The Nasal Smear for Eosinophils
Its Value in Children With Seasonal
Robert E. Miller, MD, MS(Hyg); Jack L. Paradise, MD; Gilbert A. Friday, MD; Philip Fireman, MD; Dorothy Voith,
\s=b\ Nasal smears for eosinophils ob-
tained by nose blowing and/or posterior
nasopharyngeal swabbing were stained
with Wright's or Hansel's stains and read
in three groups of children aged 4 to 15
years: 65 with seasonal allergic rhinitis,
42 with perennial rhinitis and negative
skin tests, and 70 nonallergic controls.
Of smears obtained by either or both
methods, 69%, 11%, and 7% were posi-
tive (\m=ge\4%)in the three groups, respec-
tively. Almost identical results were ob-
tained using only the nose-blowing
method. In children with seasonal nasal
symptoms, the nasal smear for
eosinophils appears to be a reliable
diagnostic test with moderately high
sensitivity and high specificity.
(Am J Dis Child 1982;136:1009-1011)
stained for eosino¬
Nasal
phils
help
to
smears
have been used commonly
determine the presence or
absence of allergic rhinitis,1"6 but the
reliability and validity of this tech¬
nique have not been established for
children. We undertook the present
study to test these attributes, and
also to compare commonly used tech¬
niques for obtaining and staining
specimens of nasal secretions.
SUBJECTS AND METHODS
The study population consisted of three
diagnostically distinct groups of children,
aged 4 to 15 years, selected during the
periods April through October 1978 and
April through July 1979. The groups were
defined as follows: (1) seasonal allergic rhi¬
nitis: children who experienced at least one
of the symptoms and one of the signs listed
From the Departments of Pediatrics (Drs
Miller, Paradise, Friday, and Fireman) and Com-
munity Medicine (Dr Paradise), University of
Pittsburgh School of Medicine, and the Children's
Hospital of Pittsburgh. Dr Miller is now with
Waldorf Medical Park, Waldorf, Md.
Read before the annual meeting of the Ameri-
can Academy of Pediatrics, Detroit, Oct 25,1980.
Reprint requests to Ambulatory Care Center,
Children's Hospital of Pittsburgh, 125 Desoto St,
Pittsburgh, PA 15213 (Dr Paradise).
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Allergic Rhinitis
in Table 1 either seasonally or perennially
with seasonal exacerbations, and who had
one or more positive skin tests for trees,
grasses, or ragweed consistent with the
seasonal occurrence of symptoms; (2) pe¬
rennial rhinitis and negative skin tests:
children who experienced chronically at
least one of the symptoms and one of the
signs listed in Table 1, but who had negative
skin tests for allergens and no clinical signs
of nasal infection or roentgenographic find¬
ings suggesting adenoidal obstruction of
the nasopharyngeal airway (this combina¬
tion of findings is often considered indica¬
tive of vasomotor rhinitis); (3) nonallergic
controls: children with none of the symp¬
toms or signs listed in Table 1 and with
negative skin tests for allergens.
The seasonal allergic rhinitis group was
selected from the private practice of one of
us (G. A. F) and his colleagues at office visits
for hyposensitization injections during the
tree, grass, or ragweed seasons. The pe¬
rennial rhinitis/negative skin test and non-
allergic control groups were selected from
subjects enrolled in the Children's Hospital
of Pittsburgh study of indications for ton¬
sillectomy and adenoidectomy7 during rou¬
tine follow-up visits. The protocol for initial
evaluation of these children included
allergen skin testing.
Children who had perennial rhinitis
without seasonal exacerbations and who
were presumed to be allergic on the basis of
positive skin tests were excluded from this
study. Also excluded were children with
clinical signs of either respiratory tract
infection or asthma and children receiving
medications other than antihistamines.
Skin testing with pollen extracts had previ¬
ously been carried out on all children, using
the prick method; if prick tests were nega¬
tive, the intracutaneous method was used.
