AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 41 6–4 1 9

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Variance of melatonin and cortisol rhythm in patients with

allergic rhinitis☆,☆☆

Vural Fidan, MD a,⁎, Hamit Hakan Alp, PhD b , Mustafa Gozeler, MD a ,

Onder Karaaslan, MD c , Omer Binay, MD d , Cemal Cingi, MD e
a
Erzurum Education and Research Hospital, Otorhinolaryngology Dept Erzurum, Turkey
b
Ataturk University Faculty of Medicine, Biochemistry Dept Erzurum, Turkey
c
Ataturk Training and Research Hospital, Plastic and Reconstructive Surgery Dept Izmir, Turkey
d
Eskisehir Yunus Emre Goverment Hospital, Otorhinolaryngology Dept Eskisehir, Turkey
e
Osmangazi University Faculty of Medicine, Otorhinolaryngology Dept Eskisehir, Turkey

ARTI CLE I NFO A BS TRACT

Article history: Objective: Allergic rhinitis is an IgE-mediated inflammatory disease which effects 10%–50%
Received 26 November 2012 of the normal population. The mechanism of its formation and the circadian rhythm of
cortisol and melatonin in allergic rhinitis have not been investigated.
Study design: Salivary levels of melatonin and cortisol were measured by
radioimmunoassay in 35 newly diagnosed allergic rhinitis patients and in 23 control
subjects matched for age and gender.
Results: In the study group; amplitude, baseline and peak levels of salivary melatonin were
significantly decreased compared with healty controls (p < 0.001). No differences were
found in the acrophase and the peak duration of salivary melatonin between the study and
control groups (p > 0.05).
In the study subjects, the circadian rhythm of cortisol was flattened when compared with
the control group. The amplitude and the 24 h mean levels of salivary cortisol in the study
group were significantly lower than in the control group and the acrophase was delayed in
patients compared with control subjects (p < 0.001).
Conclusion: The circadian rhythms of salivary melatonin and cortisol were found to be
disrupted in patients with allergic rhinitis. These results may also be contributive data to
explain the pathogenesis of allergic rhinitis and also they can be applicable as adjunctive
therapeutic tools in the future and melatonin drugs might be an alternative in the therapy of
resistant allergic rhinitis patients or allergic rhinitis patients who cannot use cortisol drugs.
© 2013 Elsevier Inc. All rights reserved.

1. Introduction circadian rhythm, being worst at night and in the early

morning [1]. Also sneezing and rhinorrhea secondary to AR are
Allergic rhinitis (AR) is an inflammation of the nose. The also greater in intensity during the morning in approximately
typical symptoms of AR are rhinorrhea, itching, sneezing and 70% of sufferers [2]. The mechanism involved in circadian
nasal blockage. The severity of nasal congestion follows a rhythm of AR is not clearly understood yet. Asthma, nasal

☆
This study was accomplished at Erzurum Education and Research Hospital.
☆☆
This is an original paper and it was not presented in any meeting. We did not have any financial support or grantor.
⁎ Corresponding author. Erzurum Education and Research Hospital, Otorhinolaryngology Dept Erzurum, Turkey. Tel.: +90 505 5606842.
E-mail address: vuralf@mynet.com (V. Fidan).

