generated by treatment, prophylaxis and diagnostic procedures as well as the deterioration in the quality of life of patients mean that AR is also an important epidemiological and social problem [3, 4]. Allergen immunotherapy (AIT) is the only disease-modifying treatment option available for patients with IgE-mediated allergic diseases [5, 6]. AIT induces immune tolerance, and prevents the development of new sensitization and the progression from AR to asthma [7, 8]. The effectiveness of immunotherapy depends on the type of sensitizing allergen. Studies show that the treatment in selected patients with intermittent allergic rhinitis is more effective [9]. The identification of specific biomarkers, which may predict response to AIT treatment in AR patients, is currently an active field of research in the aspect of recommended personalization of medicine [10, 11].


The aim of the study was to evaluate rhinological parameters that are practicable in the specialist office in patients with intermittent allergic rhinitis qualified for treatment with subcutaneous allergen immunotherapy (SCIT).

Material and methods

Study setting and participants

This single-center prospective observational study included patients of an allergy and ENT outpatient clinic with intermittent allergic rhinitis qualified for subcutaneous immunotherapy in accordance with the EAACI guidelines in the pollen seasons from January to July 2018 and 2019 [12]. Diagnosis of intermittent allergic rhinitis was based on clinical history and skin prick test results. Rhinitis was classified as intermittent according to ARIA criteria [13]. The patients with intermittent allergic rhinitis were evaluated twice: before AIT during the pollen season (V1) and in the next pollen season (V2) after introduction of subcutaneous immunotherapy (Figure 1). Both during the initial visit (V1) and at follow-up (V2) total nasal symptom score (TNSS), rhinomanometry and nasal cytology were performed.

Figure 1

Study flow. V1 – the first visit during the pollen season with qualification to AIT, V2 – the second visit during the next pollen season after the course of AIT


All patients denied the use of nasal or systemic corticosteroids, antihistamines or antileukotrienes for least 14 days prior to each assessment. Exclusion criteria covered: patients under 18 years of age, concomitant bronchial asthma, allergy to perennial allergens such as house dust mites, Alternaria, Cladosporium, animal dander, patients with chronic rhinosinusitis with nasal polyps (CRSwNP), clinically relevant nasal septum deviation and contraindications to SIT according to EAACI recommendation [12, 14].

Skin prick tests

The skin prick tests were performed according to the European Academy of Allergy and Clinical Immunology guidelines. Wheal diameters ≥ 3 mm were considered as positive [15]. The panel consisted of: house dust mites (Dermatophagoides farinae and Dermatophagoides pteronyssinus), Alternaria tenuis, animal dander (cat, dog), grass pollen, rye, tree (birch, alder, hazel, beech) pollen, mugwort, positive (histamine 10 mg/ml) and negative (physiological saline 0.9% NaCl) controls. Allergen-specific IgE serum concentrations were not measured in the studied patients.

Severity allergic rhinitis evaluation

Total nasal symptom score (TNSS) was used to measure the clinical severity of AR and it included the following four symptoms: nasal congestion, runny nose, nasal itching and sneezing in the last 2 weeks. The symptoms were rated on a scale of 0 to 3 for each symptom, with 0 meaning no symptoms and the 3 most pronounced symptoms in the last 2 weeks. The maximum number of points was 12. The severity was assessed as mild for points 0–4, moderate for 5–8 and severe for 9–12.


Rhinomanometry using Rhinotest MP 1000 (producer MES Poland) according to the International Committee for the Standardization of Rhinomanometry (ICSR) guidelines was performed. The values of total flow and total resistance at the 150 Pa level were calculated [16].

Nasal cytology evaluation

The nasal mucosa samples under direct vision in anterior rhinoscopy were collected. Two scrapes of the epithelial membrane of the inferior turbinate using disposable nasal brushes were performed to obtain the sample. The specimen was immediately smeared on a glass slide and fixed for 1 min in 95% ethyl alcohol and stained with hematoxylin and eosin. Slides were examined using oil immersion light microscopy. The percentage of eosinophils per 100 cells was calculated [17].


Therapy was performed with depot allergoids (Purethal-HAL Allergy B.V., Leiden) – a mixture of tree pollen, grass pollen or grass/tree pollen at a concentration of 20 000 BAU (bioequivalent allergy unit)/1 ml. Patients received a conventional administration schedule of SIT by subcutaneous injections of Purethal, starting with 0.05 ml, and then administered at weekly intervals until the maintenance dose (0.5 ml) was reached. Subsequently, maintenance dosages, corresponding to 0.5 ml of drug solution, were given at 4-weekly intervals.

