Rhinitis, Cold Air-Induced

Basics

  • Cold air–induced rhinitis produces nasal symptoms when exposed to cold air.
  • Also known as nasal hyperreactivity and is a form of nonallergic 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 nonallergic 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
  • Nonallergic 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. TRP ion channels appear to be involved.
  • 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

Diagnostic Procedures/Other

  • Rhinopharyngoscopy for suspected anatomic obstructions
  • 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.

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.

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. [PMID:21364230]
  • 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. [PMID:7592204]
  • Silvers WS. The skier’s nose: a model of cold-induced rhinorrhea. Ann Allergy. 1991;67(1):32–36. [PMID:2968060]
  • 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. [PMID:2414318]
  • Wallace DV, Dykewicz MS, Bernstein DI, et al; for Joint Task Force on Practice Parameters. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(Suppl 2):S1–S84. [PMID:18662584]

Codes

ICD-10

  • J31.0 Chronic rhinitis

ICD-9

  • 472.0 Chronic rhinitis

SNOMED

  • 311000119101 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.

Authors

Gemma Kim, MD
Tae K. Kim, MD
Kenneth T. Acha, MD

Bibliography

  1. Cruz AA, Togias A. Upper airways reactions to cold air. Curr Allergy Asthma Rep. 2008;8(2):111–117. [PMID:18417052]
  2. 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. [PMID:17088139]
  3. Fokkens WJ. Thoughts on the pathophysiology of nonallergic rhinitis. Curr Allergy Asthma Rep. 2002;2(3):203–209. [PMID:11918861]
  4. Salib RJ, Harries PG, Nair SB, et al. Mechanisms and mediators of nasal symptoms in non-allergic rhinitis. Clin Exp Allergy. 2008;38(3):393–404. [PMID:18201248]
  5. 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. [PMID:19463202]
  6. 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. [PMID:10988126]

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