ORIGINAL�ARTICLE Materials and Methods: A total of 200 patients diagnosed clinically as 'Allergic Rhinitis', were selected by convenient sampling. Clinical diagnosis was made on the basis of history and complete ENT examination and findings recorded. Detailed history for intermittent or persistent symptoms of nasal congestion, watery rhinorrhea, nasal itching with sneezing and ocular symptoms as paroxysmal redness, itching and watering of eyes was taken. Detailed physical examination including complete ENT examination carried out and a record of presence of post nasal drip, hypertrophic pale or bluish boggy mucosa covered with thin secretion was made. Blood samples were taken for Serum IgE Levels and Total Eosinophil Count. The data was analyzed for frequencies by SPSS 24. Since the data was not parametric, non-parametric tests were applied. Results: Gender distribution showed a male predominance with males 58.5% (117) and females 41.5% (83). rd th Most of the patients were among the age group 3 to 5 decades. Serum IgE was raised in 152 (76%) patients, while Total Eosinophil Counts were raised in 104 (52%) patients. Serum IgE levels were found significant as p ≤ 0.50, while Total Eosinophil Count was not found significant as p ≥ 0.50. Conclusion: Serum IgE Levels and Total Eosinophil Counts are good reflector of Allergic Rhinitis. Although Serum IgE levels appear to be very significant in diagnosing Allergic Rhinitis, Total Eosinophil Count has yet to be established as a significant diagnostic tool. Being expensive tests, only Serum IgE levels should be advised in patients with suspicion of Allergic Rhinitis, and Total Eosinophil Count should not be advised routinely. Key Words: Allergic Rhinitis, Serum IgE Levels, Total Eosinophil Count. ABSTRACT Objective: To determine the significance of Serum IgE Level and Total Eosinophil Count in establishing diagnosis of Allergic Rhinitis. Study Design: A descriptive study. Place and Duration of Study: ENT Department Islamabad Medical Complex, from December 2016 to December 2018. most common cause of chronic rhinitis and affects 3 10-20 % of the population. Previously it was considered as a localized disease but now it has been acknowledged as a part of a systemic disorder. The close functional and immunological relationship between the upper and lower respiratory tracts, on provocation, not only causes inflammation in the upper respiratory tract but also involves the lower respiratory tract. Therefore, mostly it accompanies 4 allergic asthma and eczema. In an atopic individual, whenever the nasal mucosa comes in contact with certain allergens, the inflammatory cells including the mast cells, B cells, T cells, eosinophils and macrophages infiltrate the nasal mucosa. The T cells release the cytokines that result in production of the 5 IgE by the plasma cells. The IgE binds with the mast cells resulting in release of the inflammatory mediators like histamine and leukotrines, that are responsible for the inflammatory reaction causing vascular dilatation, increased vascular permeability, Introduction Rhinitis is defined as inflammation of the nasal mucosa resulting in nasal congestion, rhinorrhea, itching of the nasal mucosa, and sneezing. It may occur as a result of infection, allergy, vasomotor imbalance (NARES), and may be drug induced or idiopathic. The term 'Allergy' was first introduced by Clemens 1 von Pirquet in 1906. Allergic Rhinitis is defined as IgE 2 mediated inflammation of the nasal mucosa. It is the Serum IgE Levels and Total Eosinophil Count in Allergic Rhinitis 1 2 3 Mirza Khizar Hameed , Atif Sharif , Mahum Khizar Correspondence: Dr. Mirza Khizar Hameed Department of ENT Foundation University Medical College, Islamabad E-mail: mirzakhizar@yahoo.com 1,3 Department of ENT Foundation University Medical College, Islamabad 2 Department of ENT Islamabad Medical Complex, Islamabad Funding Source: NIL; Conflict of Interest: NIL Received: April 21, 2020; Revised: August 05, 2020 Accepted: August 06, 2020 Diagnosis of Allergic RhinitisJIIMC 2020 Vol. 15, No.3 154 So far we have not seen any study that could show how accurate is the diagnosis of Allergic Rhinitis made on the basis of history and physical 14 examination. Moreover, there are not many studies on the diagnosis of Allergic Rhinitis. As most of these patients are managed on the basis of clinical diagnosis, and are subjected to a life-long anti allergic treatment, a need was felt that this long term treatment should be advised evidence based, after confirming the diagnosis on the basis of laboratory tests. This was the rationale behind the present study with an objective to determine the significance of Serum IgE Level and Total Eosinophil Count in establishing diagnosis of Allergic Rhinitis. Materials and Methods A descriptive study was carried out in Islamabad Medical Complex ENT Department from December 2016 to December 2018. Approval of Hospital Ethical Committee for this