We report the case of a 44 years old woman referred to the
outpatient Sleep Disorder Service of the Neurological Clinic, Marche
Polytechnic University for a symptomatology characterized by
difficulty in maintaining sleep and a feeling of unrefreshing sleep on
waking. On clinical history, she referred an allergic rhinitis, treated
with short cycles of inalatory steroids and vasoconstrictors. At the
moment of our observation, she did not assume any treatment .
Due to the reported symptoms, particular attention was paid to the
possible presence of sleep disturbances, in particular sleep-related
breathing disorders. In this respect, patient reported a morning
dry mouth. Further, the partner referred an important snoring
and continuous lightening of sleep. Nocturnal apnea events were
not reported as well as discomfort or abnormal movements in
the legs. No other disturbance suggestive for NREM or REM sleep
disturbances, nor fewer specific phases were evidenced. Patient
was then submitted to a polygraphy which showed a rhonchopathy
associated with air flow limitations, a high arousal index and
elevated heart rate variability. The exam excluded periodic limb
movements (Figure 1) [2,3]. Considering the history of allergic
rhinitis and also to evaluate the possible presence of anomalies
of the upper airways, an ENT assessment was indicated. Further,
in relation to the difficulty in maintaining sleep and for the high
indices of autonomic dysfunction, a pharmacological treatment
with trazodone at the dose of sleep stabilizer, 30 mg in the evening
ENT evaluation showed a pattern of nasal congestion without
other alteration of the upper airways. Specific topical therapy was
prescribed, not taken by the patient for the improvement with
trazodone. Infact after few days of treatment with trazodone the
patient reported a significant improvement of symptomatology and
after 30 days a poligraphic control showed a complete recovery
of respiratory alterations and a normalization of autonomic
dysfunction (Figure 2) . The particularly favorable and rapid
evolution of patient’s symptomatology could be interpreted on the
basis of the pharmacological properties of trazodone. It is possible
to hypothesize that trazodone at low dosages, in addition to the
anxiolytic and hypno-inducing effect, for its an antihistamine action
was able to contemporary solve clinical pictures related to both
insomnia and the respiratory dysfunction . Therefore, trazodone,
in addition to stabilizing the sleep structure by increasing the
arousal threshold, should deserve consideration in patients
affected by allergic rhinitis with sleep disturbances. The advantage
of having a valid therapeutic alternative would be very important
in relation to the fact that steroids and vasoconstrictors, normally
used in the treatment of allergic rhinitis, find an indication only in
the short-term approach and have no effect on sleep disturbances.
Figure 1: Basal polygraphic picture: flow limitations, absence of periodic movements; arousal index (AI) 49.7;heart rate
variability (HRV) 4.1; Snoring 27.
HRV: LF/HF ratio,
LF (Low Frequency): Frequencies included between 0.04 and 0.15 Hz.
HF (High Frequency): Frequencies included between 0.15 and 0.4 Hz.
The LF band is considered mainly related to the activity of the sympathetic nervous system while the HF band is considered
an expression of the parasympathetic activity.
The ratio between low and high frequencies (LF/HF) allows quantify the balance between the sympathetic and parasympathetic
systems constituting the so-called
Figure 2: Polygraphic picture after one-month treatment with trazodone: resolution of the respiratory picture and normalization
of the autonomic indices arousal index (AI) 11, heart rate variability (HRV) 1.3 Snoring 3%.