Statement of ethics

The research was approved by the Bioethics Committee at the Medical University of Silesia in Katowice, Poland. Resolution No. KNW/0022/KB1/107/I/16/18. Written informed consent was obtained from each participant prior to the study.

Statistical analysis

Data are presented as median with interquartile range for variables with non-normal distribution and mean ± SD for variables with normal distribution. Wilcoxon’s test to compare non-normal variables, Kruskal-Wallis test to compare more than two groups and Spearman´s rank test to evaluate associations between variables were used. P-values < 0.05 were considered significant. Analysis was performed using Statistica 13.3 software (Statistica 13.3, StatSoft Poland).


Forty-two patients (female: 19; 45%, male: 23; 55%) in the age range from 18 to 51 years with moderate (16, 38%) and severe (26, 62%) intermittent allergic rhinitis were enrolled in this study and qualified for subcutaneous immunotherapy. Fourteen (33.3%) patients were desensitized with grass pollen allergen extracts – subgroup G; 12 (28.6%) with tree pollen allergen extracts – subgroup T; and 16 (38.1%) with grass and tree pollen allergen extracts – subgroup GT. The subgroups were comparable in terms of age and sex.

The characteristics of the study groups are summarized in Table 1.

Table 1

Characteristics of all patients and subgroups sensitized to grass pollen (G), tree pollen (T), and to grass and tree pollen (GT)

N (%)4214 (33.3)12 (28.6)16 (38.1)
Age [years] median39.5 (30–46; 18–51)36 (25–47; 18–51)41 (36–-48.5; 28–50)38 (30–42; 24–51)
Male, n (%)23 (54.8)8 (57.2)6 (50)9 (54.5)
Female, n (%)19 (45.2)6 (42.8)6 (50)7 (43.5)

All patients were followed up in the next season (V2). All examined parameters significantly improved after 1 year of allergen immunotherapy: both percentage of eosinophils in nasal mucosa samples and TNSS symptoms decreased, whereas the nasal flow rate increased and nasal resistance decreased. All results are shown in Table 2. In 26 (62%) TNSS was assessed as mild, in 14 (33%) as moderate and in 2 (5%) as severe rhinitis.

Table 2

Rhinological parameters in patients before and after one course of subcutaneous immunotherapy

CharacteristicsMedian and IQR or mean ± SDRangeP-value
Cytology (%):
 V172.2 ±11.350-92
 V241.6 ±6.632-55< 0.0001
 Delta30.6 ±13.8
TNSS sum [points]:
 V110 (8–12)6–12
 V24 (2–6)0–11< 0.0001
 Delta5 (4–7)1–12
TNSS – nasal congestion:
 V13 (2–3)2–3
 V21 (1–2)0–3< 0.0001
TNSS – discharge:
 V13 (2–3)2–3
 V21 (1–2)0–3< 0.0001
TNSS – itching:
 V12.5 (2–3)1–3
 V21 (1–2)0–3< 0.0001
TNSS – sneezing:
 V12 (1–3)1–3
 V22 (1–3)1–3< 0.0001
  V1197.3 (170–246)95–364.5
  V2470.5 (382.5–569.5)120–770.5< 0.0001
  V10.83 (0.68–1.02)0.41–1.68
  V20.4 (0.3–0.51)0.23–1.34< 0.0001

[i] TNSS – total nasal symptom score, IQR – interquartile range, SD – standard deviation, V1 – the first visit during the pollen season with qualification for AIT, V2 – the second visit during the next pollen season after the course of AIT.

A significant correlation was found between the absolute change in TNSS and change in percentage of eosinophils in nasal mucosa assessed before beginning and after the first year of subcutaneous allergen immunotherapy (rs = 0.39, p < 0.05; Spearman correlation test). The comparisons of subgroups of patients sensitive to grass pollen, tree pollen or grass and tree pollen revealed that the change in percentage of eosinophils in nasal mucosa samples was significantly different in the subgroups and was the highest in the subgroup sensitive to grass pollen (44.5 (40–52)), less in the subgroup sensitive to tree pollen (30.5 (26–36.5)) and the least in the grass and tree pollen sensitive group (18 (31–21)), p < 0.001, Kruskal-Wallis test (Figures 2, 3).

