过敏性鼻炎的诊断和治疗

NasalmucosalhyperreactiverhinopathyAllergicRhinitis(AR)Perennial~(PAR),Seasonal~(SAR)（Pollinosis）Morbidity:10%~20%Inhalantallergens——dustmite,housedust,pollen,fungi,animaldanders,cockroach；Foodallergens——milk,eggs,fishandshrimp,meat,vegetables,fruits.MiteMoldPollenCatAntigensforallergicrhinitis变应性鼻炎的病因学内在因素──遗传因素：有家族史者较无家族史者发病危险高２～６倍母系第１１对染色体长臂ｑ段外在因素（环境因素）：基因表达受非遗传因素影响。７０００对孪生儿，同时有AR症状者为２１％易感个体在一定环境条件作用下才发病变应原与致敏靶细胞表面IgE结合致敏靶细胞脱粒、释放、合成生物活性介质肥大细胞储备的介质新合成的介质组胺缓激肽白三烯血小板活化因子前列腺素D2毛细血管扩张、通透性增加，腺体分泌增多嗜酸/碱性粒细胞哮喘鼻炎发病机制Pathology：TypeallergyAllergicinflammation:PredominantTcells&eosinophiliccellsinfiltrate.Symptoms&Signs：Nasalirritationandichingrecurrentattacksofparoxysmalsneezingcopiouswateryrhinorrheanasalobstruction鼻后滴漏Diagnosis：1、History（allergenexposure,hypersensitivity,familyhistory）2、Examination3、Skintest:skinpricktest4、IgEantibody，SerumtotalIgE、specialIgE5、NasalprovocationornasalchanllengetestsDifferentialDiagnosis：1、Vastomotorrhinitis2、Nonallergicrhinitiswitheosinophiliasyndrome,NARES3、Hyperreflectoryrhinitis4、AcuterhinitisComplications：1、Allergicsinusitis2、Asthma3、Secretoryotitismedia4、AllergicpharyngolaryngitisTreatment：1、Avoidance2、Drugs1）Antihistamines2）Corticosteroids3）Sodiumcromoglycate(SCG)Cromolynsodium4）Anticholinergicagents5）Vasoconstrictorsympasthomimetics3、Hyposensitization4、Others：TraditionalChinesemedicine,laser,operationNasalPolyp&NasalPolyposisEtiology：mutilfactors1.allergic；2.chronicinflammationPathology：highlyswelledconnectivetissue.Predominanteosinophiliccellsinfiltrate.Lymphaticcells,neutrophils,basophils,mastcells.Polypinmaxillarysinus（L），polypinmiddlemeatus（R）Symptoms&Sign：persistentnasalobstruction，closenasalsound，hyposmia,rhinorrhea,snore,“frognose”AntrochoanalpolypAntrochoanalpolypDiagnosis：Anteriorrhinoscopy：translucent,soft,smoothmasses.Endoscopy,X-rayandCTscanner.DifferentialDiagnosis：Papillomainverted，angiofibromaofnasopharynx，malignanttumorofnasalcavity，meningoencephaloceleTreatment：1、conservativetreatment——corticosteroids2、surgicaltreatmentPolyps（above），papilloma（below）papilloma（L），MTofnasalcavity（R）SinusitisAcutesuppurativesinusitisFeaturesofsinusanatomy：1、smallostiaofthesinuses；2、continuativemucosabetweennasalcavityandsinuses；3、contiguousoftheostia；4、locationoftheastiaandfeaturesofthesinuses.FrontalSinusEthmoidSinusMaxillarySinusEtiology：1、Generalfactors:Poorgeneralhealth(influenza,measles,whoopingcough…)2、Localfactors：Sinusdiseases；Infectivefocusoferipheralorgans，Directinfection；Nasaltampon(packing)；RapidchangeofatmosphericpressureABS主要病原体：肺炎链球菌和嗜血流感杆菌SAHP.OtolaryngolHeadNeckSurg.2004;130:1-45.20-43%22-35%Anaerobes0-9%Staphylococcusaureus0-8%Otherbacteria4%MoraxellacatarrhalisOtherstreptococci3-9%2-10%S.pneumoniae成人Acutebacterialrhinosinusitis(ABS)病因H.influenzae儿童Acutebacterialrhinosinusitis(ABS)病因•ABS主要病原体：肺炎链球菌、嗜血流感杆菌和卡他莫拉菌H.influenzae15-20%S.pneum25-30%Sterile20-35%Anaerobes2-5%S.pyogenes2-5%M.catarrhalis15-20%OtolaryngolHeadNeckSurg.2004;130:1-45.Symptoms&Signs：Generalsymptoms：Malaise,fever.Localsymptoms:1）Nasalobstructionsustained,withhyposmia2）Suppurativerhinorrhea,streakywithblood,foulsmell(odontogentic~)3）headachorlocalacheAntralpain——frominnercanthusdownwardsacrossthecheek,upperalveolusontheaffectedside.Ethmoidalpain——overbridgeofthenose&innercanthusbehindtheeye.Frontalpain——forehead,periodicity,persistforanhourortowaftergettingupinthemorning,andclearduringtheafternoon.Sphenoidalpain——occipitalorverticalheadache.Diagnosis：History，Signs,Anteriorrhinoscopy,Nasalendoscopy,Radiologicalexamination,PunctureandirrigationofmaxillarysinusTreatment：Eradicatecauses，keepdrainage；controlinfectionandpreventcomplications1、Generaltreatment：takerest，antibiotics，antihistamine(ifnecessary)2、Localtreatment3、Bodydrainage4、Physicaltherapy5、PunctureandirrigationofmaxillarysinusMaxillarysinuspunctureandirragationChronicsuppurativesinusitisEtiology：Acute——ChronicSymptoms&Signs：General~:Local~：rhinorrhea,nasalobstruction,headache,hyposmia,visiondisorderDiagnosis：1、History；2、Examination：anteriorrhinoscopy,nasalendoscopy3、Radiologicalexamination：CTorMRI4、PunctureandirrigationofsinusNormalimageofnasalendoscopyMaxillarysinusitis——pusinthemiddlemeatusMaxillarysinusitis(R)Sphenoidsinusitis——pusinthesphenoethmoidalrecessSphenoidsinusitisPansinusitisPansinusitisTreatment：1、Intranasalmedications：Corticosteroid，Vasoconstrictorsympasthomimetics2、Punctureandirrigationofmaxillarysinus3、Displacementmethod——frontalsinusitis,ethmoidalsinusitis,sphenoidalsinusitis,pansinusitis4、Surgery——traditionalsinussurgeryFunctionalEndoscopicSinusSurgery(FESS)OstiometalcomplexOMCFunctionalEndoscopicSinusSurgery(FESS)复习与思考：1、鼻腔外侧壁的解剖结构及其与临床的关系如何？2、变应性鼻炎有何临床表现，应与哪些疾病相鉴别？3、如何诊断鼻窦炎？4、鼻息肉应与哪些疾病相鉴别?5、上颌窦穿刺术有何临床意义？