Abstract
Allergic rhinitis is a global health problem and patients present with varied symptoms. The severity of symptoms is evaluated by a 5 point Nasal Obstruction Symptom Evaluation Scale (NOSE) and levels of absolute eosinophil count (AEC). A prospective observational study was conducted in 140 patients in a tertiary care hospital over a period of 1 year. A detailed clinical examination was performed, NOSE scale scoring based on symptomatology was done, and AEC values were assessed. Subjects were treated with intra nasal steroid spray and symptom evaluation done by NOSE scale at 3 months of use for follow up. NOSE scale and AEC values were correlated in our study. The mean NOSE 1 scale was 64.07 ± 16.71 in the study population, the mean AEC value was 633.07 ± 152.77. In our study correlation between intra nasal steroid spray and NOSE scale has been done. NOSE scale evaluation is simple, economical, and non-invasive. Therefore, it may be used in the management of allergic rhinitis.
Keywords: Absolute eosinophil count (AEC), Allergic rhinitis (AR), Nasal obstruction symptom evaluation (NOSE) scale, Steroid nasal spray
Introduction
Allergic rhinitis is a global health problem and it is increasing in prevalence rapidly [1]. Rhinitis is defined clinically as having two or more symptoms of anterior or posterior rhinorrhoea, sneezing, nasal blockage and/or itching of the nose during two or more consecutive days for more than 1 h on most days [2]. Rhinitis affects 40% of population globally [3]. The incidence of allergic rhinitis ranges between 10 and 20% [4]. Severe allergic rhinitis has been associated with significant impairments in quality of life, sleep and work performance [4]. Allergic rhinitis (AR) is an inflammatory nasal airway disease in which production of inflammatory mediators and inflammatory cell infiltration are prominent [5]. The clinical manifestations are sneezing, nasal congestion, nasal itching, and rhinorrhoea.
The Nasal Obstruction Symptom Evaluation (NOSE) scale is an outcome instrument used in a multicentre observational clinical study funded by American Academy of Otolaryngology–Head and Neck Surgery Foundation and coordinated under the auspices of its National Centre for the Promotion of Research in Otolaryngology [6].
Absolute Eosinophil count (AEC) is a valuable test for diagnosis of Allergic Rhinitis. AEC is an easy, simple, non-invasive, reliable test, valuable and very economical. Association between absolute Eosinophil count and clinical severity of symptoms has been proven by many studies [7]. Blood eosinophilia, is an important diagnostic indicator in the initial stage i.e. first 1–2 weeks of allergic rhinitis symptom [8]. Medical therapy in allergic rhinitis used in the form of systemic or local antihistamines, corticosteroids, mast cell stabilizers, and immunotherapy. There is no study in the literature which correlates subjective and objective measurements in allergic rhinitis. In this study, we have correlated NOSE scale and AEC and efficacy of steroid nasal spray (Fluticasone furoate), based on NOSE scale in Allergic rhinitis (Fig. 1).
Fig. 1.
Absolute eosinophil count variables in the study
Aims and Objectives
The aim of the study was to assess the role of NOSE scale in the management of allergic rhinitis.
Materials and Methods
A prospective observational study was conducted at the ENT out-patient department of a tertiary care centre between July 2018 and July 2019 with signs and symptoms of allergic rhinitis were included in this study. Total 140 subjects were included in the study.
Inclusion Criteria
Patients having symptoms of allergic rhinitis—sneezing, nasal pruritus, rhinorrhoea, nasal congestion, eye watering and itching pharyngeal itching were included (Fig. 2).
Fig. 2.
Predictive validity of NOSE 1 scale with AEC. Area under curve (Blue) line implies AEC
Exclusion Criteria
Smokers, pregnant women, people with life threatening/chronic persistent severe asthma, chronic respiratory illnesses like bronchiectasis, pulmonary tuberculosis and other obstructive airway disease Recent nasal surgery or anatomic defects of the nose, recent two courses of parenteral steroids within 3 months of screening and presence of any co-morbid systemic illness and use of oral and nasal decongestants 1 week prior to the treatment were excluded (Table 1).
Table 1.
