Inflammtory diseases of Inflammtory diseases of nasal cavitynasal cavity

Department of Otolaryngology, Affiliated Ninth People’ s Hospital of Shanghai

Jiaotong University, School of Medicine Wang Peihua

Chronic rhinitisChronic rhinitischronic rhinitischronic rhinitis >4 weeks>4 weeks

cause of disease::

1. systemic factors:systemic dieases, malnutrition, endocrine disturbance, immunodeficiency

2. local factor: acute rhinitis, nasal sinusitis, anatomic abnormalities, some naristillaes

3. occupational and environmental factors

Chronic rhinitisChronic rhinitis

chronic simple rhinitischronic simple rhinitis

Inflammatory cell infiltration without mucosal hyperplasia

chronic hypertrophic rhinitischronic hypertrophic rhinitis

mucosal and submucosal extensive fibroplasia

Chronic rhinitisChronic rhinitisSymptoms of chronic simple rhinitisSymptoms of chronic simple rhinitis ::1.1. Nasal obstruction: intermittent, Nasal obstruction: intermittent,

alternativealternative2.2. Nasal discharge: mucusNasal discharge: mucus ，， mucopurulencemucopurulence3.3. Others Others

Examination :Examination :1.1. Mucous hyperemia, swelling of inferior Mucous hyperemia, swelling of inferior

turbinate, sensitive to amidephrineturbinate, sensitive to amidephrine2.2. Viscous nasal dischargeViscous nasal discharge

Chronic rhinitisChronic rhinitis

TreatmentTreatment: remove the causes of dieases, : remove the causes of dieases, recuperate ventilation of nasal cavity.recuperate ventilation of nasal cavity.

11. etilogical treatment. etilogical treatment

22. local treatment. local treatment

(1)(1)amidephrineamidephrine

(2)(2)block therapyblock therapy

(3)(3)acupuncture therapyacupuncture therapy

((4)Chinese medicine4)Chinese medicine

Chronic rhinitisChronic rhinitisSymptoms of chronic hypertrophic rhinitisSymptoms of chronic hypertrophic rhinitis

1.1. Nasal obstruction: persistentNasal obstruction: persistent2.2. Nasal discharge: mucusNasal discharge: mucus ，， mucopurulence(not too mucopurulence(not too

much)much)3.3. Closed rhinolalia, tinnitus, headache, dizziness…Closed rhinolalia, tinnitus, headache, dizziness…

Examination :Examination :1.1. Nasal mucomembranous thickening and hyperplasia, Nasal mucomembranous thickening and hyperplasia, 2.2. Swelling of inferior turbinate and turbinate bone, Swelling of inferior turbinate and turbinate bone,

insensitive to amidephrineinsensitive to amidephrine

Treatment:Treatment: 1. Conservative therapy -sclerosing agent, laser and 1. Conservative therapy -sclerosing agent, laser and

microwave.microwave.2. partial inferior turbinectomy2. partial inferior turbinectomy

Main points of identificationMain points of identification

鼻塞 鼻塞 间歇性（冬季、夜间、静坐时明显，间歇性（冬季、夜间、静坐时明显， 持续性 持续性 夏季白天、运动时减轻或消失）；夏季白天、运动时减轻或消失）；两侧交替性 两侧交替性

鼻涕 鼻涕 略多，粘液性 略多，粘液性 多，粘液性或粘脓性，不易擤出 多，粘液性或粘脓性，不易擤出

嗅觉减退嗅觉减退 不明显不明显 可有 可有 闭塞性鼻音闭塞性鼻音 无无 有有头痛、头昏头痛、头昏 可有可有 常有常有咽干、咽痛咽干、咽痛 可有可有 常有常有耳鸣、耳闭塞感耳鸣、耳闭塞感 无无 可有可有

前鼻孔镜所见前鼻孔镜所见 下鼻甲粘膜肿胀表面光滑，暗红色下鼻甲粘膜肿胀表面光滑，暗红色 下鼻甲粘膜肥厚暗红色，表面光 下鼻甲粘膜肥厚暗红色，表面光 滑或不平，或呈结节状、桑椹状 滑或不平，或呈结节状、桑椹状