0196-0709/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjoto.2013.03.004
 AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 41 6–4 1 9
polyposis and AR frequently coexist in the same patient and
are thought to share common predisposing genetic factors
which interact with the environmental influences [3].
Clinical guidelines for AR have identified sleep impairment
as a significiant problem [4]. Also AR leads to sleep impair-
ment [5]. In addition, sleep impairment is accompanied by a
damaged circadian rhythm, which affects cortisol and mela-
tonin secretion.
Melatonin is the main hormone product of pineal gland
and it coordinates the circadian rhythm in humans. Also, it
has an important role in the immunomodulation, anti-
inflammatory cascade and the antioxidative defense sys-
tem [6–9]. Cortisol is a hormone which shows a cyclic
secretion. It has a typical circadian pattern with higher
levels in the early morning [10]. Cortisol excretion is
coordinated via the hippocampus and the hypothalamic–
pituitary–adrenal axis [11]. There is a considerable affiliation
between the plasma/serum and salivary levels of melatonin
and cortisol [12].
Disturbed circadian rhythm of body may have a role in the
development of AR. To our knowledge, no studies to date have
searched the circadian rhythm of cortisol and melatonin in
patients with AR without asthma. Therefore, this study was
conducted to appreciate the circadian rhythm of melatonin
and cortisol in this patient group.
2. Patients and methods
2.1. Study population
Thirty-five newly diagnosed AR patients without asthma (age
range 18–37 years (mean ± SD age, 25.3 ± 6.6)) who presented
at the Otolaryngology Clinic of Erzurum Education and
Research Hospital between January 2009 and March 2011
were included in this study. Twenty-four age and gender
matched volunteer control subjects (age range 18–39 years
(mean ± SD age, 26.1 ± 7.2)) were chosen among healthy
patients attending the same hospital during the same period.
We received approval by the Local Hospital Ethical Committee
and also obtained the informed consent from the patients
before 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 performed
in all subjects.
Study patients and control subjects with any clinical or
laboratory evidence of inflammation, infection or asthma,
those who had received hormone therapy and/or steroid
therapy in the one month prior to the study, or those who
were taking any drugs that might affect melatonin and
cortisol 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 to
participate and the aim of the study and possible risks were
fully explained. This study was acknowledged by the Ethical
Committee of Erzurum Education and Research Hospital.
417
2.2. Saliva collection
The sampling process was started at 12:00 in all cases and
samples were taken at 4 hourly intervals. Saliva samples were
taken under indoor light conditions. The intensity of light was
limited to 300 lux in full light, but at 00:00 and 04:00 only
flashlight (about 50 lux) was used to light up the mouth.
Approximately 10–20 ml of saliva was taken from each
subject. Saliva was collected prior to meals using a sugarless
gum to stimulate saliva flow if necessary. The samples were
inserted into 50 ml tubes and placed in the refrigerator at ±
4 °C for 24 h. The samples were then centrifuged for 10 min at
2000 × g to remove mucins from the saliva and all samples
were kept at − 40 °C until chemical analysis.
2.3. Saliva assay
Melatonin in the saliva was 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) and
peak duration (time interval during the periodic curve de-
viates from the baseline level) were used as parameters to
assess the melatonin rhythm.
Salivary cortisol was evaluated by ELISA. The kit is
manufactured by Eagle Biosciences, Inc. (82 Broad Street,
Suite 383, Boston, USA) (COR32-K01). The standard range of
the 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 statistically
using nonparametric tests, using the Friedman two-way
ANOVA to establish whether melatonin levels differed in the
samples taken at the various times to evaluate both the ENP
patient and control groups. After confirmation, the Wilcoxon
matched-pairs signed-rank test was used to determine the
differences between sample times, and a repeated-measures
ANOVA with between subject factors was used to compare the
cases with the control group. Finally, we used the Mann–
Whitney test to compare peak values between the patient and
control groups. A value of P < 0.05 was considered to be
statistically 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
418 AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 41 6–4 1 9
Fig. 1 – Circadian rhythm of salivary melatonin in the AR and
control groups.
subjects who were age and gender matched with the AR
group (mean ± SD age 26.1 ± 7.2 years; 14 (58.3%) males, 10
(41.7%) females).