The NOSE scale and severity score
| Symptom | Not a problem (A) | Very mild problem (B) | Moderate problem (C) | Fairly bad problem (D) | Severe problem (E) |
|---|---|---|---|---|---|
| Nasal stuffiness | |||||
| Nasal blockage or obstruction | |||||
| Trouble breathing through my nose | |||||
| Trouble sleeping | |||||
| Unable to get enough air through my nose during exertion/exercise |
Methodology
Clinical examination of ear, nose throat was done in all cases. The common signs of Allergic rhinitis observed include pale and oedematous nasal mucosa, swollen turbinates and thin, watery or mucous nasal discharge. Ocular features were oedema of eye lids, congestion of conjunctiva and watering of eyes. Subjects were reassessed after 3 months use of steroid nasal spray and NOSE scale was taken which was compared with NOSE scale before steroid spray was instituted.
NOSE Scale
Nasal obstruction symptom evaluation scale was given to all the subjects who enrolled for this study (Table 2).
Table 2.
Comparison between NOSE 1 and NOSE 2 scale
| Parameter | Mean + SD | Median | Minimum | Maximum | 95% CI | |
|---|---|---|---|---|---|---|
| Upper | Lower | |||||
| NOSE 1 scale | 64.07 ± 16.71 | 70.00 | 30.00 | 95.00 | 61.28 | 66.86 |
| NOSE 2 scale | 31.07 ± 6.26 | 30.00 | 20.00 | 45.00 | 30.03 | 32.12 |
Absolute eosinophil count (AEC) count was taken before starting steroid nasal spray. Normal AEC count is less than 350. NOSE 1 scale was taken before starting steroid nasal spray and it was correlated with Absolute eosinophil count. NOSE 2 scale was taken after use of steroid nasal spray for 3 months and followed up and correlated with NOSE 1 scale. NOSE 1 scale and NOSE 2 scale were considered as primary outcome variables. AEC was considered as primary explanatory variable. The utility of NOSE 1 score in predicting AEC abnormality was assessed by Receiver Operative curve (ROC) analysis. Area under the ROC curve along with its 95% CI and p value are presented. Basing on the ROC analysis, it was decided to consider 42.5 as the cut off value. The association between quantitative explanatory variables and ordinal variables was assessed by spearman’s rank correlation. p value < 0.05 was considered statistically significant (Table 3).
Table 3.
Absolute eosinophil count variables in the study
| Parameter | Mean ± SD | Median | Minimum | Maximum | 95% CI | |
|---|---|---|---|---|---|---|
| Lower | Upper | |||||
| AEC value | 633.07 ± 152.77 | 650.00 | 340.00 | 900.00 | 607.54 | 658.60 |
Results
A total of 140 who reported at the ENT out-patient department of a tertiary care centre from July 2018 to July 2019 with signs and symptoms of allergic rhinitis were included in this study. Out of 140 patients, 126 patients (90%) had abnormal AEC. 14 (10%) of the study population had normal AEC values. Normal AEC value less than 350 has been taken into consideration.
Among the study population, 14 (10%) had normal AEC and 126 (90.00%) had abnormal AEC (Table 4).
Table 4.
The NOSE 1 scale with area under the curve
| Area under the curve | SE | 95% confidence interval of AUC | p value | |
|---|---|---|---|---|
| Lower bound | Upper bound | |||
| Test result variable(s): NOSE 1 score | ||||
| 0.948 | 0.019 | 0.910 | 0.985 | < 0.001 |
The mean NOSE 1 scale was 64.07 ± 16.71 in the study population, minimum level was 30 and maximum level was 95 in the study population (95% CI 61.28–66.86). The mean NOSE 2 scale was 31.07 ± 6.26 in the study population, minimum level was 20 and maximum level was 45 in the study population (95% CI 30.03–32.12).
The mean AEC value was 633.07 ± 152.77 in the study population, minimum level was 340 and maximum level was 900 in the study population (95% CI 607.54–658.60).
The NOSE 1 scale had excellent predictive validity in predicting abnormal AEC, as indicated by area under the curve of 0.019 (95% CI 0.910–0.985, p value < 0.001).
Correlation between NOSE 1 scale and AEC in study population (N = 140). There was strong positive correlation between NOSE 1 scale and AEC (rs value: 0.905, p value: < 0.001) (Table 5).
Table 5.