study was taken beforehand. A total of 200 patients diagnosed clinically as 'Allergic Rhinitis', were selected by convenient sampling after taking informed consent from them for this study. Clinical diagnosis was made on the basis of history and complete ENT examination and findings recorded on a preformed Performa. Detailed history for intermittent or persistent symptoms of nasal congestion, watery rhinorrhea, nasal itching with sneezing and ocular symptoms as paroxysmal redness, itching and watering of eyes was taken. Detailed physical examination including complete ENT examination carried out and a record of presence of post nasal drip, hypertrophic pale or bluish boggy mucosa covered with thin secretion was made. Inclusion criteria comprised of at least three of the following symptoms: nasal congestion, watery rhinorrhea, itching of nose with sneezing, post nasal drip, whether intermittently or persistently, for at least two years. Presence of turbinate hypertrophy with pale or bluish boggy mucosa covered by thin secretions was recorded. Exclusion criteria included any active infection or trauma of respiratory tract, local use of steroid nasal spray or drops, intake of systemic steroids, antihistamine, montelukast or mast cell stabilizers in past one month, age below 12 years or above seventy years, and pregnancy. Patients were called one month after cessation of any local or systemic medicine intake for their watery rhinorrhea, mucus secretion and smooth 6 muscle contraction. In the next stage, these mediators induce a further cellular inflammatory response, the late phase response, responsible for 7 recurrent nasal congestion. Allergic rhinitis may be divided into two types; intermittent or persistent, as previously described as 8 seasonal and perennial. On the basis of severity it may be divided into mild, moderate and severe forms for management purposes. Traditionally the diagnosis is clinical, on the basis of history and physical examination. History of nasal congestion, itching, and sneezing, watery rhinorrhea, along with itchiness, redness and watering of eyes is fairly 9 common. In most of the cases there is an association with asthma. There may be a positive family history. Certain environmental factors as dust, pollens, humidity, fumes, exposure to furred animals, tobacco, fumes or intake of drugs as beta blockers, NSAIDS, aspirin, ACE inhibitors, certain hormones 10 may be the triggering factors. Physical examination may reveal a transverse nasal crease on the dorsum (allergic salute), dark circles around the eyes (allergic shiners), turbinate hypertrophy with pale or bluish boggy mucosa covered by thin watery secretion, nasal polyps, post nasal drip, prominent lymphoid follicles on posterior pharyngeal wall (cobble stoning), adeno-tonsillar hypertrophy, OME, wheeze, skin eczema etc. Besides the history and physical examination, certain Allergic Tests are also carried out to reach the diagnosis, as the clinical features may appear similar in other types of non-infective rhinitis. These tests include skin prick tests for specific allergens. Allergen specific IgE tests (RASTs/ ELISA) are considered equally effective in reaching the diagnosis as they 11 indicate atopy, but are considered a bit expensive. Since there is an established association of eosinophilia with allergic respiratory disease, nasal smears for eosinophilia and systemic eosinophilia are also considered an important investigative tool 12 for the diagnosis of allergic rhinitis. Although Allergic Rhinitis badly affects the quality of life of the patients, most of them do not appreciate this and do not seek treatment. Even the primary physicians fail to diagnose these patients hence some sort of screening tests need to be carried out in 13 such patients with such a longstanding history. JIIMC 2020 Vol. 15, No.3 155 Diagnosis of Allergic Rhinitis One-sample Binomial Test (Non parametric) shows Significance level to be 0.50. Serum IgE levels were found significant as p ≤ 0.50, while Total Eosinophil Count was not found significant as p ≥ 0.50. Discussion Allergic Rhinitis is one of the commonest chronic 15 disorders that affect the quality of life badly. Though it is quite common with an incidence of 10- 20% of population suffering from it, the diagnosis presents a significant challenge due to similarity of its clinical picture with other forms of non-infective 16 rhinitis. Our study shows gender distribution with a male predominance. Similarly a study by Jagadeeshwar et al (2001) also shows a male predominance in 17 patients with Allergic Rhinitis. Jung et al (2011) also show a male predominance among patients with 18 Allergic Rhinitis. But in another study carried out by Khan (2013) shows a female predominance in 19 patients with Allergic Rhinitis. But our study results can be explained as convenience sampling was done. In our study, the incidence seems to be more in rd th 20 patients of 3 to 5 