Figure 2

Percentage of eosinophils in nasal mucosa during V1 in subgroups of patients (p = 0.00001, Kruskal-Wallis test). G – grass pollen sensitized group, T – tree pollen sensitized group, GT – grass and tree pollen sensitized group

Figure 3

Changes in percentage of eosinophils in nasal mucosa after one course of subcutaneous immunotherapy. G – grass pollen sensitized group, T – tree pollen sensitized group, GT – grass and tree pollen sensitized group



Ineffective pharmacological treatment in patients with intermittent allergic rhinitis may be reduced via allergen immunotherapy [5]. Allergen immunotherapy is a long-term therapeutic process and can cause some side effects; therefore qualification for this treatment should be considered very carefully [18, 19]. The new treatment strategies for SCIT require identification of factors predicting better effectiveness of this treatment [20, 21]. The efficacy of SCIT has been confirmed by numerous clinical trials and a meta-analysis [22, 23]. In this study, the authors performed a rhinological assessment in patients with intermittent allergic rhinitis during the pollen season and in the next season after initializing subcutaneous immunotherapy. In order to assess the rhinology state, the standardized methods of high diagnostic relevance, available in everyday clinical practice, were used. Objective and subjective methods were used. Among the objective methods of rhinological assessment, rhinomanometry is recommended [16]. In our study, we used Eccles’ guidelines for rhinomanometric testing [24]. After one course of SCIT, a significant increase of the air flow in rhinomanometry was observed, accompanied by a significant decline in total resistance. Rhinomanometric evaluation was confirmed by a subjective standardized test using TNSS. TNSS is recommended by the authors in order to objectively assess the severity of symptoms of intermittent allergic rhinitis [25]. The TNSS assessment showed a significant reduction in the severity symptoms.

It is recommended to find biomarkers which may predict a positive response to SCIT treatment in AR patients [26]. The ratio of specific IgE to total IgE ratio before treatment and basophil activation can be considered as a potential biomarker which can predict the efficacy of SCIT [27, 28]. For the selection of the right extracts for allergen immunotherapy composition Matricardi recommends a molecular diagnosis (Matricardi 2019). In our study we found that percentage of eosinophilic infiltration in nasal cytology can predict clinical efficacy of subcutaneous immunotherapy. The patients with high eosinophilic infiltration of the mucous membrane had markedly greater rhinitis symptoms reduction after SCIT. The reduction was particularly significant in patients allergic to grass pollen. Nasal cytology results confirm the reports suggesting that monovalent allergies to grass pollen correspond to a better response to SCIT [29]. The high percentage of nasal eosinophilia in intermittent allergic rhinitis was confirmed by other researchers [30, 31]. However, nasal cytology is a simple tool which may be considered as a predictive marker of successful subcutaneous immunotherapy. To our knowledge, there are no other data concerning the nasal cytology after SCIT. The limitation of the study was the inability to compare the results with other studies, and lack of data on pollen count in particular seasons. Another limitation was the short period of observation of the allergic rhinitis patients, made only during one course of SCIT immunotherapy. Consequently, further studies are needed to elucidate the role of percentage eosinophilic infiltration of the nasal mucous membrane after allergen immunotherapy in intermittent allergic rhinitis.


Objective and subjective methods of rhinological assessment confirmed high effectiveness of SCIT in intermittent allergic rhinitis. A high percentage of eosinophils in nasal cytology before subcutaneous immunotherapy can predict its clinical efficacy for allergic rhinitis, especially in grass pollen allergy.


The study was supported by grant KNW-1-181/N/6/16 from the Medical University of Silesia.

The study was supported by grant KNW-1-180/N/6/K from the Medical University of Silesia Katowice, Poland.

Conflict of interest

The authors declare no conflict of interest.



Canonica GW, Bousquet J, Mullol J, et al. A survey of the burden of allergic rhinitis in Europe. Allergy 2007; 62: 17-25.


Brożek JL, Bousquet J, Agache I, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines-2016 revision. J Allergy Clin Immunol 2017; 140: 950-8.


Meltzer EO. Allergic rhinitis: burden of illness, quality of life, comorbidities, and control. Immunol Allergy Clin North Am 2016; 36: 235-48.


Belhassen M, Demoly P, Bloch-Morot E, et al. Costs of perennial allergic rhinitis and allergic asthma increase with severity and poor disease control. Allergy 2017; 72: 948-58.


Alvarez-Cuesta E, Bousquet J, Canonica GW, et al. Standards for practical allergen-specific immunotherapy EAACI, Immunotherapy Task Force. Allergy 2006; 61 Suppl 82: 1-20.


Malling HJ. Immunotherapy as an effective tool in allergy treatment. Allergy 1998; 53: 461-72.


Bousquet J, Lockey R, Malling HJ. Allergen immunotherapy: therapeutic vaccines for allergic diseases. A WHO position paper. J Allergy Clin Immunol 1998; 102: 558-62.


