**3. Results**

We have collected in **Figure 1** the results of the cytological tests performed from October 2013 to September 2018 (**Figure 1**).

Of the 300 patients studied, 154 (equal to 53.66%) were affected by a pathology of the nasal mucosa of neutrophilic type that is characterized by the presence of more or less numerous neutrophil granulocytes. The majority of them, 136 patients (88.31%), had chronic nonpolyposis pathology, while only 18 (11.69%) of them presented a polyposis pathology (**Figure 2**). The patients with nonpolyposis pathology were subjected to cone beam computed tomography (CBCT). Ninety-seven patients (71.32%) showed a pathological thickening of the paranasal sinuses mucosa. This situation indicates an involvement of the paranasal sinuses by the pathology and suggests a diagnosis of chronic rhinosinusitis (**Figure 3**).

Thirty-four patients, equal to 11.85% of the total, showed a significant presence in the nasal mucosa of eosinophilic granulocytes. Of these, 29.41% of patients (10) had polyposis, while 70.59% of patients (24) had nonpolyposis (**Figure 4**).

Only five patients (1.74% of the total) showed instead a significant presence of mast cells in the nasal mucosa, and in no case we observed a form of polyposis. Finally, 32.75% of patients (94) had a mixed cell infiltration in the samples of nasal mucosa (**Figure 1**). Of these, 23.40% (22 patients) presented a polyposis pathology (**Figure 5**).

We analyzed the cytotypes of the "mixed cellularity rhinosinusopathy" category, distinguishing four subclasses: neutrophil-eosinophil forms (50 patients, equal to 53.19%), neutrophil-mast cell forms (8 patients equal to 8.51%),

**33**

**Figure 4.**

neutrophil-eosinophil-mastocyte forms (24 patients equal to 25.53%), and eosino-

In 33 patients (equal to 11% of the total patients studied), we did not find any

phil-mast cell forms (12 patients equal to 12.77%) as indicated in **Figure 6**.

pathological changes in the nasal mucosa.

*Eosinophil pathology: presence of polyps.*

*Neutrophil nonpolypoid pathology: mucosal thickening.*

*Use of Nasal Cytology in Diagnosis of Sinonasal Disorders*

*DOI: http://dx.doi.org/10.5772/intechopen.84231*

**Figure 2.**

**Figure 3.**

*Neutrophil pathology: presence of polyps.*

**Figure 1.** *Type of cells in nasal pathology.*

**Figure 2.** *Neutrophil pathology: presence of polyps.*

*Rhinosinusitis*

immersion.

**3. Results**

nusitis (**Figure 3**).

(**Figure 5**).

are then shown in a **Table 1**.

October 2013 to September 2018 (**Figure 1**).

Initially, a general inspection of the material is carried out with a lower magnification objective (4×/0.10). Once the most significant part of the sample has been identified, the evaluation will be carried out with increasingly powerful objectives to exploit the maximum possible magnification (100×/1.25) with the help of oil for

In accordance with the guidelines of the Italian Academy of Nasal Cytology (AICNA), for each sample taken, we analyze at least 50 fields at maximum magnification (100×/25) by counting the different types of cells found. The observed data

We have collected in **Figure 1** the results of the cytological tests performed from

Thirty-four patients, equal to 11.85% of the total, showed a significant presence in the nasal mucosa of eosinophilic granulocytes. Of these, 29.41% of patients (10)

had polyposis, while 70.59% of patients (24) had nonpolyposis (**Figure 4**). Only five patients (1.74% of the total) showed instead a significant presence of mast cells in the nasal mucosa, and in no case we observed a form of polyposis. Finally, 32.75% of patients (94) had a mixed cell infiltration in the samples of nasal mucosa (**Figure 1**). Of these, 23.40% (22 patients) presented a polyposis pathology

We analyzed the cytotypes of the "mixed cellularity rhinosinusopathy" category, distinguishing four subclasses: neutrophil-eosinophil forms (50 patients, equal to 53.19%), neutrophil-mast cell forms (8 patients equal to 8.51%),

Of the 300 patients studied, 154 (equal to 53.66%) were affected by a pathology of the nasal mucosa of neutrophilic type that is characterized by the presence of more or less numerous neutrophil granulocytes. The majority of them, 136 patients (88.31%), had chronic nonpolyposis pathology, while only 18 (11.69%) of them presented a polyposis pathology (**Figure 2**). The patients with nonpolyposis pathology were subjected to cone beam computed tomography (CBCT). Ninety-seven patients (71.32%) showed a pathological thickening of the paranasal sinuses mucosa. This situation indicates an involvement of the paranasal sinuses by the pathology and suggests a diagnosis of chronic rhinosi-

**32**

**Figure 1.**

*Type of cells in nasal pathology.*

**Figure 3.** *Neutrophil nonpolypoid pathology: mucosal thickening.*

**Figure 4.** *Eosinophil pathology: presence of polyps.*

neutrophil-eosinophil-mastocyte forms (24 patients equal to 25.53%), and eosinophil-mast cell forms (12 patients equal to 12.77%) as indicated in **Figure 6**.

In 33 patients (equal to 11% of the total patients studied), we did not find any pathological changes in the nasal mucosa.

