The Nose Knows

Abstract & Commentary

By Barbara A. Phillips, MD, MSPH, Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington. Dr. Phillips serves on the speaker's bureau of Cephalon, Boehringer Ingelheim, Merck, ResMed, and GlaxoSmithKline, and is a consultant for Boehringer Ingelheim, Wyeth-Ayerst, and ResMed.

Synopsis: People who have symptoms of allergic rhinitis report more sleep complaints, including daytime sleepiness, than do those without allergic rhinitis.

Source: Leger D, et al. Allergic rhinitis and its consequences on quality of sleep: An unexplored area. Arch Intern Med. 2006;166:1744-1748.

This report comes from a cross-sectional study of patients recruited by French otolaryngologists. The study was entitled DREAMS (Etude Descriptive des RhinitES Allergies et des Modifications du Sommeil). Eligible patients were those aged 18 to 50 with a score of 7 or higher on the Score for Allergic Rhinitis questionnaire1 who had symptoms for at least a year. Subjects were assigned a point score based on their responses to the following items on the allergic rhinitis questionnaire:

  • Blocked/runny nose or sneezing in the past year (nasal symptoms)
  • Duration of symptoms (perennial vs seasonal)
  • Nasal symptoms PLUS itchy eyes
  • Triggers
  • Perceived allergic status
  • Previous allergy tests
  • Previous medical diagnosis of allergy
  • Family history of allergy

People with nasal septal deviation or polyps were included. A French version of the Sleep Disorders Questionnaire2 and the Epworth Sleepiness Scale3 were used to assess sleep symptoms. The investigators assembled a fairly well-matched control group from general practice clinics. Altogether, there were 591 allergy patients and 502 control subjects. Their mean age was about 40 and most were nonsmokers, though there were slightly more smokers in the control group. Their BMI was about 24 Kg/m2. In their analysis, the authors controlled for age and gender. In this study, persistent moderate-to-severe allergic rhinitis was the most frequent type of allergy (about 60%), and 85% of patients with this condition were being treated for it. Almost a quarter of those with allergic rhinitis had asthma, compared with only about 2% of the control group.

Patients with moderate-to-severe allergic rhinitis were more likely to have severe insomnia, hypersomnia, snoring, witnessed apneas, and daytime sleepiness. In general, patients with allergic rhinitis were more likely to use sedative drugs and alcohol. The authors estimated, based on symptoms of snoring and sleepiness, that sleep apnea was more prevalent in patients with allergic rhinitis than in the control group.

Patients with allergic rhinitis also reported more symptoms of morning headache, anxiety, and impaired memory and mood than did the control group.

The authors identified other factors that were predictive of sleep disturbances in this group of patients. Not surprisingly, male patients were more likely to be at risk for symptoms of sleep apnea, and those with insomnia were more likely to take anxiolytic drugs. They also noted that those with asthma were more likely to report severe insomnia.

Commentary

Intéressant, n'est ce pas? Although these French authors subtitled their report "an unexplored area," there is actually quite a bit known about allergies and sleep. A substantial body of literature demonstrates increased sleep complaints in individuals with respiratory disease all of all types, including asthma, rhinitis, and chronic obstructive pulmonary disease. The relationship is probably multifactorial, including disturbances related to trying to breathe, depression, medication effects and coughing due to secretions.

Particularly, allergic rhinitis and sinusitis are strongly associated with daytime fatigue. There are two schools of thought about this. The first is that fatigue results from the chronic activation of immune mediators (evil substances such as interleukins, interferons and tissue necrosis factor) in people who have chronic airway inflammation.4 The second idea is that the increased inspiratory airflow resistance associated with upper airway inflammation results in significant sleep-disordered breathing, a/k/a sleep apnea.5 Indeed, nasal obstruction is associated with an increased risk of sleep apnea.6 The strongest evidence that rhinitis impairs sleep by contributing to sleep apnea comes from studies of the use of nasal steroids in patients with rhinitis and sleep disturbance. Much of the work in this area has been done by Craig and colleagues,7 who have demonstrated in several placebo-controlled trials with at least 3 different nasal steroids (budesonide, flunisolide, and fluticasone) that these agents can decrease nasal congestion, sleep complaints, and sleepiness in treated patients with allergic rhinitis. Further, there is a correlation between reduction in nasal congestion and an improvement of sleep and daytime somnolence. Measured improvement in the severity of sleep apnea has been demonstrated with use of nasal steroids for both adults8 and children,9 and the Cochrane Database has recently noted that fluticasone, in particular, is a promising agent for pharmacologic treatment of sleep apnea.

Rhinitis and sinusitis are extraordinarily common, as are complaints of fatigue, insomnia, and snoring. The relationship between these problems is robust and probably not coincidental. Since sleep apnea kills, it's important to consider it in the patient with fatigue and nasal congestion. If sleep apnea turns out not to be the problem, nasal steroids are safe, effective, and relatively cheap.

References

1. Annesi-Maesano I, et al. The score for allergic rhinitis (SFAR): a simple and valid assessment method in population studies. Allergy. 2002;57:107-114.

2. Miles LEM. Sleep questionnaire and assessment of wakefulness (SQAW). In: Guilleminault C, et al. editors. Sleeping Disorders. Indications and techniques. Menlo Park, California: Addison-Wesley. 1982; 383-414.

3. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14:540-545.

4. Krouse H, et al. Immune mediators in allergic rhinitis and sleep. Otolaryngol Head Neck Surg. 2002;126:607-613.

5. Canova CR, et al. Increased prevalence of perennial allergic rhinitis in patients with obstructive sleep apnea. Respiration. 2004;71:138-143.

6. Young T, et al. Nasal obstruction as a risk factor for sleep-disordered breathing. The University of Wisconsin Sleep and Respiratory Research Group. J Allergy Clin Immunol. 1997;99:S757-S762.

7. Craig TJ, et al. How do topical nasal corticosteroids improve sleep and daytime somnolence inallergic rhinitis? J Allergy Clin Immunol. 2005;116:1264-1266.

8. Kiely JL, et al. Intranasal corticosteroid therapy for obstructive sleep apnoea in patients with co-existing rhinitis. Thorax. 2004;59:50-55.

9. Brouillette RT, et al. Efficacy of fluticasone nasal spray for pediatric obstructive sleep apnea. J Pediatr. 2001;138:838-844.

10. Smith I, et al. Drug therapy for obstructive sleep apnoea in adults. Cochrane Database Syst Rev. 2006;(2):CD003002.