Introduction: In this study, we aimed to investigate sympathetic nervous system functions by local sympathetic skin responses of the nasal septum in patients with acute allergic rhinitis.Material and Methods: Eighty-five patients who were diagnosed as acute allergic rhinitis according to medical history and otorhinolaryngological examination with positive allergy evaluations via skin prick testing and 50 healthy subjects were included to the study. Sympathetic skin responses of the nasal septum were recorded in patients and in the control groups, and sympathetic skin response latencies and amplitudes were compared between groups.Results: The mean value of sympathetic skin response latencies was significantly longer in the patient group than that of the control group (p<0.001). In addition, mean value of sympathetic skin response amplitudes was significantly lower in the patient group than the control group (p<0.001).Conclusion: Our study is the first which electrophysiologically evaluated the local sympathetic nervous functions that shows objective evidence of local sympathetic nervous system dysfunction. This way to access local sympathetic nervous system dysfunction would be helpful in deciding patients' treatment

Ardıç, Fazıl Necdet

Değirmenci, Eylem

Erdoğan, Çağdaş

Kara, Cüneyt Orhan

Tekin, Selma

Topuz, Bülent

Tümkaya, Funda

English

Pamukkale Üniversitesi Açık Erişim Arşivi

104
Turk J Immunol 2018; 6(3):104−107
ORIGINAL ARTICLE / ÖZGÜN MAKALE Turkish Journal of Immunology - Open Access
www.turkishimmunology.org
Local Sympathetic System Dysfunction in Patients with 
Acute Allergic Rhinitis; an Electrophysiological study of 
Local Sympathetic Skin Responses Test 
Akut Allerjik Rinitli Hastalarda Lokal Sempatik Sistem Disfonksiyonunu Gösteren Lokal 
Sempatik Deri Yanıtları Testi’nin Elektrofizyolojik Çalışması
Eylem DEĞIRMENCI1 , Selma TEKİN1 , Funda TÜMKAYA2 , Çağdaş ERDOĞAN1 , Fazıl Necdet ARDIÇ2 ,  
Cüneyt Orhan KARA2 , Bülent TOPUZ2
1Department of Neurology, Pamukkale 
University School of Medicine, Denizli, 
Turkey
2Department of Otorhinolaryngology, 
Pamukkale University School of 
Medicine, Denizli, Turkey
Correspondence:
Selma TEKİN 
Pamukkale Universitesi Tip Fakultesi, 
Noroloji Anabilim Dalı, 20070,  
Kinikli- Denizli, Turkey 
E-mail: selmabilgintekin@gmail.com
Received: May 10, 2018
Accepted: Sep 18, 2018
https://doi.org/10.25002/tji.2018.867
©2018 Turkish Journal of Immunology.
All rights reserved.
Abstract
Introduction: In this study, we aimed to investigate sympathetic nervous system functions by local sympathetic skin 
responses of the nasal septum in patients with acute allergic rhinitis.
Material and Methods: Eighty-five patients who were diagnosed as acute allergic rhinitis according to medical history 
and otorhinolaryngological examination with positive allergy evaluations via skin prick testing and 50 healthy subjects 
were included to the study. Sympathetic skin responses of the nasal septum were recorded in patients and in the control 
groups, and sympathetic skin response latencies and amplitudes were compared between groups.
Results: The mean value of sympathetic skin response latencies was significantly longer in the patient group than that 
of the control group (p<0.001). In addition, mean value of sympathetic skin response amplitudes was significantly 
lower in the patient group than the control group (p<0.001).
Conclusion: Our study is the first which electrophysiologically evaluated the local sympathetic nervous functions that 
shows objective evidence of local sympathetic nervous system dysfunction. This way to access local sympathetic nervous 
system dysfunction would be helpful in deciding patients’ treatment.
Keywords: Acute allergic rhinitis, sympathetic skin responses, sympathetic nervous system
Öz
Giriş: Bu çalışmada akut allerjik rinitli hastalarda, nazal septumun lokal sempatik deri yanıtlarına bakarak, sempatik 
sinir sistemi fonksiyonunun araştırılması amaçlanmıştır.
Gereç ve Yöntemler: Çalışmaya tıbbi öykü, yapılan otolaringolojik muayene ve deri prick testi sonucunda pozitif 