**Figure 5.** *Mixed pathology: presence of polyps.*

**Figure 6.** *Types of cells in mixed rhinosinusitis.*

The picture that emerged from this evaluation allowed us to distinguish nasal pathologies in a practical and clear way on the basis of cytological aspects and therefore, in our opinion, to simplify their classification. Furthermore, the cytological characterization allows us to address the therapy in a very personal way and, in addition, to periodically evaluate the results in a more rigorous way.

We therefore distinguished the nasosinusal pathologies in groups based on the inflammatory cytotype most significantly represented in the analyzed sample:


However, in some patients we found that it was not possible to define a dominant cytotype as the nasal mucosa was quantitatively similarly affected by more than one cell type. In these cases we use the term rhinosinusitis with mixed cellularity.

**35**

resistance to drugs.

*Use of Nasal Cytology in Diagnosis of Sinonasal Disorders*

• Neutrophil-eosinophil-mastocitary form

We then divided the mixed cellular rhinosinusitis into four subclasses:

In our experience, it represents the most frequently encountered pathology. This condition is characterized by the more or less significant presence of inflammatory

The neutrophil granulocyte has a roundish shape and presents a clear ("neutral") cytoplasm with a purplish-red polylobate nucleus after MGG staining. The neutrophil granulocytes are distinguished in six different types based on the shape of the nucleus [2]. It is possible that the number of lobes is related to the age of the cell. In fact, in young granulocytes the nucleus often appears to be reniform, while in the

The neutrophilic granulocyte plays an important immune function defending us from pathogenic microorganisms [6] and other irritating substances toward which it has an effective phagocytic activity. Once the phagocytosis process has been performed, a "killing" function is performed against pathogens thanks to the intracytoplasmic release of substances with a lithic action including hydrogen peroxide, superoxide ion, and some enzymes as elastase, lysozyme, collagenase, phosphatase,

According to Gelardi et al., the presence of sporadic neutrophils in the nasal mucosa would not represent an index of pathology. Instead, we have to make a diagnosis in case of high number of neutrophils. With infectious rhinosinusitis, the number of neutrophil granulocytes increases significantly. They are called back in the nasal mucosa in order to engulf the pathogenic microorganisms and eliminate them [7]. We observe in **Figure 7** some granulocytes with intracytoplasmic bacteria. In this image the moment immediately following the phagocytosis is shown, before the lithic enzymes are activated for digestive purposes. In the proposed image, we observe a bacterial infectious pathology. Microscopic observation can help us to differentiate the various types of germs involved in infection. We can in fact recognize the round shape of the bacteria as the *Staphylococcus Au*, the *Streptococcus Pn*, and the *Moraxella C.* or the elongated shape of the haemophilus I and the diphtheroids. Neutrophilic rhinosinusopathy with an infectious etiology may also present a viral or fungal etiology. In the latter case, we will observe the presence of fungal spores

In infectious neutrophil rhinosinusitis, in addition to the increase in neutrophils

We found very interesting the observation of bluish areas that we define "infectious spots" [2]. Those represent the expression of bacterial biofilm or an exopolysaccharide matrix within which fungal bacteria and spores live. The structure of the biofilm would correspond to a sort of shell that guarantees pathogens a greater

and the presence of microbial agents (**Figure 8**), we will also be able to see an increase in lymphocytes, macrophages, and plasma cells and an increase in mucipar

that present themselves with a particular "bulb" shape.

cells associated with decreased ciliated cells.

*DOI: http://dx.doi.org/10.5772/intechopen.84231*

• Neutrophilic-eosinophilic form

• Neutrophilic-mast cell form

• Eosinophilic-mast cell form

cells called neutrophils granulocytes.

older ones, it has different lobes.

and lactoferrin.

**3.1 Neutrophil rhinosinusitis**

*Use of Nasal Cytology in Diagnosis of Sinonasal Disorders DOI: http://dx.doi.org/10.5772/intechopen.84231*

We then divided the mixed cellular rhinosinusitis into four subclasses:


*Rhinosinusitis*

**Figure 5.**

**Figure 6.**

*Mixed pathology: presence of polyps.*

**34**

cellularity.

The picture that emerged from this evaluation allowed us to distinguish nasal pathologies in a practical and clear way on the basis of cytological aspects and therefore, in our opinion, to simplify their classification. Furthermore, the cytological characterization allows us to address the therapy in a very personal way and,

We therefore distinguished the nasosinusal pathologies in groups based on the inflammatory cytotype most significantly represented in the analyzed sample:

However, in some patients we found that it was not possible to define a dominant cytotype as the nasal mucosa was quantitatively similarly affected by more than one cell type. In these cases we use the term rhinosinusitis with mixed

in addition, to periodically evaluate the results in a more rigorous way.

• Neutrophilic rhinosinusitis

*Types of cells in mixed rhinosinusitis.*

• Eosinophilic rhinosinusitis

• Mast cell rhinosinusitis


#### **3.1 Neutrophil rhinosinusitis**

In our experience, it represents the most frequently encountered pathology. This condition is characterized by the more or less significant presence of inflammatory cells called neutrophils granulocytes.

The neutrophil granulocyte has a roundish shape and presents a clear ("neutral") cytoplasm with a purplish-red polylobate nucleus after MGG staining. The neutrophil granulocytes are distinguished in six different types based on the shape of the nucleus [2]. It is possible that the number of lobes is related to the age of the cell. In fact, in young granulocytes the nucleus often appears to be reniform, while in the older ones, it has different lobes.