或分叶状，鼻甲骨可肥大或分叶状，鼻甲骨可肥大

下鼻甲探针触诊下鼻甲探针触诊 柔软，有弹性，轻压时有凹陷，探针柔软，有弹性，轻压时有凹陷，探针 有硬实感，轻压时无凹陷，但不有硬实感，轻压时无凹陷，但不移去后立即恢复移去后立即恢复 立即恢复立即恢复

对对 11 ％～％～ 22 ％麻黄％麻黄 粘膜收缩明显，下鼻甲缩小粘膜收缩明显，下鼻甲缩小 粘膜不收缩或轻微收缩，下鼻甲粘膜不收缩或轻微收缩，下鼻甲素的反应素的反应 大小无明显改变大小无明显改变

治疗治疗 非手术治疗非手术治疗 一般宜手术治疗一般宜手术治疗

慢性单纯性鼻炎慢性单纯性鼻炎 慢性肥厚性鼻炎慢性肥厚性鼻炎

Allergic rhinitisAllergic rhinitis

Allergic disorder of nasal mucosa. Allergic disorder of nasal mucosa. Rhinocnesmus, Rhinocnesmus, sneezingsneezing, hypersecretion, , hypersecretion, swelling and distension of nasal mucosa.swelling and distension of nasal mucosa.Development of allergic rhinitis is Development of allergic rhinitis is correlated with heredity and environment. correlated with heredity and environment.

internal cause: atopyinternal cause: atopy..

external cause: indoor/outdoor external cause: indoor/outdoor contaminants. contaminants. Pathogenesis :Pathogenesis :

Type I allergic reaction which has Type I allergic reaction which has correlation with cytokines, correlation with cytokines, intercellular adheintercellular adhesion molecule-1sion molecule-1, neuropeptide., neuropeptide.

ARIA Classification

季节性 常年性

间歇性 间歇性 持续性 持续性

中重度 轻度 中重度 轻度 中重度 轻度 中重度 轻度

Lanzhou ConferenceLanzhou Conference ，， 20042004

Main kind of allergensMain kind of allergens ：：Dermatophagoides pteronyssinus and its Dermatophagoides pteronyssinus and its

dead body, spawn, discharge…dead body, spawn, discharge…

Pollens, fungal sporesPollens, fungal spores

Exuviae and feathers of animals

Foods Foods

Chemical Chemical substancesubstance

Allergic rhinitis --cascade reaction

Allergic rhinitis --cascade reaction

Clin Drug Invest 2005; 25 (3): 153-164

Allergic rhinitisClinical manifestationClinical manifestation

SymptomsSymptoms ：： sneezing, nasal discharge, sneezing, nasal discharge, rhinocnesmus, nasal obstruction rhinocnesmus, nasal obstruction

Allergic SaluteAllergic Salute （（ Linea NasalisLinea Nasalis ）） Allergic ShinerAllergic Shiner

ExaminationExamination ：： nasal mucosal edema(pallor, gray-nasal mucosal edema(pallor, gray-blue, kermesinus)blue, kermesinus)

Secretions(serosity or seromucus)Secretions(serosity or seromucus) Swelling of inferior turbinateSwelling of inferior turbinate HyposmiaHyposmia Itching of eye, palate, earItching of eye, palate, ear

Allergic rhinitis1.1. Specific skin tests:Specific skin tests: Prick Test & Intracutaneous TestPrick Test & Intracutaneous Test

2. Nasal Provocation Test 2. Nasal Provocation Test ：：Identify allergenIdentify allergenAfford supports to skin testAfford supports to skin testTest one allergen for one time Test one allergen for one time Potential riskPotential risk

Allergic rhinitis

Treatment

To advoid allergensPharmacotherapyImmunotherapyOthers:laser, radiofrequency ablation , surgery and so on.

Treatment to AR (ARIA)

PharmacotherapyLocal application of corticosteroid hormone is the first choice （（ WHO 1994 2001 WHO 1994 2001 ）） e.g. Beclometasone Dipropionate, fluticasone, budesonide, momestasone furoate. combination： antihistaminics, peroral corticosteroids, mastocyte inhibitor, antileukotriene

Directions of corticosteroid nasal spray:persistent AR ： decrease progressively to

minimum maintenance doseintermittent AR ： use it 1 month before the

period of onset, for 3-4 years. coryza professionalis ： long-term useCauses of treatment failure: anatomic abnormality, sinusitis,

polyps, fugus and so on.

