Introduction
Allergic rhinitis affects approximately 10–30 per cent of adults and up to 40 per cent of children each year. Although allergic rhinitis is not a life-threatening disease, it is a major cause of suffering and impaired quality of life (QoL).Reference Wallace, Dykewicz, Bernstein, Blessing-Moore, Cox and Khan1 The symptoms of allergic rhinitis (rhinorrhoea, nasal congestion and sneezing) are annoying in themselves, but patients also experience non-nasal symptoms that are troublesome, including headache, thirst and disturbed sleep.Reference Juniper2 Learning is impaired in children, and some adults report a decrease in productivity and concentration.Reference Ledford3
Allergic rhinitis is often associated with co-morbid asthma and, if not managed properly, exacerbates other conditions, including acute and chronic sinusitis, recurrent nasal polyposis, otitis media, sleep apnoea, respiratory infections, and asthma.Reference Leynaert, Neukirch, Demoly and Bousquet4 Asthma affects people of all ages, from children to older adults, and its incidence has seen a worldwide increase in recent years.Reference Dogra, Ardern and Baker5 There is strong evidence that perennial rhinitis and asthma frequently occur together.Reference Vignola, Chanes, Godard and Bousquet6 Asthma is a chronic disease that can result in variable restriction in the physical, emotional and social aspects of the patient's life.Reference Bousquet, Knani, Dhivert, Richard, Chicoye and Ware7 Asthma and rhinitis are often co-morbid conditions, and the overall characteristics of the diseases and the treatment options for the disorders are similar.Reference Leynaert, Neukirch, Demoly and Bousquet4 Asthma and chronic hay fever share some similar pathophysiology with chronic inflammation. Thus, the presence of hay fever may contribute to an increased risk of stroke, in a similar fashion as asthma, through a combination of elevated blood pressure (BP) and inflammation.Reference Matheson, Player, Mainous, King and Everett8
In addition, population studies have demonstrated that the prevalence of both hypertension and allergic diseases continue to increase year on year.Reference Aung, Bisognano and Morgan9 Because rhinitis symptoms are known to be associated with snoring and obstructive sleep apnoea (OSA), and snoring and OSA are associated with hypertension, a link between rhinitis and BP seems plausible.Reference Larsson, Lindberg, Franklin and Lundback10–Reference Heinrich, Topp and Brasche12 Kony et al. found an association between questionnaire-reported rhinitis and measured arterial systolic BP in 146 middle-aged males.Reference Kony, Zureik, Neukrich, Leynaert, Vervloet and Neukirch13 However, Heinrich et al. found no association between allergic rhinitis and measured BP.Reference Heinrich, Topp and Brasche12
This study aimed to investigate the likelihood of allergic rhinitis and potential co-morbidities, and to assess whether rhinitis is associated with arterial BP and hypertension.
Materials and methods
This study was conducted according to the Declaration of Helsinki, and was approved by the ethical committee of Eskisehir Osmangazi University Faculty of Medicine.
Participants
This study was designed as a population-based study. The study population had consisted of 401 participants aged 18–50 years. However, of the asthmatic patients, nine had seasonal allergic rhinitis and five had perennial allergic rhinitis; of the hypertensive patients, four had seasonal allergic rhinitis and four had perennial allergic rhinitis; and even in the control group, six of the healthy volunteers had seasonal allergic rhinitis and four had perennial allergic rhinitis. These individuals, who had more than one disease (asthma plus allergic rhinitis, hypertension plus allergic rhinitis), or controls with allergic rhinitis, were excluded from the study.
A total of 369 participants with pure allergic rhinitis, asthma or hypertension, or healthy controls with no other diseases, were included in the study and analysis. These individuals were divided into four groups, as follows. The control group comprised 90 participants (38 male, 52 female), with a mean age of 32.04 ± 8.58 years (range, 20–50 years). The allergic rhinitis group consisted of 99 individuals (39 male, 60 female), with a mean age of 32.08 ± 11.35 years (range, 18–50 years). The asthma group comprised 87 participants (30 male, 57 female), with a mean age of 34.84 ± 9.30 years (range, 20–50 years). The hypertension group consisted of 93 individuals (32 male, 61 female), with a mean age of 35.49 ± 11.67 years (range, 18–50 years).
Informed consent was obtained from all participants. The patients’ demographics, and information on allergic rhinitis and other co-morbidities, including asthma, atopic eczema, laryngopharyngeal reflux, otitis media with effusion, nasal polyposis, and hypertension, were recorded.