The neutrophilic granulocyte plays an important immune function defending us from pathogenic microorganisms [6] and other irritating substances toward which it has an effective phagocytic activity. Once the phagocytosis process has been performed, a "killing" function is performed against pathogens thanks to the intracytoplasmic release of substances with a lithic action including hydrogen peroxide, superoxide ion, and some enzymes as elastase, lysozyme, collagenase, phosphatase, and lactoferrin.

According to Gelardi et al., the presence of sporadic neutrophils in the nasal mucosa would not represent an index of pathology. Instead, we have to make a diagnosis in case of high number of neutrophils. With infectious rhinosinusitis, the number of neutrophil granulocytes increases significantly. They are called back in the nasal mucosa in order to engulf the pathogenic microorganisms and eliminate them [7]. We observe in **Figure 7** some granulocytes with intracytoplasmic bacteria. In this image the moment immediately following the phagocytosis is shown, before the lithic enzymes are activated for digestive purposes. In the proposed image, we observe a bacterial infectious pathology. Microscopic observation can help us to differentiate the various types of germs involved in infection. We can in fact recognize the round shape of the bacteria as the *Staphylococcus Au*, the *Streptococcus Pn*, and the *Moraxella C.* or the elongated shape of the haemophilus I and the diphtheroids. Neutrophilic rhinosinusopathy with an infectious etiology may also present a viral or fungal etiology. In the latter case, we will observe the presence of fungal spores that present themselves with a particular "bulb" shape.

In infectious neutrophil rhinosinusitis, in addition to the increase in neutrophils and the presence of microbial agents (**Figure 8**), we will also be able to see an increase in lymphocytes, macrophages, and plasma cells and an increase in mucipar cells associated with decreased ciliated cells.

We found very interesting the observation of bluish areas that we define "infectious spots" [2]. Those represent the expression of bacterial biofilm or an exopolysaccharide matrix within which fungal bacteria and spores live. The structure of the biofilm would correspond to a sort of shell that guarantees pathogens a greater resistance to drugs.

#### *Rhinosinusitis*

**Figure 7.** *Phagocytosis (neutrophil granulocyte with intracytoplasmic bacteria).*

**Figure 8.** *Infectious neutrophil rhinosinusitis.*

In the forms of viral etiology, we will not be able to find pathogenic microorganisms due to the insufficient magnification power of the optical microscope. However, we can observe some indirect signs of ciliated cells strongly suggestive of viral infection. In fact, they can present both alterations of the nuclear structure (polynucleation) and of the cytoplasmic component (inclusions and separations). Also usually in the viral infection, we observe an important increase of the lymphocytes. The finding of neutrophils in the nasal mucosa, however, also occurs in cases of noninfectious diseases. In these cases we can observe a variable number of neutrophil granulocytes without the cytological aspects described above. In this case, we are talking about a form of irritating rhinosinusitis in which often the etiologic agent is represented by a substance with an irritating action, which can be exogenous (powders, environmental pollutants, tobacco smoke, and toxic substances present in the professional field) or endogenous (gastroesophageal reflux disease) (**Figure 9**) [8].

In addition to the already described presence of neutrophils we can observe an alteration of the normal relationship between ciliate cells and muciparous cells. In fact, we often observe a reduction of the former and an increase in the latter. In other cases we can observe areas of squamous epithelium. According to some authors the severity of these rhinopathies would be associated with the number of neutrophils present.

In fact, by releasing their lithic enzymes and their toxic substances, they would cause damage to the respiratory mucosa proportional to the quantity of substances released.

Furthermore, in these patients, chronic mucosal damage and consequent alteration of mucociliary clearness would favor greater nasal fragility and a greater risk of contracting respiratory infections.

**37**

**Figure 10.**

*Use of Nasal Cytology in Diagnosis of Sinonasal Disorders*

*DOI: http://dx.doi.org/10.5772/intechopen.84231*

**3.2 Eosinophilic rhinosinusitis**

*Noninfectious neutrophil rhinosinusitis.*

**Figure 9.**

This condition is represented by the presence in the nasal mucosa of eosinophilic granulocytes. The eosinophilic granulocyte belongs, as well as neutrophil, to the group of leukocytes and also presents a roundish form, although of slightly greater

The cytoplasm is of variable color from orange to intense pink, very distinctive and unmistakable. Inside, small granules are observed that contain substances such as the major basic protein (MBP), the eosinophilic cationic protein, and the eosinophilic peroxidase [9]. These substances have a cytotoxic and antibacterial function. In the cytoplasm of eosinophils, we also find enzymes (collagenase, phosphatase, and phospholipase) and substances derived from the metabolism of arachidonic acid as leukotrienes and prostaglandins (LTC4, PGD2, PGE1). These substances play a fundamental role in the mechanisms of inflammation, especially in the

The LTC4 leukotriene in particular has a bronchoconstriction action as well as prostaglandin PGD2, while prostaglandin E1 has a vasodilatory action. Other substances present in nongranular form in the cytoplasm of eosinophils are released

dimensions. Frequently the nucleus appears bilobed (**Figure 10**).

delayed phase of the allergic reaction (**Figure 11**).

