From the Guidelines
Allergic rhinitis and Obstructive Sleep Apnea (OSA) have a significant bidirectional relationship, with allergic rhinitis potentially worsening OSA symptoms and vice versa, as evidenced by studies showing improved OSA symptoms with treatment of allergic rhinitis 1. The relationship between allergic rhinitis and OSA is complex, with allergic rhinitis causing nasal congestion, inflammation, and increased mucus production, which can obstruct nasal airways and force mouth breathing during sleep. This nasal obstruction increases negative pressure in the upper airway, contributing to pharyngeal collapse and worsening OSA.
Key Points
- Allergic rhinitis is a common comorbidity in patients with OSA, with studies suggesting that patients with allergic rhinitis have a higher prevalence of OSA 1.
- Treating allergic rhinitis can improve OSA symptoms, with intranasal corticosteroids (such as fluticasone 50mcg 1-2 sprays per nostril daily or mometasone 50mcg 2 sprays per nostril daily) being first-line treatments, often combined with oral antihistamines (such as loratadine 10mg daily or cetirizine 10mg daily) 1.
- For OSA, continuous positive airway pressure (CPAP) therapy remains the gold standard, but adherence may improve when nasal symptoms are controlled 1.
- Nasal saline irrigation and allergen avoidance can also help manage nasal symptoms, and the connection between these conditions stems from shared inflammatory pathways and the anatomical relationship between the nasal and pharyngeal airways, making comprehensive treatment essential for optimal sleep quality and respiratory health 1.
Management
- Management should address both conditions simultaneously, with a focus on treating allergic rhinitis to improve OSA symptoms.
- Intranasal corticosteroids and oral antihistamines are effective treatments for allergic rhinitis, and CPAP therapy is the gold standard for OSA.
- Nasal saline irrigation and allergen avoidance can also help manage nasal symptoms and improve sleep quality.
From the Research
Relationship Between Allergic Rhinitis and Obstructive Sleep Apnea (OSA)
The relationship between allergic rhinitis and OSA is complex, with several studies suggesting a significant association between the two conditions.
- Allergic rhinitis and nonallergic rhinitis are common disorders that have been considered as potential risk factors for OSA 2.
- In adults, allergic rhinitis and nonallergic rhinitis may be considered as symptoms potentiating, rather than risk potentiating factors in the pathophysiology of OSA, whereas in children, these are considered to be independent predictors for sleep-disordered breathing (SDB) and failure of adeno-tonsillectomy, the recommended first-line therapy for children with OSA 2.
- Allergic rhinitis increases the risk of developing OSA by two major mechanisms: 1) increase in airway resistance due to higher nasal resistance and 2) reduction in pharyngeal diameter from mouth breathing that moves the mandible inferiorly 3.
Pathophysiological Mechanisms
Several pathophysiological mechanisms have been proposed to explain the relationship between allergic rhinitis and OSA.
- Elevated Th17/Treg ratio correlates positively with apnea-hypopnea index of OSA patients, and Th17 and Treg imbalances caused by allergic rhinitis and OSA, respectively, may possibly promote each other, leading to further imbalance 2.
- Obesity is a strong risk factor for OSA, and leptin plays an important role in ventilatory function and upper airway obstruction 2.
- The variant trigeminocardiac reflex and nasotrigeminal reflex may also be involved in the association between rhinitis and OSA 2.
Treatment and Management
Treatment of allergic rhinitis, particularly with intranasal steroids, has been shown to improve OSA symptoms 3.
- Leukotriene receptor antagonists were also associated with positive results on OSA in adult patients with concomitant allergic rhinitis, but current data are limited in the case of children 3.
- Fluticasone propionate aqueous nasal spray is an effective treatment for allergic rhinitis, with a rapid onset of action and significant reduction in nasal symptoms 4, 5, 6.