allerji değerlendirmesi olan 85 hasta ile 50 sağlıklı kontrol alındı. Sempatik deri yanıtları hem hasta hem de kontrol 
gruplarından nazal septumdan kayıtla bakılmış olup, gruplar arası sempatik deri yanıtları latans ve amplitüdleri 
karşılaştırılmıştır.
Bulgular: Sempatik deri yanıtları latansının ortalama değerleri, hasta grupta kontrol gruba göre anlamlı şekilde uzun 
saptanmıştır (p<0,001). Ayrıca sempatik deri yanıtları amplitüdlerinin ortalama değerleri hasta grupta, kontrol gruba 
göre anlamlı derecede düşük saptanmıştır. (p<0,001).
Sonuç: Çalışmamız, lokal sempatik sinir sistemi disfonksiyonunun objektif kanıtını gösteren lokal sempatik sinir 
fonksiyonlarını elektrofizyolojik olarak değerlendiren ilk çalışmadır. Lokal sempatik sinir sistemi disfonksiyonunun bu 
yolla değerlendirilmesi, hastanın tedavi seçiminde etkili olacaktır.
Anahtar Kelimeler: Akut allerjik rinit, sempatik deri yanıtları, sempatik sinir sistemi
104
Introduction
Allergic rhinitis (AR) is one of the most common allergic diseases. AR is usually defined 
as inflammatory disorder but another pathology that may contribute AR is nasal hyper-
responsiveness.[1] The effect of neural mechanisms on nasal hyper-responsiveness is still 
not known but some studies points out the role of autonomic nervous system (ANS) 
dysfunction in AR.[1,2] In addition, it is reported that sensory nerves may play a role 
in nasal hypersensitivity.[2] ANS dysfunction has been described in patients with non-
Değirmenci et al.  n  SSR in Acute Allergic Rhinitis 105
allergic rhinitis (NAR) and AR, but the evaluations of 
autonomic tests were performed by systemic autonomic 
tests before.[2,3] Ozkaya et al. evaluated ANS testing by 
measuring sympathetic skin response (SRR) and heart rate 
(R-R) interval variation (RRIV) in children with perennial 
AR and they reported that SSR test results were not 
significantly different between patient and control groups, 
but they evaluated systemic SSR.[4] In this study we aimed 
to investigate sympathetic nervous system functions by 
local SSR of the nasal septum in patients with acute AR. 
Material and Methods
Patients 
This study was approved by the Ethical Committee of 
Pamukkale University (PAU). Patients who consented 
to participate in the study were recruited from the PAU 
Hospital Otorhinolaryngology and Allergy Clinic. The 
patients who were diagnosed as acute AR according to 
medical history and otorhinolaryngological examination 
with positive allergy evaluations via skin prick testing 
were included to the study. The patients with sinus 
infection in the previous four months, physical findings 
such as mucous membrane swelling and thickening on 
endoscopic sinonasal examination were excluded. In 
addition, patients who had been medically treated for 
acute rhinosinusitis, nasal polyposis, and neoplasms in the 
last three months were excluded. All subjects underwent 
a complete physical and endoscopic examination and a 
detailed medical history with special attention given 
to sinonasal/allergy signs and symptoms was taken. 
Severity of clinical symptoms was evaluated according to 
classification of Bousquet and ARIA Workshop Group[5] 
and the patients were additionally classified as patients 
with mild or moderate-severe allergic rhinitis. 
The control group consisted of voluntary subjects of our 
medical stuff. The subjects younger than 16 or older than 
65, smokers, subjects with a history of cardiovascular 
disease, diabetes mellitus, neurological disease, and 
rhinological problems were excluded from the study. 
SSR test
The SSR was carried out according to the Technical 
Standards of the International of Clinical Neurophysiology.
[6] Patients were examined in a quiet room and disposable 
electrodes were used for each patient and control subjects. 
The SSR test was performed by a computerized EMG 
system (Medelec/Teca Premier Plus, England) with 
standard disposable electromyographic surface electrode. 
Active electrode was placed on nasal septum and reference 
