allergic rhintis general consideration

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‘¥≈
‘‘
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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. „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— “√°àÕ
À≈“¬ “‡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 Õ
À≈—° ‰¥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 ·≈– basophils
À≈“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≈—ß
‰¥·°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 ¢Õß
factor ‡™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 Ë
nasal septum), septal spur ‡ªìπµâπ. ‡´≈≈åÀ≈—°∑’Ëæ∫„π nasal secretions §◊Õ eosinophils
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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«·≈–°“√°≈‘Èß
622 ⁄¯„¡ »•Ł 24 '””•Ł 7 ¡ˆ¡fi ⁄` 2551

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≈—Ëß
molecule-1 (ICAM-1), E-selectin ·≈– vascu- ¡“°¢÷π ·≈–°“√‡æ‘¡§«“¡‰«µàÕ°“√µÕ∫ πÕߢÕß end
È Ë
lar 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 nasal
function 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 end
adhesion 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∑”„Àâ
tors ‰¥â¡“°¡“¬ ‡™àπ IL-1, IL-1 β, IL-6, IL-8, ¡’Õ“°“√µà“ßÊ √–À«à“ß —¡º— °—∫ “√°àÕ¿Ÿ¡‘·æâ ´÷Ëß™à«ß
GM-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 adhesion
æ∫«à“ ºŸâªÉ«¬∑’Ë·æâ‰√ΩÿÉπ ·¡â¢≥–‰¡à¡’Õ“°“√°Á¡’ mild molecules ·≈–°“√ √â“ß chemoattractants ‡æ◊ËÕ
expression ¢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 â
cells · ¥ß∂÷ß°“√¡’ inflammatory reaction Õ¬Ÿà ∑’ˉ¡à„™à “√°àÕ¿Ÿ¡‘·æâ.
µ≈Õ¥‡«≈“ ·¡„πª√¡“≥∑πÕ¬ (minimal persistent
â ‘ Ë’ â
26
inflammation) ¥—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. °—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√– ߧå‡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. ¿“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 cell
plete 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≈’°‡≈’ˬß
„ππÈ”¡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. - 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. ‡«™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≈’°‡≈’Ë¬ß ‘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§«√‡≈’È¬ß —µ«åπ—Èπ À√◊ÕÕ¬à“ßπâÕ¬‰¡à§«√π” —µ«åπ—Èπ‡¢â“‰ª„πÀâÕßπÕπ. πÕ°®“°π—Èπ§«√À≈’°‡≈’ˬß
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. ·ºπ¿Ÿ¡‘·π«∑“ß°“√√—°…“‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡‘·æâ
¥â«¬¬“„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 ‰¡à
712 ⁄¯„¡ »•Ł 24 '””•Ł 8 ˚§¸ ⁄` 2551

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 «—π
‰¥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. §«√„™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°“√√—°…“‚¥¬
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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 à
Õ“°“√¢Õß‚√§ÀÕ∫À◊¥√à«¡¥â«¬. §—¥®¡Ÿ° À√◊ÕπÈ”¡Ÿ°‰À≈ ´÷Ëß„Àâ°“√√—°…“‚¥¬°“√„™â¬“
3. ‰¡ “¡“√∂§«∫§¡Õ“°“√‰¥¥«¬¬“
à ÿ â â Õ¬à“߇µÁ¡∑’Ë·≈⫉¡à¥’¢÷Èπ
À√◊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 π
Immunotherapy 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¡
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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
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