本文選題：過敏性鼻炎 + 鼻阻力��； 參考：《南方醫(yī)科大學》2012年碩士論文

【摘要】：過敏性鼻炎(allergicrhinitis,AR)是一種易感機體接觸致敏變應原后導致的主要由IgE介導的炎性介質(zhì)的釋放和多種免疫活性細胞,炎性細胞因子參與的鼻粘膜非感染性炎性疾病。過敏性鼻炎在世界范圍內(nèi)的患病率呈上升趨勢,歐美國家成人中過敏性鼻炎患病率一般為10%-25%,我國近年門診病人明顯上升,嚴重影響了患者的生活質(zhì)量。到目前,還沒有一種可有效預防和根治這些疾病的治療方法。 全身與局部雙途徑抗變態(tài)反應和抗炎是治療過敏性鼻炎的主要途徑,這種雙途徑治療主要包括全身抗組胺藥物(如,西替利嗪和氯雷他定)和局部抗變態(tài)反應抗炎藥(如內(nèi)舒拿及布地奈德)最為安全和有效。一項最新的meta分析,糠酸莫米松-內(nèi)舒拿可以有效減輕過敏性鼻炎患者的鼻癥狀總計分和單個癥狀計分,包括鼻塞癥狀。但藥物只是對癥治療,它并不能在停藥后持久地維持療效。 變應原特異性免疫治療是給對某種變應原敏感的患者逐漸增加該變應原產(chǎn)品的用量,從而減輕其以后暴露在有該變應原的環(huán)境下的癥狀的療法,其可以誘導臨床和免疫耐受,經(jīng)過一段時間的SIT后,即使停止治療仍對機體有長期的療效并能預防變應性疾病的進一步發(fā)展,降低哮喘的發(fā)病率,同時它還能提高過敏性疾病患者的生活質(zhì)量。特異性免疫治療的原理就是調(diào)節(jié)Th1和Th2免疫反應失衡。免疫治療才是改變疾病發(fā)展過程唯一的對因治療。變應原產(chǎn)品的成分質(zhì)量對疾病的診斷治療預防很重要。安脫達是全球最多患者選用及具有最多文獻記載的免疫治療制劑。 目前過敏性鼻炎藥物治療前后及變應原特異性免疫治療前后缺少客觀的指標評價治療的效果,在臨床實際工作中,目前仍然以患者主訴作為評價治療效果及調(diào)整治療方案的主要依據(jù)。癥狀分級記分標準(如鼻癥狀總計分和單個癥狀計分)在過敏性鼻炎嚴重性及臨床療效判定中廣泛使用,臨床上需要通過客觀的方法去評價過敏性鼻炎的治療效果,鼻阻力及鼻細胞學檢查是一個客觀的評價癥狀嚴重程度的方法,并作為癥狀分級記分標準的補充 本文通過變應原特異性免疫治療前后鼻阻力及鼻細胞學相關指標的變化規(guī)律了解其在評價治療效果及調(diào)整治療方案中的應用價值,假如AR患者癥狀嚴重程度及治療后緩解程度與鼻阻力、EOS、ECP呈負相關,配合主觀癥狀評分及鼻粘膜病理檢查,評價其相關性。如果知道AR患者在安脫達脫敏治療前后鼻阻力及鼻灌洗液中EOS,ECP的動態(tài)變化情況就可以客觀地知道它們對疾病的控制情況,就可為臨床療效評價或調(diào)整治療提供指導意見�？梢悦鞔_監(jiān)測鼻阻力、鼻灌洗液中EOS、ECP在過敏性鼻炎療效評價中的作用。而鼻阻力、鼻灌洗液中EOS、ECP在臨床療效判定應用中的文章很少。目前尚無應用鼻阻力及鼻灌洗液中嗜酸性粒細胞及嗜酸性粒細胞陽離子蛋白檢測在藥物治療和安脫達脫敏治療過敏性鼻炎前后中應用研究報道。 1、觀察比較安脫達脫敏治療過敏性鼻炎前后鼻阻力及鼻腔灌洗液中嗜酸性粒細胞EOS及嗜酸性粒細胞陽離子蛋白ECP的動態(tài)變化情況。 2、鼻阻力及鼻腔灌洗液中嗜酸性粒細胞EOS及嗜酸性粒細胞陽離子蛋白ECP在過敏性鼻炎療效判斷中的應用價值。 追蹤觀察自2009年1月到2011年5月在中山市中醫(yī)院耳鼻喉科門診主要癥狀為打噴嚏、鼻塞、流清涕、鼻癢43例成人患者,均有2—14年的相關病史. 