Ar.paraya2551

486 vues

Publié le

allergic rhintis general consideration

Publié dans : Formation
0 commentaire
0 j’aime
Statistiques
Remarques
  • Soyez le premier à commenter

  • Soyez le premier à aimer ceci

Aucun téléchargement
Vues
Nombre de vues
486
Sur SlideShare
0
Issues des intégrations
0
Intégrations
3
Actions
Partages
0
Téléchargements
4
Commentaires
0
J’aime
0
Intégrations 0
Aucune incorporation

Aucune remarque pour cette diapositive

Ar.paraya2551

  1. 1. ‡«™ªØ‘ ∫— µ‘ ª √‘ ∑— » πå § ≈‘ π‘ ° ‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ (µÕπ∑’Ë 1) Allergic rhinitis ‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡·æâ (allergic rhinitis) ‡ªπ‚√§∑æ∫‰¥∫Õ¬„πª√–‡∑»‰∑¬ ·≈– ‘ ì Ë’ â à ª√–‡∑»ÕπÊ∑«‚≈° ‚√§π‡ªπ‚√§∑¡§«“¡º¥ª°µ¢Õß√–∫∫¿¡§¡°π¢Õß√“ß°“¬™π¥Àπß ‚¥¬‡ªπ Ë◊ Ë— È’ ì Ë’ ’ ‘ ‘ Ÿ ‘ âÿ — à ‘ Ë÷ ì IgE mediated type I hypersensitivity reaction ∑’ˇ°‘¥∑’ˇ¬◊ËÕ∫ÿ®¡Ÿ° ∑”„À⇰‘¥Õ“°“√µ—Èß·µàπâÕ¬ ®π∂÷߇ªìπ¡“° ®π∑”„Àâ§ÿ≥¿“æ™’«‘µ∑—Èß∑“ߥâ“π√à“ß°“¬ ®‘µ„® ·≈–°“√‡¢â“ —ߧ¡·¬à≈ß ‡¡◊ËÕ‡∑’¬∫ °—∫§πª°µ‘∑—Ë«‰ª.1 ‡¡◊ËÕ°àÕπ¡’°“√·∫àߪ√–‡¿∑¢Õß‚√§π’È ‚¥¬Õ“»—¬√–¬–‡«≈“∑’˺ŸâªÉ«¬¡’Õ“°“√ ¥—ßπ’È 1. Seasonal allergic rhinitis ºŸâªÉ«¬®–¡’Õ“°“√ „π√–¬–∑’Ë¡’ “√°àÕ¿Ÿ¡‘·æâ¡“°„π Õ“°“»‡æ¬ß√–¬–‡«≈“Àπß À√Õƒ¥Àπ߇∑“ππ.  “√°Õ¿¡·æ¡°‡ªπ “√°Õ¿¡·æ∑Õ¬¿“¬πÕ°∫“π ’ Ë÷ ◊ Ÿ Ë÷ à È— à Ÿ ‘ â — ì à Ÿ ‘ â Ë’ àŸ â (outdoor allergens) ‡™àπ ≈–ÕÕ߇° √À≠â“, «—™æ◊™ À√◊Õ¥Õ°‰¡â ·≈–‡™◊ÈÕ√“. 2. Perennial allergic rhinitis ºŸâªÉ«¬¡—°®–¡’Õ“°“√µ≈Õ¥∑—Èßªï ·≈– “√°àÕ¿Ÿ¡‘·æâ∑’Ë ‡ªì𠓇Àµÿ ¡—°‡ªìπ “√°àÕ¿Ÿ¡‘·æâ¿“¬„π∫â“π∑’ËÕ¬ŸàÕ“»—¬ À√◊Õ ∂“π∑’Ë∑”ß“π¢ÕߺŸâªÉ«¬ ‡™àπ ‰√ΩÿÉπ, ·¡≈ß “∫, ¢π·≈–√—ß·§ —µ«å ·≈–‡™◊ÈÕ√“. ‡¡◊ËÕ‡√Á«π’ÈÊ §≥–∑”ß“π¢ÕßÕߧ尓√Õπ“¡—¬‚≈° (WHO) ‰¥â‡ πÕ°“√·∫àß™π‘¥¢Õß‚√§®¡Ÿ° Õ—°‡ ∫®“°¿Ÿ¡‘·æâ·∫∫„À¡à ‚¥¬·∫àßÕÕ°‡ªìπ 2 ™π‘¥2 (¿“æ∑’Ë 1) §◊Õ 1. Intermittent À¡“¬∂÷ß ºŸâªÉ«¬¡’Õ“°“√‡ªìπ∫“ߧ√—Èß ‚¥¬¡’Õ“°“√πâÕ¬°«à“ 4 «—π µàÕ 1  —ª¥“Àå À√◊Õ¡’Õ“°“√µ‘¥µàÕ°—ππâÕ¬°«à“ 4  —ª¥“Àå. 2. Persistent À¡“¬∂ß ºª«¬¡Õ“°“√µ≈Õ¥‡«≈“ ‚¥¬¡Õ“°“√¡“°°«“ 4 «π µÕ 1  ª¥“Àå ÷ Ÿâ É ’ ’ à — à — ª“√¬– Õ“»π–‡ π æ.∫., ºŸ™«¬»“ µ√“®“√¬å  “¢“«‘™“‚√§®¡Ÿ°·≈–‚√§¿Ÿ¡·æâ â à ‘ ¿“§«‘™“‚ µ π“ ‘° ≈“√‘ß´å«∑¬“ ‘ §≥–·æ∑¬»“ µ√å»√√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ ‘‘⁄¯„¡ »•Ł 24 ””•Ł 7 ¡ˆ¡fi ⁄` 2551 619
  2. 2. ¿“æ∑’Ë 1. °“√·∫àß™π‘¥¢Õß‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ. ·≈–¡’Õ“°“√µ‘¥µàÕ°—ππ“π°«à“ 4  —ª¥“Àå. ‚≈°3-6 „πª√–‡∑»‰∑¬Õÿ∫—µ‘°“√≥å¢Õß‚√§π’È„π‡¥Á° ‡π◊ËÕß®“°¬—߉¡à¡’ objective parameters ∑’Ë «—¬‡√’¬π (6-7 ªï) À√◊Õπ—°‡√’¬π (13-14 ªï) ®“°  —¡æ—π∏å°—∫Õ“°“√¢ÕߺŸâªÉ«¬‚√§π’È™—¥‡®π WHO ®÷߉¥â °“√»÷°…“¢Õß ª°‘µ «‘™¬“ππ∑å·≈–§≥–7 „πªï æ.». ‡ πÕ„À„™Õ“°“√∑“ߧ≈π°∑¡º≈µÕ§≥¿“晫µ¢Õß â â ‘ ‘ Ë’ ’ à ÿ ’‘ 2538 æ∫«à“‡ªìπ‚√§π’È√âÕ¬≈– 38  Ÿß¢÷Èπ°«à“∑’Ë¡’°“√ ºŸâªÉ«¬ ·∫àߧ«“¡√ÿπ·√ߢÕß‚√§ÕÕ°‡ªìπ 2 °≈ÿࡧ◊Õ  ”√«®„πªï æ.». 2518 ‚¥¬¡πµ√’ µŸâ®‘𥓷≈–§≥– 8 1. Mild. (√âÕ¬≈– 23) ‡°◊Õ∫∂÷ß 2 ‡∑à“. ®“°°“√ ”√«®„πªï 2. Moderate-severe. æ.». 2538 ‚¥¬Àπ૬‚√§¿Ÿ¡‘·æâ ¿“§«‘™“‚ µ π“ ‘° ‚¥¬„π°≈ÿà¡ mild ‰¡à¡’Õ“°“√¥—ßµàÕ‰ªπ’È ≈“√‘ß´å«‘∑¬“ §≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈ æ∫  à«π„π°≈ÿà¡ moderate-severe ¡’Õ“°“√¥—ßµàÕ‰ªπ’È «à“„π°≈ÿࡪ√–™“°√∑—Ë«‰ª ¡’ºŸâ‡ªìπ‚√§®¡Ÿ°Õ—°‡ ∫®“° 1 Õ“°“√À√◊Õ¡“°°«à“§◊Õ ¿¡·æâ √Õ¬≈– 8-13 9 „π°≈¡π°»°…“¢Õß¡À“«∑¬“≈¬ Ÿ ‘ â ÿà — ÷ ‘ — 10 - Sleep disturbance. ¡À‘¥≈ ¡’Õÿ∫—µ‘°“√≥å√âÕ¬≈– 22.  ”À√—∫ºŸâªÉ«¬∑’Ë¡“√—∫ - Impairment of daily activities, lei- °“√√—°…“∑’Ë·ºπ°ºŸâªÉ«¬πÕ° ÀŸ §Õ ®¡Ÿ° ¢Õß‚√ß sure and/or sport. 欓∫“≈»‘√‘√“™ æ∫«à“ „πªï æ.». 2533-2535 ¡’ - Impairment of school or work. ®”π«π√âÕ¬≈– 13 ·µà„πªï æ.». 2540-2542 ¡’®”π«π - Troublesome symptoms. ‡æ‘Ë¡¢÷Èπ‡ªìπ√âÕ¬≈– 22 ´÷Ëß· ¥ß«à“ Õÿ∫—µ‘°“√≥å¢Õß ‚√§π’È¡’·π«‚πâ¡ Ÿß¢÷Èπ‡√◊ËÕ¬Ê ‚¥¬‡©æ“–„π‡¡◊Õß„À≠à ∑’Ë¡’¡≈æ‘…∑“ßÕ“°“»‡æ‘Ë¡¢÷Èπ. ‡™◊ËÕ«à“°“√∑’Ë¡’ª√‘¡“≥ Õÿ∫— µ‘°“√≥å ¢Õß “√°àÕ¿Ÿ¡‘·æâ¡“°¢÷Èπ ·≈–ª√–™“°√ —¡º— °—∫ Õ∫µ°“√≥¢Õß‚√§®¡°Õ°‡ ∫®“°¿¡·æâ æ∫ ‰¥â ÿ — ‘ å Ÿ — Ÿ ‘  “√°àÕ¿Ÿ¡‘·æâ ·≈– “√√–§“¬‡§◊Õß„πÕ“°“»¡“°¢÷Èπ ª√–¡“≥√âÕ¬≈– 10-25 ¢Õß®”π«πª√–™“°√∑—Ë« ∑”„Àâæ∫ºŸâªÉ«¬‡æ‘Ë¡¢÷Èπ.620 ⁄¯„¡ »•Ł 24 ””•Ł 7 ¡ˆ¡fi ⁄` 2551
  3. 3. „π‡¥Á°®–æ∫‚√§π’È„π‡¥Á°™“¬∫àÕ¬°«à“‡¥Á°À≠‘ß æ¬“∏ √√«∑¬“¢Õß allergic inflamma- ‘ ’ ‘·µà„πºŸâ„À≠à®–æ∫„πºŸâÀ≠‘߉¥â∫àÕ¬°«à“ºŸâ™“¬ ‚√§π’È tion¡—°®–‡√‘Ë¡· ¥ßÕ“°“√„π«—¬‡√’¬πÀ√◊Õ«—¬√ÿàπ. ‡√‘Ë¡®“° sensitization phase ·≈⫵“¡¥â«¬ clinical phase (¿“æ∑’Ë 2) ‚¥¬ºŸâªÉ«¬∑’Ë¡’≈—°…≥– ∑“ßæ—π∏ÿ°√√¡ ∑’Ë¡’·π«‚πâ¡®–‡ªìπ‚√§¿Ÿ¡‘·æâ (genet- “‡Àµÿ ic predisposition for atopic disease) ¡’°“√ √â“ß ‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ ‡ªìπ‚√§∑’ˇ°‘¥®“° IgE µàÕ “√°àÕ¿Ÿ¡‘·æ⇰‘¥¢÷Èπ À≈—ß®“° —¡º—  “√°àÕÀ≈“¬ “‡Àµÿ (multifactorial disease) æÕ·∫àß ¿Ÿ¡‘·æâ ‡√’¬°«à“ çsensitizationé. À≈—ß®“°π—Èπ anti- “‡ÀµÿÀ≈—°ÕÕ°‰¥â 3 ª√–°“√ §◊Õ gen-presenting cells ‡™àπ macrophages À√◊Õ 1. Predisposing factor ªí®®—¬∑’ˇªì𠓇Àµÿ dendritic cells ®–π” antigen π—È π ‰ª‡ πÕµà ÕÀ≈—° ‰¥â·°à ‡√◊ËÕߢÕßæ—π∏ÿ°√√¡ (heredity) ‚¥¬ T-helper cells (TH : CD 4+) ·≈– B cell ‚¥¬ºŸâªÉ«¬∑’ˇªìπ‚√§¿Ÿ¡‘·æâ (atopic disease) ¡’§«“¡ Interleukin (IL)-4 ·≈– IL-13 ®“° TH-2 lym-º‘¥ª°µ‘¢Õß immune response gene (IR-gene) phocytes ®–°√–µÿâπ„Àâ B cells  √â“ß IgE ¢÷Èπ¡“´÷Ëß∑”Àπâ“∑’˧«∫§ÿ¡°“√ √â“ß¿Ÿ¡‘§ÿâ¡°—π¢Õß√à“ß°“¬ ‚¥¬ allergen-specific IgE ‡À≈à“π’È®–®—∫°—∫ high·≈– gene ∑’˺‘¥ª°µ‘π’È “¡“√∂∂à“¬∑Õ¥‰ª¬—ß≈Ÿ° ·≈– affinity receptors ∫π mast cells ·≈– basophilsÀ≈“π‰¥â.11 √«¡∑—Èß low affinity receptors ∫π‡´≈≈åÕ◊ËπÊ ¥â«¬ 2. Primary or specific factor ªí®®—¬∑’Ë ‡™àπ monocytes, eosinophils ·≈– platelet.12-15‡ªì𠓇Àµÿ‚¥¬µ√ß ‰¥â·°à  ‘Ëß∑’˺ŸâªÉ«¬·æâ À√◊Õ “√°àÕ À≈—ß®“°π—Èπ ‡¡◊ËÕºŸâªÉ«¬ —¡º— °—∫ “√°àÕ¿Ÿ¡‘·æâÕ’° an-¿Ÿ¡‘·æâ (antigen, allergen) ™π‘¥∑’Ë∑”„À⇰‘¥Õ“°“√ tigen ®–∑”„À⇰‘¥ cross-linking ¢Õß IgE ∑’ËÕ¬Ÿà‰¥â∫àÕ¬§◊Õ  “√∑’ËÕ¬Ÿà„πÕ“°“» (aeroallergen) ·≈– „°≈⇧’¬ß°—π°√–µÿâπ„À⇰‘¥ degranulation ¢Õß mast‡¢â“ Ÿà√à“ß°“¬‚¥¬°“√À“¬„® (inhalant) ‡™àπ ΩÿÉπ∫â“π cells ª≈àÕ¬ inflammatory mediators ÕÕ°¡“(house dust), µ—«‰√„πΩÿÉπ∫â“π (house-dust mite), ¡“°¡“¬ ‡™àπ histamine, leukotriene C4 (LTC 4),‡° √æ◊™ (pollen), ™‘Èπ à«π À√◊Õ ‘Ëߢ—∫∂à“¬¢Õß·¡≈ß prostaglandin D2 (PGD 2) 16 ‡°‘¥ early-phase∑’ËÕ“»—¬Õ¬Ÿà„π∫â“𠇙àπ ·¡≈ß “∫ ¬ÿß ·¡≈ß«—π ¡¥. response (EPR) mediators ∑’ËÀ≈—ËßÕÕ°¡“π’È ®– “√°àÕ¿Ÿ¡‘·æâ∑’Ë ”§—≠∑’Ë ÿ¥„πΩÿÉπ §◊Õ µ—«‰√ΩÿÉπ ´÷Ëß ‰ª°√–µÿπ end organs „π‡¬◊Õ∫ÿ®¡Ÿ° ‡™àπ ‡ âπª√– “∑, â Ë “√°àÕ¿Ÿ¡‘·æâπ—Èπ ¡’Õ¬Ÿà∑—Èß„πµ—«‰√ ·≈–„π ‘Ëߢ—∫∂à“¬ µàÕ¡ √â“ß “√§—¥À≈—Ëß ·≈–µàÕ¡ √â“ß¡Ÿ°, À≈Õ¥‡≈◊Õ¥¢Õß¡—π. ∑”„À⇰‘¥Õ“°“√ §—π, ®“¡, §—¥®¡Ÿ° ·≈–πÈ”¡Ÿ°‰À≈ ´÷Ëß 3. Secondary or precipitating factors Õ“°“√‡À≈à“π’È¡—°À“¬‡Õß ·µàÕ“®°≈—∫¡“‰¥âÕ’°À≈—߉¥·°à ‡Àµ‡ √¡∑∑”„ÀÕ“°“√· ¥ßÕÕ°¡“ À√Õ¡Õ“°“√ â ÿ ‘ ’Ë â ◊ ’  —¡º—  “√°àÕ¿Ÿ¡‘·æâ ·≈â« 3-10 ™—Ë«‚¡ß.¡“°¢π‰¥â ‡™π ‚√§µ¥‡™Õ,  “√√–§“¬‡§Õßµ“ßÊ (di- È÷ à ‘ È◊ ◊ à °“√°≈—∫¡“¢ÕßÕ“°“√∑“ß®¡Ÿ°‡À≈à“π’ȧ◊Õ °“√rect irritants) ‡™àπ °≈‘Ëπ©ÿπ, §«—πµà“ßÊ, ΩÿÉπ≈–ÕÕß ‡°‘¥ late-phase response (LPR) æ∫‰¥âª√–¡“≥∑ÿ°ª√–‡¿∑, physical factors ‡™àπ °“√ÕÕ°°”≈—ß°“¬, √âÕ¬≈– 50 ¢ÕߺŸâªÉ«¬ 17 ´÷ËßÕ“°“√∑’ˇ¥àπ§◊Õ Õ“°“√°“√‡ª≈’ˬπ·ª≈ßÕ¬à“ß√«¥‡√Á«¢ÕßÕÿ≥À¿Ÿ¡‘, psychic §—¥®¡Ÿ°. ≈—°…≥– ”§—≠¢Õß LPR §◊Õ °“√¡’ influx ¢Õßfactor ‡™à𠇧√’¬¥, «‘µ°°—ß«≈, §«“¡º‘¥ª°µ‘∑“ß ‡´≈≈åµà“ßÊ ‡¢â“¡“„π‡¬◊ËÕ∫ÿ®¡Ÿ°¡“°¢÷È𠇙àπ eosino-°“¬«‘¿“§„π®¡Ÿ° ‡™àπ ºπ—ß°—Èπ™àÕß®¡Ÿ°§¥ (deviated phils, basophils, mononuclear cells ·≈– T cells ´÷ß Ënasal septum), septal spur ‡ªìπµâπ. ‡´≈≈åÀ≈—°∑’Ëæ∫„π nasal secretions §◊Õ eosinophils⁄¯„¡ »•Ł 24 ””•Ł 7 ¡ˆ¡fi ⁄` 2551 621
  4. 4. ¿“æ∑’Ë 2. ·ºπ¿Ÿ¡‘· ¥ß欓∏‘ √’√«‘∑¬“¢Õß allergic inflammation „π√–¬–·√° (phase 1) ¡’°“√ √â“ß IgE À≈—ß  —¡º—  “√°àÕ¿Ÿ¡‘·æâ ‡¡◊ËÕ¡’°“√ —¡º—  “√°àÕ¿Ÿ¡‘·æâπ—ÈπÕ’° (phase 2) °Á®–‡°‘¥Õ“°“√‚¥¬ªØ‘°‘√‘¬“ early- phase response ª√–°Õ∫¥â«¬ mast cell activation ·≈–¡’°“√À≈—ËߢÕß mediators À≈—ß®“°π—Èπ®–¡’ cellular infiltration ∑”„À⇰‘¥ªØ‘°‘√‘¬“ late-phase response ·≈– hyperresponsiveness µàÕ antigenic ·≈– non-antigenic stimuli ´÷Ëߺ≈¢Õß°√–∫«π°“√¥—ß°≈à“« Õ“®À“¬‡Õ߉¥âÀ√◊Õ∑”„À⇰‘¥¿“«–·∑√°´âÕπµ“¡ ¡“‰¥â. „π¢≥–∑’Ë TH-lymphocytes æ∫¡“°„π™—Èπ sub- lymphocytes ·≈– IL-6 ®“° epithelial cells21 mucosa · ¥ß∂÷ß°“√¡’ cytokine profiles ∑’Ë·µ° neuronal reflex ‡Õß °Á¡∫∑∫“∑„π allergic response ’ µà“ß°—π√–À«à“ß à«π¢Õß nasal secretions ·≈– nasal ‚¥¬™à«¬§«∫§ÿ¡ªØ‘°‘√‘¬“µÕ∫ πÕßµàÕ mediator mucosa18 eosinophils  “¡“√∂À≈—Ëß mediators, µà“ßÊ „π‡¬◊ËÕ∫ÿ®¡Ÿ° ·≈–¡’∫∑∫“∑„π°“√°√–µÿâπ T- neurotoxins ·≈– peroxidases „πªØ‘°‘√‘¬“ LPR lymphocyte22 influx ¢Õ߇´≈≈å∑’ˇæ‘Ë¡¢÷Èπ„π LPR ¡’À≈—°∞“π«à“ basophils ‡ªìπµ—«°“√À≈—Ëß histamine ‡°‘¥®“° expression ¢Õß adhesion molecules „πªØ‘°‘√‘¬“ LPR19 ´÷Ëß influx ¢Õß basophils ∑’ˇ¢â“ ∫π cell ·≈– vascular endothelial cells ´÷ËßÕ¬Ÿà ¡“„π‡¬◊ËÕ∫ÿ®¡Ÿ°π—È𠬑Ëß∑”„Àâ¡’‚Õ°“ ®– —¡º— °—∫ “√ ¿“¬„µâ°“√§«∫§ÿ¡¢Õß cytokines ™π‘¥µà“ßÊ. °àÕ¿Ÿ¡‘·æ≥⡓°¢÷Èπ ‡°‘¥ allergic inflammation °“√‡§≈◊ËÕπ‰À«¢Õß leukocytes „π√–∫∫‰À≈ ‰¥â¡“°¢÷Èπ. πÕ°®“°π—Èπ æ∫«à“ cytokines ®“°‡´≈≈å ‡«’¬π‡≈◊Õ¥¡“¬—߇¬◊ËÕ∫ÿ®¡Ÿ° ¡’·∫∫·ºπ·≈–¢—ÈπµÕπ µà“ßÊ ‰¥â∂Ÿ°À≈—ËßÕÕ°¡“¥â«¬ ‡æ◊ËÕ§«∫§ÿ¡ inflam- ∑’Ë·πàπÕπ ‚¥¬‡√‘Ë¡®“° leukocyte activation, ex- matory response ‡™àπ IL-4 ®“° mast cells20, pression ¢Õß adhesion molecules ∫π vascular IL-3, IL-4, IL-5 ·≈– GM-CSF ®“° TH-2 endothelial cells, ‡°‘¥°“√‡§≈◊ËÕπ‰À«·≈–°“√°≈‘Èß622 ⁄¯„¡ »•Ł 24 ””•Ł 7 ¡ˆ¡fi ⁄` 2551
  5. 5. (rolling) ¢Õß leukocytes ‰ªµ“¡ºπߢÕßÀ≈Õ¥‡≈Õ¥, — ◊ πÕ°®“° EPR ·≈– LPR ·≈⫬—߇°‘¥ª√“°Ø-migration ¢Õß leukocytes ºà“π endothelium °“√≥å ∑’ˇ¬◊ËÕ∫ÿ®¡Ÿ°‰«µàÕ “√°àÕ¿Ÿ¡‘·æ⇪ìπ摇»…∑’Ë¢ÕßÀ≈Õ¥‡≈◊Õ¥‰ª¬—߇¬◊ËÕ∫ÿ®¡Ÿ° À√◊Õµ”·Àπàß∑’Ë¡’°“√ ‡√’¬°«à“ çpriming effecté ´÷Ëߪ√“°Ø°“√≥åπ’È “¡“√∂Õ—°‡ ∫ ·≈– migration ¢Õ߇´≈≈åºà“π nasal epithe- °≈—∫§◊π Ÿ¿“«–ª°µ‘‰¥â‡¡◊Õ‰¡à¡°“√ —¡º—  “√°àÕ¿Ÿ¡·æâ à Ë ’ ‘lium ‰ª¬—ß nasal secretions. Õ’°µàÕ‰ª °≈‰°¢Õß°“√‡æ‘Ë¡§«“¡‰«¢Õ߇¬◊ËÕ∫ÿ®¡Ÿ° Adhesion molecules ∑’Ë ”§—≠∑’˪√“°Ø∫π À√◊Õ hyperresponsiveness π’ȇ°‘¥®“° inflam-endothelial cells §◊Õ intercellular adhesion matory cellular infiltration, mediators ∑’ËÀ≈—Ëßmolecule-1 (ICAM-1), E-selectin ·≈– vascu- ¡“°¢÷π ·≈–°“√‡æ‘¡§«“¡‰«µàÕ°“√µÕ∫ πÕߢÕß end È Ëlar cell adhesion molecule-1 (VCAM-1) ´÷Ëß organ inflammatory cells ∑’ˇ¢â“¡“„π‡¬◊ËÕ∫ÿ®¡Ÿ°§Ÿà ligands ∑’ËÕ¬Ÿà∫π eosinophils §◊Õ lymphocyte ∑’Ë¡“°¢÷Èππ’È ®–∑”„Àâ “√°àÕ¿Ÿ¡‘·æâºà“π‡¢â“‰ª„π nasalfunction associated antigen-1 (LFA-1) ·≈– mucosa ‰¥â¡“°¢÷Èπ ‡π◊ËÕß®“°°“√‡ª≈’ˬπ·ª≈ß per-macrophage antigen-1(MAC-1)  ”À√—∫ ICAM- meability ·≈–‡ªìπ target ¢Õß°“√ —¡º— °—∫ “√1, very late antigen-4 (VLA-4)  ”À√—∫ VCAM- °àÕ¿Ÿ¡‘·æâ‡æ‘Ë¡¢÷Èπ ¡’°“√ √â“ß inflammatory me-1 ·≈– sialyl-Lewis X  ”À√—∫ E-selectin ´÷Ëß diators ¡“°¢÷Èπ ·≈–‰ª‡æ‘Ë¡°“√µÕ∫ πÕߢÕß endadhesion molecules ·≈– co-receptors ‡À≈à“π’È¡’ organ. πÕ°®“°π—Èπ ºŸâªÉ«¬¬—ß¡’§«“¡‰«µàÕ “√Õ◊ËπÊ à«π√à«¡„π migration ¢Õ߇´≈≈å. ∑‰¡„™ “√°Õ¿¡·æ¥«¬ ‡™π histamine, Õ“°“»‡¬π, Ë’ à à à Ÿ ‘ â â à Á 22, 27, 28 ‡¡◊ËÕ‰¡àπ“π¡“π’È ‰¥â¡’À≈—°∞“π· ¥ß«à“ epithe- methacholine.lial cells ¡’∫∑∫“∑„πªØ‘°‘√‘¬“ allergic inflamma- ‚¥¬ √ÿª allergic inflammation ª√–°Õ∫¥â«¬tion √–¥—∫ nasal mucosa ¥â«¬ πÕ°‡Àπ◊Õ®“°°“√ sensitization phase ´÷Ëß¡’°“√ √â“ß IgE À≈—ß®“°‡ªìπ natural barrier ‚¥¬ “¡“√∂ —߇§√“–Àå media-  —¡º— °—∫ “√°àÕ¿Ÿ¡‘·æâ ·≈– clinical phase ´÷Ëß∑”„Àâtors ‰¥â¡“°¡“¬ ‡™àπ IL-1, IL-1 β, IL-6, IL-8, ¡’Õ“°“√µà“ßÊ √–À«à“ß —¡º— °—∫ “√°àÕ¿Ÿ¡‘·æâ ´÷Ëß™à«ßGM-CSF, TNF- α, MCP-1, RANTES 23 πÕ° π’Ȭ—ß·∫àßÕÕ°‡ªìπ EPR ´÷Ë߇°’ˬ«¢âÕß°—∫ degranula-®“°π—Èπ æ∫«à“¡’ expression ¢Õß adhesion mole- tion ¢Õß mast cell ·≈– LPR ´÷Ë߇°’ˬ«¢âÕß°—∫°“√cules ∑’ˇæ‘Ë¡¢÷Èπ∫π nasal epithelium √–À«à“ß∑’Ë¡’ ‡æ‘Ë¡¢÷Èπ¢Õß inflammatory cells „π‡¬◊ËÕ∫ÿ®¡Ÿ° ·≈–allergic inflammation À≈—ß —¡º— °—∫ seasonal ¡’°“√À≈—Ëß cytokines ¡“°¢÷Èπ cytokines ·≈– me-antigen24 À√◊ÕÀ≈—ß antigen challenge ·≈–¬—ß 25 diators ‡À≈à“π’È∑”„À⇰‘¥ expression ¢Õß adhesionæ∫«à“ ºŸâªÉ«¬∑’Ë·æâ‰√ΩÿÉπ ·¡â¢≥–‰¡à¡’Õ“°“√°Á¡’ mild molecules ·≈–°“√ √â“ß chemoattractants ‡æ◊ËÕexpression ¢Õß ICAM-1 ∑—Èß∫π nasal ·≈– con- ¥÷ߥŸ¥‡´≈≈åµà“ßÊ ‡¢â“¡“„π‡¬◊ËÕ∫ÿ®¡Ÿ° ´÷Ëß¡’º≈µàÕ°“√junctival epithelium ‚¥¬æ∫√à«¡°—∫ inflammatory µÕ∫ πÕߢÕ߇¬◊Õ∫ÿ®¡Ÿ°µàÕ “√°àÕ¿Ÿ¡·æâ·≈– ‘ß°√–µÿπ Ë ‘ Ë âcells · ¥ß∂÷ß°“√¡’ inflammatory reaction Õ¬Ÿà ∑’ˉ¡à„™à “√°àÕ¿Ÿ¡‘·æâ.µ≈Õ¥‡«≈“ ·¡„πª√¡“≥∑πÕ¬ (minimal persistent â ‘ Ë’ â 26inflammation) ¥—ßπ—Èπ expression ¢Õß ICAM-1∫π‡¬◊ËÕ∫ÿ®¡Ÿ° ®÷߇ªìπ —≠≠“≥∑’Ë∫àß∫Õ°∂÷ß°“√¡’ in- ≈—°…≥–∑“ߧ≈‘π‘°flammatory reaction §◊Õ ∫Õ°∂÷ߧ«“¡ “¡“√∂ Õ“°“√„π°“√¥÷ߥŸ¥‡¡Á¥‡≈◊Õ¥¢“«„À⇧≈◊ËÕπ∑’ˉª¬—߇¬◊ËÕ∫ÿ®¡Ÿ° ‡¡◊ËÕºŸâªÉ«¬ —¡º—  “√°àÕ¿Ÿ¡‘·æâ ‡™àπ ΩÿÉπ∫â“π∑”„À⇰‘¥ allergic inflammation ‰¥âµ≈Õ¥‡«≈“. ºŸâªÉ«¬®–¡’Õ“°“√§—π®¡Ÿ° ·≈–Õ“®¡’Õ“°“√®“¡µ‘¥Ê⁄¯„¡ »•Ł 24 ””•Ł 7 ¡ˆ¡fi ⁄` 2551 623
  6. 6. °—πÀ≈“¬§√—Èß ·≈–¡’πÈ”¡Ÿ°„ Ê ·≈–Õ“°“√§—¥®¡Ÿ° ®¡Ÿ°Õ“®¡’ polypoid change À√◊Õ¡’√‘¥ ’¥«ß®¡Ÿ° Õ“°“√¥—ß°≈à“«¡—°‡ªìπÕ¬Ÿà‡ªìππ“∑’ À√◊Õ™—Ë«‚¡ß À≈—ß √à«¡¥â«¬‰¥â. ®“°π—Èπ®–À“¬‰¥â‡Õß ‚¥¬Õ“®¡’Õ“°“√§—π∑’˵“, §Õ, ÀŸ °“√µ√«®‚¥¬ posterior rhinoscopy Õ“® À√◊Õ∑’Ë‡æ¥“πª“°¥â«¬. πÕ°®“°π’È ºŸâªÉ«¬Õ“®¡’Õ“°“√ æ∫«à“ª≈“¬¥â“πÀ≈—ߢÕß inferior turbinate ∫«¡‚µ Õ◊ËπÊ √à«¡¥â«¬ ‡™àπ Õ“°“√ª«¥»’√…–, ‡ ’¬ß‡ª≈’ˬπ ‡ÀÁπ‡ªìπ°âÕπ¢√ÿ¢√–§≈⓬πâÕ¬Àπà“Õ¬Ÿà∫√‘‡«≥ choana (hyponasality), ®¡Ÿ°‰¡à‰¥â°≈‘Ëπ (anosmia), πÈ”¡Ÿ° (mulberry turbinate) ‡¬◊Ë Õ ∫ÿ „ π nasopharynx ‰À≈≈ß§Õ (postnasal drip) ´÷Ëß®–„  µà“ß®“°„π‚√§ À√◊Õ√Õ∫√Ÿ‡ªî¥¢Õß∑àÕ eustachian tube Õ“®∫«¡ ‰´π— Õ—°‡ ∫‡√◊ÈÕ√—ß´÷Ëß®–¢âπ ¡’ ’‡À≈◊ÕßÀ√◊Õ‡¢’¬« Õ“® ´’¥ ·≈–¡’πÈ”¡Ÿ°„ Ê πÕ°®“°π—Èπ Õ“®æ∫ adenoid ¡’Õ“°“√ÀŸÕ◊ÈÕ À√◊Õ¡’‡ ’¬ß¥—ß„πÀŸ ®“°√Ÿ‡ªî¥¢Õß eusta- hyperplasia ‰¥â. chian tube ∫«¡, Õ“°“√§≈⓬°—∫¡’°âÕπ À√◊Õ¡’Õ–‰√ °“√µ√«® oropharynx Õ“®æ∫ºπ— ß §Õ µ‘¥Ê „π§Õ (sense of lump in the throat) À√◊Õ ‡ªìπµÿà¡πŸπ·¥ß°√–®“¬Õ¬Ÿà∑—Ë«‰ª ∑’ˇ√’¬°«à“ çgranular Õ“®¡’Õ“°“√‡®Á∫§Õ‡√◊ÈÕ√—ß ®“°°“√∑’Ë¡’ postnasal drip pharynxé ´÷Ë߇°‘¥®“°°“√√–§“¬‡§◊Õ߇√◊ÈÕ√—ߢÕߺπ—ß ·≈–°“√∑’ËÀ“¬„®∑“ߪ“°‡ªìπª√–®”‡π◊ËÕß®“°§—¥®¡Ÿ°. §Õ®“° postnasal drip À√◊Õ®“°°“√À“¬„®∑“ߪ“°. Õ“°“√· ¥ß ºŸâªÉ«¬∑’Ë¡’Õ“°“√µ—Èß·µàÕ“¬ÿ¬—ßπâÕ¬ ·≈–‡ªìπ °“√«‘π‘®©—¬‚√§ Õ¬Ÿàπ“π ∑”„ÀâµâÕßÀ“¬„®∑“ߪ“°‡ ¡Õ Õ“®∑”„Àâ ¡’®ÿ¥ª√– ß§å‡æ◊ËÕ¬◊π¬—π°“√«‘π‘®©—¬‚√§ √«¡∑—Èß °“√‡®√‘≠‡µ‘∫‚µ¢Õß°√–¥Ÿ°„∫Àπâ“·≈–øíπº‘¥ª°µ‘ ∑’Ë «π®©¬‚√§Õπ ∑‡°¥√«¡°∫‚√§®¡°Õ°‡ ∫®“°¿¡·æâ ‘ ‘ — Ë◊ Ë’ ‘ à — Ÿ — Ÿ ‘ ‡√’¬°«à“ long-face syndrome §◊Õ„∫Àπâ“ à«π≈à“ß®– ·≈–º≈·∑√°´âÕπ∑’ËÕ“®®–‡°‘¥¢÷Èπ®“°‚√§π’È ‡æ◊ËÕ∑’Ë®– ¬“«°«à“ª°µ‘ ‡π◊ËÕß®“°µâÕßÕ⓪“°À“¬„®µ≈Õ¥‡«≈“ ‰¥â„Àâ°“√√—°…“‰ª¥â«¬æ√âÕ¡°—π (¿“æ∑’Ë 3) ‡π◊ËÕß®“° ‡æ¥“𪓰®–·§∫·≈–‚§âß Ÿß (gothic arch) ‡«≈“ ¡— ° æ∫‚√§ÀÕ∫À◊ ¥ „πºŸâ ªÉ « ¬‚√§®¡Ÿ ° Õ— ° ‡ ∫®“° ¬‘È¡®–¡Õ߇ÀÁπ à«π¢Õ߇Àß◊Õ°∑’ËÕ¬Ÿà‡Àπ◊Õøíπ∫π‰¥â¡“° ¿Ÿ¡‘·æ≥â∫àÕ¬29 ®÷ߧ«√´—°∂“¡Õ“°“√‡°’ˬ«°—∫‚√§π’È ‡√’¬°«à“ çgummy smileé Õ“®¡’§«“¡º‘¥ª°µ‘ „π ¥â«¬ ·≈–§«√øíߪե¥â«¬∑ÿ°§√—Èß. °“√ ∫øíπ√à«¡¥â«¬ („π ¡—¬°àÕπ¡—°æ∫√à«¡°—∫°“√∑’Ë 1. ª√–«—µ‘ ‚¥¬Õ“»—¬≈—°…≥–‡©æ“–¢ÕßÕ“°“√ ¡µÕ¡ adenoid ‚µ ®ß¡°‡√¬°«“ çadenoid faciesé). ’ à ÷ — ’ à ‡¡◊ËÕ —¡º— °—∫ “√°àÕ¿Ÿ¡‘·æâ ·≈–§«√∂“¡∂÷ß‚√§¿Ÿ¡‘·æâ „π‡¥Á°∑’Ë¡’Õ“°“√§—π®¡Ÿ° ‡¥Á°¡—°®–¬°¡◊Õ¢÷Èπ¢¬’È À√◊Õ Õ◊ËπÊ (atopic diseases) ·≈–Õ“°“√¢Õß‚√§‡À≈à“π—Èπ ‡ ¬∑’˪≈“¬®¡Ÿ°∫àÕ¬Ê ≈—°…≥–‡™àππ’ȇ√’¬°«à“ çaller- ∑’˺ŸâªÉ«¬Õ“®‡ªìπ¥â«¬ ‡™àπ ‚√§ÀÕ∫À◊¥, ‚√§µ“Õ—°‡ ∫ gic saluteé °“√∑”‡™àππ’Èπ“πÊ Õ“®∑”„À⇰‘¥¡’ ®“°¿Ÿ¡‘·æâ, ‚√§º‘«Àπ—ßÕ—°‡ ∫®“°¿Ÿ¡‘·æâ. πÕ°®“° √Õ¬¬àπ∑’Ë —π®¡Ÿ° ‡√’¬°«à“ çallergic nasal lineé π’È §«√∂“¡‡√◊ËÕßÕ“™’æ,  —µ«å‡≈’È¬ß ·≈– ‘Ëß·«¥≈âÕ¡¢Õß √“¬∑’Ë¡’Õ“°“√§—¥®¡Ÿ°Õ¬Ÿàπ“πÊ Õ“®∑”„Àâ¡’°“√§—Ëß ºª«¬ ∑ß∑∫“π·≈–∑∑”ß“π √«¡∑ß “√∑ºª«¬§¥«“ âŸ É È— Ë’ â Ë’ È— Ë’ âŸ É ‘ à ¢Õß venous blood ∫√‘‡«≥„µâ¢Õ∫µ“≈à“߉¥â ‡√’¬°«à“ µπ·æâ ª√–«—µ‘§√Õ∫§√—«°Á¡’ à«π™à«¬ „π°“√«‘π‘®©—¬ çallergic shinersé. ‚√§ ‚¥¬ºŸâªÉ«¬‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ Õ“®¡’∫‘¥“, ¢≥–∑’˺ŸâªÉ«¬°”≈—ß¡’Õ“°“√ ∂⓵√«®®¡Ÿ°‚¥¬ ¡“√¥“ À√◊Õ≠“µ‘æ’ËπâÕß ‡ªìπ‚√§„π°≈ÿà¡ atopy ‰¥â. «‘∏’ anterior rhinoscopy ®–æ∫«à“‡¬◊ËÕ∫ÿ®¡Ÿ°‚¥¬ 2. °“√µ√«®√à“ß°“¬ ∂“µ√«®¢≥–∑¡Õ“°“√ â Ë’ ’ ‡©æ“– inferior turbinate ®–∫«¡ Õ“®¡’ ’´’¥ (pale) °ÁÕ“®æ∫Õ“°“√· ¥ßÕ¬à“ß∑’Ë°≈à“«‰«â¢â“ßµâπ ∂⓵√«® À√◊Õ ’§≈È” (bluish) ¡’πÈ”¡Ÿ°„ Ê ®”π«π¡“° ‡¬◊ËÕ∫ÿ ¢≥–∑’ˉ¡àÕ“°“√ À√◊ÕºŸâªÉ«¬°‘π¬“√–ß—∫Õ“°“√¢Õß‚√§624 ⁄¯„¡ »•Ł 24 ””•Ł 7 ¡ˆ¡fi ⁄` 2551
