14高反应性鼻炎

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-reactivityNasalcavity:FirstlineofairwaySensitivity:richnervedistributionMucosalcompound:respiratoryepithelialcellsGobletcellglands(serousormucous)richvesselsImmunecompound:Toll-likereceptorslymphocytes(T,B)serouscellsmastcellsepithelialcellsResponseofnoseinducedbysomefactorsChallengefactors:•enviromentalWeather、temperature、humidityinhalants:Dust、allergen、chemicalspollutionmostofabove•Intrinsic:•nervous、stressordisappoint、depressoranxiousNasalresponse——Protective•Congestion—reducepatencyoftheairwayandamountofharmfulgasandparticlestoenterairway•Rhinorrhea—Todischargeforeignparticlesandinflammatorymediators•Sneeze—rapidlyruleoutharmfulgasandparticleshyper-reactivityofNasalmucosa•ThedifferenceofnasalmucosalreactionbetweenphysiologicandpathologicconditionphysiologicpathologicInducernervousstressimmunologic(allergy)temperaturechangesuddenlypsychologicodordustendocrineduration2days4days(consecutively)1h1hpathologicnervereflexinflammationbase（mainly)（mainly)高反应性鼻病•Definition：•HyperreactiveRhinopathyissymptomicdisorderandthereactionofnasalmucosainducedbystimuliexceednormallimit•Mainincluding:AllergicRhinitisNon-allergicrhinitis——coldairinducingrhinitisendocrinerhinitisdruginducingrhinitisnonallergicallergicrhinitiswitheosinophiliavasomotorrhinitis(idiopathicrhinitis)Allergicrhinitis•AllergicrhinitisisasymptomaticdisorderofthenoseinducedafterallergenexposurebyanimmunoglobulinE(IgE)-mediatedinflammationofthemembranesliningthenoseDifinitionofAllergicrhinitisKeypointofthedifinition•Susceptibleindividual•Inducedbyallergenexposure•IgEmediatedmainly•Nasalmucosainfalmmation•Mainsymptomsincludesneeze,rhinorrheaandobstructionallergen•Pollen:•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SymptomsNasalobstructionSymptoms1hrdaylyLasting4dsweeklysneezeNoserunningPale-edemamucosaNoseitchHowarethesymptomscaused?•Irritationoffreenerveendings----Itchingandsneezing•Increasedmucusproduction------Rhinorrhoea•Vasodilation--------Mucosacongestion•Increasedvascularpermeability----MucosaoedemaRelationshipbetweenupandlowairway•MorbidityofasthmainPatientswithallergicrhinitisis3timesmorethanonewhonoallergicrhinitis•20%ofchildrenwithallergicrhinitiswilloccurasthmainlifelateRelationshipbetweenupandlowairway•Mucosalinflammationispresentintheentireairwayofpatientswithallergicrhinitisand/orasthma.•Upperairwayinflammationisassociatedwithbronchialhyperresponsiveness•Lowerairwayremodelingispresentinasthmatic,butalsoinallergicrhinitispatients.Relationshipbetweenupandlowairway•Allergicrhinitisandasthmaarecharacterizedbyaninflammatoryprocessthatismarkedhistologicallybytissueeosinophils,mastcells,Tlymphocytes,macrophages,andepithelialcells.InflammationInflammationInflammationinflammationImportantConceptOneairway,OnediseaseGrowsman-1997WorldwideprevalencePrevalenceofAllergicrhinitisinCHINA（2007）IncreasingprevalenceofAR•Thecausemaybeassociatedwithfactorsasfollows:•Airpollution:exhaustparticle;•ozone,NO2(nitrogendioxide),SO2(sulfurdioxide)•Lifestyle:unsaturatedacid•Hyper-HygieneTheimpactofARonqualityofLive•Qualityoflive(QOL):SleepingworkstudyentertainmentsocialcommunicationsystemicfellingAllergicrhinitisandItsimpactonasthma（ＡＲＩＡ2008）—theWHOGuideline:•Allergicrhinitisisaglobalhealthproblemthatcausesmajorillnessanddisabilityworldwide.•Itaffectssociallife,sleep,schoolandwork.•Bothallergicrhinitisandasthmaaresystemicinflammatoryconditionsandareoftenco-morbidities.•Theeconomicimpactofallergicrhinitisissubstantial.Intermittent•4daysperweek•or4weeksClassficationofARPersistent•≥4daysperweek•and≥4weeksMild•normalsleep•noimpairmentofdailyactivities,sport,leisure•normalworkandschool•notroublesomesymptomsModerate-severe•oneormoreitems•abnormalsleep•impairmentofdailyactivities,sport,leisure•abnormalworkandschool•troublesomesymptomsARIA2008,CHINAGuideofAR2009DiagnosisofARDiagnosisofAR•History•Specificdiagnosis——IgEinvitro——specificIgEforaallergenTotalIgE(withastnma)invivo——allergenskintestHistory—cornerstoneofdiagnosis•Duringandseverity•Inducer:•grasspollendampmatter•oldclothingsandbeddingpad•pet(cat,dog)•Nasalhyper-reactivity：sneezingrhinorrhea•ResponsetoH1antihistaminetherapyAllergyskinpricktesting(SPT)•Skinpricktest/positiveresult•ImmediatehypersensitivityskintestsareusedtodemonstrateanIgEmediatedreaction.Adropofallergensolutionisplacedontheskinandintroducedintotheepidermisbyasterileneedleorstylette,byalightpunctureoftheskin.•Positiveandnegativecomparatortestsusinghistamineandsalinecanbeperformedtoprovethattheskiniscapableofdemonstratingapositivereaction,andtopreventtheinterpretationoffalse-positiveresultsoccurringasaresultofdermatographism.•Apositivewhe