高反應性鼻炎診斷與治療

耳鼻咽喉頭頸外科學第二篇鼻科學及顱面疾?。?）第十一章

鼻黏膜高反應性鼻病第一節(jié)

變態(tài)反應性鼻炎RespiratorymucosainnoseThenasalmucosashowedbytransmi-ssionalelectromi-Croscope.ThepictureofnormalmucosashowedbynasalendoscopeNasalhyper-reactivityNasalcavity:FirstlineofairwaySensitivity:richnervedistributionMucosalcompound:respiratoryepithelialcellsGobletcellglands(serousormucous)richvesselsImmunecompound:Toll-likereceptorslymphocytes(T,B)serouscellsmastcellsepithelialcells

ResponseofnoseinducedbysomefactorsChallengefactors:enviromentalWeather、temperature、humidityinhalants:Dust、allergen、chemicalspollutionmostofaboveIntrinsic:nervous、stressordisappoint、depressoranxious

Nasalresponse——ProtectiveCongestion—

reducepatencyoftheairwayandamountofharmfulgasandparticlestoenterairwayRhinorrhea—TodischargeforeignparticlesandinflammatorymediatorsSneeze—rapidlyruleoutharmfulgasandparticles

hyper-reactivityofNasalmucosaThedifferenceofnasalmucosalreactionbetweenphysiologicandpathologiccondition

physiologicpathologic

Inducernervousstressimmunologic(allergy)temperaturechangesuddenlypsychologic

odordustendocrineduration<2days>4days(consecutively)<1h>1hpathologicnervereflexinflammationbase（mainly)（mainly)高反應性鼻病Definition：

HyperreactiveRhinopathyissymptomicdisorderandthereactionofnasalmucosainducedbystimuliexceednormallimitMainincluding:AllergicRhinitisNon-allergicrhinitis——coldairinducingrhinitisendocrinerhinitisdruginducingrhinitisnonallergicallergicrhinitiswitheosinophiliavasomotorrhinitis(idiopathicrhinitis)

AllergicrhinitisAllergicrhinitisisasymptomaticdisorderofthenoseinducedafterallergenexposurebyanimmunoglobulinE(IgE)-mediatedinflammationofthemembranesliningthenoseDifinitionofAllergicrhinitisKeypointofthedifinitionSusceptibleindividualInducedbyallergenexposureIgEmediatedmainlyNasalmucosainfalmmationMainsymptomsincludesneeze,rhinorrheaandobstructionallergenPollen:tree,grass,cropplantfugidustmitepetdanderMechanismofallergicinflammation-Th2responseTh2BIL-4變應原NaiveThIgEIL-4IL-5釋放炎癥介質毒性蛋白細胞因子釋放炎癥介質和細胞因子Eo變應性鼻炎免疫學機制－以Th2反應為主的免疫性疾病嗜酸性粒細胞肥大細胞和嗜堿性粒細胞速發(fā)反應（EarlyPhaseReaction）遲發(fā)反應（LatePhaseReaction）抗原提呈細胞SymptomsNasalobstructionSymptoms>1hrdaylyLasting>4dsweeklysneezeNoserunningPale-edemamucosaNoseitchHowarethesymptomscaused?Irritationoffreenerveendings---- ItchingandsneezingIncreasedmucusproduction------ RhinorrhoeaVasodilation--------MucosacongestionIncreasedvascularpermeability----MucosaoedemaRelationshipbetweenupandlowairwayMorbidityofasthmainPatientswithallergicrhinitisis3timesmorethanonewhonoallergicrhinitis20%ofchildrenwithallergicrhinitiswilloccurasthmainlifelateRelationshipbetweenupandlowairwayMucosalinflammationispresentintheentireairwayofpatientswithallergicrhinitisand/orasthma.UpperairwayinflammationisassociatedwithbronchialhyperresponsivenessLowerairwayremodelingispresentinasthmatic,butalsoinallergicrhinitispatients.RelationshipbetweenupandlowairwayAllergicrhinitisandasthmaarecharacterizedbyaninflammatoryprocessthatismarkedhistologicallybytissueeosinophils,mastcells,Tlymphocytes,macrophages,andepithelialcells.inflammationImportantConceptOneairway,OnediseaseGrowsman-1997Worldwideprevalence

PrevalenceofAllergicrhinitisinCHINA（2007）IncreasingprevalenceofARThecausemaybeassociatedwithfactorsasfollows:Airpollution:exhaustparticle;ozone,NO2(nitrogendioxide),SO2(sulfurdioxide)Lifestyle:unsaturatedacidHyper-HygieneTheimpactofARonqualityofLiveQualityoflive(QOL):Sleepingworkstudyentertainmentsocialcommunicationsystemicfelling

AllergicrhinitisandItsimpactonasthma（ＡＲＩＡ2008）—theWHOGuideline:Allergicrhinitisisaglobalhealthproblemthatcausesmajorillnessanddisabilityworldwide.Itaffectssociallife,sleep,schoolandwork.

