BASICS
- Cold air " �induced rhinitis produces nasal symptoms when exposed to cold air.
- Also known as nasal hyperreactivity and is a form of nonallergenic rhinitis
DESCRIPTION
- Nasal hyperreactivity is an increased sensitivity to everyday nonspecific external stimuli.
- Cold air " �induced rhinitis can occur in chronic allergic and nonallergic rhinitis and those with no nasal disease.
- Symptoms include rhinorrhea, nasal congestion, postnasal drainage, and nasal burning, within minutes after exposure to cold air.
- Symptoms resolve soon after exposure is eliminated.
EPIDEMIOLOGY
Prevalence
- Overall epidemiology of rhinitis conditions is difficult to assess due to challenges in classifying rhinitis.
- Prevalence of cold air sensitivity in nonallergenic chronic rhinitis is not known (1)[C].
- Rhinitis is a very common disorder affecting 20 " �40% of the Western population (2)[C].
- Most ENT clinics report a 50 " �50 division between allergic and nonallergic patients (2)[C].
- Can occur in those with or without nasal disease
- Nonallergenic rhinitis presents later in life than allergic rhinitis, with 70% of patients presenting after 20 years of age.
- The prevalence of nonallergic rhinitis in children is not well studied.
ETIOLOGY AND PATHOPHYSIOLOGY
- Exact mechanism of cold air " �induced rhinitis pathophysiology is uncertain.
- A major function of the nose is to warm and humidify inhaled air (1)[C].
- As the nose warms and humidifies air, the nasal mucosa loses heat and water (1)[C].
- Nasal mucosa has a dense subepithelial capillary network, allowing for exchange of heat and water to humidify air.
- Cold air " �induced rhinorrhea is a state of mucosal hyperresponsiveness.
- Mechanism of action is through activation of mast cell and sensory nerve stimulation, which generates a cholinergic secretory response.
- Cholinergic stimulation causes anterior glandular activation, producing predominately rhinorrhea (3)[C].
- The associated rhinorrhea appears to be largely the result of glandular parasympathetic stimulation, as it is partially blocked by atropine (4)[A].
- Physical stimulus causes mast cell activation.
- Activation of mast cells causes release of inflammatory mediators, which take part in mediating nasal congestion (4)[A].
- Blocking mast cell products with antihistamine does not alter clinical response to cold air.
- Symptoms may reflect activation of a compensating mechanism to restore mucosal hemostasis (1)[C].
RISK FACTORS
- Nasal hypersensitivity is common in both allergic and nonallergic rhinitis.
- Persistent allergic rhinitis is a risk factor for developing sudden temperature change " �related rhinitis even in the absence of allergen exposure (2)[B].
GENERAL PREVENTION
Trigger avoidance � �
COMMONLY ASSOCIATED CONDITIONS
- Allergic rhinitis
- Nonallergic rhinitis
- Asthma
- Sinusitis
DIAGNOSIS
Nasal symptoms initiated by climate or temperature changes not usually occurring in healthy populations � �
HISTORY
- Response of cold, dry air exposure was rhinorrhea and congestion within the first 10 minutes of exposure.
- Sneezing is not a frequent symptom.
- Symptoms are primarily rhinorrhea and nasal congestion, frequently associated with a burning sensation inside the nose (1)[C].
- Symptoms resolve when stimulus is removed.
- Cold air " �induced rhinitis is more common in patients with other nasal disease (1)[C].
- Among patients with chronic rhinitis, >50% of those with perennial allergies report cold air as a trigger.
- Individuals with asthma and allergic rhinitis have more intense symptoms to cold air compared with individuals who have only allergic rhinitis (1)[C].
PHYSICAL EXAM
- Nasal examination may be helpful but not necessary for diagnosis.
- Turbinates may appear boggy and edematous as seen with allergic rhinitis.
- Mucosal tissue is more often erythematous compared to the pale bluish hue or pallor seen with allergic rhinitis.
- However, mucosa can appear relatively normal.
