Steroid-induced reduction of histamine release does not alter the clinical nasal response to cold, dry air

Cold-Induced Rhinitis in Skiers—Clinical Aspects and Treatment with Ipratropium Bromide Nasal Spray: A Randomized Controlled Trial

Cold-induced rhinitis (CIR) is common among skiers and is perceived as a troublesome disease. We studied the clinical characteristics of CIR in a population of skiers and we evaluated the effectiveness of ipratropium bromide nasal spray (IBNS) in relieving symptoms in a double-blind placebo-controlled fashion. By means of specific questionnaires, we evaluated 144 subjects (69% men; mean age, 42.2 years). The prevalence of CIR was 48.6% and the distinctive symptom was rhinorrhea (96%), often severe. The prevalence of atopy was higher in the CIR patients (χ2; p = 0.004). Twenty-eight CIR subjects participated in a double-blind placebo-controlled cross-over trial for evaluating the effectiveness of IBNS (80 μg twice per day [b.i.d.]). The severity of symptoms was assessed by a visual analog scale, and the number of cleaning tissues used also was evaluated. The actively treated group showed a significant improvement of rhinorrhea (p = 0.0007) and a reduction in the number of cleaning tissues used (p = 0.0023). Only four mild local side effects were reported. We conclude that IBNS could be regarded as an optimal therapeutic option for treating CIR symptoms in skiers.

Nasal obstruction and rhinorrhea reflect nonspecific nasal hyper-reactivity as evaluated by cold dry air provocation

CONCLUSION

Nasal obstruction, rhinorrhea, and the amount of rhinorrhea that confidently reflect the parasympathetic stimulation can be used to more precisely predict nonspecific nasal hyper-reactivity (NHR).

OBJECTIVE

We aimed to identify factors that confidently reflected the presence and the degree of NHR, measured by cold dry air (CDA) provocation and acoustic rhinometry.

METHODS

A total of 156 patients with allergic or non-allergic rhinitis were classified into three groups according to the decrease of minimal cross-sectional area (MCA) after CDA provocation (group A: n = 40, MCA decrease >60%; group B: n = 29, MCA decrease 30-60%; group C: n = 87, MCA decrease <29%). Symptom scores using the visual analog scale (VAS) were obtained before and after CDA provocation. Changes of VAS were compared between groups. The amount of rhinorrhea was measured after CDA provocation.

RESULTS

VAS scores for nasal obstruction, rhinorrhea, and sneezing were significantly higher in groups A and B than in group C before and after CDA provocation. Change of nasal obstruction and rhinorrhea was significantly larger in group A compared with group B or C. There were also significant differences in the amount of rhinorrhea between groups. All these parameters significantly correlated with the change of MCA values after CDA provocation.

Usefulness of the subjective cold hyperresponsiveness scale as evaluated by cold dry air provocation

BACKGROUND

There is still no study about the correlation between the symptom score and the reactivity to cold dry air (CDA). The authors developed a subjective cold hyperresponsiveness (SCH) scale for CDA and we evaluated its usefulness by comparing the changes of the symptom score and the acoustic parameters between different SCH groups and analyzing the correlation between the SCH scale and other parameters.

METHODS

One hundred fifty-two patients were classified according to their SCH scale. The symptom score by the visual analog scale (VAS), the total nasal volume (TNV), and the minimal cross-sectional area (MCA) by acoustic rhinometry were obtained before and after CDA provocation. Changes of these values were compared between groups and an analysis was performed for the correlation between SCH scale and change of the VAS, TNV, or MCA.

RESULTS

The patients with SCH grade 2 or 3 had a greater change of the VAS scores for nasal obstruction and rhinorrhea. The patients with SCH grade 2 or 3 had a greater change of the TNV (grade 0, 26.1 ± 17.2%; grade 1, 33.3 ± 26.5%, versus grade 2, 44.2 ± 30.0%; grade 3, 61.6 ± 40.0%; p < 0.05) and MCA (grade 0, 23.0 ± 25.3%; grade 1, 35.7 ± 51.1%, versus grade 2, 61.2 ± 72.4%; grade 3, 80.5 ± 56.4%; p < 0.05). Significant correlation existed between the SCH scale and changes in the TNV or MCA.

CONCLUSION

We developed the SCH scale and proved its usefulness for evaluating nonspecific hyperreactivity.

Use of cold dry air provocation with acoustic rhinometry in detecting nonspecific nasal hyperreactivity

BACKGROUND

Cold dry air provocation is useful for evaluating nonspecific nasal hyperreactivity. However, there is no research on nasal volume and dimensions after cold dry air provocation. In this respect, acoustic rhinometry is a useful tool in objectively assessing nasal cavity volume and dimension. The goal of this study was to evaluate nonspecific hyperreactivity using cold dry air provocation with acoustic rhinometry.

