Rhinitis and sleep

Summary

Allergic rhinitis is a very prevalent disease in developed nations and has been increasing throughout the world. Nasal congestion is one of the most common and bothersome symptoms of rhinitis in both children and adults. Congestion is associated with sleep-disordered breathing and is thought to be a key cause of sleep impairment in rhinitis. The end result is decrease in quality of life and productivity and increased daytime sleepiness.

Treatment with intranasal corticosteroids has been shown to reduce nasal congestion. Data on sleep-related endpoints from clinical trials of intranasal corticosteroids indicate that this reduction is associated with improved sleep, reduced daytime fatigue, and improved quality of life. Other therapies, such as montelukast, also have a positive influence on congestion and sleep, while still other therapies for rhinitis do not affect either symptom.

This review examines nasal congestion and the associated sleep impairment with allergic rhinitis. It explores the adverse effects of disturbed sleep on patients’ quality of life and how these disturbances can be reduced by therapies that address nasal congestion.

Introduction

Inflammatory disorders of the upper respiratory tract are prevalent in the general population. This is especially seen in developed countries. Allergic rhinitis affects up to 40% of the population, and its prevalence appears to be increasing. Recent estimates suggest that 20 to 40 million people in the United States are affected, including up to 40% of children. The disorder is not limited to the United States, with a European prevalence estimated to be 23%.1, 2, *3, 4, 5, *6

Nasal congestion is a prominent and troublesome symptom of both allergic and non-allergic rhinitis. Additional symptoms of allergic rhinitis include rhinorrhea, sneezing, and pruritus of the eyes, nose, and throat, particularly in patients with perennial allergic rhinitis (PAR).⁴ Typical sleep-related problems seen include sleep-disordered breathing, sleep apnea, and snoring, all of which are associated with nasal congestion/obstruction.7, 8, 9, 10

Allergic rhinitis can affect the mucous membranes of the nose, eyes, eustachian tubes, middle ear, sinuses, and pharynx and is usually triggered by immunoglobulin E in response to an allergen. Mediators involved in clinical symptoms include histamine, tryptase, chymase, heparin as well as leukotrienes. Non allergic rhinitis is a term used to describe a variety of diseases including, infectious, vasomotor, occupational, hormonal, gustatory, and drug induced rhinitis. In non-allergic etiologies, autonomic parasympathetic stimuli lead to localized nasal swelling and secretions.

Nasal congestion is a problem seen in both children and adults. This was noted in the recent publication of the “Pediatric Allergies in America Survey” which emphasized that congestion is the main symptom that affects children with rhinitis.¹¹ A similar survey completed in over 7000 subjects of whom 89.3% were adults, demonstrated the burden of sleep disturbance in patients with rhinitis.¹²

Sleep disturbance is a significant problem for patients with rhinitis. In a recent survey of individuals with allergic rhinitis, 68% of respondents with PAR and 48% with seasonal allergic rhinitis (SAR) reported that their condition interfered with sleep.¹³ Sleep disturbance can be caused by the mechanical obstruction of nasal congestion. However, additional symptoms of rhinitis and the release of inflammatory mediators may influence sleep and resultant daytime fatigue and somnolence.

The socioeconomic burden of rhinitis is also significant. It is estimated that more than $6 billion were spent on prescription medications for allergic rhinitis in 2000.1, 2, 14 The socioeconomic costs of these disorders include the costs of treatment and the secondary cost of poor productivity, which results from the impact of symptoms on patient lives and the use of inappropriate therapies. A patient's quality of life is significantly affected by allergic rhinitis, which has been shown using generic health-related quality-of-life questionnaires, such as the Medical Outcomes Study Short Form Health Survey (SF-36), and disease-specific measures, such as the rhinoconjunctivitis quality of life questionnaire (RQLQ).15, 16, 17, 18, *19, 20, 21As noted above, these effects may not solely be related to the rhinitis itself, and in part, may be a consequence of sleep impairment.

Treatments that improve the symptoms of allergic rhinitis, particularly those that relieve nasal congestion, have been shown to improve patients’ sleep and quality of life. However, the data are limited that prove nasal congestion and its associated sleep disturbance is the only culprit. Thus, further research is warranted in this area. This review explores the importance of congestion in rhinitis. It also addresses the adverse effects of disturbed sleep on the quality of life of patients with rhinitis and how these effects can be reduced by therapies addressing the underlying problems affecting sleep.