Rhinitis and sleep disorders: The trigeminocardiac reflex link?
Introduction
Rhinitis, allergic as well as non-allergic, is a common respiratory condition that may often be chronic. Allergic rhinitis (AR) is a multifactorial condition with both inflammation and neurological involvement (neurogenic inflammation) playing significant roles [1]. Nasal congestion, seen in rhinitis, is a known risk factor for sleep-disordered breathing (including snoring, hypopnea, apnea), [2] while inflammation has been associated with suppression of both REM and NREM sleep [3]. The relationship between rhinitis, nasal obstruction and sleep disordered breathing is well established [4]. The resulting sleep impairment can have significant impact on quality of life. However, the mechanisms underlying sleep disorders in rhinitis are still not well established.
In recent years, trigeminocardiac reflex (TCR), one of the most powerful autonomic reflexes of the body, has been found to have a role in sleep disorders like sleep bruxism (SB), sleep apnea (SA) and obstructive sleep apnea (OSA) [5]. Another variant of the TCR, the diving reflex (DR), has recently been linked to sudden infant death syndrome (SIDS) [6] where there is unexplained death of a seemingly healthy infant, usually during asleep. The TCR can be activated by stimulation of the trigeminal nerve anywhere along its course and manifests as mild to severe negative cardiorespiratory changes such as bradycardia, asystole, hypotension or apnea, due to sympathetic withdrawal and parasympathetic overactivity via the vagus nerve. Various subtypes of the TCR are reported and include the peripheral TCR (occulocardiac reflex, nasocardiac reflex, maxillomandibular reflex), gasserian ganglion type and the central TCR [7]. The TCR assumes significance in clinical practice as its role in various neurosurgical and maxillofacial procedures is well established [8]. This reflex can be elicited by either mechanical, chemical or electrical stimuli [9] in the areas innervated by trigeminal nerve such as surgery, cold exposure, smoke, secretions or inflammation. Here, we intend to hypothesize the role of the TCR in nasal inflammation/ infection (rhinitis) associated sleep disorders.
Section snippets
The hypothesis/theory
Allergic rhinitis and non-allergic rhinitis (NAR) are associated with a high incidence of different sleep disorders. In addition, there exists an autonomic imbalance in rhinitis, with parasympathetic overactivity. Also, the DR has been reported to be exaggerated in non-eosinophilic non-allergic rhinitis (NENAR) [10]. On the other hand, TCR has been implicated in sleep disorders like REM sleep apnea, SB and OSA [5]. It is also speculated that the nasotrigeminal reflex, a form of TCR, may have a
Rhinitis and sleep disorders
AR affects up to 40% of population worldwide [15]. It occurs due to air borne particles (allergens) in people who are allergic to them [16] and is an important cause of nasal congestion. Sneezing, nasal obstruction, rhinorrhea and nasal itching are the most common signs of AR [17]. NAR most commonly presents with nasal obstruction and rhinorrhea, while sneezing and itching are less common [18].
Typical sleep disorders seen in AR include sleep disordered breathing (SDB), sleep apnea and snoring.
Consequences of hypothesis and discussion
AR affects a wide percentage of population with reported prevalence of up to 40% in both children and adults. Approximately 80% of them are symptomatic before the age of 20 years [30]. Upto 68% of those with perennial AR and 48% of those with seasonal AR report sleep disturbances [31]. Apart from this, AR can directly cause impaired cognition, reduced productivity, impaired work performance and learning impairment in children. These effects are likely to be exaggerated by sleep impairment [32].
Funding
None.
Conflict of interest
None to declare.
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Allergic rhinitis and sleep disorders in children – coexistence and reciprocal interactions
2022, Jornal de PediatriaCitation Excerpt :Thus, regardless of which pathological changes appear first, both AR and OSA will facilitate manifestations of Th17/Treg imbalance.78 The trigeminocardiac reflex (TCR) has been advanced as a putative mechanism linking AR to sleep disorders, as TCR can be activated by stimulation of the trigeminal nerve anywhere along its course, eliciting from mild to severe negative cardiorespiratory changes, such as bradycardia, asystole, hypotension or apnea, either due to sympathetic withdrawal or to parasympathetic overactivity via the vagus nerve.81 Further, AR is known to induce neuronal hyperresponsiveness of the upper airways to stimuli that activate nasal afferents.
Influence of respiratory allergy and restless sleep on definite sleep bruxism: a cross-sectional clinical study
2020, Sleep MedicineCitation Excerpt :This condition would induce a reflex reaction in the nucleus of the trigeminal nerve [35] and activate the trigeminocardiac reflex, which has demonstrated a role in sleep disorders like SB [36]. Nonetheless, the mechanisms underlying the influence of sleep disorders in the prevalence of the rhinitis is still not well established [36]. However, a significant relationship has been established between SB and allergen positivity and increased respiratory-disturbance indices [37].
The risk factors related to bruxism in children: A systematic review and meta-analysis
2018, Archives of Oral BiologyCitation Excerpt :Actually, these results were biologically plausible. Exposure to smoke or nicotine can active Trigeminal basal afferents, resulting in the trigeminocardiac reflex, and the trigeminocardiac reflex plays an important role in pathogenesis of sleep bruxism (Bindu, Singh, Chowdhury, & Schaller, 2017; Chowdhury, Bindu, Singh, & Schaller, 2017). In addition, the included trial is a RCT, and the quality assessment of the RCT was high, and the age is not related to bruxism.
Sleep related bruxism—comprehensive review of the literature based on a rare case presentation
2024, Frontiers of Oral and Maxillofacial MedicineAssociation of sleep timing and sleep patterns with allergic rhinitis among Chinese adolescents
2022, Zhongguo Ertong Baojian ZazhiAssociation of Allergic Symptoms in the First 2 Years of Life With Sleep Outcomes Among Chinese Toddlers
2022, Frontiers in Pediatrics