A M E R I C A N J O U R N A L O F O T O L A R Y N G O L O G Y – H E A D A N D N E C K M E D I C I N E A N D S U R G E R Y 3 4 ( 2 0 1 3 ) 4 1 6 – 4 1 9

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Variance of melatonin and cortisol rhythm in patients withallergic rhinitis☆,☆☆

Vural Fidan, MDa,⁎, Hamit Hakan Alp, PhDb, Mustafa Gozeler, MDa,Onder Karaaslan, MDc, Omer Binay, MDd, Cemal Cingi, MDe

a Erzurum Education and Research Hospital, Otorhinolaryngology Dept Erzurum, Turkeyb Ataturk University Faculty of Medicine, Biochemistry Dept Erzurum, Turkeyc Ataturk Training and Research Hospital, Plastic and Reconstructive Surgery Dept Izmir, Turkeyd Eskisehir Yunus Emre Goverment Hospital, Otorhinolaryngology Dept Eskisehir, Turkeye Osmangazi University Faculty of Medicine, Otorhinolaryngology Dept Eskisehir, Turkey

A R T I C L E I N F O

☆ This study was accomplished at Erzurum☆☆ This is an original paper and it was not⁎ Corresponding author. Erzurum Education a

E-mail address: vuralf@mynet.com (V. Fid

0196-0709/$ – see front matter © 2013 Elsevhttp://dx.doi.org/10.1016/j.amjoto.2013.03.00

A B S T R A C T

Article history:Received 26 November 2012

Objective: Allergic rhinitis is an IgE-mediated inflammatory disease which effects 10%–50%of the normal population. The mechanism of its formation and the circadian rhythm ofcortisol and melatonin in allergic rhinitis have not been investigated.Study design: Salivary levels of melatonin and cortisol were measured byradioimmunoassay in 35 newly diagnosed allergic rhinitis patients and in 23 controlsubjects matched for age and gender.Results: In the study group; amplitude, baseline and peak levels of salivary melatonin weresignificantly decreased compared with healty controls (p < 0.001). No differences werefound in the acrophase and the peak duration of salivary melatonin between the study andcontrol groups (p > 0.05).In the study subjects, the circadian rhythm of cortisol was flattened when compared withthe control group. The amplitude and the 24 h mean levels of salivary cortisol in the studygroup were significantly lower than in the control group and the acrophase was delayed inpatients compared with control subjects (p < 0.001).Conclusion: The circadian rhythms of salivary melatonin and cortisol were found to bedisrupted in patients with allergic rhinitis. These results may also be contributive data toexplain the pathogenesis of allergic rhinitis and also they can be applicable as adjunctivetherapeutic tools in the future andmelatonin drugsmight be an alternative in the therapy ofresistant allergic rhinitis patients or allergic rhinitis patients who cannot use cortisol drugs.

© 2013 Elsevier Inc. All rights reserved.

1. Introduction

Allergic rhinitis (AR) is an inflammation of the nose. Thetypical symptoms of AR are rhinorrhea, itching, sneezing andnasal blockage. The severity of nasal congestion follows a

Education and Researchpresented in any meetingnd Research Hospital, Otan).

ier Inc. All rights reserve4

circadian rhythm, being worst at night and in the earlymorning [1]. Also sneezing and rhinorrhea secondary to AR arealso greater in intensity during the morning in approximately70% of sufferers [2]. The mechanism involved in circadianrhythm of AR is not clearly understood yet. Asthma, nasal

Hospital.. We did not have any financial support or grantor.orhinolaryngology Dept Erzurum, Turkey. Tel.: +90 505 5606842.

d.

417A M E R I C A N J O U R N A L O F O T O L A R Y N G O L O G Y – H E A D A N D N E C K M E D I C I N E A N D S U R G E R Y 3 4 ( 2 0 1 3 ) 4 1 6 – 4 1 9

polyposis and AR frequently coexist in the same patient andare thought to share common predisposing genetic factorswhich interact with the environmental influences [3].

Clinical guidelines for AR have identified sleep impairmentas a significiant problem [4]. Also AR leads to sleep impair-ment [5]. In addition, sleep impairment is accompanied by adamaged circadian rhythm, which affects cortisol and mela-tonin secretion.

Melatonin is the main hormone product of pineal glandand it coordinates the circadian rhythm in humans. Also, ithas an important role in the immunomodulation, anti-inflammatory cascade and the antioxidative defense sys-tem [6–9]. Cortisol is a hormone which shows a cyclicsecretion. It has a typical circadian pattern with higherlevels in the early morning [10]. Cortisol excretion iscoordinated via the hippocampus and the hypothalamic–pituitary–adrenal axis [11]. There is a considerable affiliationbetween the plasma/serum and salivary levels of melatoninand cortisol [12].