Allergic rhinitis
The patients were asked if they had allergic rhinitis related symptoms such as nasal discharge, nasal itching, sneezing or nasal obstruction. A detailed ENT examination was performed. The diagnosis of allergic rhinitis was initially made based on symptoms and clinical findings. Specific immunoglobulin E levels were subsequently studied to confirm the allergic rhinitis diagnosis. The arterial BP of patients with rhinitis was measured.
Patients who suffered from rhinitis symptoms while being near to animals (such as cats, dogs or horses), near feathers (including pillows, quilts or duvets) or in dusty parts of the house were considered to have perennial rhinitis. Patients who suffered with a runny or stuffy nose or started sneezing when exposed to trees, grass or flowers, or when the pollen count was high, were considered to have seasonal rhinitis.Reference Heinrich, Topp and Brasche12
Asthma
Patients who answered ‘yes’ to both the questions ‘Have you ever had asthma?’ and ‘Was it confırmed by a doctor?’ were considered to suffer from asthma.Reference Kony, Zureik, Neukrich, Leynaert, Vervloet and Neukirch13 Patients were defined as having current asthma if they had suffered at least 1 asthma attack or had taken asthma medication in the previous 12 months.Reference Leynaert, Bousquet, Neukirch, Liard and Neukirch14
Hypertension
Patients were considered hypertensive if their systolic BP was at least 140 mmHg and/or their diastolic BP was at least 90 mmHg, and/or they reported using antihypertensive medication.Reference Heinrich, Topp and Brasche12, Reference Kony, Zureik, Neukrich, Leynaert, Vervloet and Neukirch13 Both systolic and diastolic BP were measured with a digital electronic tensiometer (VitalScan 1 BP 1600; Braun, Kronberg, Germany). Two independent measurements were taken, with a 5-minute interval, while the patients were in a supine position. The second values were used for the statistical analysis.Reference Kony, Zureik, Neukrich, Leynaert, Vervloet and Neukirch13
Statistical analysis
The software package SPSS® (version 16.0) was used for statistical evaluation. Kruskal–Wallis variance analysis, Mann–Whitney U test, Mann–Whitney U test with Bonferroni adjustment, and Spearman's correlation rho efficient tests were used to analyse the data.
A p-value of less than 0.05 was taken to indicate statistical significance. Where the Mann–Whitney U test with Bonferroni adjustment was used, an adjusted p-value of less than 0.0125 was considered statistically significant.
Results
In the allergic rhinitis group, 54 patients (54.5 per cent) had seasonal allergic rhinitis and 45 patients (45.5 per cent) had perennial allergic rhinitis.
The BP values of the four groups (control, allergic rhinitis, asthma and hypertension) are shown in Table I. There were no significant differences between males and females in terms of systolic BP and diastolic BP for any group (p < 0.05). In the allergic rhinitis group, for the males, the mean systolic BP was 110.97 ± 18.86 mmHg and the mean diastolic BP was 67.87 ± 11.69 mmHg; for the females, the mean systolic BP was 110.32 ± 14.92 mmHg and the mean diastolic BP was 67.47 ± 11.09 mmHg.
Table I Blood pressure values of the groups
* Mann–Whitney U test.
† Kruskal–Wallis variance analysis.
BP = blood pressure; SD = standard deviation
The differences between groups in terms of both systolic BP and diastolic BP, for the males and the females, was assessed using Kruskal–Wallis variance analysis. The differences were statistically significant (p < 0.05) (Table I).
To find the values causing the differences, pairwise comparisons using a Mann–Whitney U test with Bonferroni adjustment were performed (Table II). An adjusted p-value of less than 0.0125 was considered statistically significant. In the hypertension group, all systolic BP and diastolic BP values of the males and the females were significantly higher than those of the allergic rhinitis group. With the exception of males’ diastolic BP, females’ systolic BP and diastolic BP, and males’ systolic BP values, were significantly higher in the hypertension group than in the control group. Females’ systolic BP values were also significantly higher in the hypertension group than in the asthma group (adjusted p < 0.0125). Pairwise comparisons revealed no significant differences between: the control and allergic rhinitis groups, the control and asthma groups, and the allergic rhinitis and asthma groups.
Table II Pairwise comparisons*
* Conducted using the Mann–Whitney U test with Bonferroni adjustment.
† Adjusted p < 0.0125 considered as statistically significant.