Morjaria JB, Caruso M, Emma R, et al. Treatment of allergic rhinitis as a strategy for preventing asthma. Curr Allergy Asthma Rep 2018; 18: 23.


Calderon MA, Alves B, Jacobson M, et al. Allergen injection immunotherapy for seasonal allergic rhinitis. Cochrane Database Syst Rev 2007; 1: CD001936.


Kappen JH, Durham SR, Veen HI, Shamji MH. Applications and mechanisms of immunotherapy in allergic rhinitis and asthma. Ther Adv Respir Dis 2017; 11: 73-86.


Shamji MH, Durham SR. Mechanisms of allergen immunotherapy for inhaled allergens and predictive biomarkers. J Allergy Clin Immunol 2017; 140: 1485-98.


Agache I. EAACI guidelines on allergen immunotherapy – Out with the old and in with the new. Allergy 2018; 73: 737-38.


Brozek JL, Bousquet J, Baena-Cagnani CE, et al. Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol 2010; 126: 466-76.


Pitsios C, Demoly P, Bilò MB, et al. Clinical contraindications to allergen immunotherapy: an EAACI position paper. Allergy 2015; 70: 897-909.


Bousquet J, Heinzerling L, Bachert C, et al. Practical guide to skin prick tests in allergy to aeroallergens. Allergy 2012; 67: 18-24.


Clement PA. Committee report on standardization of rhinomanometry. Rhinology 1984; 22: 151-5.


Gelardi M, Iannuzzi L, Quaranta N, et al. NASAL cytology: practical aspects and clinical relevance. Clin Exp Allergy 2016; 46: 785-92.


James C, Bernstein DI. Allergen immunotherapy: an updated review of safety. Curr Opin Allergy Clin Immunol 2017; 17: 55-9.


Makatsori M, Calderon MA. Anaphylaxis: still a ghost behind allergen immunotherapy. Curr Opin Allergy Clin Immunol 2014; 14: 316-22.


Jakalski M, Bozek A, Canonica GW. Responders and nonresponders to pharmacotherapy and allergen immunotherapy. Hum Vaccin Immunother 2019; 15: 2896-902.


Würtzen PA, Gupta S, Brand S, Andersen PS. Grass pollen immunotherapy: where are we now. Immunotherapy 2016; 8: 399-411.


Scadding GW, Eifan AO, Lao-Araya M, et al. Effect of grass pollen immunotherapy on clinical and local immune response to nasal allergen challenge. Allergy 2015; 70: 689-96.


Dhami S, Nurmatov U, Arasi S, et al. Allergen immunotherapy for allergic rhinoconjunctivitis: a systematic review and meta-analysis. Allergy 2017; 72: 1597-631.


Eccles R. A guide to practical aspects of measurement of human nasal airflow by rhinomanometry. Rhinology 2011; 49: 2-10.


Gross GN, Berman G, Amar NJ, et al. Efficacy and safety of olopatadine-mometasone combination nasal spray for the treatment of seasonal allergic rhinitis. Ann Allergy Asthma Immunol 2019; 122: 630-38.


Shamji MH, Kappen JH, Akdis M, et al. Biomarkers for monitoring clinical efficacy of allergen immunotherapy for allergic rhinoconjunctivitis and allergic asthma: an EAACI Position Paper. Allergy 2017; 72: 1156-73.


Di Lorenzo G, Mansueto P, Pacor ML, et al. Evaluation of serum s-IgE/total IgE ratio in predicting clinical response to allergen-specific immunotherapy. J Allergy Clin Immunol 2009; 123: 1103-10.


Shamji MH, Layhadi JA, Scadding GW, et al. Basophil expression of diamine oxidase: a novel biomarker of allergen immunotherapy response. J Allergy Clin Immunol 2015; 135: 913-21.


Matricardi PM, Dramburg S, Potapova E, et al. Molecular diagnosis for allergen immunotherapy. J Allergy Clin Immunol 2019; 143: 831-43.


Berkiten G, Aydoğdu I, Kumral TL, et al. Nasal eosinophilia in nasal smears of patients with persistent and intermittent allergic rhinitis. J Laryngol Otol 2018; 132: 1018-21.


Pal I, Babu AS, Halder I, Kumar S. Nasal smear eosinophils and allergic rhinitis. Ear Nose Throat J 2017; 96: 10-1.

Copyright: © 2022 Termedia Sp. z o. o. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
Quick links
© 2023 Termedia Sp. z o.o. All rights reserved.
Developed by Bentus.