  7. 7. ¿“æ∑’Ë 3. ·ºπ¿Ÿ¡‘·π«∑“ß°“√µ√«®«‘π‘®©—¬‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ (®“°·π«∑“ß°“√µ√«®√—°…“‚√§®¡Ÿ°Õ—°‡ ∫®“° ¿Ÿ¡‘·æâ„πºŸâ„À≠à ”À√—∫ª√–‡∑»‰∑¬. «“√ “√ÀŸ §Õ ®¡Ÿ°·≈–„∫Àπâ“ ªï∑’Ë 2 ©∫—∫∑’Ë 2 µÿ≈“§¡ 2544).¿Ÿ¡‘·æâÕ¬Ÿà °ÁÕ“®‰¡àæ∫ ‘Ëߺ‘¥ª°µ‘„¥Ê. ·≈–‡™àπ‡¥’¬«°—π ∂Ⓣ¡àæ∫ eosinophils À√◊Õæ∫ 3. °“√µ√«®æ‘‡»… ®–™à«¬¬◊π¬—π°“√«‘π‘®©—¬ πâÕ¬°«à“√âÕ¬≈– 30 °Á‰¡à‰¥â∫Õ°«à“ºŸâªÉ«¬‰¡à‡ªìπ‚√§π’È.‚√§ „π√“¬∑’Ë¡’ª√–«—µ‘ ·≈–°“√µ√«®√à“ß°“¬‡¢â“‰¥â°—∫ 3.3 °“√µ√«®À“ basophil ·≈–/À√◊Õ‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ ·≈–®–™à«¬„π°“√«‘π‘®©—¬ mast cell ‚¥¬°“√∑” nasal scraping ´÷Ëߧ◊Õ°“√„π√“¬∑’Ë¡’ª√–«—µ‘ ·≈–°“√µ√«®√à“ß°“¬‰¡à™—¥‡®π ¢Ÿ¥™—Èπº‘«¢Õ߇¬◊ËÕ∫ÿ®¡Ÿ° ∫√‘‡«≥µ√ß°≈“ߢÕß inferi-°“√µ√«®æ‘‡»…‡À≈à“π’È ‰¥â·°à or turbinate ¡“·ºà„Àâ∫“ß∫π ‰≈¥å ·≈⫬âÕ¡¥â«¬ 3.1 °“√µ√«®À“®”π«π eosinophils Hanselûs stain À√◊Õ Wrightûs stain „πºŸâªÉ«¬‚√§„π peripheral blood smear ‚¥¬°“√‡®“– com- ®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ®–æ∫ basophil ·≈– mast cellplete blood count ∂â“æ∫«à“ eosinophils  Ÿß¡“° ¡“°°«à“§πª°µ‘.°«à“√âÕ¬≈– 10 ®–™à«¬ π—∫ πÿπ ·µà∂Ⓣ¡à Ÿß ‰¡à‰¥â 3.4 °“√À“ IgE ∑’º«Àπ—ß ‚¥¬°“√∑¥ Õ∫ Ë ‘∫Õ°«à“ºŸâªÉ«¬‰¡à‡ªìπ‚√§π’È. ¿Ÿ¡‘·æâ∑“ߺ‘«Àπ—ß (allergy skin test) ´÷Ëß®–™à«¬ 3.2 °“√µ√«®À“®”π«π eosinophil „Àâ¢âÕ¡Ÿ≈‡°’ˬ«°—∫ ‘Ëß∑’˺ŸâªÉ«¬·æâ ∑”„À⺟âªÉ«¬À≈’°‡≈’ˬ߄ππÈ”¡Ÿ° ‚¥¬π”πÈ”¡Ÿ°ºŸâªÉ«¬¡“ªÑ“¬∫π·ºàπ ‰≈¥å ‰¥â∂Ÿ°µâÕß ·≈–„Àâ¢âÕ¡Ÿ≈ „π°√≥’∑’˵âÕß√—°…“ºŸâªÉ«¬·≈⫬âÕ¡¥â«¬ Wrightûs stain ∂â“æ∫«à“¡“°°«à“ ¥â«¬«‘∏’ immunotherapy °“√µ√«®«‘∏’π’ȇªìπ«‘∏’∑’Ë¡’√âÕ¬≈– 30 ¢Õß leukocytes ∑’˵√«®æ∫‡ªìπ eosino- §«“¡‰«·≈–§«“¡®”‡æ“– Ÿß ÿ¥ „π°“√µ√«®«‘π‘®©—¬phils °π“®–‡ªπªØ°√¬“¿¡·æâ ·≈–®–™«¬ π∫ ππ Á à ì ‘ ‘‘ Ÿ ‘ à — ÿ ‚√§¿Ÿ¡‘·æâ ¡’ 2 «‘∏’ §◊Õ⁄¯„¡ »•Ł 24 ””•Ł 7 ¡ˆ¡fi ⁄` 2551 625
  8. 8. - Skin prick test „™âπÈ”¬“ °—¥®“° «‘∏’ Paper Radio-Immunosorbent Test (PRIST)  “√°àÕ¿Ÿ¡‘·æâ À¬¥≈ß∫πº‘«Àπ—ß∑’Ë·¢π ·≈â«„™â‡¢Á¡ ·≈–À“ specific IgE §◊ÕÀ“√–¥—∫ IgE ∑’Ë®”‡æ“–µàÕ  –°‘¥µ√ß°≈“ßÀ¬¥πÈ”¬“ ‡æ◊ËÕ‡ªî¥º‘«Àπ—ß™—Èπ∫πÕÕ°.  “√°àÕ¿Ÿ¡‘·æâ·µà≈–™π‘¥ ´÷ËßÀ“‚¥¬«‘∏’ Radio Aller- ∂⓺ŸâªÉ«¬¡’ IgE ∑’Ë®”‡æ“–µàÕ “√°àÕ¿Ÿ¡‘·æâπ—Èπ °Á®– gosorbent test (RAST) °“√À“ total IgE ‰¡à ‡°‘¥ªØ‘°‘√‘¬“ allergic inflammation ¢÷Èπ‚¥¬‡°‘¥ ™à«¬¡“°π—°„π°“√«‘π‘®©—¬‚√§.  à«π°“√À“ specific √Õ¬πŸπ (wheal) ·≈– º◊Ëπ·¥ß (flare) Õà“πº≈‰¥â„π IgE ‡ªìπ∑’Ëπ‘¬¡„πµà“ߪ√–‡∑» ‡π◊ËÕß®“°‰¡à‡ ’ˬߵàÕ ‡«≈“ 20 π“∑’ À≈—ß°“√∑¥ Õ∫. systemic reaction, ºŸâªÉ«¬‰¡à®”‡ªìπµâÕßߥ¬“,‰¡à - Intradermal test „™âπÈ”¬“ °—¥®“° “√ µâÕß„™â‡«≈“¢ÕߺŸâªÉ«¬π“π„π°“√∑¥ Õ∫ ‰¡à‡À¡◊Õπ °àÕ¿Ÿ¡‘·æâ ®”π«π 0.02 ¡≈. ©’¥‡¢â“„π™—Èπº‘«Àπ—ß „Àâ °“√∑” skin test ∑”„Àâ –¥«° ‡æ’¬ß·§à‡®“–‡≈◊Õ¥ 1 ‡°‘¥√Õ¬πŸπ∑’Ë¡’‡ âπºà“»Ÿπ¬å°≈“ߪ√–¡“≥ 5 ¡¡. Õà“π §√—Èß À“ “√∑’˺ŸâªÉ«¬·æ≥âÀ≈“¬™π‘¥ ·µà„πª√–‡∑» º≈„π‡«≈“ 20 π“∑’ À≈—ß©’¥‚¥¬«—¥¢π“¥¢Õß√Õ¬πŸπ ‰∑¬‰¡àπ‘¬¡„™â ‡π◊ËÕß®“°¡’√“§“·æß. ∑’Ë¢¬“¬„À≠à¢÷Èπ. 3.6 °“√À“ allergen-specific IgE ∑’Ë  “√°àÕ¿Ÿ¡‘·æâ∑’Ëπ”¡“∑¥ Õ∫ ¡—°‡ªì𠇬◊ËÕ∫ÿ®¡Ÿ° ‚¥¬°“√∑” nasal provocation test  “√°àÕ¿Ÿ¡‘·æâ ∑’Ëæ∫‰¥â∫àÕ¬ ‡™àπ ΩÿÉπ∫â“π, µ—«‰√„πΩÿÉπ, ‚¥¬π” “√∑’Ë ß —¬«à“‡ªìπ “√°àÕ¿Ÿ¡‘·æâ „ à‡¢â“‰ª„π ·¡≈ßµà“ßÊ ∑’ËÕ“»—¬„π∫â“𠇙àπ ·¡≈ß “∫ ·≈–®–¡’ ‡¬◊ËÕ∫ÿ®¡Ÿ° ·≈â«¥ŸªØ‘°‘√‘¬“¢Õ߇¬◊ËÕ∫ÿ®¡Ÿ° ·≈–Õ“°“√ positive (histamine) ·≈– negative control (car- ¢ÕߺŸâªÉ«¬ ´÷Ëß¡—°®–„™â„π°“√∑”«‘®—¬¡“°°«à“ Õ¬à“߉√ rier substance) √à«¡„π°“√∑¥ Õ∫¥â«¬ ‡æ◊Õ„Àâ·πà„®«à“ Ë °Áµ“¡ Õ“®¡’ª√–‚¬™πå„π°“√«‘π‘®©—¬ occupational ºŸâªÉ«¬‰¡à‰¥â·æâ  “√∑’Ë„™â≈–≈“¬„π “√°àÕ¿Ÿ¡‘·æâ ∑’Ëπ” rhinitis. ¡“∑¥ Õ∫ ·≈–º‘«Àπ—ßµÕ∫ πÕ߉¥â¥’µàÕ histamine. 3.7 X-ray sinus ‡æ◊ËÕ¥Ÿ«à“ºŸâªÉ«¬‚√§®¡Ÿ° ‚¥¬∑—Ë«‰ª®–∑¥ Õ∫‚¥¬«‘∏’ skin prick test °àÕπ Õ—°‡ ∫®“°¿Ÿ¡‘·æâ ¡’‚√§‰´π— Õ—°‡ ∫√à«¡¥â«¬À√◊Õ‰¡à ‚¥¬∂◊Õ«à“‡ªìπ screening test ∂⓺≈ skin prick test ´ß‡ªπ¿“«–·∑√°´Õπ∑æ∫‰¥∫Õ¬ ·≈–§«√∑”∑°√“¬ ÷Ë ì â ’Ë â à ÿ „Àâº≈≈∫ ®÷ß∑¥ Õ∫‚¥¬«‘∏’ intradermal test µàÕ‰ª ®“°°“√»÷ ° …“ plain film sinus „πºŸâ ªÉ « ¬‚√§ ∂â“ skin prick test „Àâº≈∫«°™—¥‡®π ‰¡à®”‡ªìπµâÕß ®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ∑’Ë‚√ß欓∫“≈»‘√‘√“™®”π«π ∑”°“√∑¥ Õ∫‚¥¬«‘∏’ intradermal test Õ’° ‡æ◊ËÕ≈¥ 356 √“¬ æ∫«à “ ¡’ æ ¬“∏‘   ¿“懰‘ ¥ ¢÷È π ∑’Ë ‰ ´π—   ∂÷ ß Õµ√“‡ ¬ßµÕ°“√‡°¥ systemic reaction. °“√∑¥ Õ∫ — Ë’ à ‘ √âÕ¬≈– 40. 30 ‚¥¬µ√«®À“ IgE ∑’˺‘«Àπ—ßπ’È §«√¡’‡§√◊ËÕß¡◊Õ‡µ√’¬¡ 3.8 Nasal endoscopy ‡æÕ¥√“¬≈–‡Õ¬¥ ◊Ë Ÿ ’ æ√âÕ¡ ”À√—∫ resuscitation ¥â«¬‡ ¡Õ ‡º◊ËÕ„π°√≥’ „π™àÕß®¡Ÿ°„Àâ™—¥‡®π¡“°¢÷Èπ „π√“¬∑’Ë ß —¬«à“®– ‡°‘¥ anaphylactic reaction. ¡’¿“«–·∑√°´âÕπ À√◊Õ¡’‚√§Õ◊Ëπ√à«¡¥â«¬ ‡™àπ ºπ—ß°—Èπ 3.5 °“√À“ª√‘¡“≥ IgE „π‡≈◊Õ¥ ´÷Ëß ™àÕß®¡Ÿ°§¥, √‘¥ ’¥«ß®¡Ÿ°, ‰´π— Õ—°‡ ∫, ‡π◊ÈÕßÕ° À“‰¥â∑—Èß total IgE §◊Õ‡ªìπ√–¥—∫¢Õß IgE √«¡∑—ÈßÀ¡¥ ¢Õß®¡Ÿ°·≈–‰´π— , §«“¡º‘¥ª°µ‘∑“ß°“¬«‘¿“§Õ◊ËπÊ ‰¡®”‡æ“–µÕ “√°Õ¿¡·æ™π¥„¥™π¥Àπß À“‰¥‚¥¬ à à à Ÿ ‘ â ‘ ‘ Ë÷ â ∑’Ë∑”„À⺟âªÉ«¬¡’Õ“°“√∑“ß®¡Ÿ°. (µÕπ®∫ Õà“πµàÕ©∫—∫Àπâ“)626 ⁄¯„¡ »•Ł 24 ””•Ł 7 ¡ˆ¡fi ⁄` 2551