Disturbed circadian rhythm of body may have a role in thedevelopment of AR. To our knowledge, no studies to date havesearched the circadian rhythm of cortisol and melatonin inpatients with AR without asthma. Therefore, this study wasconducted to appreciate the circadian rhythm of melatoninand cortisol in this patient group.

2. Patients and methods

2.1. Study population

Thirty-five newly diagnosed AR patients without asthma (agerange 18–37 years (mean ± SD age, 25.3 ± 6.6)) who presentedat the Otolaryngology Clinic of Erzurum Education andResearch Hospital between January 2009 and March 2011were included in this study. Twenty-four age and gendermatched volunteer control subjects (age range 18–39 years(mean ± SD age, 26.1 ± 7.2)) were chosen among healthypatients attending the same hospital during the same period.We received approval by the Local Hospital Ethical Committeeand also obtained the informed consent from the patientsbefore study.

At study entry, all subjects were examined in detail.And also; routine blood and urine analyses, electrocardio-graphs, spirometry, chest and sinus X-rays were performedin all subjects.

Study patients and control subjects with any clinical orlaboratory evidence of inflammation, infection or asthma,those who had received hormone therapy and/or steroidtherapy in the one month prior to the study, or those whowere taking any drugs that might affect melatonin andcortisol levels (including antidepressants, antipsychotic med-ications, benzodiazepines, calcium channel blockers, beta-blockers, anticoagulants, interleukin-2, non-steroidal anti-inflammatory drugs) were also excluded from the study.

All subjects had given written informed consent toparticipate and the aim of the study and possible risks werefully explained. This study was acknowledged by the EthicalCommittee of Erzurum Education and Research Hospital.

2.2. Saliva collection

The sampling process was started at 12:00 in all cases andsamples were taken at 4 hourly intervals. Saliva samples weretaken under indoor light conditions. The intensity of light waslimited to 300 lux in full light, but at 00:00 and 04:00 onlyflashlight (about 50 lux) was used to light up the mouth.Approximately 10–20 ml of saliva was taken from eachsubject. Saliva was collected prior to meals using a sugarlessgum to stimulate saliva flow if necessary. The samples wereinserted into 50 ml tubes and placed in the refrigerator at ±4 °C for 24 h. The samples were then centrifuged for 10 min at2000 × g to remove mucins from the saliva and all sampleswere kept at −40 °C until chemical analysis.

2.3. Saliva assay

Melatonin in the salivawas evaluated by a radioimmunoassay(RIA) using kits obtained from BÜHLMANN Laboratories AG(Baselstr. 55 CH-4124, Schönenbuch, Switzerland) (RK-DSM2).The standard range of melatonin in this kit was 0.5–50 pg/ml).Day time (baseline) level, night time (peak) level, acrophase(clock time at which the melatonin reaches peak level),amplitude (difference between peak and baseline level) andpeak duration (time interval during the periodic curve de-viates from the baseline level) were used as parameters toassess the melatonin rhythm.

Salivary cortisol was evaluated by ELISA. The kit ismanufactured by Eagle Biosciences, Inc. (82 Broad Street,Suite 383, Boston, USA) (COR32-K01). The standard range ofthe cortisol kit was 0.1–30 ng/ml. The 24-h mean level,amplitude (distance from mean to peak levels) and acrophase(clock time at which the cortisol levels reaches highest level)were used as parameters to assess the cortisol rhythm.

2.4. Statistics

Statistical analyses were performed by using the SPSS®software package, version 17.0 (SPSS Inc., Chicago, IL, USA)for Windows®. Categorical variables are presented as per-centages and continuous variables are presented as mean ±SD. Data continuous variables were analyzed statisticallyusing nonparametric tests, using the Friedman two-wayANOVA to establish whether melatonin levels differed in thesamples taken at the various times to evaluate both the ENPpatient and control groups. After confirmation, the Wilcoxonmatched-pairs signed-rank test was used to determine thedifferences between sample times, and a repeated-measuresANOVAwith between subject factors was used to compare thecases with the control group. Finally, we used the Mann–Whitney test to compare peak values between the patient andcontrol groups. A value of P < 0.05 was considered to bestatistically significant.

3. Results

Thirty-five patients with AR were included in the study(mean ± SD age 25.3 ± 6.6 years; 22 (62.9%) males, 13 (37.1%)females). The control group included 24 healthy volunteer

Fig. 1 – Circadian rhythm of salivary melatonin in the AR andcontrol groups.

Fig. 2 – Circadian rhythm of salivary cortisol in the AR andcontrol groups.

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subjects who were age and gender matched with the ARgroup (mean ± SD age 26.1 ± 7.2 years; 14 (58.3%) males, 10(41.7%) females).