Correlation between NOSE 1 scale and AEC
| Parameter | Spearman’s rho correlation | p value |
|---|---|---|
| NOSE 1 scale | 0.905 | < 0.001 |
Discussion
Allergic rhinitis is the most frequent manifestation of allergic disease affecting the airways and its development depends on the interaction between genes, environment and immunological factors. The diagnosis of rhinitis is based on the report of subjective nasal complaints (nasal blockage, itching, sneezing and increased secretions), increased nasal responsiveness and increased nasal airway resistance. To date, the different tests for rhinitis have low sensitivity and specificity and the diagnosis is therefore predominately made on the basis of clinical history [9, 10]. The basic investigations required in the evaluation of a patient with suspected Allergic rhinitis include complete blood picture with peripheral eosinophil percentage, absolute eosinophil count, total IgE levels, and nasal smear examination for eosinophils. The association between eosinophil and allergic disease has been published in various studies. A correlation between the degree of and peripheral blood eosinophilia has been observed in subjects who exhibited a dual response following allergen challenge [7]. Eosinophilia is common finding in Allergic rhinitis. In a study by Kumar et al. [7], nasal eosinophilia was seen in 52.4% cases of allergic rhinitis while blood eosinophilia was seen in 54% of allergic rhinitis. Patel et al. [11], conducted a prospective study on 70 patients and concluded that there was no correlation of blood AEC with severity of clinical score and majority (94.29%) of the patients had no eosinophilia. Bellamkonda et al. [12], observed normal AEC was found in 55% of cases and raised AEC was seen in only 45% of cases implicating that AEC was not raised in more than half the allergic rhinitis patients. In our study mean AEC value was 633.07 ± 152.77 in the study population, minimum level was 340 and maximum level was 900 in the study population.
The NOSE questionnaire provides validated symptom-specific quality-of-life questionnaire, which specifically assesses the symptom of nasal obstruction and its consequences. In our study the mean NOSE 1 scale was 64.07 ± 16.71 in the study population, minimum level was 30 and maximum level was 95 in the study population. The mean NOSE 2 scale was 31.07 ± 6.26 in the study population, minimum level was 20 and maximum level was 45 in the study population. In our study, follow up patients with intra nasal steroid spray showed symptomatic improvement with reduced NOSE scale.
Like many similar instruments, the NOSE scale was validated for use in groups of patients. Therefore it could be used for comparing disease-specific health status between groups of patients before and after treatment, or used to compare the effects of different treatment. It could also be used to compare symptom severity between different groups of patients, for example, those with and without nasal polyps. However, it was not designed to be used with individual patient data or to predict outcome in individuals. The NOSE scale could also be used with a global or generic quality of life instrument, to assess the relative impact of the specific disease on different aspects of global quality of life. In our study, NOSE 1 scale had excellent predictive validity in predicting AEC in Allergic rhinitis. There was strong positive correlation between NOSE 1 scale and AEC in study population, indicating both variables are interrelated indicating severity of symptoms of Allergic rhinitis. In our study NOSE 1 scale was correlated with AEC and it was statistically significant. On using intra nasal steroid spray, comparing NOSE 1 and NOSE 2 scale, it was found that there was improvement in symptoms and reduced NOSE 2 scale. AEC was not done after use of intra nasal steroid spray, as the subjects were symptomatically better.
Intranasal corticosteroids are the most potent and effective agents for the treatment of Allergic rhinitis; they are recommended as first-line agents for moderate/severe or persistent Allergic rhinitis [13]. These agents effectively reduce inflammation of the nasal mucosa and improve mucosal pathology through their anti-inflammatory mechanism of action [13]. Intranasal corticosteroids provide relief for the four major symptoms of Allergic rhinitis: sneezing, itching, rhinorrhoea, and nasal congestion when used both continuously. Intranasal corticosteroids improved symptoms of Allergic rhinitis particularly nasal obstruction leading to lower NOSE scale [14, 15].
Conclusion
NOSE scale evaluation is simple, economical, and non-invasive. Hence it may be used in the management of Allergic rhinitis in clinical setup. In this study correlation between intra nasal steroid spray and NOSE scale has been done.
Funding
None.
Compliance with Ethical Standards
Conflict of interest
All authors declare that they have no conflict of interest.
Ethical Approval
Permission taken from institutional ethical committee for doing this study.
Footnotes
Publisher's Note
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