Table 1.—Symptoms and
Symptoms
Frequent, clear nasal discharge
Nasal congestion
Repeated sneezing
Itchy palate, throat, or eyes
MT
All clinical aspects of the study were
performed by one of us (R.E.M.). After
having received an explanation of the study
and having provided informed consent, the
parents of all subjects were interviewed,
using a standardized form. The subjects
were then examined, and nasal smears
were obtained by one or more of three
methods in the following order: (1) nose
blowing into waxed paper; (2) nasopharyn¬
geal swabbing performed by one of us
(R.E.M.); and (3) nose blowing by the
subject into waxed paper after the naso¬
pharyngeal swabbing. Whenever possible,
all three methods of obtaining specimens
were employed. However, from those sub¬
jects who for any reason (inability or un¬
willingness to cooperate, scant nasal
mucus) could not provide an adequate nose-
blowing specimen, nasopharyngeal swab¬
bing or subsequent nasopharyngeal swab¬
bing specimens or both were obtained.
Specimens of mucus were streaked on
glass slides, and were stained and read
independently by one of us (D. V.) who had
no prior knowledge of the patients' clinical
status. Two nose-blowing slides from each
of 20 children with seasonal allergic rhinitis
were stained with Hansel's and Wright's
stains, respectively, for comparison pur¬
poses. For some of the children, two slides
were made from each nose-blowing speci¬
men (NBi and NB2) to test intraspecimen
variability.
Slides were scanned microscopically
across from left to right in the upper,
middle, and lower thirds and read for (1)
mucus and debris (gross, moderate, scant,
or inadequate); (2) polymorphonuclear leu¬
kocytes (many, few, or none); (3) bacteria
(many, few, or none); and (4) eosinophils
(estimated as 0% to 3%, 4% to 25%, 26% to
50%, 51% to 75%, or 76% to 100%, depend-
Signs of Allergic Rhinitis
Signs
Pale or violaceous nasal mucosa
Edematous nasal mucosa
Transverse nasal crease
 Table 2.—Age and
Seasonal
Allergic
Rhinitis
Age, yr_M_F_M_
4-7 11 3 12
8-11 28 8 4
12-15 10 5_3_5_3
Total 49 16
Table 3.—Results of Nasal Smear for
Seasonal allergic rhinitis (N 65) =
Perennial rhinitis/negative skin test (N
Nonallergic control (N 70) =
*X2. 2 off=71, P<.0005. First
P<.0005.
fDefined as any slide (first nose
positive.
ing on the estimated ratio of eosinophils to
total number of leukocytes). A slide was
considered positive if the estimated per¬
centage of eosinophils was 4% or more. A
mean of five minutes was required for read¬
ing a slide.
RESULTS
Initially there were 63, 42, and 70
subjects in the seasonal allergic rhi¬
nitis, perennial rhinitis/negative skin
test, and nonallergic control groups,
respectively. Three subjects with sea¬
sonal allergic rhinitis were eliminated
from the analysis because their speci¬
mens were inadequate. Table 2 shows
the age and sex distribution of the
three study groups. The mean ages of
the seasonal allergic rhinitis, peren¬
nial rhinitis/negative skin test, and
nonallergic control groups were, re¬
spectively, 8.4, 7.8, and 7.9 years.
White children preponderated in the
study group as a whole, constituting
95%, 90%, and 79%, respectively, of
the seasonal allergic rhinitis, peren¬
nial rhinitis/negative skin test, and
nonallergic control groups.
Reliability of the
Nasal Smear for Eosinophils
Intraspecimen variation was deter¬
mined by calculating the agreement
rates of slides NB, and NB2 for the 79
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Sex Distribution of Study Population
No. of Subjects
Perennial
Rhinitis/
Negative
Skin Test
Nonallergic
Control
11 22 13 45
7 15 17 47
0 16
19 23 40 30 108
Eosinophils, by Group*
Nasal Smear
Positive!
45
=
42) 5 37
5 65
second group: 2, 1 off =35, P-C.0005. First third group:
blowing, nasopharyngeal swabbing, or subsequent nasal blowing)
subjects from whom these slides had
been obtained. Agreement rates were
74%, 95%, and 91% for the seasonal
allergic rhinitis, perennial rhinitis/
negative skin test, and nonallergic
control groups, respectively, and 85%
for the three groups combined.
Intraobserver reliability was tested
by comparing the results of readings of
20 randomly selected slides on two
successive occasions by one of the au¬
thors (D.V.). The results of the first
reading were not known when the sec¬
ond reading was performed. The con¬
cordance rate was 90% (ten were posi¬
tive at both readings; eight, negative
at both readings; nine, first positive,
then negative; and one, first negative,
then positive).