*Eosinophilous (frequently the nucleus appears bilobed).*

*Use of Nasal Cytology in Diagnosis of Sinonasal Disorders DOI: http://dx.doi.org/10.5772/intechopen.84231*

**Figure 9.** *Noninfectious neutrophil rhinosinusitis.*

*Rhinosinusitis*

**Figure 7.**

**Figure 8.**

*Infectious neutrophil rhinosinusitis.*

*Phagocytosis (neutrophil granulocyte with intracytoplasmic bacteria).*

In the forms of viral etiology, we will not be able to find pathogenic microorganisms due to the insufficient magnification power of the optical microscope. However, we can observe some indirect signs of ciliated cells strongly suggestive of viral infection. In fact, they can present both alterations of the nuclear structure (polynucleation) and of the cytoplasmic component (inclusions and separations). Also usually in the viral infection, we observe an important increase of the lymphocytes. The finding of neutrophils in the nasal mucosa, however, also occurs in cases of noninfectious diseases. In these cases we can observe a variable number of neutrophil granulocytes without the cytological aspects described above. In this case, we are talking about a form of irritating rhinosinusitis in which often the etiologic agent is represented by a substance with an irritating action, which can be exogenous (powders, environmental pollutants, tobacco smoke, and toxic substances present in the professional field) or endogenous (gastroesophageal reflux disease) (**Figure 9**) [8]. In addition to the already described presence of neutrophils we can observe an alteration of the normal relationship between ciliate cells and muciparous cells. In fact, we often observe a reduction of the former and an increase in the latter. In other cases we can observe areas of squamous epithelium. According to some authors the severity of these rhinopathies would be associated with the number of

In fact, by releasing their lithic enzymes and their toxic substances, they would cause damage to the respiratory mucosa proportional to the quantity of substances released. Furthermore, in these patients, chronic mucosal damage and consequent alteration of mucociliary clearness would favor greater nasal fragility and a greater risk of

**36**

neutrophils present.

contracting respiratory infections.

### **3.2 Eosinophilic rhinosinusitis**

This condition is represented by the presence in the nasal mucosa of eosinophilic granulocytes. The eosinophilic granulocyte belongs, as well as neutrophil, to the group of leukocytes and also presents a roundish form, although of slightly greater dimensions. Frequently the nucleus appears bilobed (**Figure 10**).

The cytoplasm is of variable color from orange to intense pink, very distinctive and unmistakable. Inside, small granules are observed that contain substances such as the major basic protein (MBP), the eosinophilic cationic protein, and the eosinophilic peroxidase [9]. These substances have a cytotoxic and antibacterial function. In the cytoplasm of eosinophils, we also find enzymes (collagenase, phosphatase, and phospholipase) and substances derived from the metabolism of arachidonic acid as leukotrienes and prostaglandins (LTC4, PGD2, PGE1). These substances play a fundamental role in the mechanisms of inflammation, especially in the delayed phase of the allergic reaction (**Figure 11**).

The LTC4 leukotriene in particular has a bronchoconstriction action as well as prostaglandin PGD2, while prostaglandin E1 has a vasodilatory action. Other substances present in nongranular form in the cytoplasm of eosinophils are released

**Figure 10.** *Eosinophilous (frequently the nucleus appears bilobed).*

#### *Rhinosinusitis*

**Figure 11.** *Eosinophil rhinosinusitis (we observed an important degranulation reaction).*

for chemotactic and amplification of the inflammatory processes. We recall among these IL2, which performs chemotactic action toward mast cells, IL3 with chemotactic action toward eosinophils, and IL5 with chemotactic action toward neutrophils [10].

Frequently we have found eosinophilic rhinosinusitis. Of 34 patients with this type of pathology, 38.24% (or 13 patients) had allergic rhinitis, the remainder suffered from other forms of rhinitis.

We have found in the 32.35% of subjects (11 patients) a vasomotoria rhinitis and in the 29.41% (10 patients) a nasal polyposis.

Eosinophilic rhinosinusitis has very specific clinical features. Affected patients complain of a very troublesome symptomatology, often characterized by sneezing and rhinorrhea, nasal itching, and nasal congestion. Symptoms can be triggered suddenly by the contact of the nasal mucosa with a known allergen, but also by the occurrence of some particular stimuli (such as sudden changes in temperature or humidity, contact with intense perfumes, tobacco smoke).

Patients with eosinophilic rhinosinusitis are often affected by other eosinophilic phenotype disorders such as bronchial asthma. For a long time, we have known that the course of the nasal pathology has a singular influence on the prognosis of the associated bronchial pathology. For this reason, a correct treatment and a good control of the nasal pathology are to be considered necessary.

We know that some granular components of eosinophils, such as major basic protein (MBP), have the ability to attack the desmosomal junctions by weakening the barrier action of the respiratory mucosa and exposing it to the action harmful to infectious chemical or physical agents [11]. Therefore patients suffering from eosinophilic rhinosinusitis not only suffer from symptoms that we could define direct and that are related to the action of components such as prostaglandins and leukotrienes but also indirect symptoms (purulent rhinorrhea, headache, pharyngodynia, cough, recurrent fever, episodes of dyspnea) derived from the overlap of other diseases favored by the weakening of the mucosal barrier and by the inefficiency of mucociliary clearance.

#### **3.3 Mast cell rhinosinusitis**

This condition is characterized by the presence of mast cells in the nasal mucosa. The mast cell is presented to the observation with a variable optical microscope: it can be vaguely roundish or lozenge shaped. It is characterized by a marked basophilia and has a coarsely oval nucleus generally covered by numerous granules (**Figure 12**). They are generally larger in size than eosinophilic granules.