Both the study and control groups displayed periodic
patterns in the amounts of salivary melatonin detected.
However, the circadian rhythm profiles were more flattened
in 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 salivary melatonin in
the AR group were significantly lower than in the control
group (p < 0.001). No differences were seen in the acrophase
and the peak duration of salivary melatonin between the
study and control groups (p > 0.05).
As shown in Fig. 2, the salivary cortisol patterns were
circadian in both groups. The amplitude and the 24 h mean
levels of salivary cortisol in the AR group were significantly
lower than in the control group (p < 0.001) (Table 2). The
acrophase was delayed by about 8 h in AR patients (p < 0.001).
4. Discussion
Sleep impairment is a major problem for patients who have
inflammatory disorders of the upper airway tract, such as
allergic rhinitis, rhinosinusitis, and nasal polyposis [6].
Several studies of melatonin and cortisol levels in inflam-
matory diseases have been published. To our knowledge, the
present study is one of the first to report disturbed salivary
melatonin and cortisol levels in patients with AR. Sleep
disturbances due to AR may be the causitive factor for the
abnormal cortisol/melatonin levels. Papers describing lower
melatonin levels in inflammatory patients can be found in the
published literature [13–15].
Table 1 – The circadian rhythm parameters of salivary melatonin (mean ± SD).
AR Group (n = 35)
Day Time (Baseline) (pg/ml) 4.3 ± 1.9
Night Time (Peak) (pg/ml) 25.1 ± 7.8
Amplitude (pg/ml) 19.2 ± 3.0
Acrophase (hour:min) 03:01 ± 1:09
Peak Duration (hour:min) 9.6 ± 1.2
Fig. 2 – Circadian rhythm of salivary cortisol in the AR and
control groups.
In our clinical trial, we observed overall decreased levels of
salivary melatonin in AR patients but rhythmicity was seen in
all subjects similar to the previously published papers [13–15].
The underlying mechanism causing the decline of melatonin
in AR patients is still unknown. Although, we may not
strongly hypothesize a cause and effect relationship between
AR and levels of cortisol/melatonin, but this decrease may be
associated with sleep impairment, but it could also be
associated with inflammation such as other studies [13–15].
Some investigators have claimed that the decline in the
melatonin levels might be either due to the direct inhibitory
effect of cortisone on pinealocytes or because melatonin is more
rapidly metabolized during the stress caused by disease [16].
In the present study, we found that salivary cortisol levels
were lower in patients with AR compared to healthy subjects
and we know that chronic inflammation is present in patients
with AR. Some researchers have also detected lower cortisol
levels among patients with inflammatory diseases [13–15,17].
Chronic inflammation is seen in atopic disease, and
chronic inflammation may be associated with a lower
response of the hypothalamopituitary axis, as different pro-
inflammatory cytokines inhibit the ACTH-induced production
of cortisol [18,19]. In an expermental mouse model of asthma,
increased airway inflammation was associated with de-
creased corticosterone levels [20]. Lower basal cortisol levels
may contribute to a lack of suppression of airway inflamma-
tion and thus increased sinonasal inflammation, which leads
to AR.
We have also documented that the acrophase was
significantly delayed in the AR group. Similar to our result,
other researchers have found that acrophase occurs later in
inflammatory patients [14,15,21]. This delay can be explained
by sleep disturbance.
According to our results, cortisol levels were disturbed in
both the quantitative evaluation and the cyclic pattern in
Control Group (n = 23) P (One-way ANOVA)
8.5 ± 3.2 <.001
77.6 ± 19.8 <.001
70.1 ± 18.7 <.001
03:12 ± 1:26 >.05
10.1 ± 1.3 >.05
 AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 41 6–4 1 9
Table 2 – The circadian rhythm parameters of salivary cortisol (mean ± SD).
AR Group (n = 35)
24-h Mean Level (ng/ml) 3.8 ± 0.9
Amplitude (ng/ml) 2.9 ± 0.6
Acrophase (hour:min) 14:22 ± 1:35
patients with AR. Since cortisol is anti-inflammatory, the
decrease in this parameter could worsen the inflammatory
process in the nose as well as the whole body. Therefore,
steroid therapy is an effective alternative in the treatment of
AR. We have suggested that melatonin treatment can be
applied with or without therapies in AR patients. In addition,
chronotherapy should be used to improve the effect of
medications in this patient group.
The findings of the present study add to our knowledge of
the melatonin and cortisol rhythm in AR patients. Further-
more, our results may be applicable as therapeutic or
diagnostic tools in the near future and melatonin drugs
might 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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