  9. 9. ‡«™ªØ‘ ∫— µ‘ ª √‘ ∑— » πå § ≈‘ π‘ ° ‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ (µÕπ®∫) Allergic rhinitis °“√√—°…“ °“√√—°…“‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡·æâ §«√‡√‘¡µ—ß·µàÕ∏‘∫“¬‡√◊Õß‚√§π’È „À⺪«¬·≈–§π„π§√Õ∫§√—« ‘ Ë È Ë Ÿâ É ºŸâªÉ«¬‡¢â“„® ·≈–·π–π”„À⺟âªÉ«¬¥Ÿ·≈µπ‡Õß„Àâ‡À¡“– ¡ ‡™àπ 欓¬“¡√—°…“ ÿ¢¿“æ√à“ß°“¬„Àâ·¢Áß ·√ßÕ¬Ÿà‡ ¡Õ ‚¥¬ÕÕ°°”≈—ß°“¬ ¡Ë”‡ ¡Õ, √—∫ª√–∑“πÕ“À“√∑’Ë¡’ª√–‚¬™πå„Àâ§√∫ 5 À¡Ÿà, πÕπÀ≈—∫ æ—°ºàÕπ„Àâ‡æ’¬ßæÕ ·≈–√—°…“ ÿ¢¿“殑µ„Àâ ¥™◊Ëπ ·®à¡„  ‡æ√“–∂â“¡’Õ“°“√‡§√’¬¥ °—ß«≈ Õ“®∑” „ÀâÕ“°“√¢Õß‚√§‡ªìπ¡“°¢÷Èπ. ∂⓺ŸâªÉ«¬¡’Õ“°“√¢Õß‚√§ÀÕ∫À◊¥ À√◊Õ‚√§∑“߇¥‘πÀ“¬„® à«π≈à“ß °Á§«√„Àâ°“√√—°…“√à«¡¥â«¬ À≈—°°“√√—°…“¡’Õ¬Ÿà 3 ¢—ÈπµÕπ §◊Õ 1. °“√À≈’°‡≈’Ë¬ß À√◊Õ°”®—¥ ‘Ëß∑’Ë·æâ (avoidance) ‡ªìπ°“√√—°…“∑’Ë ”§—≠∑’Ë ÿ¥ ‚¥¬À≈’°‡≈’ˬߠ‘Ëß∑’Ë·æâ À√◊Õ°”®—¥ À√◊Õ≈¥ª√‘¡“≥¢Õß “√°àÕ ¿Ÿ¡‘·æâ∑’Ë¡’Õ¬Ÿà„π ‘Ëß·«¥≈âÕ¡√Õ∫µ—«„Àâ‡À≈◊ÕπâÕ¬∑’Ë ÿ¥ ‚¥¬‡©æ“–„πÀâÕßπÕπ´÷ËߺŸâªÉ«¬µâÕß„™â‡«≈“Õ¬Ÿà „πÀâÕßπ’È 6-8 ™—Ë«‚¡ßµàÕ«—π ‚¥¬¥Ÿ¥ΩÿÉπ∑”§«“¡ –Õ“¥Õ¬à“ß ¡Ë”‡ ¡Õ √«¡∑—Èß∑”§«“¡ –Õ“¥‡§√◊ËÕß ª√—∫Õ“°“»„πÀâÕßπÕπ¥â«¬ π”∑’ËπÕπ·≈–À¡Õπ¡“µ“°·¥¥∑ÿ° —ª¥“Àå ·≈–´—°∑”§«“¡ –Õ“¥ ºâ“ªŸ∑’ËπÕπ, ª≈Õ°À¡Õπ, ºâ“Àà¡ ·≈–ºâ“§≈ÿ¡‡µ’¬ß Õ¬à“ßπâÕ¬‡¥◊Õπ≈– 2 §√—Èß. „π√“¬∑’Ë·æâ¢π —µ«å °Á‰¡à§«√‡≈’Ȭߠ—µ«åπ—Èπ À√◊ÕÕ¬à“ßπâÕ¬‰¡à§«√π” —µ«åπ—Èπ‡¢â“‰ª„πÀâÕßπÕπ. πÕ°®“°π—Èπ§«√À≈’°‡≈’Ë¬ß ª“√¬– Õ“»π–‡ π æ.∫., ºŸ™«¬»“ µ√“®“√¬å  “¢“«‘™“‚√§®¡Ÿ°·≈–‚√§¿Ÿ¡·æâ â à ‘ ¿“§«‘™“‚ µ π“ ‘° ≈“√‘ß´å«∑¬“ ‘ §≥–·æ∑¬»“ µ√å»√√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ ‘‘⁄¯„¡ »•Ł 24 ””•Ł 8 ˚§¸ ⁄` 2551 711
  10. 10. ·ºπ¿Ÿ¡‘·π«∑“ß°“√√—°…“‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æ⠥⫬¬“„πºŸâªÉ«¬∑’ˇªìπ Intermittentallergic rhinitis Intermittent allergic rhinitis Õ“°“√πâÕ¬À√◊Õ¡“° ? Õ“°“√‡≈Á°πâÕ¬ Õ“°“√ª“π°≈“ß/¡“° ¬“µâ“πŒ‘ µ“¡’π™π‘¥°‘π À√◊Õ s ¬“µâ“πŒ‘ µ“¡’π™π‘¥°‘πÀ√◊Õæàπ À√◊Õ ™π‘¥æàπ®¡Ÿ°‡ªìπ§√—Èߧ√“« s ¬“µâ“πŒ‘ µ“¡’π√à«¡°—∫ decongestant ™π‘¥°‘π À√◊Õ s Corticosteroids æàπ®¡Ÿ° ¿“æ∑’Ë 4. ·ºπ¿Ÿ¡‘·π«∑“ß°“√√—°…“‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ¥â«¬¬“„πºŸâªÉ«¬∑’ˇªìπ intermittent allergic rhinitis (®“°·π«∑“ß°“√µ√«®√—°…“‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ„πºŸâ„À≠à ”À√—∫ª√–‡∑»‰∑¬. «“√ “√ÀŸ §Õ ®¡Ÿ°·≈– „∫Àπâ“ ªï∑’Ë 2 ©∫—∫∑’Ë 2 µÿ≈“§¡ 2544).  “√√–§“¬‡§◊Õß À√◊Õªí®®—¬™—°π”µà“ßÊ ∑’Ë®–∑”„Àâ  “√°àÕ¿Ÿ¡‘·æâ. ªí®®ÿ∫—ππ‘¬¡„™â second-generation Õ“°“√¢Õß‚√§¡“°¢÷Èπ¥â«¬ ‡™àπ °“√Õ¥πÕπ, °“√ antihistamine ‡ªìπµ—«‡≈◊Õ°Õ—π¥—∫·√° ‡π◊ËÕß®“°¡’ ¥¡ √“,  ∫∫À√,’Ë °“√ ¡º Ω𠧫π °≈π©π Õ“°“»‡¬π ◊Ë ÿ Ÿ ÿ — — ÿÉ — ‘Ë ÿ Á º≈¢â“߇§’¬ß‡√◊ËÕßßà«ß´÷¡ À√◊Õ anticholinergic effect À√◊Õ√âÕπ®—¥‡°‘π‰ª ®÷ßµâÕß·π–π”„À⺟âªÉ«¬ —߇°µ«à“ πâÕ¬ ‡¡◊ËÕ‡∑’¬∫°—∫ first generation. πÕ°®“°π—Èπ  “√À√◊Õ¿“«–·«¥≈âÕ¡Õ–‰√∑’Ë∑”„ÀâÕ“°“√‡ªìπ¡“°¢÷Èπ ªí®®ÿ∫—π¬—ß¡’ antihistamine „π√Ÿª·∫∫ topical ‡æ◊ËÕ∑’Ë®–‰¥âÀ≈’°‡≈’Ë¬ß Õ¬à“߉√°Áµ“¡ ∫“ߧ√—Èß°“√À≈’° ´÷Ëß¡’°“√¥Ÿ¥´÷¡‡¢â“„π°√–· ‡≈◊Õ¥‰¥âπâÕ¬ ÕÕ°ƒ∑∏‘χ√Á« ‡≈’ˬ߇ªìπ ‘Ëß∑’˪ؑ∫—µ‘‰¥â¬“°„π™’«‘µª√–®”«—π. („™‡«≈“πÕ¬°«“ 15 π“∑) ·µ®–„™‰¥º≈‡©æ“–Õ“°“√ â â à ’ à â â ∑“ß®¡Ÿ°‡∑à“π—Èπ. °“√„™â antihistamine π’È·π–π” 2. °“√„™â¬“∫√√‡∑“Õ“°“√ (pharma- „Àâ„™â„πºŸâªÉ«¬∑’Ë¡’Õ“°“√‰¡à¡“° ·≈–¡’Õ“°“√‡æ’¬ß§√—Èß cological treatment) ¢÷ÈπÕ¬Ÿà°—∫™π‘¥·≈–§«“¡ §√“« (intermittent allergic rhinitis) ´÷Ë߬“π’È À≈—° √ÿπ·√ߢÕß‚√§ (¿“æ∑’Ë 4, 5) „π°“√„™â§◊Õ „™â√–ß—∫ À√◊Õ∫√√‡∑“Õ“°“√‡∑à“π—Èπ. - Antihistamine (H 1-receptor anta- - Decongestant ¡’∑—Èß„π√Ÿª syste- gonist) ´÷Ë߬“®–‰ª·¬àß®—∫ histamine receptor ∑” mic ·≈– topical ‚¥¬®–‰ª°√–µÿâπ α-adrenergic „ÀâªÑÕß°—π°“√ÕÕ°ƒ∑∏‘Ï¢Õß histamine ∑’Ë∂Ÿ°À≈—Ëß receptor „π®¡Ÿ°∑”„ÀâÀ≈Õ¥‡≈◊Õ¥À¥µ—« ·≈–‡π◊ÈÕ‡¬◊ËÕ ÕÕ°¡“ ´÷Ëß®–‰¥âº≈¥’°ÁµàÕ‡¡◊ËÕ„À⬓°àÕπ∑’Ë®– —¡º— °—∫ „π®¡Ÿ°¬ÿ∫∫«¡. °“√„™â topical decongestant ‰¡à712 ⁄¯„¡ »•Ł 24 ””•Ł 8 ˚§¸ ⁄` 2551
  11. 11. Persistent allergic rhinitis Õ“°“√πâÕ¬À√◊Õ¡“° ? Õ“°“√‡≈Á°πâÕ¬ ∑“߇≈◊Õ°∑’Ë 2 Õ“°“√ª“π°≈“ß/¡“° ∑“߇≈◊Õ°∑’Ë 1 Corticosteroids Corticosteroids ¬“µâ“πŒ‘ µ“¡’π™π‘¥°‘πÀ√◊Õæàπ À√◊Õ ™π‘¥æàπ®¡Ÿ° „π°√≥’∑’Ë¡’Õ“°“√§—¥®¡Ÿ°√à«¡¥â«¬ „Àâ ™π‘¥æàπ®¡Ÿ° ∂â“¡’Õ“°“√§—¥®¡Ÿ°¡“° „™â decongestant ™π‘¥°‘π¥â«¬ 2-4  —ª¥“Àå „Àâ ‰¡à‡°‘π 2  —ª¥“Àå 2-4 Corticosteroids °‘π 2-4  —ª¥“Àå À√Õ decongestant æπ  —ª¥“Àå ◊ à ‰¡à‰¥âº≈ ®¡Ÿ°‰¡à‡°‘π 10 «—𠉥âº≈ ? ‰¥âº≈ ? ‰¡à‰¥âº≈ ‰¥âº≈ ‰¥âº≈ ‰¡à‰¥âº≈ ‰¥âº≈ ? „ÀâµàÕ‡¡◊ËÕ¡’Õ“°“√ ≈¥¢π“¥ æ∫ºŸâ‡™’ˬ«™“≠ ‰¥âº≈ Corticosteroids ≈ß „À⬓µàÕ‡π◊ËÕßÕ¬à“ßπâÕ¬ 3 ‡¥◊Õπ·≈â«≈¥¢π“¥¬“≈ß À“ “‡Àµÿ∑’Ë∑”„Àâ‰¡à‰¥âº≈ æ∫ æ∫ “‡Àµÿ∑’Ë∑”„Àâ√—°…“ √—°…“µ“¡ “‡Àµÿ√à«¡¥â«¬ ¥â«¬¬“‰¡à‰¥âº≈ ? ‰¡àæ∫ s ‡æ‘Ë¡¬“ corticosteroids æàπ®¡Ÿ°‡ªìπ 2 ‡∑à“ À√◊Õ s „À⬓Õ◊Ëπ√à«¡¥â«¬ ‡™àπ - ¡’Õ“°“√®“¡ §—π À√◊ÕπÈ”¡Ÿ°¡“° „À⬓µâ“πŒ‘ µ“¡’π√à«¡ - ¡’πÈ”¡Ÿ°¡“° „À⬓µâ“πŒ‘ µ“¡’π√ÿàπ∑’Ë 1 À√◊Õ Ipratropium bromide æàπ®¡Ÿ° - ¡’Õ“°“√§—¥®¡Ÿ°¡“° „À⬓ decongestant ™π‘¥°‘π ‰¡à‰¥âº≈ æ‘®“√≥“√—°…“¥â«¬«—§´’𠉥âº≈ ? ‰¥âº≈ „™â¬“ corticosteroids æàπ®¡Ÿ°µàÕ‡π◊ËÕß Õ¬à“ßπâÕ¬ 3 ‡¥◊Õπ ·≈â«≈¥¢π“¥¬“≈ß¿“æ∑’Ë 5. ·ºπ¿Ÿ¡‘·π«∑“ß°“√√—°…“‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ¥â«¬¬“„πºŸâªÉ«¬∑’ˇªìπ persistent allergic rhinitis (®“° ·π«∑“ß°“√µ√«®√—°…“‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ„πºŸâ„À≠à ”À√—∫ª√–‡∑»‰∑¬. «“√ “√ÀŸ §Õ ®¡Ÿ°·≈–„∫Àπâ“ ªï∑’Ë 2 ©∫—∫∑’Ë 2 µÿ≈“§¡ 2544).⁄¯„¡ »•Ł 24 ””•Ł 8 ˚§¸ ⁄` 2551 713