electrode was places on the skin over the zygomatic arch to 
make standardization for all subjects. We preferred to use 
zygomatic arch as the place of reference electrode, because 
this area is 4 or 5 cm around the active electrode which 
is a preferred area in the previous studies, not mobile, 
hairless, just above the bone tissue like dorsum of the hand 
or foot, sooth, abraded non-glabrous skin site. Only two 
SSR test for performed for all subjects to avoid irritation 
or discomfort of the study. Two consecutive electrical 
stimuli with 150V intensity and 100µ second duration 
were applied to the left median nerve at the wrist. The 
input sensitivity was 200 µV/ division and time base was 5 
seconds. The latency and amplitude (peak to peak) of the 
two responses were measured and mean value of the two 
responses was recorded for each subject.
Statistics
Descriptive studies were used to evaluate patients’ 
characteristics. We used t-test to compare continuous 
parametric vales and Chi-Square test to compare 
nonparametric values between groups. A p-value < 0.05 
was considered to indicate statistical significance. 
Results 
After the selection of patients and control groups a total of 
85 patients with the diagnosis AR and a total of 50 healthy 
subjects were included the study. Mean age of the patients 
was 31.1±12.6 years and the mean age of the control 
group was 34.1±11.4. The difference was insignificant 
(p = 0.189). The ratio of the males was 36.4% in the patient 
group 36.0% in the control group and the difference was 
insignificant (p=0.956).
Table 1 shows the compared parameters (SSR latency and 
amplitude) of SSR test between groups. The mean value 
of SSR latencies was significantly longer in the patient 
group (1.93±0.70s) than the control group (1.09±0.46s) 
(p<0.001). In addition, mean value of SSR amplitudes 
was significantly lower in the patient group (3.66±0.86 
mV) than the control group (4.24±0.56 mV) (p<0.001). 
There were 13 patients (15.3%) with mild AR whereas 
72 patients (84.7%) had severe AR. The mean value of 
SSR latencies was longer in the patient with moderate-
severe AR (1.96±0.67s) than the patients with mild 
106 Turk J Immunol 2018; 6(3):104–107
AR (1.8±0.86s) but the difference was not significant 
(p=0.449). The mean value of SSR amplitudes was higher 
with moderate-severe AR (3.71±0.79 mV) than the 
patients with mild AR (3.38±1.17 mV) but the difference 
was not significant (p=0.203).
Figure 1 shows a typical local SSR test of a patient and a 
healthy subject. 
Discussion
To our knowledge this is the first study to assess local SSR 
for evaluation of patients with AR. Our results showed 
that SSR of the nasal septum is disturbed in acute AR 
and this indicates existence of a local sympathetic nervous 
system (SNS) dysfunction. The adrenergic fibers of the 
SNS control vasoconstriction of the mucosa.[3,4] So, 
dysfunction of SNS, which has been objectively shown 
in our study, is the one of the causes of vasodilatation and 
nasal congestion in patients with acute AR. 
It has been found that central nervous system, especially 
the SNS, plays an important role in the clinical symptoms 
of allergic diseases.[7] The results of our study showed that 
there is a local sympathetic dysfunction in patients with 
acute AR. As AR is a multifactorial disease with different 
predisposing factors, to perform practical tests which give 
objective results about the pathogenesis of the disease 
would be helpful in deciding patients’ treatment. 
It is reported that decreased sympathetic tone results in a 
pro-inflammatory reaction in immune mediated diseases.
[8] In addition, Jordan et al. pointed a possible neurological 
participation in the development of the allergic late-
phase inflammation and consequent hyperresponsiveness 
of the nasal mucosa.[9] Our results showed a local SNS 
dysfunction in patients with acute AR, but we evaluated 
patients who are on the acute phase of the disease. To 
evaluate the patients after the treatment and to evaluate 
the patients who are diagnosed as chronic allergic rhinitis 