Effect to rhinitisEffect to rhinitis

喷嚏喷嚏 流涕流涕 鼻塞鼻塞 鼻痒鼻痒 眼症状眼症状鼻内色酮鼻内色酮 ＋＋ ＋＋ ＋＋ ＋＋ －－

口服减充血药口服减充血药 －－ －－ ＋＋ －－ －－鼻内减充血药鼻内减充血药 －－ －－ ＋＋＋＋＋＋＋＋ －－ －－

抗胆碱能药抗胆碱能药 －－ ＋＋＋＋ －－ －－ －－

抗白三烯药抗白三烯药 －－ ＋＋ ＋＋＋＋ －－ ＋＋＋＋

口服口服 H1H1 －抗组胺－抗组胺药药 ＋＋＋＋ ＋＋＋＋ ＋＋ ＋＋＋＋＋＋ ＋＋＋＋

鼻内鼻内 H1H1 －抗组胺－抗组胺药药 ＋＋＋＋ ＋＋＋＋ ＋＋ ＋＋＋＋ ——

鼻内糖皮质激素鼻内糖皮质激素 ＋＋＋＋＋＋ ＋＋＋＋＋＋ ＋＋＋＋＋＋ ＋＋＋＋ ＋＋＋＋

Van Caµwenberge P, et al.Eµropean Academy of Allergology and Clinical Immµnology. Allergy, 2000;55(2):p116-34

Immunotherapy Immunotherapy

Indication :ARIA multistep Indication :ARIA multistep therapy (Ⅱtherapy (Ⅱ 、、Ⅲ Ⅲ grade)grade)

MethodMethod ：：1.1.Specific allergic vaccines, Specific allergic vaccines,

allergic ploypeptide vaccines, allergic ploypeptide vaccines, research on allergic generesearch on allergic gene

2.2.Non-specific immunotherapy(T Non-specific immunotherapy(T cell and cytokines)cell and cytokines)

vasomotor rhinitisvasomotor rhinitisvasomotor rhinitis vasomotor rhinitis Nonspecific stimulus induced neurogenic Nonspecific stimulus induced neurogenic inflammation of nasal mucosa.inflammation of nasal mucosa.

Cause of disease: mental stress, anxiety, Cause of disease: mental stress, anxiety, change of environment temperature, change of environment temperature, endocrine disorderendocrine disorder

Pathology: neurogenic inflammation mediated Pathology: neurogenic inflammation mediated by neurotransmitters.by neurotransmitters.

vasomotor rhinitisvasomotor rhinitisClinical manifestation: similar with Clinical manifestation: similar with AR.AR.

Nasal obstructionNasal obstruction

Sneezing Sneezing

RhinorrheaRhinorrhea

vasomotor rhinitisvasomotor rhinitisExamination : Examination : Chronic congestion of

nasal mucosa, dark red or pallor.Diagnosis :Diagnosis :

1. nasal symptom >1h1. nasal symptom >1h 2. skin test (-)2. skin test (-)

3. 3. nasal smear: eosinophile nasal smear: eosinophile granulocyte / neutrophilic granulocyte / neutrophilic granulocyte(-)granulocyte(-)

4. eliminate medicamentous rhinitis4. eliminate medicamentous rhinitis

vasomotor rhinitisvasomotor rhinitisTreatmentTreatmentChief method: pharmacotherapy.

Nasal mucosal edema and severe sneezing--Nasal mucosal edema and severe sneezing--antihistaminicsantihistaminicsNasal obstruction—decongestant Nasal obstruction—decongestant naristillae± corticosteroid nasal spraynaristillae± corticosteroid nasal sprayNasal serous discharge—anticholinergics Nasal serous discharge—anticholinergics e.g. 0.03e.g. 0.03 ％％ ipratropium bromideipratropium bromideSensitive to temperature and dust/sneezing Sensitive to temperature and dust/sneezing frequently--laser, radiofrequency ablation , frequently--laser, radiofrequency ablation , microwaves and so onmicrowaves and so on