鼻窦炎-过敏性鼻炎-鼻息肉.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Sinusitis,Rhinosinusitis,鼻窦炎的重要影响,严重的社会经济问题,每年16%的成年人患鼻窦炎,1,是花费最大的前,10,位健康问题之一,2,1996,年:,2700,万次门诊和急诊,3,每年直接花费为,$35,亿,4,，总损失超过,65,亿美元,占抗生素应用第5位,5,占儿童应用抗生素处方量的9%,占成年人抗生素处方量的21%,1.Brook I.,Ann Otol Rhinol Larynogl.,2000;182(suppl):2-20.,2.Goetzel RZ et al.,J Occup Environ Med.,2003;45:5-14.,3.Kaliner MA et al.,Otolaryngol Head Neck Surg.,1997;116:S1S20.,4.Ray NF et al.,J Allergy Clin Immunol.,1999;103:408-414.,5.Sinus and Allergy Health Partnership.Otolaryngol Head Neck Surg.2004;130:144,在美国每年,1,1200,万天误工,5900,万天活动受限,2000,万天卧床,是初级医疗保健咨询的最常见原因之一,1,2,可以导致严重的并发症，降低病人的生活质量,，,降低工作效率,1-4,1.Brooks I et al.,Ann Otol Rhinol Laryngol.,2000;182(suppl):220.,2.Laurier C et al.,Pharmacoeconomics,.1999;15:97113.,3.Dykewicz MS.,J Allergy Clin Immunol,.2003;111:S520S529.,4.Mucha SM,Baroody FM.,Curr Opin Allergy Clin Immunol,.2003;3:33-38.,鼻窦炎的重要影响,儿童和成人每年分别约有38次和23次病毒性上呼吸道感染,约0.5%2%形成继发性急性细菌性鼻窦炎,美国每年有2000万个急性细菌性鼻窦炎病例,按此估计，中国每年至少有1亿个急性细菌性鼻窦炎病例,Ahn J et al.International Society of Pharmacoeconomic Outcomes Research 2002.Poster PIN 14(PROMPT study).,急性细菌性鼻窦炎的重要影响,In fact,on clinical ground,CRS appears to be a,continuous spectrum,of illness ranging from chronic,infectious rhinosinusitis,to relatively,pure noninfectious inflammation,(J Allergy Immunol 2000;106;213-7),“Rhinosinusitis is,a group of disorders,characterized by inflammation of the mucosa of the nose and the paranasal sinuses.”,(OtOHead and Neck Surgery,2004,131,s1-s62),CRS,一个复杂的疾病,个学术组织,The American Academy Asthma and Immunology,The American Academy of Otolaryngology,The American Academy of OtolaryngologyHead and Neck Surgery,The American College of Allergy,Asthma and Immunology,The American Rhinologic Society,30,位学者中,80%,学者认同的观点,Rhinosinusitis:Establishing definitions for,clinical research,and patient care,(OTOHNS,2004,，,131,s1-s62),CRS,权威的综述,(2004),欧洲过敏和临床免疫学会（,EAACI,）组织专家小组发表,“European Position Paper on Rhinosinusitis,and Nasal Polyps(EP,3,OS)”,2005,15,位专家参与编写,全书,88,页,652,篇参考文献,受到耳鼻咽喉科及其它有关学科专家和临床医生的认可,(Rhinology,2005,Supplement 18:1-88),European Position Paper on,Rhinosinusitis and Nasal Polyps,-EP,3,OS,2005,版,编辑小组在,2006,年对该文献进行了补充和修改,25,位来自世界各地的鼻和变态反应专家参与编写,综述了,1112,篇文献,全书,139,页,W.Fokkens(Chair),V.Lund(Co-Chair),J.Mullol,C.Bachert,P.Helllings,M.Holmstrom,N.Jones,Noam Cohen,L.Kalogjera,D.Kennedy,M.Kowalski,D.Passali,H.Stammberger,P.Stierna,M.Hytnen,L-M.Klossek,G.Scadding,B.Naclerio,E.Meltzer,M.Desrosiers,H.Riechelmann,D-Y.Wang,European Position Paper on,Rhinosinusitis and Nasal Polyps,，,EP,3,OS,，,2007,版,编辑小组在,2012,年对该文献进行了补充和修改,57,位来自世界各地的鼻和变态反应专家参与编写,综述了,2000,多篇文献,全书,200,多页,W.Fokkens(Chair),V.Lund(Co-Chair),J.Mullol,C.Bachert,P.Helllings,M.Holmstrom,N.Jones,Noam Cohen,L.Kalogjera,D.Kennedy,M.Kowalski,D.Passali,H.Stammberger,P.Stierna,M.Hytnen,L-M.Klossek,G.Scadding,B.Naclerio,E.Meltzer,M.Desrosiers,H.Riechelmann,D-Y.Wang,European Position Paper on,Rhinosinusitis and Nasal Polyps,，,EP,3,OS,，,2012,版,Acute