**39**

*Use of Nasal Cytology in Diagnosis of Sinonasal Disorders*

The surface of mast cells is characterized by the presence of IgE receptors. When they bind to these receptors, the mast cell releases by exocytosis its granules with the substances contained therein including histamine, a preformed substance with

In fact, it acts on the vascular receptors favoring vasodilation and edema of the surrounding tissues. It also acts on the nasal glands, feeding the rhinorrhea, and stimulates the nerve endings favoring itching and sneezing. The mast cell through its granules also eliminates some preformed chemotactic factors such as IL4, IL5, and IL13. Arachidonic acid is also synthesized by newly formed metabolites such as PGD2 and LTC4, whose actions on smooth muscles and vessels have already been

The mast cell, once stimulated, determines immediate symptoms. This rapidity of action can be observed in the early phase of the allergic reaction [13]. However, this cell is able, through the release of chemotactic factors, to influence also late

As we can show in **Figure 1**, mast cells are rarely the only cells involved in the pathogenesis of a rhinopathy. In fact, we found only 5 cases of mastocytic rhinosinusitis in 300 patients studied (1.67%). Of these patients two presented an allergic

On the other hand, cases of mixed cellular pathologies with the presence of mast

Mast cell rhinosinusitis are characterized by very intense symptoms, characterized by marked nasal obstruction, serous rhinorrhoea, nasal pruritus, and sneezing. Also in this case as in eosinophilous cellularity diseases, we have reestablished an association with other pathologies with a similar phenotype such as bronchial asthma.

We found a mixed rhinosinusitis in 94 patients corresponding to 32.75% of patients with rhinosinusitis and inflammatory phenotype (**Figure 1**). As we can see from the graph below, mixed rhinosinusitis is characterized by the presence in the

In 53.19% of the cases (50 patients), we found a pathology characterized by neutrophil and eosinophilic infiltration; in 25.53% of cases (24 patients), a type with neutrophilia-eosinophilia-mast cell; in 12.77% of cases (12 patients), eosinophilic and mast cell type and in 8; and 51% of the cases (8 patients), we found neutrophils and mast cells in the nasal mucosa. In many cases, mixed rhinosinusitis is found in

nasal mucosa of several inflammatory cytotypes (**Figures 13** and **14**).

disease, while three patients had a nonallergic disease.

*DOI: http://dx.doi.org/10.5772/intechopen.84231*

multiple actions [12].

*Mast cell with degranulation.*

**Figure 12.**

described previously.

phlogistic reactions.

cells are very frequent.

**3.4 Mixed rhinosinusitis**

*Use of Nasal Cytology in Diagnosis of Sinonasal Disorders DOI: http://dx.doi.org/10.5772/intechopen.84231*

**Figure 12.** *Mast cell with degranulation.*

*Rhinosinusitis*

neutrophils [10].

**Figure 11.**

fered from other forms of rhinitis.

ficiency of mucociliary clearance.

**3.3 Mast cell rhinosinusitis**

in the 29.41% (10 patients) a nasal polyposis.

humidity, contact with intense perfumes, tobacco smoke).

*Eosinophil rhinosinusitis (we observed an important degranulation reaction).*

control of the nasal pathology are to be considered necessary.

for chemotactic and amplification of the inflammatory processes. We recall among these IL2, which performs chemotactic action toward mast cells, IL3 with chemotactic action toward eosinophils, and IL5 with chemotactic action toward

Frequently we have found eosinophilic rhinosinusitis. Of 34 patients with this type of pathology, 38.24% (or 13 patients) had allergic rhinitis, the remainder suf-

We have found in the 32.35% of subjects (11 patients) a vasomotoria rhinitis and

Eosinophilic rhinosinusitis has very specific clinical features. Affected patients complain of a very troublesome symptomatology, often characterized by sneezing and rhinorrhea, nasal itching, and nasal congestion. Symptoms can be triggered suddenly by the contact of the nasal mucosa with a known allergen, but also by the occurrence of some particular stimuli (such as sudden changes in temperature or

Patients with eosinophilic rhinosinusitis are often affected by other eosinophilic

phenotype disorders such as bronchial asthma. For a long time, we have known that the course of the nasal pathology has a singular influence on the prognosis of the associated bronchial pathology. For this reason, a correct treatment and a good

We know that some granular components of eosinophils, such as major basic protein (MBP), have the ability to attack the desmosomal junctions by weakening the barrier action of the respiratory mucosa and exposing it to the action harmful to infectious chemical or physical agents [11]. Therefore patients suffering from eosinophilic rhinosinusitis not only suffer from symptoms that we could define direct and that are related to the action of components such as prostaglandins and leukotrienes but also indirect symptoms (purulent rhinorrhea, headache, pharyngodynia, cough, recurrent fever, episodes of dyspnea) derived from the overlap of other diseases favored by the weakening of the mucosal barrier and by the inef-

This condition is characterized by the presence of mast cells in the nasal mucosa. The mast cell is presented to the observation with a variable optical microscope: it can be vaguely roundish or lozenge shaped. It is characterized by a marked basophilia and has a coarsely oval nucleus generally covered by numerous granules

(**Figure 12**). They are generally larger in size than eosinophilic granules.

**38**

The surface of mast cells is characterized by the presence of IgE receptors. When they bind to these receptors, the mast cell releases by exocytosis its granules with the substances contained therein including histamine, a preformed substance with multiple actions [12].