DIFFERENTIAL DIAGNOSIS
- Allergic rhinitis
- Infective rhinitis
- Idiopathic rhinitis
- Nonallergic rhinitis with eosinophilia syndrome
- Occupational rhinitis
- Drug-induced rhinitis
- Hormonal rhinitis
- Irritants rhinitis
- Gustatory rhinitis
- Emotional rhinitis
- Atrophic rhinitis (4)[A]
DIAGNOSTIC TESTS & INTERPRETATION
- Consider empiric trial of nonsedating antihistamines or nasal steroids if allergic rhinitis suspected.
- Skin prick testing in those whom allergic rhinitis is suspected but who do not respond to above. Rarely needed.
- CT scans for suspected adenoidal or sinus disease
- Diagnosis is based on history and physical combined with negative allergen testing. Therefore, it is a diagnosis of exclusion.
Diagnostic Procedures/Other
Rhinopharyngoscopy for suspected anatomic obstructions � �
TREATMENT
MEDICATION
- Anticholinergic treatments are effective in cold air " �induced rhinorrhea.
- Nasal steroids are not effective in cold air-induced rhinitis (5)[A].
- Histamine also does not appear to be involved in symptoms (4)[A].
First Line
Ipratropium bromide nasal solution, an anticholinergic drug, decreases rhinorrhea by inhibiting the nasal parasympathetic mucous glands (6)[A]. � �
- Ipratropium increases the ability of the nose to condition cold, dry air (6)[A].
- Safety and efficacy of nasal spray has been shown in cold air " �induced rhinorrhea.
- Action onset within 30 minutes
- Common side effects include mouth dryness, local irritation, and epistaxis.
REFERENCES
11 Cruz � �AA, Togias � �A. Upper airways reactions to cold air. Curr Allergy Asthma Rep. 2008;8(2):111 " �117.22 Graudenz � �GS, Landgraf � �RG, Jancar � �S, et al. The role of allergic rhinitis in nasal responses to sudden temperature changes. J Allergy Clin Immunol. 2006;118(5):1126 " �1132.33 Fokkens � �WJ. Thoughts on the pathophysiology of nonallergic rhinitis. Curr Allergy Asthma Rep. 2002;2(3):203 " �209.44 Salib � �RJ, Harries � �PG, Nair � �SB, et al. Mechanisms and mediators of nasal symptoms in nonallergenic rhinitis. Clin Exp Allergy. 2008;38(3):393 " �404.55 Jacobs � �R, Lieberman � �P, Kent � �E, et al. Weather/temperature-sensitive vasomotor rhinitis may be refractory to intranasal corticosteroid treatment. Allergy Asthma Proc. 2009;30(2):120 " �127.66 Assanasen � �P, Baroody � �FM, Rouadi � �P, et al. Ipratropium bromide increases the ability of the nose to warm and humidify air. Am J Respir Crit Care Med. 2000;162(3 Pt 1):1031 " �1037.
ADDITIONAL READING
- Greiner � �AN, Meltzer � �EO. Overview of the treatment of allergic rhinitis and nonallergic rhinopathy. Proc Am Thorac Soc. 2011;8(1):121 " �131.
- Naclerio � �RM, Proud � �D, Kagey-Sobotka � �A, et al. Cold dry air-induced rhinitis: effect of inhalation and exhalation through the nose. J Appl Physiol (1985). 1995;79(2):467 " �471.
- Silvers � �WS. The skier 's nose: a model of cold-induced rhinorrhea. Ann Allergy. 1991;67(1):32 " �36.
- Togias � �AG, Naclerio � �RM, Proud � �D, et al. Nasal challenge with cold, dry air results in release of inflammatory mediators. Possible mast cell involvement. J Clin Invest. 1985;76(4):1375 " �1381.
- Wallace � �DV, Dykewicz � �MS, Bernstein � �DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(2 Suppl):S1 " �S84.
CODES
ICD10
J31.0 Chronic rhinitis � �
ICD9
472.0 Chronic rhinitis � �
SNOMED
non-allergic rhinitis (disorder) � �
CLINICAL PEARLS
- Rhinorrhea is the most frequent symptom of cold air " �induced rhinorrhea.
- Diagnosis of exclusion
- Anticholinergic treatments are effective by decreasing nasal secretions.