Both the study and control groups displayed periodicpatterns in the amounts of salivary melatonin detected.However, the circadian rhythm profiles were more flattenedin the AR group as shown in Fig. 1.

As illustrated in Table 1, the amplitude, and the day time(baseline) and night time (peak) levels of salivarymelatonin inthe AR group were significantly lower than in the controlgroup (p < 0.001). No differences were seen in the acrophaseand the peak duration of salivary melatonin between thestudy and control groups (p > 0.05).

As shown in Fig. 2, the salivary cortisol patterns werecircadian in both groups. The amplitude and the 24 h meanlevels of salivary cortisol in the AR group were significantlylower than in the control group (p < 0.001) (Table 2). Theacrophase was delayed by about 8 h in AR patients (p < 0.001).

4. Discussion

Sleep impairment is a major problem for patients who haveinflammatory disorders of the upper airway tract, such asallergic rhinitis, rhinosinusitis, and nasal polyposis [6].

Several studies of melatonin and cortisol levels in inflam-matory diseases have been published. To our knowledge, thepresent study is one of the first to report disturbed salivarymelatonin and cortisol levels in patients with AR. Sleepdisturbances due to AR may be the causitive factor for theabnormal cortisol/melatonin levels. Papers describing lowermelatonin levels in inflammatory patients can be found in thepublished literature [13–15].

Table 1 – The circadian rhythm parameters of salivary melaton

AR Group (n = 35)

Day Time (Baseline) (pg/ml) 4.3 ± 1.9Night Time (Peak) (pg/ml) 25.1 ± 7.8Amplitude (pg/ml) 19.2 ± 3.0Acrophase (hour:min) 03:01 ± 1:09Peak Duration (hour:min) 9.6 ± 1.2

In our clinical trial, we observed overall decreased levels ofsalivary melatonin in AR patients but rhythmicity was seen inall subjects similar to the previously published papers [13–15].The underlying mechanism causing the decline of melatoninin AR patients is still unknown. Although, we may notstrongly hypothesize a cause and effect relationship betweenAR and levels of cortisol/melatonin, but this decrease may beassociated with sleep impairment, but it could also beassociated with inflammation such as other studies [13–15].

Some investigators have claimed that the decline in themelatonin levels might be either due to the direct inhibitoryeffect of cortisoneonpinealocytesorbecausemelatonin ismorerapidly metabolized during the stress caused by disease [16].

In the present study, we found that salivary cortisol levelswere lower in patients with AR compared to healthy subjectsand we know that chronic inflammation is present in patientswith AR. Some researchers have also detected lower cortisollevels among patients with inflammatory diseases [13–15,17].

Chronic inflammation is seen in atopic disease, andchronic inflammation may be associated with a lowerresponse of the hypothalamopituitary axis, as different pro-inflammatory cytokines inhibit the ACTH-induced productionof cortisol [18,19]. In an expermental mouse model of asthma,increased airway inflammation was associated with de-creased corticosterone levels [20]. Lower basal cortisol levelsmay contribute to a lack of suppression of airway inflamma-tion and thus increased sinonasal inflammation, which leadsto AR.

We have also documented that the acrophase wassignificantly delayed in the AR group. Similar to our result,other researchers have found that acrophase occurs later ininflammatory patients [14,15,21]. This delay can be explainedby sleep disturbance.

According to our results, cortisol levels were disturbed inboth the quantitative evaluation and the cyclic pattern in

in (mean ± SD).

Control Group (n = 23) P (One-way ANOVA)

8.5 ± 3.2 <.00177.6 ± 19.8 <.00170.1 ± 18.7 <.001

03:12 ± 1:26 >.0510.1 ± 1.3 >.05

Table 2 – The circadian rhythm parameters of salivary cortisol (mean ± SD).

AR Group (n = 35) Control Group (n = 23) p (One-way ANOVA)

24-h Mean Level (ng/ml) 3.8 ± 0.9 8.2 ± 1.4 <0.001Amplitude (ng/ml) 2.9 ± 0.6 5.1 ± 1.8 <0.001Acrophase (hour:min) 14:22 ± 1:35 06:13 ± 1:19 <0.001

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patients with AR. Since cortisol is anti-inflammatory, thedecrease in this parameter could worsen the inflammatoryprocess in the nose as well as the whole body. Therefore,steroid therapy is an effective alternative in the treatment ofAR. We have suggested that melatonin treatment can beapplied with or without therapies in AR patients. In addition,chronotherapy should be used to improve the effect ofmedications in this patient group.

The findings of the present study add to our knowledge ofthe melatonin and cortisol rhythm in AR patients. Further-more, our results may be applicable as therapeutic ordiagnostic tools in the near future and melatonin drugsmight be useful in the therapy of AR.

Acknowledgment

Statistical assessment can be found in Methods section.There is no conflict of interests between authors.

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