BP = blood pressure
In the allergic rhinitis group, the Mann–Whitney U test was used to determine the differences in systolic BP and diastolic BP values for the patients with seasonal and perennial allergic rhinitis. There was no significant difference for systolic BP (p = 0.174, z = −1.358) or diastolic BP (p = 0.491, z = −0.689).
The relationship between group (control, allergic rhinitis, asthma and hypertension), age, gender, allergic rhinitis type (seasonal and perennial), systolic BP and diastolic BP, was analysed using the Spearman's correlation rho efficient test, and a correlation matrix was developed (Table III). The analysis of allergic rhinitis type was only performed for the allergic rhinitis group. The findings revealed that both systolic BP and diastolic BP values increased with patient age (p < 0.05). As systolic BP increased, diastolic BP also increased in all groups (p < 0.05). In the allergic rhinitis group, perennial allergic rhinitis was detected more often in older patients, whereas seasonal allergic rhinitis was more likely in younger patients (p < 0.05).
Table III Correlation matrix*
* P-values represent the results of Spearman's correlation rho efficient test.
† Analysis was performed in allergic rhinitis group.
BP = blood pressure
Of the patients with allergic rhinitis, one had nasal polyposis, one had external ear canal eczema and one had atopic eczema. Of the patients with asthma, nine had seasonal allergic rhinitis and five had perennial allergic rhinitis. Of the patients with hypertension, four had seasonal allergic rhinitis and four had perennial allergic rhinitis.
Discussion
Asthma and rhinitis commonly occur as co-morbidities, and both diseases impair QoL.Reference Leynaert, Neukirch, Demoly and Bousquet4, Reference Casale and Lazarus15 Affected individuals report problems with social and daily activities, often experience difficulty sleeping at night, suffer from daytime somnolence, and have poorer mental health and well-being than patients without rhinitis or asthma.Reference Schoenwetter, Dupclay, Appjosyula, Botteman and Pashos16 Leynaert et al. found that 78 per cent of asthmatics also had allergic rhinitis, and individuals with both asthma and allergic rhinitis experienced more physical limitations than patients with allergic rhinitis alone.Reference Leynaert, Neukirch, Liard, Bousquet and Neukirch17 The authors concluded that both asthma and allergic rhinitis were associated with an impairment in QoL. We found that 14 asthmatic patients also had allergic rhinitis.
There is strong evidence that perennial rhinitis and asthma frequently occur together, but the nature of the association is not well known.Reference Corren18 Leynaert et al. observed that individuals with perennial rhinitis were more likely than control subjects to have current asthma.Reference Leynaert, Bousquet, Neukirch, Liard and Neukirch14 They concluded that the strong association between perennial rhinitis and asthma in non-atopic subjects with normal immunoglobulin E levels is consistent with the hypothesis that rhinitis is an independent risk factor for asthma. Leynaert et al. suggested that patients with perennial and seasonal rhinitis are more likely to have asthma than those patients with either seasonal or perennial rhinitis alone, and that asthma and rhinitis are associated co-morbidities in both allergic and non-allergic rhinitis.Reference Leynaert, Neukirch, Demoly and Bousquet4 In our study, nine asthmatic patients had seasonal allergic rhinitis and five had perennial allergic rhinitis.
A high prevalence of both rhinitis and hypertension has been reported, with approximately 25 per cent of the population living in industrialised countries.Reference Hannson, Lloyd, Anderson and Kopp19 Rhinitis may be related to cardiovascular risk factors, particularly hypertension, as rhinitis is associated with snoring and obstructive sleep apnoea, and snoring and OSA are associated with hypertension.Reference Settipane20, Reference Peppard, Young, Palta and Skatrud21 Kony et al. found that hypertension was more frequent in males with rhinitis (35.7 per cent) than in males without rhinitis (15.6 per cent).Reference Kony, Zureik, Neukrich, Leynaert, Vervloet and Neukirch13 However, Heinrich et al. observed no statistically significant association between rhinitis and BP in males with or without allergic rhinitis.Reference Heinrich, Topp and Brasche12 In our study, four hypertensive patients had seasonal allergic rhinitis and four had perennial allergic rhinitis.
In the present study, we investigated the BP values in allergic rhinitis patients. The study consisted of patients with allergic rhinitis, asthma and hypertension, and a control group comprising healthy participants. In the allergic rhinitis group, 54 patients (54.5 per cent) had seasonal allergic rhinitis and 45 patients (45.5 per cent) had perennial allergic rhinitis. There were no significant differences in systolic BP and diastolic BP between the males and the females for any group (p < 0.05).