  12. 12. §«√„™âµ‘¥µàÕ°—ππ“π‡°‘π 1  —ª¥“Àå ‡æ√“–®–∑”„Àâ °“√»÷°…“„À¡àÊ æ∫«à“°“√„™â topical steroids ™π‘¥ ‡°‘¥ rebound vasodilatation ·≈–‡°‘¥ rhinitis ∑’ËÕÕ°ƒ∑∏‘χ√Á« ‡ªìπ§√—Èߧ√“« ·∫∫µ“¡§«“¡®”‡ªìπ medicamentosa µ“¡¡“‰¥â ·µà„À≥â„π√–¬–‡«≈“ —πÊ È (as needed) °Á‰¥âº≈¥’‡™àπ°—π. 31 „πºŸâªÉ«¬∑’Ë¡’Õ“°“√§—¥®¡Ÿ°¡“°. Decongestant §«√ WHO ‰¥â·π–π”„Àâ„™â¬“π’‡ªìπ first-line agent È „™âÕ¬à“ß√–«—ß„πºŸâªÉ«¬Õ“¬ÿπâÕ¬°«à“ 1 ªï, ºŸâªÉ«¬Õ“¬ÿ „π°“√√—°…“ºŸâªÉ«¬∑’Ë¡’Õ“°“√¢Õß‚√§®¡Ÿ°Õ—°‡ ∫®“° ¡“°°«à“ 60 ªï, ºŸâÀ≠‘ßµ—Èߧ√√¿å À√◊Õ√“¬∑’Ë¡’¢âÕÀâ“¡„™â. ¿Ÿ¡‘·æâ·∫∫ moderate ∂÷ß severe À√◊Õ√“¬∑’ˇªìπ - Corticosteroids  “¡“√∂„À≥â„π persistent allergic rhinitis À√◊Õ„π√“¬∑’Ë¡’Õ“°“√ √Ÿª·∫∫ systemic (oral form) À√◊Õ topical ‚¥¬ §—¥®¡Ÿ°‡ªìπÕ“°“√‡¥àπ.2 oral corticosteroids ¡’¢âÕ∫àß™’È„π°“√„™â√—°…“‚√§ - Anticholinergic drug ‡™àπ ipra- ®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ §◊Õ tropium bromide ®–™à«¬„π°“√≈¥πÈ”¡Ÿ° „π√“¬∑’Ë 1. „π√“¬∑’Ë¡’Õ“°“√§—¥®¡Ÿ°¡“° ´÷Ëß „Àâ°“√√—°…“‚¥¬¬“¢π“πÕ◊Ëπ·≈â« ºŸâªÉ«¬¬—ß¡’ªí≠À“ ∑”„Àâ°“√„™â topical steroids ‰¥âº≈‰¡à¥’ ‡π◊ËÕß®“° πÈ”¡Ÿ°‰À≈¡“°Õ¬Ÿà À√◊Õ„À≥â„π√“¬∑’ËÕ“°“√ ”§—≠¢Õß ¬“‰¡à “¡“√∂‡¢â“‰ª„π®¡Ÿ°‰¥â∑—Ë«∂÷ß. ºŸâªÉ«¬§◊Õ πÈ”¡Ÿ°‰À≈. 2. „π√“¬∑’Ë¡’ anosmia √à«¡¥â«¬. - Anti-leukotrienes ‚¥¬¬“π’È®– 3. „π√“¬∑’Ë¡’ nasal polyp ‡≈Á ° Ê ™à«¬≈¥Õ“°“√§—¥®¡Ÿ°‡ªìπÀ≈—° Õ“®„À⇠√‘¡„π°√≥’ √à«¡¥â«¬ ·≈–„Àâ oral steroids ‡æ◊ËÕ∑” medical „À⬓Õ◊ËπÊ ™à«¬∫√√‡∑“Õ“°“√§—¥®¡Ÿ°·≈â« ·µàÕ“°“√ polypectomy. ‰¡à¥’¢÷Èπ. 4. „π√“¬∑’Ë¡’ rhinitis medicamen- - Future modalities °“√√— ° …“ tosa √à«¡¥â«¬ ‡π◊ËÕß®“°°“√„™â topical decongestant „À¡àÊ ∑’ˉ¥â¥”‡π‘π°“√«‘®—¬Õ¬Ÿà‡™àπ °“√„™â humanised π“π‡°‘π‰ª. monoclonal antibodies µà Õ IgE ´÷Ë ß ‡ªì π °“√ Systemic steroids ¡’¢âÕ¥’‡Àπ◊Õ topical  √â“ß·Õπµ‘∫Õ¥’µàÕ à«π ”§—≠¢Õß free IgE ∑’Ë„™â„π steroids §◊Õ ¡’º≈µàÕ∑ÿ° à«π¢Õß®¡Ÿ°·≈–‚æ√ßÕ“°“» °“√®—∫°—∫ receptor ∑’Ë mast cell À√◊Õ basophil ¢â“ß®¡Ÿ° ·µàÕ“®¡’º≈¢â“߇§’¬ß‡°‘¥¢÷Èπ‰¥â¡“° ®÷߉¡à ∑”„Àâª√‘¡“≥ IgE ∑’ËÕ¬Ÿà∫π‡´≈≈å ¥—ß°≈à“«π’È≈¥≈ß §«√„™â ∂Ⓣ¡à®”‡ªìπ®√‘ßÊ. ∑”„À⇰‘¥ªØ‘°‘√‘¬“¿Ÿ¡‘·æ≥âπâÕ¬≈ß. πÕ°®“°π—Èπ ¬—ß  à«π topical steroids ∂◊Õ‡ªìπ°“√√—°…“ ¡’°“√æ—≤π“ inhibitor µàÕ eosinophil chemotactic ¡“µ√∞“π¢Õß‚√§π’È ‚¥¬‡ªìπ¬“∑’Ë¡’ª√– ‘∑∏‘¿“æ„π factors À√◊Õ antibody µàÕ cytokines ™π‘¥Õ◊ËπÊ ∑’Ë °“√√—°…“‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ¡“°∑’Ë ÿ¥. ¥—ßπ—Èπ ¡’∫∑∫“∑„πªØ‘°‘√‘¬“¿Ÿ¡‘·æâ. ®÷ß„™â¬“π’È„π°“√√—°…“·≈–ªÑÕß°—πÕ“°“√ ·≈– “¡“√∂ ÕÕ°ƒ∑∏‘ω¥â¥’ ‚¥¬¡’§«“¡‡¢â¡¢âπ¢Õ߬“ Ÿß∑’Ë receptor 3. °“√©’¥«—§´’π (allergen immuno- „π‡¬◊ËÕ∫ÿ®¡Ÿ°. ·≈–¡’°“√¥Ÿ¥´÷¡‡¢â“ Ÿà√–∫∫‰À≈‡«’¬π therapy) ‡≈◊Õ¥πâÕ¬¡“° ∑”„Àâ¡’ systemic adverse effects ‡ªìπ°“√©’¥ “√°àÕ¿Ÿ¡‘·æâ ∑’˧‘¥«à“‡ªìπ πâÕ¬ ‡™àπ HPA-axis suppression. Õ¬à“߉√°Áµ“¡  “‡Àµÿ∑”„À⇰‘¥Õ“°“√ ‡¢â“‰ª„π√à“ß°“¬∑’≈–πâÕ¬ Õ“®æ∫º≈¢â“߇§’¬ß‡©æ“–∑’ˉ¥â∫â“߇™àπ ‡°‘¥ –‡°Á¥ ‚¥¬©’¥‡¢â“„πº‘«Àπ—ß (intradermal) À√◊Õ„µâº‘«Àπ—ß (crust) „π‚æ√ß®¡Ÿ°, ®¡Ÿ°·Àâß À√◊Õ∑”„À⇰‘¥‡≈◊Õ¥ (subcutaneous) ·≈⫧àÕ¬Ê ‡æ‘Ë¡®”π«π®π‰¥â¢π“¥ °”‡¥“‰À≈‰¥â. °“√„™â topical steroids §«√„™âµàÕ  Ÿß ÿ¥ ∑’˺ŸâªÉ«¬√—∫‰¥â. ‡πÕß°π ®ß®–‰¥º≈¥„π°“√§¡Õ“°“√¢Õߺª«¬. ·¡«“ ◊Ë — ÷ â ’ ÿ Ÿâ É âà ¢âÕ∫àß™’È„π°“√æ‘®“√≥“„Àâ°“√√—°…“‚¥¬714 ⁄¯„¡ »•Ł 24 ””•Ł 8 ˚§¸ ⁄` 2551
  13. 13. «‘∏’π’È §◊Õ ‡°‘¥º≈·∑√°´âÕπ®“°‚√§µ“¡¡“.2 1. ºª«¬·æ “√°Õ¿¡·æâ∑‰¡ “¡“√∂ Ÿâ É â à Ÿ ‘ ’Ë à®–À≈’°‡≈’ˬ߉¥â (unavoidable antigen). 2. ºŸâªÉ«¬¡’Õ“°“√¡“° ‚¥¬¡’Õ“°“√ °“√√—°…“‚¥¬°“√ºà“µ—¥µ≈Õ¥ªï ·≈–‡ªìπ¡“π“π‰¡àµË”°«à“ 1-2 ªï À√◊Õ¡’ ‡ªπ°“√º“µ¥√°…“Õ“°“√∫“ßÕ¬“ß ‡™π Õ“°“√ ì à — — à àÕ“°“√¢Õß‚√§ÀÕ∫À◊¥√à«¡¥â«¬. §—¥®¡Ÿ° À√◊ÕπÈ”¡Ÿ°‰À≈ ´÷Ëß„Àâ°“√√—°…“‚¥¬°“√„™â¬“ 3. ‰¡ “¡“√∂§«∫§¡Õ“°“√‰¥¥«¬¬“ à ÿ â â Õ¬à“߇µÁ¡∑’Ë·≈⫉¡à¥’¢÷ÈπÀ√◊Õ‰¡à “¡“√∂∑πÕ“°“√¢â“߇§’¬ß¢Õ߬“‡À≈à“π—Èπ‰¥â. 1. °“√ºà“µ—¥‡æ◊ËÕ√—°…“Õ“°“√§—¥®¡Ÿ° „π °“√‡ª≈’Ë ¬ π·ª≈ß∑’Ë ‡ °‘ ¥ ¢÷È π À≈— ß °“√©’ ¥ √“¬∑’Ë inferior turbinate ¡’°“√Àπ“µ—«¢÷ÈπÕ¬à“ß¡“°«—§´’π§◊Õ „π√–¬–·√°Ê √–¥—∫ IgE Õ“®‡æ‘Ë¡¢÷Èπ ‡¡◊ËÕ Õ“®∑”„Àâ¡’Õ“°“√§—¥®¡Ÿ°µ≈Õ¥‡«≈“ ´÷ËßÕ“®√—°…“„Àâ°“√√—°…“µ‘¥µàÕ°—π‡°‘π 1 ªï ®–¡’√–¥—∫ IgE „π ‚¥¬´’√—Ë¡≈¥≈ß. πÕ°®“°π—Èπ ®–¡’°“√ √â“ß IgG ‡æ‘Ë¡¢÷Èπ 1.1 °“√∑”≈“¬‡¬Õ∫®¡° ‡æÕ„À‡°¥ fibro- Ë◊ ÿ Ÿ Ë◊ â ‘´÷Ë߇ªìπ blocking antibody ‰ª·¬àß®—∫°—∫ “√°àÕ sis À¥¥÷ß√—Èß ∑”„À⇬◊ËÕ∫ÿ®¡Ÿ°¬ÿ∫µ—«≈ß¡“ ‚¥¬Õ“®„™â¿Ÿ¡‘·æâ °àÕπ∑’Ë “√°àÕ¿Ÿ¡‘·æâπ—Èπ®–‰ª®—∫°—∫ IgE ∑’˺‘« electrocautery, cryosurgery, laser photocoagu-¢Õß mast cell À√◊Õ basophil ∑”„Àâ‰¡à‡°‘¥ªØ‘°‘√‘¬“ lation À√◊Õ„™â radiofrequency.¿Ÿ¡‘·æâ¢÷Èπ. 1.2 °“√µ—¥ turbinate ÕÕ°∫“ß à«π (par- πÕ°®“°°“√„Àâ immunotherapy ‚¥¬ tial turbinectomy) ‚¥¬Õ“®µ—¥‡Õ“‡¬◊ËÕ∫ÿ∑’ËÀπ“µ—««‘∏’©’¥·≈â« ¡’√“¬ß“π«à“°“√„Àâ immunotherapy ‚¥¬ À√◊Õ°√–¥Ÿ° turbinate ÕÕ°Õ¬à“ß„¥Õ¬à“ßÀπ÷Ëß À√◊Õ°“√„Àâ∑“ß®¡Ÿ° (nasal immunotherapy) 32 „ÀâÀ¬¥ ‡Õ“ÕÕ°∑—Èß 2 Õ¬à“ß.„µâ≈‘Èπ (sublingual immunotherapy) 33, 34 °Á‰¥âº≈¥’ 2. °“√ºà“µ—¥‡æ◊ËÕ√—°…“Õ“°“√πÈ”¡Ÿ°‰À≈‡™π°π. πÕ°®“°π¡°“√æ≤π“ “√°Õ¿¡·æâ „À®”‡æ“– à — ’È ’ — à Ÿ ‘ â ‰¥â·°à °“√∑” Vidian neurectomy ´÷Ë߇ªìπ°“√µ—¥‡®“–®ß ∑’Ë®–‰ª°√–µÿâπ√–∫∫¿Ÿ¡‘§ÿâ¡°—π∑’ˇ°’ˬ«¢âÕß¡“° ‡Õ“ Vidian nerve ´÷Ëß„Àâ parasympathetic nerve¢÷Èπ (specific immunotherapy) ‚¥¬„™â recombi- ¡“‡≈’Ȭ߇¬◊ËÕ∫ÿ®¡Ÿ° ∑”„ÀâÕ“°“√πÈ”¡Ÿ°‰À≈≈¥πâÕ¬≈ß.nant allergen À√◊Õ peptide vaccines ‡ªìπµâπ. πÕ°®“°π’È „ π√“¬∑’Ë ¡’ ¿ “«–·∑√°´â Õ π‡°‘ ¥ ¢÷È πImmunotherapy π’ȇªìπ«‘∏’‡¥’¬«∑’Ë¡’·π«‚πâ¡«à“®– °ÁÕ“®µâÕß∑”ºà“µ—¥√—°…“¿“«–·∑√°´âÕππ—ÈπÊ ‡™àπ√—°…“‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ„ÀâÀ“¬‰¥â ‡π◊ËÕß®“° ‰´π— Õ—°‡ ∫∑’ˉ¡à¥’¢÷Èπ À√◊Õ¡’ nasal polyp °ÁÕ“®‡ªìπ°“√‡ª≈’ˬπ·ª≈ß°“√∑”ß“π¢Õß T-helper cell µâÕß∑” endoscopic sinus surgery (ESS) √“¬∑’Ë¡’‚¥¬°“√≈¥®”π«π TH-2 ´÷Ëß¡’∫∑∫“∑„π‚√§¿Ÿ¡‘·æâ OME ∑’Ë√—°…“·≈⫉¡à¥’¢÷Èπ °ÁÕ“®∑” myringotomy≈ß ·≈–‡æ‘Ë¡ TH-1 ´÷Ë߇ªìπµ—«µàÕµâ“π‰¡à„À⇰‘¥‚√§ with PE tube insertion.¿Ÿ¡‘·æâ.35, 36 πÕ°®“°π—Èπ immunotherapy ¬—ß≈¥inflammatory cell recruitment and activation ¿“«–·∑√°´âÕπ·≈–≈¥°“√À≈ߢÕß mediators ¥«¬.37, 38 WHO ·π–π” —Ë â „π√“¬∑’¡Õ“°“√¡“°·≈–‰¡à‰¥â√∫°“√√—°…“ Õ“® Ë ’ —„Àâ‡√‘Ë¡„Àâ immunotherapy „π√–¬–·√°¢Õß‚√§‡¡◊ËÕ ‡°‘¥‚√§·∑√°´âÕπµ“¡¡“‰¥â¥—ßπ’È¡’¢Õ∫àß™’È ‡æ◊Õ≈¥º≈¢â“߇§’¬ß®“°°“√„™â¬“ ·≈–ªÑÕß°—π â Ë 1. Upper respiratory tract infection‰¡à„ÀâÕ“°“√¢Õß‚√§∑’ˇªìπÕ¬Ÿà√ÿπ·√ß ·≈–ªÑÕß°—π‰¡à„Àâ ‡™àπ ‚√§‰´π— Õ—°‡ ∫, µàÕ¡ adenoid À√◊ÕµàÕ¡⁄¯„¡ »•Ł 24 ””•Ł 8 ˚§¸ ⁄` 2551 715
