14高反应性鼻炎医学课件

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——Protective

hyper-reactivityofNasalmucosaThedifferenceofnasalmucosalreactionbetweenphysiologicandpathologiccondition

高反应性鼻病Definition：

HyperreactiveRhinopathyissymptomicdisorderandthereactionofnasalmucosainducedbystimuliexceednormallimitMainincluding:AllergicRhinitisNon-allergicrhinitis——coldairinducingrhinitisendocrinerhinitisdruginducingrhinitisnonallergicallergicrhinitiswitheosinophiliavasomotorrhinitis(idiopathicrhinitis)

AllergicrhinitisAllergicrhinitisisasymptomaticdisorderofthenoseinducedafterallergenexposurebyanimmunoglobulinE(IgE)-mediatedinflammationofthemembranesliningthenoseDifinitionofAllergicrhinitisKeypointofthedifinitionSusceptibleindividualInducedbyallergenexposureIgEmediatedmainlyNasalmucosainfalmmationMainsymptomsincludesneeze,rhinorrheaandobstructionallergenPollen:tree,grass,cropplantfugidustmitepetdanderMechanismofallergicinflammation-Th2responseTh2BIL-4变应原NaiveThIgEIL-4IL-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,CHINAGuideofAR2009DiagnosisofARDiagnosisofARHistory—cornerstoneofdiagnosisDuringandseverityInducer:grasspollendampmatteroldclothingsandbeddingpadpet(cat,dog)Nasalhyper-reactivity：sneezingrhinorrheaResponsetoH1antihistaminetherapyApositivewheal>3mmdiameterreactionindicatesthatthepatientisproducingIgEantibodiestoaspecificallergen,andtakeninconjunctionwithapositivehistory,isevidencethattheallergenisresponsibleforthepatient’ssymptoms.ExplanationofSPTresultPositiveNotable:mayseenearly25%innormalEmphasizing:correspondingwithhistoryinformation:Yes——makediagnosisNo——maypredictive

Negativeexcludedrugeffectunknowallergenmaypresentnonallergic

SerumSpecificIgE(sIgE)DifferentialdiagnosisByexclusiveprocess(SPT;serumsIgE)Non-allergicnasalhyperreaciverhinitisVasomotorrhinitis(idiopathic)Non-allergiceosinophiliarhinitis(aspirinintolerance?)Hyper-reflectiverhinitis(Psubstance?)Endocrinerhinitis(estrogn)ManagementofARAllergenAvoidancePharmacotherapyImmunotherapyPharmacotherapyMedicationsusedtotreatallergicrhinits:AntihistaminesDecongestantsCorticosteroidsMastCellstabilizersAnticholinergicsAntileukotrienes（抗白三烯药）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-inflammationeffectissignificantlysuperiortoantihistainessafe,nosystemicsideeffectAnti-leukotrieneAnti-leukotrieneshouldbegivenforpatientswithbronchialsymptomsorseverenasalsymptomsActionsofVariousNasalPreparationsintheTreatmentofRhinitisNasalPreparationSneezingItchingRhinorrhoeaCongestionAntihistamines++++++++++++0Anticholinergics00+++++0Corticosteroids++++++++++++++++NasalPreparationSneezingItchingRhinorrhoeaCongestionDecongestants00++++++Mastcellstabiliser+++++++++0Antileukotrienes+++++0++++SpecificImmunotherapy(SIT)SITisthepracticeofadministeringgraduallyincreasingquantitiesofanallergenextracttoanallergicsubjecttoamelioratesymptomsassociatedwiththesubsequentexposuretothecausativeallergen.Specificimmunotherapyn