METHODS

Cold dry air provocation with acoustic rhinometry was performed on 21 healthy volunteers (group A), 24 patients with allergic rhinitis (group B), and 32 patients with nonallergic rhinitis (group C). The change in symptoms using a visual analog scale (VAS), amount of rhinorrhea, and change of total nasal volume (TNV) and minimal cross-sectional area (MCA) were measured in all three groups.

RESULTS

The two patient groups showed greater change in nasal symptoms (VAS, 2.0 +/- 2.3 in group C versus 0.9 +/- 1.8 in group A), more rhinorrhea (0.4 +/- 0.7 g in group B and 0.3 +/- 0.3 g in group C versus 0.1 +/- 0.1 g in group A), and greater change in total nasal volume (TNV) and MCA. The patient group with history of nonspecific hyperreactivity showed more rhinorrhea (0.5 +/- 0.7 g versus 0.1 +/- 0.2 g) and greater change in TNV and MCA (TNV, 56.8 +/- 39.5% versus 18.0 +/- 17.0%; MCA, 86.6 +/- 81.0% versus 11.5 +/- 9.7%).

CONCLUSION

Cold dry air provocation with acoustic rhinometry could be a useful adjunct tool for detecting nonspecific hyperreactivity.

Diagnostic Criteria of Nonspecific Hyperreactivity Using Cold Dry Air Provocation With Acoustic Rhinometry

Objective. The authors aimed to (1) compare symptom changes in patients with or without nonspecific hyperreactivity, (2) compare changes in total nasal volume (TNV) and minimal cross-sectional area (MCA) using acoustic rhinometry after cold dry air (CDA) challenge, and (3) set the diagnostic criteria using receiver operating characteristic (ROC) curve analysis.

Study Design. Prospective pilot.

Setting. Academic tertiary rhinologic practice.

Subjects and Methods. CDA provocation was performed on 45 patients with self-reported hypersensitivity to cold dry air (group A) and to 53 patients without such hypersensitivity (group B). Symptoms (as measured by visual analog scale [VAS]), TNV, and MCA were checked before and after provocation.

Results. The changes in nasal obstruction (1.8 ± 2.1 vs 0.0 ± 2.3) and rhinorrhea (0.8 ± 2.1 vs −0.5 ± 2.3) were significantly greater in group A ( P < .01 in each case). There were no significant differences between groups in VAS scores for sneezing and itching. From the ROC curve, the authors set the diagnostic criterion as “TNSS (total nasal symptom score) change larger than 1.5,” and its sensitivity and specificity were 75.6% and 86.8%, respectively. The criteria “TNV decrease larger than 19.5%” and “MCA change larger than 15.0%” had higher sensitivity and specificity (TNV: 84.4% sensitivity and 77.4% specificity; MCA: 93.3% sensitivity and 77.4% specificity).

Conclusions. The authors were able to propose diagnostic criteria of nonspecific hyperreactivity using a CDA provocation test with acoustic rhinometry. These results are also helpful for understanding the pathophysiologic mechanisms of nonspecific hyperreactivity.

Upper airways reactions to cold air

Cold air-induced rhinitis is a common complaint of individuals with chronic allergic or nonallergic rhinitis and those with no chronic nasal disease. It is characterized by rhinorrhea, nasal congestion, and nasal burning that appear within minutes of exposure to cold air and dissipate soon after exposure is terminated. The symptoms of cold-air rhinitis are reproduced experimentally with nasal cold-air provocation. This procedure has shown that nasal mast cell activation and sensory nerve stimulation are associated with the development of nasal symptoms. Sensory nerve activation generates a cholinergic reflex that leads to rhinorrhea; therefore, anticholinergic agents are highly effective in treating cold-air rhinitis. Experimental data suggest that individuals with nasal cold-air sensitivity may have reduced ability to compensate for the water loss that occurs during exposure to cold air. Therefore, the symptoms of cold air-induced rhinitis may reflect the activation of compensatory mechanisms to restore mucosal homeostasis.

Cold air-provoked respiratory symptoms: the mechanisms and management

OBJECTIVES

To describe the mechanisms and management of cold air-provoked respiratory symptoms.

STUDY DESIGN

A literature review.

METHODS

The review includes human epidemiological studies, human and animal experimental studies, as well as human studies about management of the cold air-provoked respiratory symptoms.

RESULTS

Cold air is unlikely to be a causal factor initiating respiratory diseases but a symptom trigger. In the present review, the airway responses beyond these symptoms were divided into three types. The short-term responses are those that develop within minutes in response to sudden cooling of the airways. Subjects with asthma or rhinitis are especially prone to these responses. The long-term responses are those that develop in response to repeated and long-standing cooling and drying of the airways, usually in endurance athletes. Finally, there are the physiological, reflex-mediated lower-airway responses to cooling of the skin or upper airways.