  14. 14. ∑Õπ´‘≈Õ—°‡ ∫, ºπ—ߧÕÕ—°‡ ∫‡√◊ÈÕ√—ß ∫“ß√“¬°“√µ‘¥ Õ—°‡ ∫®“°¿Ÿ¡‘·æâ ´÷ËߺŸâªÉ«¬∑’Ë¡’∑—Èß‚√§®¡Ÿ°Õ—°‡ ∫®“° ‡™◊ÈÕ Õ“®≈“¡‰ª∂÷ß lower respiratory tract ‰¥â. ¿Ÿ¡‘·æâ ·≈– asthma π—Èπ ∂â“Õ“°“√∑“ß®¡Ÿ°·¬à≈ß °Á 2. Otitis media with effusion (OME) ®–∑”„ÀâÕ“°“√ÀÕ∫À◊¥‡ªìπ¡“°¢÷Èπ¥â«¬ ∂â“√—°…“„Àâ ‡πÕß®“°‡¬Õ∫®¡° µ¥µÕ°∫‡¬Õ∫¢Õß nasopharynx Ë◊ Ë◊ ÿ Ÿ ‘ à — Ë◊ ÿ Õ“°“√∑“ß®¡Ÿ°¥’¢÷Èπ Õ“°“√ÀÕ∫À◊¥°Á®–¥’¢÷Èπ¥â«¬. ·≈–‡¬◊ËÕ∫ÿ√Õ∫Ê √Ÿ‡ªî¥¢Õß∑àÕ eustachian tube ‡¡◊Ë Õ 4. Nasal polyposis °“√Õ—°‡ ∫‡√◊ÈÕ√—ߢÕß ¡’°“√Õ—°‡ ∫·≈–∫«¡¢Õ߇¬◊ËÕ∫ÿ®¡Ÿ° Õ“®∑”„Àâ¡’°“√ ‡¬◊ËÕ∫ÿ®¡Ÿ° ‡ªìπªí®®—¬Àπ÷Ëß„π°“√‡°‘¥√‘¥ ’¥«ß®¡Ÿ°. ∫«¡ ·≈–Õÿ¥µ—π¢Õß√Ÿ‡ªî¥∑àÕπ’È°àÕπ ·≈⫇°‘¥ OME 5. Rhinitis medicamentosa Õ“®‡°‘¥®“° µ“¡¡“. °“√„™â topical decongestant º‘¥«‘∏’ „π°“√√—°…“ 3. Asthma ‡¡◊ËÕ‡√Á«Ê π’ȉ¥â¡’§«“¡ π„®º≈ Õ“°“√§—¥®¡Ÿ°∑’ˇ°‘¥®“°‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ. ¢Õß allergic rhinitis µàÕ asthma ‚¥¬ WHO ∂“‡√“ “¡“√∂«π®©¬‚√§®¡°Õ°‡ ∫®“°¿¡·æâ â ‘ ‘ — Ÿ — Ÿ ‘ (ARIA : Allergic rhinitis and its Impact on Asth- ·≈–„Àâ°“√√—°…“∑’∂°µâÕß·µà‡π‘πÊ °Á®– “¡“√∂ªÑÕß°—π Ë Ÿ Ë ma). 2 asthma ‡ªìπ‚√§∑’Ëæ∫√à«¡‰¥â∫àÕ¬¢Õß ‚√§®¡Ÿ° °“√‡°‘¥¿“«–·∑√°´âÕπ‡À≈à“π’ȉ¥â. ‡Õ° “√Õâ“ßÕ‘ß 1. Juniper EF, Guyatt GH. Development and International Study of Asthma and Allergies in testing of a new measure of health status for Childhood (ISAAC). Pediatr Allergy Immunol clinical trials in rhinoconjunctivitis. Clin Exp 1997;8:161-76. Allergy 1991;21:77-83. 7. Vichyanond P, Jirapongsananuruk O, Visit- 2. Bousquet J, Van Cauwenberge P, Khaltaev N, suntom N, Tuchinda M. Prevalence of asthma, ARIA Workshop Group and World Health rhinitis and eczema in children from the B Organization. Allergic rhinitis and its impact angkok area using the ISAAC (International on asthma. J Allergy Clin Immunol 2001; study for asthma and allergy in children) 108:S147-334. questionnaires. J Med Assoc Thai 1998;81: 3. International Consensus Report on Diagnosis 175-84. and Management of Rhinitis. International 8. Tuchinda M. Prevalence of allergic diseases Rhinitis Management Working Group. Allergy in students of Mahidol University. Siriraj Hosp 1994;49(19 Suppl):1-34. Gaz 1978;30:1285-98. 4. Sibbald B. Epidemiology of allergic rhinitis. 9. Bunnag C, Jareoncharsri P, Voraprayoon S, In : ML B, ed. Epidemiology of clinical al- Kongpatanakul S. Epidemiology of rhinitis lergy. Monographs in Allergy. Basel : Karger, is Thais : characteristics and risk factors. 1993:61-9. Asian Pac J Allergy Immunol 2000;18:1-7 5. Wuthrich B, Schindler C, Leuenberger P, 10. Bunnag C, Kongpatanakul S, Jareoncharsri P, AckermannLiebrich U. Prevalence of atopy Voraprayoon S, Supatchaipisit P. A survey of and pollinosis in the adult population of allergic diseases in university students of Switzerland (SAPALDIA study). Swiss Study Bangkok, Thailand. J Rhinol 1997;4:18:90-3. on Air Pollution and Lung Diseases in Adults. 11. Mc Devitt HO, Benacerraf B. Genetic control Int Arch Allergy Immunol 1995;106:149-56. of specific immune responses. Adv Immunol 6. Strachan D, Sibbald B, Weiland S, et al. World- 1969;11:31-74. wide variations in prevalence of symptoms of 12. Tada T, Ishizaka K. Distribution of gamma allergic rhinoconjunctivitis in children : the E-forming cells in lymphoid tissues of the716 ⁄¯„¡ »•Ł 24 ””•Ł 8 ˚§¸ ⁄` 2551
  15. 15. human and monkey. J Immunol 1970;104: 24. Ciprandi G, Pronzato C, Ricca V, Bagnasco M, 377-87. Canonica GW. Evidence of intercellular13. Grangette C, Gruart V, Ouaissi MA, et al. IgE adhesion molecule-1 expression on nasal receptor on human eosinophils (FcERII) : epithelial cells in acute rhinoconjunctivitis comparison with B cell CD23 and association caused by pollen exposure. J Allergy Clin with an adhesion molecule. J Immunol Immunol 1994;99:738-46. 1989;143:3580-8. 