Pairwise comparisons revealed no significant differences between: the control and allergic rhinitis groups, the control and asthma groups, or the allergic rhinitis and asthma groups. The systolic BP and diastolic BP values of the males and females were significantly higher in the hypertension group than in the allergic rhinitis group. With the exception of males’ diastolic BP, females’ systolic BP and diastolic BP, and males’ systolic BP values were significantly higher in the hypertension group than in the control group. Females’ systolic BP values were also significantly higher in the hypertension group than in the asthma group.
Correlation analysis showed that both systolic BP and diastolic BP values increased with patient age. Furthermore, increased systolic BP was related to increased diastolic BP in all groups. In the allergic rhinitis group, perennial allergic rhinitis was detected more in older patients, whereas seasonal allergic rhinitis was more likely in younger patients.
Corbo et al. detected an association between allergic rhinitis and hypertension in males, but they found no associations between systolic BP, snoring and rhinitis in pre-menopausal females.Reference Corbo, Foratiere, Agabiti, Baldacci, Farchi and Pistelli22 The increase in systolic BP between males with allergic rhinitis and without allergic rhinitis was approximately 7 mmHg in the Kony et al. studyReference Kony, Zureik, Neukrich, Leynaert, Vervloet and Neukirch13 and only 3.5 mmHg in the Aung et al. study.Reference Aung, Bisognano and Morgan9 Kony et al. reported mean systolic BP values of 130.6 ± 12.7 mmHg in males with rhinitis and 123.5 ± 13.9 mmHg in males without rhinitis.Reference Kony, Zureik, Neukrich, Leynaert, Vervloet and Neukirch13 In our study, males with allergic rhinitis had a mean systolic BP of 110.97 ± 18.86 mmHg and a mean diastolic BP of 67.87 ± 11.69 mmHg; in females, the mean systolic BP was 110.32 ± 14.92 mmHg and the mean diastolic BP was 67.47 ± 11.09 mmHg. In our study, the systolic BP and diastolic BP values of the allergic rhinitis group were at normal levels, but were lower compared to those reported by Kony et al.Reference Kony, Zureik, Neukrich, Leynaert, Vervloet and Neukirch13
• This study aimed to investigate the likelihood of allergic rhinitis and potential co-morbidities
• This population-based study investigated blood pressure (BP) values in allergic rhinitis patients
• There were no significant differences in systolic or diastolic BP between males and females with allergic rhinitis
Chronic sinusitis is a common inflammatory disease of the facial sinuses. Dales et al. found that males with sinusitis were over 2 per cent more likely to have hypertension, compared with 4 per cent for females.Reference Dales, Chen and Lin23 They reported that sinusitis was associated with hypertension in females only. Dogra et al. observed that asthmatics were 43 per cent more likely to have heart disease and 36 per cent more likely to have high BP than non-asthmatics.Reference Dogra, Ardern and Baker5 They concluded that asthmatics had increased odds of cardiovascular disease compared to non-asthmatics. A study of 3000 atopic patients showed a prevalence of 0.5 per cent for nasal polyps, whereas 300 non-allergic patients showed a prevalence of 4.5 per cent.Reference Bachert, Hörmann, Mösges, Rasp, Riechelmann and Müller24 Of those patients with allergic rhinitis in our study, one also had nasal polyps, one had external ear canal eczema and one had atopic eczema. Iribarren et al. suggested that asthma was independently associated with a modest but significantly increased risk of coronary heart disease among females.Reference Irıbarren, Tolstykh and Eisner25 They detected that asthma was associated with a 1.22-fold increased risk of coronary heart disease among females. Matheson et al. observed that of patients with a history of hay fever, 2.2 per cent had suffered a stroke, and they concluded that a history of hay fever seems to be a risk factor for stroke.Reference Matheson, Player, Mainous, King and Everett8
Conclusion
Asthma and rhinitis commonly occur as co-morbidities, and both diseases impair QoL. In this study, there were no statistically significant differences in systolic or diastolic BP between males and females with allergic rhinitis. We believe that regular checking of arterial BP is not necessary in patients with allergic rhinitis. We also found that some diseases, such as asthma and hypertension, coincide with allergic rhinitis. Further studies with larger numbers of participants are needed to investigate the impact of allergic rhinitis severity and the potential co-morbidities.
Acknowledgement
The authors thank Prof Sadullah Sakallioglu (Department of Practical Statistics, Faculty of Sciences and Letters, Çukurova University, Adana, Turkey) for statistical advice.