CONCLUSIONS

The mechanisms beyond cold air-provoked respiratory symptoms vary considerably and mainly depend on the individual's susceptibility and the ventilation level during the cold exposure. An understanding of these mechanisms is essential for successful management of the symptoms.

Thoughts on the pathophysiology of nonallergic rhinitis

Nonallergic noninfectious rhinitis is a diagnosis by exclusion, meaning that a number of poorly defined nasal conditions that have in common allergy and infection as a cause of the rhinitis have been excluded. The etiology of some subgroups of nonallergic noninfectious rhinitis, like nonallergic rhinitis with eosinophilia (NARES) and drug-induced rhinitis, are quite well defined, but in the majority of the patients, the etiology and pathophysiology are unknown. These patients are classified as idiopathic rhinitis patients. A careful determination of the intensity of the symptoms combined with modern diagnostic tools enables us to discriminate idiopathic rhinitis patients from normal controls. This review discusses the possible pathophysicologic mechanisms of nonallergic noninfectious rhinitis, with emphasis on idiopathic rhinitis.

Natural and induced allergic responses increase the ability of the nose to warm and humidify air

BACKGROUND

We have previously shown that subjects with seasonal allergic rhinitis out of season had a reduced ability to warm and humidify air compared with normal subjects.

OBJECTIVE

We sought to investigate whether allergic reactions induced by either seasonal exposure or nasal challenge with antigen would decrease the capacity of the nose to condition cold, dry air.

METHODS

We performed two prospective studies comparing the effects of allergic inflammation, induced by either seasonal exposure or nasal challenge with antigen, on nasal conditioning capacity (NCC). The total water gradient (WG) across the nose was used to represent the NCC. In the first study, the NCC was measured and compared before and during the allergy season in 10 subjects with seasonal allergic rhinitis. In the second study, 20 subjects with seasonal allergic rhinitis were recruited outside of the allergy season. NCC was measured and compared before and 24 hours after challenge with antigen.

RESULTS

In the first study, seasonal allergic subjects in season showed a significant increase in NCC when compared with their preseason baseline (total WG in season: 2050 +/- 138 mg vs total WG preseason: 1524 +/- 100 mg; P <.01). In the second study, antigen challenge led to early-phase and late-phase responses. There was a statistically significant increase in NCC 24 hours after antigen challenge compared with that before antigen challenge (total WG after antigen challenge: 1938 +/- 101 mg vs total WG before antigen challenge: 1648 +/- 84 mg; P =.01).

CONCLUSION

Allergic reactions induced by either seasonal exposure or antigen challenge increase the ability of the nose to condition inspired air. We speculate that allergic inflammation increases this ability by changing the perimeter of the nasal cavity.

The efficacy of fluticasone propionate aqueous nasal spray for allergic rhinitis and its relationship to topical effects

Fluticasone propionate aqueous nasal spray is an intranasal corticosteroid for the treatment of patients with allergic rhinitis. This double-masked, double-dummy, parallel-group study was conducted to confirm that the efficacy of fluticasone propionate nasal spray is attributable to topical rather than systemic effects. A total of 304 patients with documented seasonal allergic rhinitis were randomly assigned to receive fluticasone propionate nasal spray 200 micrograms once daily (n = 77), oral fluticasone propionate 5 mg once daily (n = 73), oral fluticasone propionate 10 mg once daily (n = 77), or placebo (n = 77) for 14 days. Plasma fluticasone propionate concentrations were determined at baseline and after 14 days of treatment (day 15). Nasal symptoms were recorded daily by patients and assessed weekly by clinicians. On day 15, more patients in the oral fluticasone propionate 5-mg or 10-mg groups, compared with patients in the fluticasone propionate nasal spray group or the placebo group, had detectable plasma fluticasone propionate concentrations, and mean concentrations were higher in the oral fluticasone propionate groups. Both clinician- and patient-rated total and individual nasal symptom scores for obstruction, rhinorrhea, sneezing, and itching were significantly lower in the fluticasone propionate nasal spray group compared with either of the oral fluticasone propionate groups or the placebo group. With few exceptions, oral fluticasone propionate (5 mg or 10 mg) was not significantly different from placebo on any measures of efficacy. These findings indicate that the efficacy of fluticasone propionate nasal spray (200 micrograms once daily) in the treatment of allergic rhinitis results from direct topical effects rather than from indirect effects after systemic absorption.