Interobserver reliability was tested
by comparing the results of a reading
of 40 randomly selected slides by two of
us (D.V. and R.E.M.). Neither reader
was aware of the results of the other.
The concordance rate was 93% (21
were positive at both readings; 16,
negative at both readings; and three,
first negative, then positive).
Staining Method
A reading of the 20 pairs of nose-
blowing slides that had been differen¬
tially stained, one of each pair with
Hansel's stain and one with Wright's
stain, showed the two stains to be
equally effective in identifying the dis¬
tinctive bilobed nuclei and pink gran¬
ules of eosinophils. However, staining
time for Hansel's stain was only one
Total
minute, compared with ten minutes for
Wright's stain. The examiner did not
know the identity of the stain when the
27 slides were read.
32
10
69 Validity of the Nasal Smear
for Eosinophils
All Methods Combined.—Consider¬
ing a positive slide by any of the three
methods (first nose blowing, nasopha¬
ryngeal swabbing, subsequent nose
Negative
blowing) as the criterion for a positive
nasal smear for eosinophils, 69% of the
20
seasonal allergic rhinitis group had
positive nasal smears for eosinophils,
compared with 11% and 7%, respec¬
2,1 df= 55,
tively, of the perennial rhinitis/nega¬
tive skin test and nonallergic control
groups (Table 3). Except for one con¬
trol subject, all children in the three
groups with smears having eosinophil¬
ia between 4% and 25% had eosinophil¬
ia closer to 25% than to 4%. Defining
the seasonal allergic rhinitis group as
allergic and the nonallergic controls as
nonallergic, and excluding from con¬
sideration the perennial rhinitis/nega¬
tive skin test group, the sensitivity of
the nasal smear for eosinophils was
thus 69% and the specificity was 93%.
Nose Blowing Method Only.—Spec¬
imens could not be obtained by the
nose-blowing method because of un¬
willingness or inability to cooperate in
seven subjects with seasonal allergic
rhinitis, five with perennial rhinitis/
negative skin tests, and ten non¬
allergic controls, respectively, and be¬
cause of scant mucus in four with sea¬
sonal allergic rhinitis, five with
perennial rhinitis/negative skin tests,
and 26 nonallergic controls, respec¬
tively. All children who failed to coop¬
erate were 8 years of age or younger.
Limiting consideration to the 88 sub¬
jects with seasonal allergic rhinitis
and nonallergic controls from whom
nose-blowing specimens could be ob¬
tained, and taking the results of the
first nose-blowing specimen as deter¬
mining whether the nasal smear for
eosinophils was positive, the sensitiv¬
ity of the method was 70% (38/54) and
the specificity was 94% (32/34).
 Among children with negative nose-
blowing specimens from whom naso¬
pharyngeal swabbing specimens were
obtained immediately afterward, the
nasopharyngeal swabbing specimens
were positive in three of 14 subjects
with seasonal allergic rhinitis and in
none of 25 with perennial rhinitis/neg¬
ative skin tests and 28 nonallergic con¬
trol subjects.
Analysis of the data for age and sex
showed no apparent differences be¬
tween age groups or between males
and females.
COMMENT
The nasal smear for eosinophils has
been used for years as a diagnostic test
in both adults and children with symp¬
toms suggesting allergic rhinitis.1·6
However, its use in children is founded
on studies2,3 with certain methodologi¬
cal limitations. Murray and Anderson2
found a higher percentage of nasal
eosinophilia in allergic children than in
controls, but their report made no
mention of skin testing having been
carried out in either group. In a subse¬
quent study, Murray3 found nasal
eosinophilia in 93% of a group of chil¬
dren with seasonal allergic rhinitis
who underwent skin testing, but a
control group apparently was not stud¬
ied.
The results of the present study
demonstrate that the nasal smear for
eosinophils is a reliable test with mod¬
erately high sensitivity and high spe¬
cificity in children with seasonal
allergic rhinitis. However, we did not
study children with perennial rhinitis
who did not have seasonal exacerba¬
tions.