25. Ciprandi G, Pronzato C, Ricca V, Passalacqua14. Melewicz FM, Spiegelberg HL. Fc receptors G, Bagnasco M, Canonica GW. Allergen-spe- for IgE on a subpopulation of human peri- cific challenge induces intercellular adhesion pheral blood monocytes. J Immunol 1980; molecule-1 (ICAM-1 or CD54) on nasal epi- 125:1026-9. thelial cells in allergic subjects. Am J Respir15. Cines DB, van der Keyl H, Levinson AI. In Crit Care Med 1994;150:1653-9. vitro binding of an IgE protein to human plate- 26. Ciprandi G, Buscaglia S, Pesce G, et al. Mini- lets. J Immunol 1986;136:3433-40. mal persistent inflammation is present at16. Gomez E, Corrado OJ, Baldwin DL, Swanston mucosal level in patients with asymptomatic AR, Davies RJ. Direct in vivo evidence for mast rhinitis and mite allergy. J Allergy Clin Immunol cell degranulation during allergen-induced 1995;96:971-9. reactions in man. J Allergy Clin Immunol 27. Walden SM, Proud D, Lichtenstein LM, Kagey- 1986;78:637-45. Sobotka A, Naclerio RM. Antigen-provoked17. Iliopoulos O, Proud D, Adkinson NF Jr, et al. increase in histamine reactivity : observations Relationship between the early, late, and on mechanisms. Am Rev Respir Dis 1991;144: rechallenge reaction to nasal challenge with 642-8. antigen: observations on the role of inflam- 28. Klementsson H, Andersson M, Baumgarten CR, matory mediators and cells. J Allergy Clin Venge P, Pipkorn U. Changes in non-specific Immunol 1990;86:851-61. nasal reactivity and eosinophil influx and18. Lim MC, Taylor RM, Naclerio RM. The his- activation after allergen challenge. Clin Exp tology of allergic rhinitis and its comparison Allergy 1990;20:539-47. to nasal lavage. Am J Respir Crit Care Med 29. Sibbald B, Strachen DP. Epidemiology of rhi- 1995;151:136-44. nitis. In : Busse WW, Holgate ST, eds. Asthma19. Naclerio RM, Proud D, Togias AG, et al. In- and Rhinitis. Boston : Blackwell Scientific flammatory mediators in the late antigen- Publications, 1995:32-43. induced rhinitis. N Eng J Med 1985;313: 30. Bunnag C, Khanjanasthiti P, Dhorranintra B. 65-70. The incidence of sinus involvement in allergic20. Bradding P, Feather IH, Howarth PH, et al. rhinitis in Thai patients. In : Takahashi R, ed. Interleukin-4 is localized to and released Proceeding international symposium of in- by human mast cells. J Exp Med 1992;176: fection and allergy of the nose and paranasal 1381-6. sinuses. Tokyo : Scimed Publications, 1977:21. Howarth P. The cellular basis for allergic rhi- 273-7. nitis. Clin Exp Allergy 1995;50(Suppl 23): 31. Jen A, Baroody FM, deTineo M, Haney L, Blair 6-10. C, Naclerio RM. As needed use of fluticasone22. Naclerio RM. Pathophysiology of perennial al- propionate nasal spray reduces symptoms of lergic rhinitis. Allergy 1997;52(Suppl 36):7-13. seasonal allergic rhinitis. J Allergy Clin Immunol23. Papi A. Epithelial ICAM-1 regulation and 2000;105:732-8. its role in allergy. Clin Exp Allergy 1997;27: 32. Andri L, Senna G, Betteli C, Givanni S, Andri 721-4. G, Falagiani P. Local nasal immunotherapy⁄¯„¡ »•Ł 24 ””•Ł 8 ˚§¸ ⁄` 2551 717
  16. 16. for Dermatophagoides-induced rhinitis : Allergy 1997;27:1007-15. efficacy of a powder extract. J Allergy Clin 36. Meissner N, Kochs S, Coutelle J, et al. Modi- Immunol 1993;91:987-96. fied T-cell activation pattern during specific 33. Mungan D, Misirligil Z, Gurbuz L. Compari- immunotherapy (SIT) in cat-allergic patients. son of the efficacy of subcutaneous and Clin Exp Allergy 1999;29:618-25. sublingual immunotherapy in mite-sensitive 37. Durham SR, Ying S, Varney VA, et al. Grass patients with rhinitis and asthmaûa placebo pollen immunotherapy inhibits allergen- controlled study. Ann Allergy Asthma Im- induced infiltration of CD4+ T lymphocytes munol 1999;82:485-90. and eosinophils in the nasal mucosa and in- 34. Passalacqua G, Albano M, Fregonese L, et al. creases the number of cells expressing mes- Randomized controlled trial of local allergoid senger RNA for interferon-gamma. J Allergy immunotherapy on allergic inflammation in Clin Immunol 1996;97:1356-65. mite-induced rhinoconjunctivitis. Lancet 38. Klimek L, Dormann D, Jarman ER, Cromwell 1998;351:629-32. O, Riechelmann H, Reske-Kunz AB. Short- 35. Ebner C, Siemann U, Bohle B, et al. Immuno- term preseasonal birch pollen allergoid immu- logical changes during specific immunotherapy notherapy influences symptoms, specific nasal of grass pollen allergy : reduced lympho- provocation and cytokine levels in nasal proliferative responses to allergen and shift secretions, but not peripheral T-cell responses, from TH2 to THl in T-cell clones specific for in patients with allergic rhinitis. Clin Exp Phl p 1, a major grass pollen allergen. Clin Exp Allergy 1999;29:1326-35. §≥–°√√¡°“√®—¥ ¡—™™“ ÿ¢¿“æ·Ààß™“µ‘ ªï 2551 ( ™.) ®—¥ª√–°«¥ÕÕ°·∫∫µ√“ —≠≈—°…≥å (logo) §”¢«—≠ (motto) ·≈–µ—« —≠≈—°…≥å (mascot) ‚¥¬º≈ß“π‡À≈à“π’È®–µâÕß ◊ËÕ§«“¡À¡“¬¢Õß ¡—™™“  ÿ¢¿“æ·Ààß™“µ‘ÕÕ°¡“‰¥âÕ¬à“ß™—¥‡®π ‡æ◊ËÕ„™â‡ªìπ —≠≈—°…≥åß“π ¡—™™“ ÿ¢¿“æ·Ààß™“µ‘∑’Ë®—¥¢÷Èπ‡ªìπ ª√–®”∑ÿ°ªï ºŸ π„® “¡“√∂ Õ∫∂“¡√“¬≈–‡Õ’¬¥‡æ‘¡‡µ‘¡‰¥â∑‚∑√»—æ∑å 0-2590-2304 ·≈– 08-6893-2131 â Ë ’Ë À√◊Õ email : contest@nationalhealth.or.th À√◊Õ‡«Á∫‰´µå www.nationalhealth.or.th  àß„∫ ¡—§√æ√âÕ¡º≈ß“π‰¥âµ—Èß·µà«—ππ’È®π∂÷ß 25  ‘ßÀ“§¡»°π’È ∑’Ë  ”π—°ß“π§≥–°√√¡°“√ ÿ¢¿“æ·Ààß™“µ‘ ™—Èπ 2 Õ“§“√¥â“π∑‘»‡Àπ◊Õ «π ÿ¢¿“æ (∂. “∏“√≥ ÿ¢ 6) ¿“¬„π∫√‘‡«≥°√–∑√«ß “∏“√≥ ÿ¢ ∂.µ‘«“ππ∑å Õ.‡¡◊Õß ®.ππ∑∫ÿ√’ 11000 «ß‡≈Á∫¡ÿ¡´Õß«à“ ç àߺ≈ß“πª√–°«¥é718 ⁄¯„¡ »•Ł 24 ””•Ł 8 ˚§¸ ⁄` 2551

×