decades. Wheatley & Togias rd th (2015) show it to peak its prevalence in the 3 and 4 21 decades. Muddaiah & Venkatarangaih (2020) also rd th show an increased incidence in age group 3 to 4 decades. Droste et al (1996) also shows an increased th incidence in the 5 decade with a male 22 predominance. Although the patients were selected on the basis of convenience sampling, the disease appears to have similar age incidence even in other studies. Being an allergic disorder, Allergic Rhinitis has a well- established association with eosinophils. In our study, raised Eosinophil count has been observed in only 52% of the patients, and thus it fails to appear as a significant indicator of Allergic Rhinitis. Similar to our observations, Patel & Nagpal (2014) also observe that although there is a strong correlation with nasal smear eosinophilia but Allergic Rhinitis has absolutely no correlation with systemic 23 eosinophilia. But another study by Mostafa et al (2020) reveals that the Absolute Eosinophil Count was positive in 70.4% patients with Allergic Rhinitis, 24 so it is considered a good indicator of the disease. Baldacci et al (2001) also consider Serum Eosinophil Count as an important though less used investigation 25 for monitoring the clinical course of AR. Another In our study the Gender distribution shows a male predominance with males 58.5% (117) and females 41.5% (83) as shown in Figure: 1 symptoms. Blood samples were taken for Serum IgE Levels and Total Eosinophil Count. Serum IgE levels were measured by chemi-luminescent micro particle immunoassay (CMIA) Cobas Methodology, while Total Eosinophil Counts were measured by Cell Dyn Ruby Methodology: MAPSS. The data were analyzed for frequencies by SPSS 24. Since the data was not parametric, non-parametric tests were applied. Results Fig 1: Gender Distribu�on (n= 200) rd Most of the patients were among the age group 3 to th 5 decade as shown in the Figure: 2. Fig: 2: Age Distribu�on (n= 200) Serum IgE was raised in 152 (76%) patients, while Total Eosinophil Counts were raised in 104 (52%) patients as given in Figure 3. Fig 3: Serum IgE Level & Total Eosinophil Count (n= 200 JIIMC 2020 Vol. 15, No.3 156 Diagnosis of Allergic Rhinitis 3. Dykewicz MS, Hamilos DL. Rhinitis and sinusitis. J Allergy Clin Immunol. 2010; 125:S103–15. 4. Al-Rabia MW. Diagnostic Accuracy of sIgE, Total IgE and Eosinophils Percentage among Patients with Asthma, Allergic Rhinitis, and Atopic Dermatitis in Saudi Arabia. IJHSR, Oct 2016; 6 (10): 33- 39. 5. Church DS, Church MK, Scadding GK. Allergic rhinitis: impact, diagnosis, treatment and management. Aug 2016; Immunology. 6. Navines-Ferrer A, Serrano-Candelas E, Molina-Molina GJ, Martin M. IgE-Related Chronic Diseases and Anti-IgE-Based Treatments. J Immunol Res, Nov 2016: 1-12. ID 8163803, http://dx.doi.org/10.1155/2016/8163803. 7. Small P, Kim H. Allergic rhinitis. Allergy Asthma Clin Immunol. Nov 2011; 7(Suppl 1): 1-3. doi: 10.1186/1710- 1492-7-S1-S3. 34 asymptomatic people. With all this evidence, we can infer that there is no single laboratory test that can replace clinical diagnosis of Allergic Rhinitis or considered superior to it and the diagnosis has to be made while considering both the clinical and 18 laboratory based evidence. In the light of above evidence we can recommend that in the presence of positive clinical evidence, the patients should undergo Serum IgE assays as it is positive in 76% of the patients. And only those patients in whom Serum IgE levels are raised, should be recommended long term anti allergic treatment. Since the scope of our study is limited, carried on only 200 patients, it is further recommended that more studies need to be carried out at larger scales to find out a suitable and cost effective evidence based strategy and guidelines be made at national level for diagnosis of Allergic Rhinitis in patients needing long term anti-allergic treatment. Conclusion Serum IgE Levels and Total Eosinophil Counts are a good reflector of the disease (Allergic Rhinitis). Although Serum IgE levels appear to be very significant in diagnosing Allergic Rhinitis, Total Eosinophil Count has yet to be established as a significant diagnostic tool. Being expensive tests, only Serum IgE levels should be advised in patients with clinical diagnosis of Allergic Rhinitis before advising long term anti allergic treatment. REFERENCES 1. Galli SJ, Tsai M, Piliponsky AM. The development of allergic inflammation. Nature. 2008; 454(7203): 445–454. 2. Choudhari SY, Sangavi AB. A clinical study of inhalant allergens in patients with allergic rhinitis. Int J Otorhinolaryngol Head Neck Surg. 2017 Apr;3(2):380-384 study by Prabakaran et al (2018) shows that in case of only nasal symptoms, the Total Eosinophil Counts do not go beyond normal range, but when nasal symptoms are associated with respiratory symptoms 26 then Serum Eosinophil levels are found elevated. 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