高反应性鼻炎课件

耳鼻咽喉头颈外科学 耳鼻咽喉头颈外科学 第二篇 鼻科学及颅面疾病（3 ） 第十一章 鼻黏膜高反应性鼻病 第一节 变态反应性鼻炎 Respiratory mucosa in nose The nasal mucosa showed by transmi- ssional electromi-Croscope. The picture of normal mucosa showed by nasal endoscope Nasal hyper-reactivity n Nasal cavity : n First line of airway n Sensitivity: n rich nerve distribution n Mucosal compound: n respiratory epithelial cells Goblet cell glands (serous or mucous) rich vessels n Immune compound: n Toll-like receptors lymphocytes (T, B) serous cells mast cells epithelial cells Response of nose induced by some factors Challenge factors: enviromental Weather、temperature、humidity inhalants: Dust、allergen、chemicals pollution most of above Intrinsic: nervous、stress or disappoint、depress or anxious Nasal responseProtective Congestion reduce patency of the airway and amount of harmful gas and particles to enter airway Rhinorrhea To discharge foreign particles and inflammatory mediators Sneeze rapidly rule out harmful gas and particles hyper-reactivity of Nasal mucosa The difference of nasal mucosal reaction between physiologic and pathologic condition physiologic pathologic Inducer nervous stress immunologic (allergy) temperature change suddenly psychologic odor dust endocrine duration 4 days (consecutively) 1h pathologic nerve reflex inflammation base （mainly) （mainly) 高反应性鼻病 Definition ： Hyperreactive Rhinopathy is symptomic disorder and the reaction of nasal mucosa induced by stimuli exceed normal limit Main including: Allergic Rhinitis Non-allergic rhinitis cold air inducing rhinitis endocrine rhinitis drug inducing rhinitis nonallergic allergic rhinitis with eosinophilia vasomotor rhinitis(idiopathic rhinitis) Allergic rhinitis Allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an immunoglobulin E(IgE)-mediated inflammation of the membranes lining the nose Difinition of Allergic rhinitis Key point of the difinition Susceptible individual Induced by allergen exposure IgE mediated mainly Nasal mucosa infalmmation Main symptoms include sneeze,rhinorrhea and obstruction allergen Pollen: tree,grass, crop plant fugi dust mite pet dander Mechanism of allergic inflammation-Th2 response Th2 B IL-4 变应原 Naive Th IgE IL-4 IL-5 释放 炎症介质 毒性蛋白 细胞因子 释放炎症介质 和细胞因子 Eo 变应性鼻炎免疫学机制 以Th2反应为主的免疫性疾病 嗜酸性粒细胞 肥大细胞和 嗜碱性粒细胞 速发反应 （Early Phase Reaction） 迟发反应 （Late Phase Reaction） 抗原提呈细胞 Symptoms Nasal obstruction Symptoms1hr dayly Lasting4ds weekly sneeze Nose running Pale-edema mucosa Nose itch How are the symptoms caused? Irritation of free nerve endings- Itching and sneezing Increased mucus production - Rhinorrhoea Vasodilation - Mucosa congestion Increased vascular permeability-Mucosa oedema Relationship between up and low airway Morbidity of asthma in Patients with allergic rhinitis is 3 times more than one who no allergic rhinitis 20% of children with allergic rhinitis will occur asthma in life late Relationship between up and low airway Mucosal inflammation is present in the entire airway of patients with allergic rhinitis and/or asthma. Upper airway inflammation is associated with bronchial hyperresponsiveness Lower airway remodeling is present in asthmatic, but also in allergic rhinitis patients. Relationship between up and low airway Allergic rhinitis and asthma are characterized by an inflammatory process that is marked histologically by tissue eosinophils, mast cells, T lymphocytes , macrophages, and epithelial cells . inflammation Important Concept One airway, One disease Growsman-1997 Worldwide prevalence Prevalence of Allergic rhinitis in CHINA（2007） Increasing prevalence of AR The cause may be associated with factors as follows: Air pollution : exhaust particle; ozone, NO2(nitrogen dioxide), SO2(sulfur dioxide) Life style: unsaturated acid Hyper-Hygiene The impact of AR on quality of Live Quality of live (QOL) : Sleeping work study entertainment social communication systemic felling Allergic rhinitis and Its impact on asthma（ 2008）the WHO Guideline: Allergic rhinitis is a global health problem that causes major illness and disability worldwide. It affects social life, sleep, school and work. Both allergic rhinitis and asthma are systemic inflammatory conditions and are often co- morbidities. The economic impact of allergic rhinitis is substantial. Intermittent 3mm diameter reaction indicates that the patient is producing IgE antibodies to a specific allergen, and taken in conjunction with a positive history, is evidence that the allergen is responsible for the patients symptoms. Explanation of SPT result Positive Notable :may see nearly 25% in normal Emphasizing: corresponding with history information: Yes make diagnosis No may predictive Negative exclude drug effect unknow allergen may present non allergic Serum Specific IgE (sIgE) Specific IgE immunoassays may be used : extensive skin disease, skin test suppressive therapy (antihistamines) that cannot be discontinued, uncooperative patients, or when the history suggests an unusually high risk of anaphylaxis from skin testing. Positive results of testing specific IgE must be correlated with history and physical findings to assess their clinical Significance Generally, sensitivety and specificity of SPT is superior to testing of serum specific IgE Differential diagnosis By exclusive process(SPT ;serum sIgE) Non-allergic nasal hyperreacive rhinitis Vasomotor rhinitis(idiopathic) Non-allergic eosinophilia rhinitis(aspirin intolerance?) Hyper-reflective rhinitis(P substance?) Endocrine rhinitis(estrogn) Management of AR Allergen Avoidance Pharmacotherapy Immunotherapy Pharmacotherapy Medications used to treat allergic rhinits: nAntihistamines nDecongestants nCorticosteroids nMast Cell stabilizers nAnticholinergics nAntileukotrienes（抗白三烯药烯药 ） Anti-Histamines Act by preventing histamine from binding to the H1-receptors Primarily helpful in controlling Sneezing, itching ineffective in releiving nasal blockage 1st generation anti-histamines - chlorpheniramine - diphenylhydramine 2nd generation anti-histamines - cetrizine - azelastine - fexofenadine - loratadine Anti-Histamines Indications: mild intermittent or persistent rhinitis moderate-severecombined with intranasal corticosteroids Generally, Second generation antihistamines is first choice advantage: long term effect no sedative Routes of administration oral or intranasal Intranasal corticosteroid therapy Potent topical activity Administration of low doses directly at site of action Considerable efficacy at low doses High topical: systemic activity ratios Rapid first-pass hepatic metabolism of any systemically absorbed drug, to compounds with negligible activity Intranasal corticosteroids Indications: Moderate-severe intermittent or persistent or complicated with asthma Advantage: anti-inflammation effect is significantly superior to antihistaines safe, no systemic side effect Anti-leukotriene Anti-leukotriene should be given for patients with bronchial symptoms or severe nasal symptoms Actions of Various Nasal Preparations in the Treatment of Rhinitis Nasal Preparation SneezingItchingRhinorrhoeaCongestion Antihistamines+0 Anticholinergics00+0 Corticosteroids+ Nasal Preparation SneezingItchingRhinorrhoeaCongestion Decongestants00+ Mast cell stabiliser +0 Antileukotrienes + + 0+ Specific Immunotherapy(SIT) SIT is the practice of administering gradually increasing quantities of an allergen extract to an allergic subject to ameliorate symptoms associated with the subsequent exposure to the causative allergen. Specific immunoth