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Rhinitis, Cold Air–Induced

BASICS

  • Cold air " пїЅinduced 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 " пїЅinduced 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 " пїЅ40% of the Western population (2)[C].
  • Most ENT clinics report a 50 " пїЅ50 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 " пїЅinduced 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 " пїЅinduced 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 " пїЅrelated rhinitis even in the absence of allergen exposure (2)[B].

GENERAL PREVENTION

Trigger avoidance пїЅ пїЅ

COMMONLY ASSOCIATED CONDITIONS

  • Allergic rhinitis
  • Nonallergic rhinitis
  • Asthma
  • Sinusitis

DIAGNOSIS

Nasal symptoms initiated by climate or temperature changes not usually occurring in healthy populations пїЅ пїЅ

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 " пїЅinduced 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 пїЅ пїЅ

TREATMENT

MEDICATION

  • Anticholinergic treatments are effective in cold air " пїЅinduced 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]. пїЅ пїЅ

  • 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 " пїЅinduced rhinorrhea.
  • Action onset within 30 minutes
  • Common side effects include mouth dryness, local irritation, and epistaxis.

REFERENCES

11 Cruz пїЅ пїЅAA, Togias пїЅ пїЅA. Upper airways reactions to cold air. Curr Allergy Asthma Rep. 2008;8(2):111 " пїЅ117.22 Graudenz пїЅ пїЅGS, Landgraf пїЅ пїЅRG, Jancar пїЅ пїЅS, et al. The role of allergic rhinitis in nasal responses to sudden temperature changes. J Allergy Clin Immunol. 2006;118(5):1126 " пїЅ1132.33 Fokkens пїЅ пїЅWJ. Thoughts on the pathophysiology of nonallergic rhinitis. Curr Allergy Asthma Rep. 2002;2(3):203 " пїЅ209.44 Salib пїЅ пїЅRJ, Harries пїЅ пїЅPG, Nair пїЅ пїЅSB, et al. Mechanisms and mediators of nasal symptoms in nonallergenic rhinitis. Clin Exp Allergy. 2008;38(3):393 " пїЅ404.55 Jacobs пїЅ пїЅR, Lieberman пїЅ пїЅP, Kent пїЅ пїЅE, et al. Weather/temperature-sensitive vasomotor rhinitis may be refractory to intranasal corticosteroid treatment. Allergy Asthma Proc. 2009;30(2):120 " пїЅ127.66 Assanasen пїЅ пїЅP, Baroody пїЅ пїЅFM, Rouadi пїЅ пїЅP, 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 " пїЅ1037.

ADDITIONAL READING

  • Greiner пїЅ пїЅAN, Meltzer пїЅ пїЅEO. Overview of the treatment of allergic rhinitis and nonallergic rhinopathy. Proc Am Thorac Soc. 2011;8(1):121 " пїЅ131.
  • Naclerio пїЅ пїЅRM, Proud пїЅ пїЅD, Kagey-Sobotka пїЅ пїЅA, et al. Cold dry air-induced rhinitis: effect of inhalation and exhalation through the nose. J Appl Physiol (1985). 1995;79(2):467 " пїЅ471.
  • Silvers пїЅ пїЅWS. The skier 's nose: a model of cold-induced rhinorrhea. Ann Allergy. 1991;67(1):32 " пїЅ36.
  • Togias пїЅ пїЅAG, Naclerio пїЅ пїЅRM, Proud пїЅ пїЅD, 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 " пїЅ1381.
  • Wallace пїЅ пїЅDV, Dykewicz пїЅ пїЅMS, Bernstein пїЅ пїЅDI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(2 Suppl):S1 " пїЅS84.

CODES

ICD10

J31.0 Chronic rhinitis пїЅ пїЅ

ICD9

472.0 Chronic rhinitis пїЅ пїЅ

SNOMED

non-allergic rhinitis (disorder) пїЅ пїЅ

CLINICAL PEARLS

  • Rhinorrhea is the most frequent symptom of cold air " пїЅinduced rhinorrhea.
  • Diagnosis of exclusion
  • Anticholinergic treatments are effective by decreasing nasal secretions.