The design of the present study
precluded independent comparisons of
results of the three methods used in
obtaining specimens of nasal mucus. It
is possible that either of the first two
methods carried out may have pro¬
duced changes that affected the re¬
sults of immediately succeeding meth¬
ods. For example, either the nose
blowing or nasopharyngeal swabbing
may, in certain subjects, have ex¬
hausted the supply of eosinophil-bear-
ing mucus. Nonetheless, with each of
the methods, specificity was high. The
slight increase in sensitivity that
might be gained by carrying out
nasopharyngeal swabbing on children
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in whom the nose-blowing technique
yields a negative result must be
weighed against the discomfort en¬
tailed by the additional procedure.
Age and sex were apparently not im¬
portant variables in determining the
presence of nasal eosinophilia in the
three groups. There were too few
blacks in our study group to permit an
analysis of the possible influence of
race, but there is no indication in the
literature that race is a variable of
importance.
The effect of antihistamine medica¬
tion also was not explored in the pres¬
ent study, but it is important to note
that some subjects had been receiving
antihistamines. The effect of anti¬
histamines on the presence or migra¬
tion of eosinophils in the nasal mucosa
is not known.
We tried various techniques of actu¬
ally counting eosinophils per high-
power field, as is done in counting
WBCs and RBCs. Because, however,
the eosinophils were usually not dis¬
tributed uniformly in smears, we were
unable to find a method that seemed as
satisfactory as scanning and estimat¬
ing. The intraspecimen variation rate
of 85%, the intraobserver reliability
rate of 90%, and the interobserver
reliability rate of 93% appear to sup¬
port the adequacy of this method.
Mygind8 defined perennial rhinitis
as a disease characterized by sneezing
attacks, serous or seromucous hyper-
secretion, and nasal blockage. He sub¬
divided the disease into three catego¬
ries: (1) allergy demonstrated; (2)
allergy not demonstrated, nasal
eosinophilia; and (3) allergy not dem¬
onstrated, no eosinophilia. He the¬
orized that patients in the second cate¬
gory might be sensitive to unidentified
allergens or substances, whereas
those in the third category might have
nasal hyperactivity due to autonomie
imbalance. The term "vasomotor rhi¬
nitis" has often been applied to the
latter category. The finding in the
present study that 11% of the perennial
rhinitis/negative skin test group had
positive nasal smears for eosinophils
lends support to the proposition that
the group may consist of two sub¬
groups distinguishable from each
other on the basis of nasal eosinophilia.
This distinction has recently been dis¬
cussed for both adults9 and children,10
but its clinical importance remains to
be determined.
IMPLICATIONS
Health professionals frequently en¬
counter children with seasonal nasal
symptoms. In such children, the his¬
tory and physical findings may be
equivocal, and there may be reluctance
to undertake skin testing because of
the attendant discomfort, anxiety, and
cost. The present study indicates that,
in such children, the nasal smear for
eosinophils is a reliable and reasonably
valid test that can be quickly and easily
performed and read. As such, it can
serve as a useful adjunct in the diag¬
nosis of seasonal allergic rhinitis. Fu¬
ture studies should address the valid¬
ity of the nasal smear for eosinophils
for determining the presence of
allergy in children whose nasal symp¬
toms are perennial rather than sea¬
sonal.
This investigation was supported in part by
grant MCT-298 from the Maternal and Child
Health Service, Public Health Service, and by
grant HD 07403 from the National Institute of
Child Health and Human Development.
Lawrence W. N. Weber, MD, and Irwin A.
Solow, MD, provided advice and encouragement.
D. Lee Miller, MD, Stephen Murphey, MD, and
Ronald A. Landay, MD, provided assistance in
coordinating patient contact. Floyd H. Taylor,
PhD, provided statistical advice.
References
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allergy. Ann Otol Rhinol Laryngol 1927;
32:808-815.
2. Murray MB, Anderson DO: The epi-
demiological relationship of clinical nasal allergy
to eosinophils and goblet cells in the nasal smear.
J Allergy 1969;43:1-8.
3. Murray MB: Nasal secretion eosinophilia in
children with allergic rhinitis. Ann Allergy
1970;32:142-148.
4. Manners BT: The diagnostic value of detect-
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5. Bhandari CM, Baldwa VS: Relative value of
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Mosley Co, 1953.
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Med J 1976;69:1049-1053.
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(ed): Nasal Allergy, ed 2. Oxford, England,
Blackwell Scientific Publications, 1979, p 230.
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