高反应性鼻炎ppt课件

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 Respiratorymucosainnose Thenasalmucosashowedbytransmi ssionalelectromi Croscope Thepictureofnormalmucosashowedbynasalendoscope Nasalhyper reactivity Nasalcavity FirstlineofairwaySensitivity richnervedistributionMucosalcompound respiratoryepithelialcellsGobletcellglands serousormucous richvessels Immunecompound Toll likereceptorslymphocytes T B serouscellsmastcellsepithelialcells Responseofnoseinducedbysomefactors Challengefactors enviromentalWeather temperature humidityinhalants Dust allergen chemicalspollutionmostofabove Intrinsic nervous stressordisappoint depressoranxious Nasalresponse Protective Congestion reducepatencyoftheairwayandamountofharmfulgasandparticlestoenterairwayRhinorrhea TodischargeforeignparticlesandinflammatorymediatorsSneeze rapidlyruleoutharmfulgasandparticles hyper reactivityofNasalmucosa Thedifferenceofnasalmucosalreactionbetweenphysiologicandpathologiccondition physiologicpathologicInducernervousstressimmunologic allergy temperaturechangesuddenlypsychologicodordustendocrineduration4days consecutively 1hpathologicnervereflexinflammationbase mainly mainly 高反应性鼻病 Definition HyperreactiveRhinopathyissymptomicdisorderandthereactionofnasalmucosainducedbystimuliexceednormallimit Mainincluding AllergicRhinitisNon allergicrhinitis coldairinducingrhinitisendocrinerhinitisdruginducingrhinitisnonallergicallergicrhinitiswitheosinophiliavasomotorrhinitis idiopathicrhinitis Allergicrhinitis AllergicrhinitisisasymptomaticdisorderofthenoseinducedafterallergenexposurebyanimmunoglobulinE IgE mediatedinflammationofthemembranesliningthenose DifinitionofAllergicrhinitis Keypointofthedifinition SusceptibleindividualInducedbyallergenexposureIgEmediatedmainlyNasalmucosainfalmmationMainsymptomsincludesneeze rhinorrheaandobstruction allergen Pollen tree grass cropplant fugi dustmite petdander Mechanismofallergicinflammation Th2response IL 4 变应原 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 EarlyPhaseReaction 迟发反应 LatePhaseReaction 抗原提呈细胞 Symptoms Nasalobstruction Symptoms 1hrdaylyLasting 4dsweekly sneeze Noserunning Pale edemamucosa Noseitch Howarethesymptomscaused Irritationoffreenerveendings ItchingandsneezingIncreasedmucusproduction RhinorrhoeaVasodilation MucosacongestionIncreasedvascularpermeability Mucosaoedema Relationshipbetweenupandlowairway MorbidityofasthmainPatientswithallergicrhinitisis3timesmorethanonewhonoallergicrhinitis20 ofchildrenwithallergicrhinitiswilloccurasthmainlifelate Relationshipbetweenupandlowairway Mucosalinflammationispresentintheentireairwayofpatientswithallergicrhinitisand orasthma UpperairwayinflammationisassociatedwithbronchialhyperresponsivenessLowerairwayremodelingispresentinasthmatic butalsoinallergicrhinitispatients Relationshipbetweenupandlowairway Allergicrhinitisandasthmaarecharacterizedbyaninflammatoryprocessthatismarkedhistologicallybytissueeosinophils mastcells Tlymphocytes macrophages andepithelialcells inflammation ImportantConcept Oneairway Onedisease Growsman 1997 Worldwideprevalence PrevalenceofAllergicrhinitisinCHINA 2007 IncreasingprevalenceofAR Thecausemaybeassociatedwithfactorsasfollows Airpollution exhaustparticle ozone NO2 nitrogendioxide SO2 sulfurdioxide Lifestyle unsaturatedacidHyper Hygiene TheimpactofARonqualityofLive Qualityoflive QOL Sleepingworkstudyentertainmentsocialcommunicationsystemicfelling AllergicrhinitisandItsimpactonasthma 2008 theWHOGuideline Allergicrhinitisisaglobalhealthproblemthatcausesmajorillnessanddisabilityworldwide Itaffectssociallife sleep schoolandwork Bothallergicrhinitisandasthmaaresystemicinflammatoryconditionsandareoftenco morbidities Theeconomicimpactofallergicrhinitisissubstantial