所有患者年齡范圍(17—46歲)平均年齡(29±4.2歲),男20人,女23人,均符合2004年蘭州會議AR診斷標準,并符合中重度過敏性鼻炎的標準,經(jīng)皮膚點刺試驗,確定為塵螨過敏,點刺結果≥++,點刺液為安刺SQ,由丹麥ALK公司提供,變應原篩選為屋塵螨及粉塵螨過敏。按安脫達脫敏治療的要求行脫敏治療,所有患者均無用藥禁忌,并除外伴隨鼻腔鼻竇炎性反應、鼻息肉、鼻中隔嚴重偏曲、藥物性鼻炎、以及伴有其他部位過敏癥狀者如哮喘等,在接受特異性免疫治療期間未接受過任何與變應性疾病有關的藥物治療。 對照組年齡范圍(17—46歲)平均年齡(29±4.2歲),男4人,女8人為我科甲狀腺腺瘤病人. 1、記錄治療前病史,鼻內(nèi)鏡檢查結果,癥狀體征評分；鼻阻力,鼻灌洗液嗜酸性粒細胞及嗜酸性粒細胞陽離子蛋白值,并取少量下鼻甲粘膜病理檢查。 2、記錄治療15周后癥狀體征評分；鼻阻力,鼻灌洗液嗜酸性粒細胞陽離子蛋白值。 3、記錄治療1年后癥狀體征評分：鼻阻力,鼻灌洗液嗜酸性粒細胞及嗜酸性粒細胞陽離子蛋白值,治療1年后取少量下鼻甲粘膜病理檢查并行鼻內(nèi)鏡檢查。 4、分析比較兩組間及免疫治療前后癥狀體征評分,鼻阻力及鼻灌洗液嗜酸性粒細胞及嗜酸性粒細胞陽離子蛋白值有無差異,比較治療前與治療1年后粘膜病理變化情況及鼻內(nèi)鏡檢查情況。 1.定量資料選擇算術均數(shù)±標準差(x±s)進行描述； 2.兩定量資料的比較采用t檢驗,計數(shù)資料的比較采用x2檢驗； 3.分析兩變量相關性時采用簡單相關或偏相關； 4.以P0.05為差異有統(tǒng)計學意義； 5.各指標測量值采用SPSS13.0的重復測量數(shù)據(jù)的方差分析及SAS9.2統(tǒng)計軟件的廣義估計方程proc genmod過程步加以分析。 1.免疫治療組治療前與治療15周后、治療1年后鼻癥狀總評分比較有統(tǒng)計學差異(χ2=78.83,P0.05),鼻阻力比較有統(tǒng)計學差異(F=318.811,P0.05)。 2.免疫治療前鼻阻力與對照組存在統(tǒng)計學差異(P0.05),而免疫治療1年后鼻阻力與對照組統(tǒng)計學無差異(P0.05)。 3.免疫治療前與治療15周后、治療1年后嗜酸性粒細胞陽離子蛋白值存在統(tǒng)計學差異(F=254.215,P0.05)。 4.免疫治療前嗜酸性粒細胞陽離子蛋白值與對照組存在統(tǒng)計學差異(P0.05),而免疫治療1年后嗜酸性粒細胞陽離子蛋白值與對照組無統(tǒng)計學差異(P0.5)。 5.鼻阻力與癥狀體征總分無相關性r=-0.77,(P0.5),嗜酸性粒細胞陽離子蛋白值與癥狀體征總分無相關性r=-0.017,(P0.5)。 6.免疫治療前與治療1年后鼻灌洗液嗜酸性粒細胞計數(shù)存在統(tǒng)計學差異(P0.05)。 1.免疫治療前后鼻阻力及鼻腔灌洗液中嗜酸性粒細胞EOS及嗜酸性粒細胞陽離子蛋白ECP都有明顯改善,與癥狀體征評分無相關。 2.本研究提示：過敏性鼻炎治療過程中,連續(xù)動態(tài)的檢測鼻阻力及檢測鼻灌洗液嗜酸性粒細胞EOS及嗜酸性粒細胞陽離子蛋白EECP可客觀判斷療效,可作為癥狀體征評分的補充。
[Abstract]:Allergic rhinitis ( AR ) is one of the primary IgE - mediated inflammatory mediators released by IgE - mediated inflammatory mediators and the non - infectious inflammatory diseases of nasal mucosa caused by IgE - mediated inflammatory mediators .