In fact, it acts on the vascular receptors favoring vasodilation and edema of the surrounding tissues. It also acts on the nasal glands, feeding the rhinorrhea, and stimulates the nerve endings favoring itching and sneezing. The mast cell through its granules also eliminates some preformed chemotactic factors such as IL4, IL5, and IL13. Arachidonic acid is also synthesized by newly formed metabolites such as PGD2 and LTC4, whose actions on smooth muscles and vessels have already been described previously.

The mast cell, once stimulated, determines immediate symptoms. This rapidity of action can be observed in the early phase of the allergic reaction [13]. However, this cell is able, through the release of chemotactic factors, to influence also late phlogistic reactions.

As we can show in **Figure 1**, mast cells are rarely the only cells involved in the pathogenesis of a rhinopathy. In fact, we found only 5 cases of mastocytic rhinosinusitis in 300 patients studied (1.67%). Of these patients two presented an allergic disease, while three patients had a nonallergic disease.

On the other hand, cases of mixed cellular pathologies with the presence of mast cells are very frequent.

Mast cell rhinosinusitis are characterized by very intense symptoms, characterized by marked nasal obstruction, serous rhinorrhoea, nasal pruritus, and sneezing. Also in this case as in eosinophilous cellularity diseases, we have reestablished an association with other pathologies with a similar phenotype such as bronchial asthma.

#### **3.4 Mixed rhinosinusitis**

We found a mixed rhinosinusitis in 94 patients corresponding to 32.75% of patients with rhinosinusitis and inflammatory phenotype (**Figure 1**). As we can see from the graph below, mixed rhinosinusitis is characterized by the presence in the nasal mucosa of several inflammatory cytotypes (**Figures 13** and **14**).

In 53.19% of the cases (50 patients), we found a pathology characterized by neutrophil and eosinophilic infiltration; in 25.53% of cases (24 patients), a type with neutrophilia-eosinophilia-mast cell; in 12.77% of cases (12 patients), eosinophilic and mast cell type and in 8; and 51% of the cases (8 patients), we found neutrophils and mast cells in the nasal mucosa. In many cases, mixed rhinosinusitis is found in

#### *Rhinosinusitis*

**Figure 13.** *Mixed rhinosinusitis with neutrophil (N), mast cell (M), and lymphocyte (L).*

**Figure 14.** *Mixed rhinosinusitis with neutrophil (N) and eosinophil (E).*

allergic patients. We have observed that a low intensity but stable and protracted allergenic stimulation, as in the case of allergies to Dermatophagoides, produces at a cytological level a framework defined by Gelardi et al. "Minimal persistent inflammation" is characterized by the presence of numerous neutrophil granulocytes and a small number of eosinophils or mast cells. Another interesting aspec is the greater association of the mixed forms with nasal polyposis compared to the other forms of rhinosinusitis as shown in the graph below (**Figures 15** and **16**).

We have indeed observed that in the category of rhinosinusitis with mixed cellularity, 23.40% of patients had developed a nasal polyposis, while in the other forms of rhinosinusitis, the percentage of patients who developed a nasal polyposis is lower (14.51%). The symptoms of this kind of disease varies according to the most characterizing cytotype. In any case we must remember how these forms are particularly harmful for the nasal mucosa and for mucociliary function, as they, according to our clinical experience, contribute in favoring an increased risk of respiratory inflammation in those affected.

**41**

**4. Discussion**

**Figure 16.**

**Figure 15.**

element.

diseases of the rhinosinusal district.

*Prevalence of polyposis in other types of rhinosinusitis.*

tion of the pathology very precisely.

regarding the classification of rhinosinusal diseases.

Our experience has allowed us to consider the nasal cytological examination as indispensable diagnostic tools for a better understanding of chronic inflammatory

Thanks to the information provided by the cytological examination, we can define the etiopathogenetic characteristics of the disease. Obviously the collection of the anamnesis represents a complementary and indispensable diagnostic

By carrying out these three diagnostic aspects, we are able to trace the identifica-

Daily experience has led us to acknowledge the necessity of a simplification

Once there was a clear demarcation between pathological processes at nasal

In agreement with the European guidelines present in the EPOS12 [14], we argue that very often the two pathologies are closely related, so that a clear border between the two is impossible. We therefore think it is practical as well as appropriate to use in clinical practice a single term that includes the two old forms of nasosinusal pathology. For these reasons, we will talk about chronic rhinosinusitis about

The teaching of the pulmonologists, as explained in the GINA guidelines, led us to consider the nasal pathology narrow related to the bronchial situation. This is

localization, the rhinitis, from those with sinus localization, the sinusitis.

any chronic inflammatory process that affects the rhinosinusal district.