Bothallergicrhinitisandasthmaaresystemicinflammatoryconditionsandareoftenco-morbidities.Theeconomicimpactofallergicrhinitisissubstantial.

Intermittent

<4daysperweekor<4weeksClassficationofARPersistent≥4daysperweekand≥4weeksMildnormalsleepnoimpairmentofdailyactivities,sport,leisurenormalworkandschoolnotroublesomesymptomsModerate-severeoneormoreitemsabnormalsleepimpairmentofdailyactivities,sport,leisureabnormalworkandschooltroublesomesymptomsARIA2008,CHINAGuideofAR2009DiagnosisofARDiagnosisofARHistorySpecificdiagnosis——IgEinvitro——specificIgEforaallergenTotalIgE(withastnma)invivo——allergenskintestHistory—cornerstoneofdiagnosisDuringandseverityInducer:grasspollendampmatteroldclothingsandbeddingpadpet(cat,dog)Nasalhyper-reactivity：sneezingrhinorrheaResponsetoH1antihistaminetherapyAllergyskinpricktesting(SPT)Skinpricktest/positiveresultImmediatehypersensitivityskintestsareusedtodemonstrateanIgEmediatedreaction.Adropofallergensolutionisplacedontheskinandintroducedintotheepidermisbyasterileneedleorstylette,byalightpunctureoftheskin.Positiveandnegativecomparatortestsusinghistamineandsalinecanbeperformedtoprovethattheskiniscapableofdemonstratingapositivereaction,andtopreventtheinterpretationoffalse-positiveresultsoccurringasaresultofdermatographism.Apositivewheal>3mmdiameterreactionindicatesthatthepatientisproducingIgEantibodiestoaspecificallergen,andtakeninconjunctionwithapositivehistory,isevidencethattheallergenisresponsibleforthepatient’ssymptoms.ExplanationofSPTresultPositiveNotable:mayseenearly25%innormalEmphasizing:correspondingwithhistoryinformation:Yes——makediagnosisNo——maypredictive

Negativeexcludedrugeffectunknowallergenmaypresentnonallergic

SerumSpecificIgE(sIgE)SpecificIgEimmunoassaysmaybeused:extensiveskindisease,skintestsuppressivetherapy(antihistamines)thatcannotbediscontinued,uncooperativepatients,orwhenthehistorysuggestsanunusuallyhighriskofanaphylaxisfromskintesting.PositiveresultsoftestingspecificIgEmustbecorrelatedwithhistoryandphysicalfindingstoassesstheirclinicalSignificanceGenerally,sensitivetyandspecificityofSPTissuperiortotestingofserumspecificIgEDifferentialdiagnosisByexclusiveprocess(SPT;serumsIgE)Non-allergicnasalhyperreaciverhinitisVasomotorrhinitis(idiopathic)Non-allergiceosinophiliarhinitis(aspirinintolerance?)Hyper-reflectiverhinitis(Psubstance?)Endocrinerhinitis(estrogn)ManagementofARAllergenAvoidancePharmacotherapyImmunotherapyPharmacotherapyMedicationsusedtotreatallergicrhinits:AntihistaminesDecongestantsCorticosteroidsMastCellstabilizersAnticholinergicsAntileukotrienes（抗白三烯藥）Anti-HistaminesActbypreventinghistaminefrombindingtotheH1-receptorsPrimarilyhelpfulincontrollingSneezing,itching&rhinorrhoea;ineffectiveinreleivingnasalblockage1stgenerationanti-histamines -chlorpheniramine -diphenylhydramine2ndgenerationanti-histamines -cetrizine -azelastine -fexofenadine -loratadineAnti-HistaminesIndications:mildintermittentorpersistentrhinitismoderate-severe——combinedwithintranasalcorticosteroidsGenerally,Secondgenerationantihistaminesisfirstchoiceadvantage:longtermeffectnosedativeRoutesofadministrationoralorintranasalIntranasalcorticosteroidtherapyPotenttopicalactivityAdministrationoflowdosesdirectlyatsiteofactionConsiderableefficacyatlowdosesHightopical:systemicactivityratiosRapidfirst-passhepaticmetabolismofanysystemicallyabsorbeddrug,tocompoundswithnegligibleactivityIntranasalcorticosteroidsIndications:Moderate-severeintermittentorpersistentorcomplicatedwithasthmaAdvantage:anti-inflammationeffectissignificantlysuperiortoantihistaines

safe,nosystemicsideeffectAnti-leukotrieneAnti-leukotrieneshouldbegivenforpatientswithbronchialsymptomsorseverenasalsymptomsActionsofVariousNasalPreparationsintheTreatmentofRhinitisNasalPreparationSneezingItchingRhinorrhoeaCongestionAntihistamines++++++++++++0Anticholinergics00+++++0Corticosteroids++++++++++++++++NasalPreparationSneezingItchingRhinorrhoeaCongestionDecongestants00++++++Mastcellstabiliser+++++++++0Antileukotrienes+++++0++++SpecificImmunotherapy(SIT)SITisthepracticeofadministering