Rhinosinusitis,Features of sinus anatomy：,1、small ostia of the sinuses；2、continuative mucosa between nasal cavity and sinuses；3、contiguous of the ostia；4、location of the ostia and features of the sinuses.,Acute sinusitis,Etiology：,1、viral infection,2、Bacteria infection3、Local anatomic factor,4,、,allergy,5,、,other diseases；Infection of peripheral organs，Direct infection；nasal tampon(packing)；rapid change of atmospheric pressure,Acute sinusitis,Symptoms&Sign：,General：,fever，discomfort.,Local:,1）Nasal obstruction,2）Suppurative rhinorrhea,streaky with blood,foul smell(odontogentic),3）hyposmia,4）headach or local ache,Maxillary sinusitis,Ethmoidal sinusitis,Frontal sinusitis,Sphenoidal sinusitis,5,）,nasal examination,Acute sinusitis,Diagnosis：,-History，,-Anterior rhinoscopy,-Nasal endoscopy,-Radiological examination,-Puncture and irrigation of maxillary sinus,Acute sinusitis,Treatment：,1、,Medical treatment,：,-antibiotics，-local corticosteroid,-m,ucolytics,-anti-allergy (if necessary),2、,other treatment -drainage -antral irrigation -physical therapy3,、,surgery,，,for severe complication,Acute sinusitis,Acute sinusitis,Chronic Rhinosinusitis,（,CRS,）,鼻粘膜粘液纤毛系统被重视,病因问题,CRS,炎症并非总与窦口阻塞有关,急性鼻窦炎的反复发作,窦口阻塞,炎症反应,CRS,病理生理认识的进步,CRS,的可能病因,Etiology of CRS,Bacterial infection,Inflammation by multiple factors,fungi,Bacterial superantigen,biofilm,Anatomical abformity,others,Symptoms&Sign：,General；,Local：,nasal obstruction,rhinorrhea,hyposmia,headache,others,Chronic sinusitis,Diagnosis：,1、History；,2、Examination：anterior rhinoscopy,nasal endoscopy,3、Radiological examination：CT or MRI,4、Puncture and irrigation of sinus,Chronic sinusitis,Chronic sinusitis:Diagnosis,Normal image of nasal endoscopy,Maxillary sinusitispus in the middle meatus,Sphenoid sinusitis,pus in the sphenoethmoidal recess,Allergic Fungal Sinusitis,Fungal ball,Treatment：,1、Intranasal medications：Corticosteroid,2、long-term macrolide,3、mucolytics,4、Vasoconstrictor sympsthomimetics,5 、Puncture and irrigation of maxillary sinus、Displacement methodfrontal sinusitis,ethmoidal sinusitis,sphenoidal sinusitis,pansinusitis,6、Surgerytraditional sinus surgery Functional Endoscopic Sinus Surgery(FESS),Chronic sinusitis,Functional Endoscopic Sinus Surgery (FESS),Allergic rhinitis,Is chronic nasal mucosa inflammation,mediated by IgE,induced by inflammatory mediator derived from kinds of immunologic-active,pro-inflammatory,and cytokines,Allergic rhinitis,Epideminology of allergic rhinitis,Prevalence:10-25%,Increase rapidly in the past decades,（,ARIA report,）,ARIA 2001,ARIA 2008,ARIA (Allergic Rhinitis and its Impact on Asthma),2001,年与,WHO,合作,37,位作者,55,个组织,其中亚洲有,:,Hongkong college of ENT.,Japan Rhinology Society,Korean Rhinology Society,Malaysion socity of oto-Has,Philippine ENT Society,Singapore ENT Society,Thai Rhinology Society,2776,篇参考文献,187,页,J allergy and Clinical Immunology 2001,108,s147-s334,43,ARIA Pocket Guide:,52 Translations 52,种文字,Morbidity:,10%,Inhalant allergens,dust mite,house