Nonallergic rhinitis. Pathophysiology and models for study

Nonallergic rhinitis is a diagnosis of exclusion which is given to patients who suffer perennial nasal congestion, rhinorrhea, and/or sneezing with no identifiable allergic etiology. Because there is still no clear understanding of the pathophysiology, it is possible that a number of different disease processes may be included within this clinically defined entity. This report does not attempt to present an overall discussion of the clinical approaches to patients with nonallergic rhinitis. Instead, an outline is presented of various research approaches which may be used in its study. A number of nasal provocation models using nonallergic stimuli are available for application in the laboratory. These include intranasal methacholine challenges, intranasal histamine challenges, nasal inhalation of cold dry air, and intranasal capsaicin challenges. These models provide certain insights into mechanisms of nonallergic hyper-responsiveness. An additional approach to the study of nonallergic rhinitis is to examine available therapies, allowing the clinician to evaluate various pathways of importance in the disease process. These approaches provide a certain understanding of this common but perplexing entity, although further study is still required.

Reflex activation of nasal secretion by unilateral inhalation of cold dry air

Exposure to cold dry air induces rhinorrhea and other nasal symptoms in many persons. To evaluate whether this response involves a neurogenic component, we delivered a unilateral cold dry air (UniCDA) nasal challenge to volunteers with previously documented reactivity to cold dry air. We measured their nasal secretory responses bilaterally using small filter paper discs to absorb secretions from the nasal mucosa. UniCDA increased nasal secretion both ipsilateral (p < 0.001) and contralateral (p < 0.001) to the challenge when compared with control challenge. Topical atropine (0.225 mg), a muscarinic antagonist, inhibited ipsilateral secretion (p < 0.002) when given ipsilateral to UniCDA. When atropine was given contralateral to UniCDA, there was a trend toward reduction of contralateral secretion but no effect on ipsilateral secretion. Topical anesthesia with lidocaine given ipsilateral to UniCDA inhibited ipsilateral (p < 0.02) and contralateral (p < 0.05) secretion immediately after challenge. Topical anesthesia did not inhibit methacholine-induced nasal secretion. Thus, UniCDA stimulates reflex secretion both ipsilateral and contralateral to challenge which is inhibitable by interrupting either the efferent or the afferent arm of the reflex arc. This human in vivo model supports the importance of neural mechanisms in airway responsiveness to an environmental stimulus.

Local application of atropine attenuates the upper airway reaction to cold, dry air

In some individuals, inhalation of cold, dry air (CDA) provokes symptoms of rhinitis, accompanied by an increase in the levels of inflammatory mediators and markers of plasma leakage of recovered nasal lavages. Because rhinorrhea is a major component of this reaction and because nasal glands are heavily innervated by the parasympathetic system, we assessed the effect of atropine on the nasal reaction to CDA. Using a double-blind, randomized, crossover design, we administered a total dose of 0.5 mg of atropine or placebo intranasally to 18 volunteers before provocation with CDA. The reaction was monitored with symptom scores and by measuring the concentrations of histamine, N-alpha-p-tosyl-L-arginine methyl ester (TAME)-esterase activity and albumin, as well as the osmolality of lavage fluids before and after the provocation. Atropine significantly reduced rhinorrhea, the levels of histamine, and TAME-esterase activity as well as the osmolality of recovered lavage fluids, but had no effect on nasal congestion or albumin. Even with atropine, however, rhinorrhea and TAME-esterase activity were still significantly increased over the prechallenge baseline. Our results demonstrate that atropine-sensitive parasympathetic efferent pathways contribute to the CDA-induced rhinitis. We speculate that (1) the glandular and the vascular events of the upper airway reaction to dry air have different pathophysiologic mechanisms; (2) a significant component of TAME-esterase activity in lavage fluids may be of glandular origin; and (3) in addition to parasympathetic nerve activation, other mechanisms are involved in the upper airway reaction to dry air. The mechanism(s) leading to the reduction of histamine is unknown.

Tryptase and histamine as markers to evaluate mast cell activation during the responses to nasal challenge with allergen, cold, dry air, and hyperosmolar solutions

We have used assays for histamine and for the specific mast cell enzyme, tryptase, to examine the response of the nasal mucosa to provocation with several different stimuli and to evaluate the reliability of histamine as a marker of mast cell activation. High levels of histamine detected in baseline lavages of some subjects are not associated with any detectable tryptase, suggesting they are not mast cell derived. During pronounced immediate allergic responses, however, mast cell degranulation clearly occurs, and a striking correlation between histamine and tryptase is observed. This correlation is weaker when a more modest allergic response is induced, possibly reflecting differential diffusion of the two mediators across the epithelium. Provocation of susceptible individuals with cold, dry air leads to increased recoveries of both histamine and tryptase, confirming that mast cell degranulation occurs during this reaction. Although hyperosmolarity of the nasal mucosa may contribute to mast cell degranulation induced by cold, dry air, a brief exposure of the nasal cavity to hyperosmolar mannitol was not associated with measurable production of tryptase. The combined use of histamine and tryptase measurements can therefore provide useful evidence regarding the role of mast cell activation in the pathogenesis of inflammatory responses.