Systemic and topical two - way anti - allergic and anti - inflammatory is the primary route for the treatment of allergic rhinitis , which is most safe and effective in the treatment of allergic rhinitis mainly including systemic anti - histamine drugs ( e.g . , citirazine and lortaxic ) and local anti - allergic anti - inflammatory drugs ( e.g . , naushannah and butende ) . A recent meta - analysis shows that mometasone furoate can effectively reduce the total score of nose symptoms and individual symptom scores in allergic rhinitis patients , including nasal obstruction symptoms . However , the drug is only symptomatic treatment , and it does not permanently maintain the efficacy after discontinuation .

allergen - specific immunotherapy is a therapy for gradually increasing the dosage of the allergen product to a patient sensitive to a certain allergen , thereby reducing the subsequent exposure to symptoms in an environment with the allergen , which can induce clinical and immune tolerance .

At present , there is no objective index to evaluate the effect of allergic rhinitis before and after treatment and before and after allergen - specific immunotherapy . In clinical practice , it is still used as the main basis for evaluating the therapeutic effect and adjusting the treatment plan . The symptom grading score criterion ( such as total score of nasal symptom and single symptom score ) is widely used in the assessment of the severity of allergic rhinitis and the clinical curative effect , and it is necessary to evaluate the therapeutic effect , nasal resistance and nasal cytology of allergic rhinitis by objective method .

In this paper , the changes of nasal resistance and nasal cytology indexes before and after allergen - specific immunotherapy are used to understand the application value of the indexes of nasal resistance , EOS and ECP in patients with allergic rhinitis .

1 . To observe the dynamic changes of EOS and ECP in nasal cavity before and after allergic rhinitis .

2 . The application value of EOS and ECP of eosinophils and ECP in the treatment of allergic rhinitis were studied .

From January 2009 to May , 2011 , the main symptoms of the outpatient department of ENT in Zhongshan were analyzed .

All patients age range ( 17 - 46 years ) mean age ( 29 鹵 4.2 years ) , male 20 , female 23 , all met the 2004 Lanzhou Conference AR diagnostic criteria , and met the criteria of moderate and severe allergic rhinitis . The prick test was conducted to determine that dust mite had an allergic reaction . The prick test was not contraindicated in all patients . Except for nasal sinusitis , nasal polyp , severe nasal septum deviation , drug rhinitis , and other allergic symptoms such as asthma , any drug therapy related to allergic disease was not received during the specific immunotherapy .

The age range of the control group ( 17 - 46 years ) mean age ( 29 鹵 4.2 years ) , 4 males and 8 females were patients with thyroid adenoma .

1 . Record the pre - treatment medical history , nasal endoscopic findings and symptom sign scores ;
Nasal resistance , nasal irrigation lotion eosinophils and eosinophils cationic protein values , and small amount of inferior nasal mucosa pathological examination .

2 . Record symptom score after treatment for 15 weeks ;
Nasal resistance , nasal irrigation lotion eosinophils cationic protein value .

3 . Record the symptoms and signs after 1 year : the nasal resistance , the eosinophils of nasal irrigation lotion and the cationic protein value of eosinophils . After 1 year of treatment , a small amount of inferior nasal mucosa pathological examination was performed in parallel nasal endoscopy .

4 . There was no difference between the scores of symptoms and signs , nasal resistance and eosinophils and cationic protein values before and after treatment , and the pathological changes of mucosa before and after treatment and nasal endoscopy were compared before and after treatment .

1 . The quantitative data selection arithmetic mean 鹵 standard deviation ( x 鹵 s ) is described ;


2 . The comparison of the two quantitative data is t - test , and the comparison of the counting data is checked by x2 ;


3 . The simple correlation or partial correlation is used to analyze the correlation of the two variables .


4 . The difference of P 0.05 was statistically significant .


5 . The measurement values of each index were analyzed by the ANOVA of SPSS 13.0 and the procedure of the proc genmod of the generalized estimation equation of SAS9.2 statistical software .

1 . After treatment before and after treatment for 15 weeks , the total score of nasal symptoms was significantly different after treatment for 1 year ( 蠂2 = 78.83 , P0.05 ) , and the nasal resistance was significantly different ( F = 318.811 , P0.05 ) .

2 . There was significant difference between the nasal resistance before and after the immunotherapy ( P0.05 ) , but the nasal resistance after 1 year was not significantly different from that of the control group ( P0.05 ) .

3 . There was a significant difference in the values of cationic protein in eosinophils ( F = 254.215 , P0.05 ) before and after treatment for 15 weeks before and after immunotherapy .

4 . There was a significant difference between the value of cationic protein and the control group ( P0.05 ) before immunotherapy , but the value of the cationic protein of eosinophils after 1 year was not significantly different from that of the control group ( P < 0 . 05 ) .

5 . There was no correlation between the nasal resistance and the total score of symptoms and signs ( r = - 0.77 , P < 0.05 ) . There was no correlation between the value of cationic protein in eosinophils and the total score of symptoms and signs ( r = - 0.17 , P < 0 . 5 ) .

6 . There was a significant difference in the count of eosinophils before and after immunotherapy ( P0.05 ) .

1 . Both the nasal resistance before and after the immunotherapy and the ECP of eosinophils and eosinophils in nasal lavage fluid were significantly improved , which was not related to the score of symptoms and signs .

2 . This study suggests that the continuous and dynamic detection of nasal resistance during the treatment of allergic rhinitis and the detection of eosinophils EOS and eosinophils cationic protein EECP can objectively determine the curative effect , and can be used as a supplement to symptom sign score .

【學位授予單位】：南方醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2012
【分類號】：R765.21

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