*Use of Nasal Cytology in Diagnosis of Sinonasal Disorders*

*DOI: http://dx.doi.org/10.5772/intechopen.84231*

*Prevalence of polyposis in mixed rhinosinusitis.*

*Use of Nasal Cytology in Diagnosis of Sinonasal Disorders DOI: http://dx.doi.org/10.5772/intechopen.84231*

*Rhinosinusitis*

**Figure 13.**

**Figure 14.**

**40**

allergic patients. We have observed that a low intensity but stable and protracted allergenic stimulation, as in the case of allergies to Dermatophagoides, produces at a cytological level a framework defined by Gelardi et al. "Minimal persistent inflammation" is characterized by the presence of numerous neutrophil granulocytes and a small number of eosinophils or mast cells. Another interesting aspec is the greater association of the mixed forms with nasal polyposis compared to the other forms of

We have indeed observed that in the category of rhinosinusitis with mixed cellularity, 23.40% of patients had developed a nasal polyposis, while in the other forms of rhinosinusitis, the percentage of patients who developed a nasal polyposis is lower (14.51%). The symptoms of this kind of disease varies according to the most characterizing cytotype. In any case we must remember how these forms are particularly harmful for the nasal mucosa and for mucociliary function, as they, according to our clinical experience, contribute in favoring an increased risk of

rhinosinusitis as shown in the graph below (**Figures 15** and **16**).

*Mixed rhinosinusitis with neutrophil (N), mast cell (M), and lymphocyte (L).*

respiratory inflammation in those affected.

*Mixed rhinosinusitis with neutrophil (N) and eosinophil (E).*

**Figure 15.** *Prevalence of polyposis in mixed rhinosinusitis.*

**Figure 16.** *Prevalence of polyposis in other types of rhinosinusitis.*

#### **4. Discussion**

Our experience has allowed us to consider the nasal cytological examination as indispensable diagnostic tools for a better understanding of chronic inflammatory diseases of the rhinosinusal district.

Thanks to the information provided by the cytological examination, we can define the etiopathogenetic characteristics of the disease. Obviously the collection of the anamnesis represents a complementary and indispensable diagnostic element.

By carrying out these three diagnostic aspects, we are able to trace the identification of the pathology very precisely.

Daily experience has led us to acknowledge the necessity of a simplification regarding the classification of rhinosinusal diseases.

Once there was a clear demarcation between pathological processes at nasal localization, the rhinitis, from those with sinus localization, the sinusitis.

In agreement with the European guidelines present in the EPOS12 [14], we argue that very often the two pathologies are closely related, so that a clear border between the two is impossible. We therefore think it is practical as well as appropriate to use in clinical practice a single term that includes the two old forms of nasosinusal pathology. For these reasons, we will talk about chronic rhinosinusitis about any chronic inflammatory process that affects the rhinosinusal district.

The teaching of the pulmonologists, as explained in the GINA guidelines, led us to consider the nasal pathology narrow related to the bronchial situation. This is

#### *Rhinosinusitis*

the reason why the phenotypic classification adopted for asthma is, in our opinion, extremely suitable also for the rhinosinusal pathology.

We have therefore redesigned the pneumological experience in order to use in our daily practice a simple and immediate distinction for the various forms of chronic rhinosinusitis. We have distinguished 2 large groups of pathologies based on the phenotype:


This first distinction in the 2 phenotypic classes arises from the firm belief that the clinical characteristics of the sinonasal pathology are closely related to the type of cell involved in the inflammatory process.

As shown in **Table 1**, in the cellular rhinosinusitis group, we contemplate the neutrophilic, eosinophilous, mast cell, and mixed cell forms. In the second group, (noncellular rhinosinusitis) we contemplate pathologies characterized by a normal cytological expression but equally characterized by sinonasal symptoms. Among these we include the iatrogenic forms, the hormonal forms, the atrophic forms, the mechanical forms (associated with septal dysmorphism), and the decubitus forms (characterized by significant nasal respiratory obstruction when the patient lies supine). In our case series, the number of patients affected by this type of pathology was much lower than patients affected by cellular rhinosinusitis. Precisely the individuals affected was 13 (equal to about 4.5%).

Indeed, the number of negative rhinocitograms was superior, almost three times as high. However, we have also included in the cellular group patients with negative cytological examination; in those cases we knew that the negative result originated from temporal circumstances. This applies, for example, to certain diseases with seasonal or recurring cellular characterizations. We have therefore attributed to the group of eosinophilic rhinosinusitis also those patients with clearly allergic symptoms and in which sensitization to seasonal allergens was ascertained despite having found in them a normal rhinocytogram. This situation occurs when we performed the sampling outside the allergy period.

We are sure of the central role of the cytotype in the sinonasal pathology manifestation, and we have also distinguished the mixed rhinosinusitis in four subclasses: the neutrophil-eosinophilic cellular form, the neutrophil-mast cell form, the neutrophil-eosinophil-mast cell form, and the eosinophilic-mast cell form.

This classification, with the support of an adequate imaging and with a correct anamnestic study, allows clinicians to diagnose all types of rhinosinusitis by means of an easy and intuitive classification.

The diagnostic classification performed by cytological examination allows a targeted therapeutic planning. In fact, the knowledge of the etiopathogenetic and cytological principles of a pathology allows a "tailor made" therapeutic planning and also allows to achieve a precise monitoring of the pathology. This leads to optimal control of symptoms and an inevitable prognostic improvement of chronic inflammatory diseases.

#### **5. Conclusion**

The classification of rhinosinusitis is still very complex and diversified today. Thanks to the information we can obtain from the nasal cytology and the anamnesis, we are able to easily frame the majority of rhinosinus pathologies in order to obtain a targeted therapeutic planning and adequate monitoring.

**43**

**Author details**

Marco Capelli

provided the original work is properly cited.