would give more informative knowledge about the 
mechanism of allergic rhinitis. 
Relation between neurological systems and nasal 
symptoms was also evaluated in patients with migraine and 
allergic rhinosinusitis by Bellamy et al. The results of their 
study showed increased trigeminal and parasympathetic 
nerve activity in patients with migraine and allergic 
rhinosinusitis.[10] It is known that neuronal reflexes play a 
Table 1. Results of SSR test and p values in patient and control 
groups
SSR Test Patients Controls p value
Latency (mean value) 1.93±0.70s 1.09±0.46s <0.001
Amplitude (mean value) 3.66±0.86 mV 4.24±0.56 mV <0.001
Figure 1. Demonstration of a local SSR test results of a patient and a healthy subject. 
Amplitude= 200 microvolt Amplitude= 200 microvolt
Control Patient: a typical local SSR test with 
prolonged latencies and smaller 
amplitudes than the controls
Değirmenci et al.  n  SSR in Acute Allergic Rhinitis 107
role in the allergic response[11] and the results of our study 
showed a local SNS dysfunction which plays an integral 
role in the pathogenesis of allergic rhinitis. 
Patients suffering from allergic or vasomotor rhinitis 
usually show nasal mucosal hyperaemia, engorgement, 
hyperrhinorrhoea and obstruction of the nasal airway.[12] 
All of the patients included to our study were examined by 
an otorhinolaryngologist and 84.7% of the patients had 
been diagnosed as moderate-severe acute AR, but both 
SSR latencies and SSR amplitudes were not significantly 
different in patients with moderate-severe acute AR than 
the patients with mild acute AR. This result would be 
attributed to the small number of patients with mild acute 
AR in our study. The small number of patients with mild 
acute AR in our study would be due to relatively mild 
complaints of patients with mild acute AR, because they 
do not prefer to see a doctor. 
Nasal congestion found to be related more to a withdrawal 
of sympathetic discharge than to an overactivity of the 
parasympathetic nerves.[12] So to evaluate ANS separately 
like sympathetic and parasympathetic systems would 
help an otorhinolaryngologist in the management of the 
patients with acute AR. To choose drugs acting on alpha-
adrenergic mechanisms would be rational in patients with 
objective evidence of local SNS dysfunction. 
In conclusion, according to knowledge of the literature, 
it is known that ANS dysfunction may be found in 
patients with acute AR, but our study is the first study 
which electrophysiologically evaluated local sympathetic 
functions. Our results showed objective evidence of 
local SNS dysfunction, by the way it would be helpful 
in deciding patients’ treatment with simple and accessible 
tests. However further studies in different patient groups 
like chronic allergic rhinitis would give additional 
knowledge about the pathogenesis of allergic rhinitis.
Ethics Committee Approval: This study was approved by the Ethical Committee of Pamukkale 
University (PAU)
Informed Consent: Written informed consent was obtained from patients who participated in 
this study.
Peer-review: Externally peer-reviewed.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: No financial support.
Author Contributions: Concept: E.D.; Design: E.D., S.T.; Supervision: E.D., Ç.E.; Resources: F.T., 
F.N.A.; Materials: S.T., F.T., C.O.K.; Data Collection and/or Processing: E.D., F.T., Ç.E.; Analysis and/or 
interpretation: F.N.A., C.O.K., B.T.; Literature search: E.D., S.T.; Writing manuscript: E.D., S.T.; Critical 
Review: Ç.E., B.T.
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Akut allerjik rinitli hastalarda lokal sempatik sistem disfonksiyonunu gösteren lokal sempatik deri yanıtları testi’nin elektrofizyolojik çalışması

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Akut allerjik rinitli hastalarda lokal sempatik sistem disfonksiyonunu gösteren lokal sempatik deri yanıtları testi’nin elektrofizyolojik çalışması

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Pamukkale Üniversitesi Açık Erişim Arşivi