Intermittent 4daysperweekor 4weeks ClassficationofAR Persistent 4daysperweekand 4weeks Mildnormalsleepnoimpairmentofdailyactivities sport leisurenormalworkandschoolnotroublesomesymptoms Moderate severeoneormoreitemsabnormalsleepimpairmentofdailyactivities sport leisureabnormalworkandschooltroublesomesymptoms ARIA2008 CHINAGuideofAR2009 DiagnosisofAR DiagnosisofAR HistorySpecificdiagnosis IgEinvitro specificIgEforaallergenTotalIgE withastnma invivo allergenskintest History cornerstoneofdiagnosis DuringandseverityInducer grasspollendampmatteroldclothingsandbeddingpadpet cat dog Nasalhyper reactivity sneezingrhinorrheaResponsetoH1antihistaminetherapy Allergyskinpricktesting SPT Skinpricktest positiveresult ImmediatehypersensitivityskintestsareusedtodemonstrateanIgEmediatedreaction Adropofallergensolutionisplacedontheskinandintroducedintotheepidermisbyasterileneedleorstylette byalightpunctureoftheskin Positiveandnegativecomparatortestsusinghistamineandsalinecanbeperformedtoprovethattheskiniscapableofdemonstratingapositivereaction andtopreventtheinterpretationoffalse positiveresultsoccurringasaresultofdermatographism Apositivewheal 3mmdiameterreactionindicatesthatthepatientisproducingIgEantibodiestoaspecificallergen andtakeninconjunctionwithapositivehistory isevidencethattheallergenisresponsibleforthepatient ssymptoms ExplanationofSPTresult PositiveNotable mayseenearly25 innormalEmphasizing correspondingwithhistoryinformation Yes makediagnosisNo maypredictive Negativeexcludedrugeffectunknowallergenmaypresentnonallergic SerumSpecificIgE sIgE SpecificIgEimmunoassaysmaybeused extensiveskindisease skintestsuppressivetherapy antihistamines thatcannotbediscontinued uncooperativepatients orwhenthehistorysuggestsanunusuallyhighriskofanaphylaxisfromskintesting PositiveresultsoftestingspecificIgEmustbecorrelatedwithhistoryandphysicalfindingstoassesstheirclinicalSignificanceGenerally sensitivetyandspecificityofSPTissuperiortotestingofserumspecificIgE Differentialdiagnosis Byexclusiveprocess SPT serumsIgE Non allergicnasalhyperreaciverhinitisVasomotorrhinitis idiopathic Non allergiceosinophiliarhinitis aspirinintolerance Hyper reflectiverhinitis Psubstance Endocrinerhinitis estrogn ManagementofAR AllergenAvoidancePharmacotherapyImmunotherapy Pharmacotherapy Medicationsusedtotreatallergicrhinits AntihistaminesDecongestantsCorticosteroidsMastCellstabilizersAnticholinergicsAntileukotrienes 抗白三烯药 Anti Histamines ActbypreventinghistaminefrombindingtotheH1 receptorsPrimarilyhelpfulincontrollingSneezing itchingineffectiveinreleivingnasalblockage 1stgenerationanti histamines chlorpheniramine diphenylhydramine2ndgenerationanti histamines cetrizine azelastine fexofenadine loratadine Anti Histamines Indications mildintermittentorpersistentrhinitismoderate severe combinedwithintranasalcorticosteroids Generally Secondgenerationantihistaminesisfirstchoiceadvantage longtermeffectnosedativeRoutesofadministrationoralorintranasal Intranasalcorticosteroidtherapy PotenttopicalactivityAdministrationoflowdosesdirectlyatsiteofactionConsiderableefficacyatlowdosesHightopical systemicactivityratios Rapidfirst passhepaticmetabolismofanysystemicallyabsorbeddrug tocompoundswithnegligibleactivity Intranasalcorticosteroids Indications Moderate severeintermittentorpersistentorcomplicatedwithasthmaAdvantage anti inflammationeffectissignificantlysuperiortoantihistainessafe nosystemicsideeffect Anti leukotriene Anti leukotrieneshouldbegivenforpatientswithbronchialsymptomsorseverenasalsymptoms ActionsofVariousNasalPreparationsintheTreatmentofRhinitis Antileukotrienes 0 SpecificImmunotherapy SIT SITisthepracticeofadministeringgraduallyincreasingquantitiesofanallergenextracttoanallergicsubject