14高反应性鼻炎医学PPT课件.ppt

耳鼻咽喉头颈外科学耳鼻咽喉头颈外科学 耳鼻咽耳鼻咽喉头颈外科学喉头颈外科学第二篇第二篇 鼻科学及颅面疾病鼻科学及颅面疾病（3）第十一章第十一章鼻黏膜高反应性鼻病鼻黏膜高反应性鼻病第一节第一节变态反应变态反应性鼻炎性鼻炎Respiratory mucosa in noseThe nasal mucosa showed by transmi-ssional electromi-Croscope.The picture of normal mucosa showed by nasal endoscope Nasal hyper-reactivitynNasal cavity:nFirst line of airwaynSensitivity:nrich nerve distributionnMucosal compound:nrespiratory epithelial cells Goblet cell glands(serous or mucous)rich vessels nImmune compound:nToll-like receptors lymphocytes(T,B)serous cells mast cells epithelial cells Response of nose induced by some factorsChallenge factors:enviromentalWeather、temperature、humidityinhalants:Dust、allergen、chemicals pollution most of aboveIntrinsic:nervous、stress or disappoint、depress or anxious Nasal responseProtective Congestion reduce patency of the airway and amount of harmful gas and particles to enter airwayRhinorrheaTo discharge foreign particles and inflammatory mediators Sneeze rapidly rule out harmful gas and particles hyper-reactivity of Nasal mucosaThe 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)1hpathologic nerve reflex inflammation base （mainly)（mainly)高反应性鼻病高反应性鼻病Definition：Hyperreactive Rhinopathy is symptomic disorder and the reaction of nasal mucosa induced by stimuli exceed normal limitMain including:Allergic RhinitisNon-allergic rhinitiscold air inducing rhinitisendocrine rhinitisdrug inducing rhinitisnonallergic allergic rhinitis with eosinophiliavasomotor rhinitis(idiopathic rhinitis)Allergic rhinitisAllergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an immunoglobulin E(IgE)-mediated inflammation of the membranes lining the noseDifinition of Allergic rhinitisKey point of the difinitionSusceptible individualInduced by allergen exposureIgE mediated mainlyNasal mucosa infalmmationMain symptoms include sneeze,rhinorrhea and obstruction allergenPollen:tree,grass,crop plant fugidust mitepet danderMechanism of allergic inflammation-Th2 responseTh2BIL-4变应原变应原Naive ThIgEIL-4IL-5释放释放 炎症介质炎症介质 毒性蛋白毒性蛋白 细胞因子细胞因子释放炎症介质释放炎症介质和细胞因子和细胞因子Eo变应性鼻炎免疫学机制变应性鼻炎免疫学机制以以Th2反应为主的免疫性疾病反应为主的免疫性疾病嗜酸性粒细胞嗜酸性粒细胞肥大细胞和肥大细胞和嗜碱性粒细胞嗜碱性粒细胞速发反应速发反应（Early PhaseReaction）迟发反应迟发反应（Late PhaseReaction）抗原提呈细胞抗原提呈细胞SymptomsNasal obstructionSymptoms1hr daylyLasting4ds weeklysneezeNose runningPale-edema mucosaNose itchHow are the symptoms caused?Irritation of freenerve endings-Itching and sneezingIncreasedmucus production -RhinorrhoeaVasodilation-Mucosa congestionIncreasedvascular permeability-Mucosa oedemaRelationship between up and low airwayMorbidity of asthma in Patients with allergic rhinitis is 3 times more than one who no allergic rhinitis20%of children with allergic rhinitis will occur asthma in life lateRelationship between up and low airwayMucosal inflammation is present in the entire airway of patients with allergic rhinitis and/or asthma.Upper airway inflammation is associated with bronchial hyperresponsivenessLower airway remodeling is present in asthmatic,but also in allergic rhinitis patients.Relationship between up and low airwayAllergic rhinitis and asthma are characterized by an inflammatory process that is marked histologically by tissue eosinophils,mast cells,T lymphocytes,macrophages,and epithelial cells.inflammationImportant ConceptOne airway,One diseaseGrowsman-1997Worldwide prevalence Prevalence of Allergic rhinitis in CHINA（2007）Increasing prevalence of ARThe cause may be associated with factors as follows:Air pollution:exhaust particle;ozone,NO2(nitrogen dioxide),SO2(sulfur dioxide)Life style:unsaturated acidHyper-HygieneThe impact of AR on quality of Live Quality of live(QOL):Sleepingworkstudyentertainmentsocial communication systemic fellingAllergic 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 4 days per weekor 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 PositiveNotable:may see nearly 25%in normal Emphasizing:corresponding with history information:Yes make diagnosisNo may predictive Negative exclude drug effectunknow 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 SignificanceGenerally,sensitivety and specificity of SPT is superior to testing of serum specific IgE Differential diagnosisBy exclusive process(SPT;serum sIgE)Non-allergic nasal hyperreacive rhinitisVasomotor rhinitis(idiopathic)Non-allergic eosinophilia rhinitis(aspirin intolerance?)Hyper-reflective rhinitis(P substance?)Endocrine rhinitis(estrogn)Management of ARAllergen AvoidancePharmacotherapyImmunotherapyPharmacotherapyMedications used to treat allergic rhinits:nAntihistaminesnDecongestantsnCorticosteroidsnMast Cell stabilizersnAnticholinergicsnAntileukotrienes（抗白三（抗白三烯药烯药Anti-HistaminesAct by preventing histamine from binding to the H1-receptorsPrimarily helpful in controlling Sneezing,itching&rhinorrhoea;ineffective in releiving nasal blockage1st generation anti-histamines-chlorpheniramine-diphenylhydramine2nd generation anti-histamines-cetrizine-azelastine-fexofenadine-loratadineAnti-HistaminesIndications:mild intermittent or persistent rhinitismoderate-severecombined with intranasal corticosteroids Generally,Second generation antihistamines is first choice advantage:long term effect no sedativeRoutes of administration oral or intranasalIntranasal corticosteroid therapyPotent topical activityAdministration of low doses directly at site of actionConsiderable efficacy at low dosesHigh topical:systemic activity ratiosRapid first-pass hepatic metabolism of any systemically absorbed drug,to compounds with negligible activityIntranasal corticosteroidsIndications:Moderate-severe intermittent or persistentor complicated with asthmaAdvantage:anti-inflammation effect is significantly superior to antihistaines safe,no systemic side effect Anti-leukotrieneAnti-leukotriene should be given for patients with bronchial symptoms or severe nasal symptomsActions of Various Nasal Preparations in the Treatment of RhinitisNasal PreparationSneezingItchingRhinorrhoeaCongestionAntihistamines+0Anticholinergics00+0Corticosteroids+Nasal PreparationSneezingItchingRhinorrhoeaCongestionDecongestants00+Mast cell stabiliser+0Antileukotrienes+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 immunotherapy needs a precise diagnosis of IgE-mediated allergy.Only measure to alter natual process of allergic rhinitis so farSpecial immunotherapyAllergen-specific immunotherapy was traditionally administered by the subcutaneous route but local routes are now available.Subcutaneous immunotherapy is effective in adults and children for pollen and mite allergy,but it is burdened by the risks of side effects.These reactions may be life-threatening.Sublingual immunotherapy is recommended for the treatment of pollen or mite allergy in adults.Special immunotherapyIndication:Early use to protect from development of bronchial complication(ARIA 2008)Hypersensitive to Dust mited or pollenAge:6 Contraindication:severe lung dysfunctionother immunologic diseasesBeta-blocker being usedpregnancy Step by step for AR treatment