dust,pollen,fungi,animal danders,cockroach,；,Food allergens,milk,eggs,fish and shrimp,meat,vegetables,fruits.,Pathology：,Type,allergy,Allergic inflammation:Predominant T cells&eosinophilic cells infiltrate.,Allergic Rhinitis(AR),Allergen,mite,dander,pollen,Leather,Classification of AR,Old Classification:,Perennial(PAR),Seasonal(SAR)（Pollinosis）,New WHO-ARIA,间歇性,症状发生的天数,4,天,/,周,或病程,4,天,/,周,和病程,4,周,轻度,睡眠正常,日常活动、体育和娱乐正常,工作、学习正常,无令人烦恼的症状,中,-,重度,下列一项或多项,不能正常睡眠,日常活动、体育锻炼、娱乐等受影响,不能正常工作或学习,有令人烦恼的症状,Symptoms&Signs：,1,nasal irritation and iching,2,recurrent attacks of paroxysmal sneezing,3,nasal obstruction 4,watery rhinorrhea.,Allergic Rhinitis(AR),Diagnosis：,1、history,（at least 2 of,4 main symptoms,，,more than half day,，,at least 4 of 7 days,）,2、,examination,3、,skin test:skin prick test,4、,IgE antibody,：,Serum total IgE、special IgE,5、nasal provocation or nasal challenge tests,Allergic Rhinitis(AR),Differential Diagnosis：,1、vastomotor rhinitis,2、nonallergic rhinitis with eosinophilia syndrome,3、cold air-inducing rhinitis,4、hyperreflectory rhinitis,5、endocrine rhinitis,6、acute rhinosinusitis,Allergic Rhinitis(AR),Complications：,1、asthma,2、allergic sinusitis,pharyngitis,laryngitis,3、secretory otitis media,4、sleeping disorders,Allergic Rhinitis(AR),Treatment：,1、Allergen avoidance,2、Drugs,1）Antihistamines,2）Corticosteroids,3）Vasoconstrictor sympsthomimetics,4）Anticholinergic agents,5）Sodium cromoglycate(SCG)Cromolyn sodium,3、Hyposensitization,4、Others：Traditional Chinese medicine,laser,operation education,Allergic Rhinitis(AR),轻度,间歇性,轻度,持续性,中,/,重度,间歇性,中,/,重度,持续性,避免接触变应原,免疫治疗,鼻用,(10 days),或口服减冲剂,色甘酸钠,口服或鼻用无嗜睡作用抗组胺,过敏性鼻炎的治疗,(ARIA),鼻用激素,Nasal Polyp&Nasal Polyposis,慢性鼻,-,鼻窦炎的分型,CRS,分成伴有鼻息肉的,CRS,和不伴鼻息肉,伴有鼻息肉的,CRS(CRSwNP)20,不伴鼻息肉的,CRS(CRSsNP)80%,Etiology：,multi-factors:,-micro-environmental theory of middle meatus,-allergic,-aspirin sensitive,-chronic inflammation,Nasal Polyp&Nasal Polyposis,Pathology：,-highly swelled connective tissue.,-Predominant eosinophilic cells infiltrate.,-Lymphatic cells,-neutrophils,-basophils,-mast cells.,Nasal Polyp&Nasal Polyposis,Symptoms&,Sign：,-persistent nasal obstruction，,-close nasal sound，,-hyposmia,-rhinorrhea,-snore,-“frog nose”,Nasal Polyp&Nasal Polyposis,Polyp in olfactory cleft and middle meatus,Antrochoanal polyp,Polyps（above,），,papilloma（below）,papilloma（L），MT of nasal cavity（R）,Diagnosis：,Anterior rhinoscopy：translucent,soft,smooth,masses.Endoscopy,X-ray and CT scanner.,Differential Diagnosis：,Papilloma inverted，,angiofibroma of nasopharynx，,malignant tumor of nasal cavity，,meningoencephalocele,Nasal Polyp&Nasal Polyposis,Treatment：,1、conservative treatment -corticosteroids -macrolides -anti-Leukotrience,D:/%E6%9C%80%E4%BD%B3FESS/%E9%BC%BB%E7%AA%A6%E7%82%8E%E7%97%87/%E6%9C%80%E6%B8%85%E6%99%B0%E5%85%A8%E7%BB%84%E9%BC%BB%E7%AA%A6%E5%BC%80%E6%94%BE%E6%9C%AF/%E6%9C%80%E4%BD%B3%E5%85%A8%E7%BB%84%E9%BC%BB%E7%AA%A6%E6%89%8B%E6%9C%AF%EF%BC%8C%E5%B7%A6%E4%BE%A7.mpg,3,、,combined treatment,Nasal Polyp&Nasal Polyposis,