Columbus Clinic Center, Milan, Italy

**Notes/thanks/other declarations**

\*Address all correspondence to: info@otorinocremona.it

*Use of Nasal Cytology in Diagnosis of Sinonasal Disorders*

We have listed the pathologies observed and classified from the cytological point of view in 5 years of experience, and we have come to propose a simple and versatile classification that takes into account the different clinical and etiopathogenetic

Based on the phenotype, we distinguished cellular rhinosinusitis from noncellular rhinosinusitis. The former are divided into four classes (the neutrophil form, the eosinophilic form, the mast cell form, and the mixed form). These types of rhinosinusitis are characterized by a specific cytological framework. We then grouped rhinosinusitis with a negative rhinocytogram in the noncellular phenotype. Among these we remember the iatrogenic forms, the forms on a hormonal base, the

According to us, the distinction we have proposed is simple and immediate.

The author would like to thank Mauro Corinti for his contribution in photo-

The author declares that there is no conflict of interest regarding the publication

positional and decubitus, the atrophic, and the mechanical forms.

Thanks to Giorgia Bottani for general support and assistance.

*DOI: http://dx.doi.org/10.5772/intechopen.84231*

characteristics of the pathologies observed.

**Acknowledgements**

graphic materials.

of this paper.

**Conflict of interest**

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Use of Nasal Cytology in Diagnosis of Sinonasal Disorders DOI: http://dx.doi.org/10.5772/intechopen.84231*

We have listed the pathologies observed and classified from the cytological point of view in 5 years of experience, and we have come to propose a simple and versatile classification that takes into account the different clinical and etiopathogenetic characteristics of the pathologies observed.

Based on the phenotype, we distinguished cellular rhinosinusitis from noncellular rhinosinusitis. The former are divided into four classes (the neutrophil form, the eosinophilic form, the mast cell form, and the mixed form). These types of rhinosinusitis are characterized by a specific cytological framework. We then grouped rhinosinusitis with a negative rhinocytogram in the noncellular phenotype. Among these we remember the iatrogenic forms, the forms on a hormonal base, the positional and decubitus, the atrophic, and the mechanical forms.

According to us, the distinction we have proposed is simple and immediate.

## **Acknowledgements**

*Rhinosinusitis*

on the phenotype:

• Cellular rhinosinusites

• Noncellular rhinosinusitis

of cell involved in the inflammatory process.

individuals affected was 13 (equal to about 4.5%).

the sampling outside the allergy period.

of an easy and intuitive classification.

the reason why the phenotypic classification adopted for asthma is, in our opinion,

We have therefore redesigned the pneumological experience in order to use in our daily practice a simple and immediate distinction for the various forms of chronic rhinosinusitis. We have distinguished 2 large groups of pathologies based

This first distinction in the 2 phenotypic classes arises from the firm belief that the clinical characteristics of the sinonasal pathology are closely related to the type

As shown in **Table 1**, in the cellular rhinosinusitis group, we contemplate the neutrophilic, eosinophilous, mast cell, and mixed cell forms. In the second group, (noncellular rhinosinusitis) we contemplate pathologies characterized by a normal cytological expression but equally characterized by sinonasal symptoms. Among these we include the iatrogenic forms, the hormonal forms, the atrophic forms, the mechanical forms (associated with septal dysmorphism), and the decubitus forms (characterized by significant nasal respiratory obstruction when the patient lies supine). In our case series, the number of patients affected by this type of pathology was much lower than patients affected by cellular rhinosinusitis. Precisely the

Indeed, the number of negative rhinocitograms was superior, almost three times as high. However, we have also included in the cellular group patients with negative cytological examination; in those cases we knew that the negative result originated from temporal circumstances. This applies, for example, to certain diseases with seasonal or recurring cellular characterizations. We have therefore attributed to the group of eosinophilic rhinosinusitis also those patients with clearly allergic symptoms and in which sensitization to seasonal allergens was ascertained despite having found in them a normal rhinocytogram. This situation occurs when we performed

We are sure of the central role of the cytotype in the sinonasal pathology manifestation, and we have also distinguished the mixed rhinosinusitis in four subclasses: the neutrophil-eosinophilic cellular form, the neutrophil-mast cell form, the neutrophil-eosinophil-mast cell form, and the eosinophilic-mast cell form. This classification, with the support of an adequate imaging and with a correct anamnestic study, allows clinicians to diagnose all types of rhinosinusitis by means

The diagnostic classification performed by cytological examination allows a targeted therapeutic planning. In fact, the knowledge of the etiopathogenetic and cytological principles of a pathology allows a "tailor made" therapeutic planning and also allows to achieve a precise monitoring of the pathology. This leads to optimal control of symptoms and an inevitable prognostic improvement of chronic inflammatory diseases.

The classification of rhinosinusitis is still very complex and diversified today. Thanks to the information we can obtain from the nasal cytology and the anamnesis, we are able to easily frame the majority of rhinosinus pathologies in order to

obtain a targeted therapeutic planning and adequate monitoring.

extremely suitable also for the rhinosinusal pathology.

**42**

**5. Conclusion**

The author would like to thank Mauro Corinti for his contribution in photographic materials.

## **Conflict of interest**

The author declares that there is no conflict of interest regarding the publication of this paper.

#### **Notes/thanks/other declarations**

Thanks to Giorgia Bottani for general support and assistance.

### **Author details**

Marco Capelli Columbus Clinic Center, Milan, Italy

\*Address all correspondence to: info@otorinocremona.it

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
