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Wise et al.

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very limited observational data suggesting a potential association between aeroallergens and EoE pathogenesis, but more study is needed. • Aggregate Grade of Evidence: C (Level 3a: 1 study; Level 4: 12 studies; Table X.J).

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X.K. Sleep disturbance and obstructive sleep apnea (OSA)

Nasal congestion is reported by as many as 90% of AR patients. 2026 Nocturnal nasal congestion can significantly affect sleep quality. Nasal obstruction due to AR has been well established as a cause of sleep disruption. 707,714,2026 One population-based survey study of children with AR identified sleep disturbance due to AR as a significant factor affecting health-related QOL. 2027 Diminished sleep quality resulting from AR has been shown to negatively impact work performance and productivity. 2028 Another population-based study found that patients with AR were more likely to report suffering from insomnia, snoring and sleep apnea than control groups. 727 The severity of AR symptoms was also shown to affect the duration of sleep, frequency of daytime somnolence, and sleep latency. The influence of AR on sleep is multifactorial. Upper airway resistance, biochemical and hormonal effects, and pharmacologic interventions all play a role in altering sleep. A large population-based survey of AR patients demonstrated a strong correlation between AR disease severity and sleep disturbance. 679 The study showed that increasing severity of AR symptoms caused worse sleep quality. When establishing a diagnosis of AR, the impact of allergy symptoms on sleep should be assessed by detailed history. There are several different instruments, which have been used to assess the impact of AR on sleep. These include: the ESS, Stanford Sleepiness Score, Jenkins Questionnaire, Pittsburgh Sleep Quality Index, University of Pennsylvania Functional Outcomes of Sleep, Sleep scale from the Medical Outcome Study, Sleep Disorders Questionnaire, The Pediatric Sleep Questionnaire, and The Pediatric Daytime Sleepiness Scale. These metrics may be useful in establishing baseline symptoms and monitoring a response to treatment. There have been several studies that have investigated the relationship between AR and sleep-disordered breathing (SDB) (Table X.K). SDB refers to a spectrum of conditions including primary snoring, upper airway resistance syndrome, and obstructive sleep apnea. In a population-based analysis, Young et al. 714 found that moderate-to-severe SDB were 1.8 times more frequent in participants with nasal congestion due to allergy. In a small case series of patients with SAR who underwent repeat PSG, patients with symptomatic AR had an average 1.7 occurrences of obstructive apnea per hour of sleep that decreased to 0.7 per hour when patients were symptom free. 718 A 2011 case-control study assessing differences in polysomnography between persistent AR sufferers and healthy controls found no statistically significant difference in apnea-hypopnea index (AHI) between the 2 groups. 720 There were modest differences in sleep efficiency, arousal index, and snoring time. A standard approach to the treatment of AR should help to decrease or alleviate the symptoms that adversely impact sleep. Medications that act to treat nasal congestion are typically effective at improving sleep quality. INCS have been shown to improve nasal

Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.