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Rhinology Flashcards

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1
Q

What bacteria is rhinophyma associated with?

A

Demodex Follicularum

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2
Q

What bacteria is rhinoscleroma associated with, Histopath and TX?

A

Klebsiella Rhinoscleromatis

Mikulicz’s cell (“moth eaten” cytoplasm, foamy macrophages), Russell bodies (bloated plasma cells with bifringent inclusions), pseudoepitheliomatous hyperplasia
Rx : Long term abx , debridement, consider laser excision or cryotherapy. Can be very disfiguring.

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3
Q

Favorable prognostic indicators for acute invasive fungal sinusitis?

A

Uncontrolled diabetes or hematologic malignancy, surgical intervention, treatment with Amphotericin B.

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4
Q

NEGATIVE prognostic indicators for acute invasive fungal sinusitis?

A

Advanced age, renal/liver failure, altered mental status, intracranial extension

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5
Q

Risk of malignant transformation for inverted papillomas

A

10% risk of transformation to a SCC

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6
Q

Most common causes of acute bacterial rhinosinusitis

A

Strep pneumo > H. flu > Moraxella

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7
Q

Mechanism of Azelastine

A

H1 receptor antagonist

Used for allergic rhinitis

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8
Q

Mechanism of Ranitidine and use

A

H2 receptor antagonist used for GERD

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9
Q

T4a maxillary sinus tumor

A

Invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, nasopharynx or clivus, CN other than V2

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10
Q

T4b maxillary sinus tumor

A

All of previous plus dura or brain involvement, middle fossa invovlement, orbital apex

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11
Q

Definition of recurrent acute rhinosinusitis

A

At least 4 episodes per year with asymptomatic episodes in between

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12
Q

Kadish staging for esthesioneuroblastoma?

A

A - Nasal cavity
B - Sinus
C - Beyond sinuses and nasal cavity
D - Presence of metastases (regional or distant)

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13
Q

Derivitives of the 5 ethmoturbinals? Where does inferior develop from?

A

1: Ascending: Agger nasi, Descending: Uncinate
2: Middle turbinate/ethmoid bulla
3: Superior turbinate
4/5: Supreme turbinate (usually regresses)
Inferior turbinate develops from maxilloturbinal

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14
Q

What do the following innervate:
External br. of anterior ethmoid n.
Interior br. of anterior ehtmoid n.
Infratrochlear n.
Infraorbital n.
sphenopalatine n.

A

External br. of anterior ethmoid n. - nasal tip
Interior br. of anterior ehtmoid n. - sup nasal cavity
Infratrochlear n. - nasal dorsum
Infraorbital n. - lateral nose, subnasal region
sphenopalatine n. - inferior + post nasal cavity
(SENSORY)

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15
Q

Two common types of fungus you can see in acute invasive, histopath features and treatment for each one?

A

Aspergillus - 45 degree septate hyphae
- Treat with IV Voriconizole
- Usually seen with neutropenia
Mucor - 90 degree NON septate hyphae
- Treat with IV Amphotericin B
- Usually seen with uncontrolled diabetes

-MRI: will see a distinctive contrast enhancing rind around dark (necrotic) tissue

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16
Q

Features of pediatric allergic fungal sinusitus (in comparison to adults)

A
  • More likely to have proptosis
  • More likely to present with unilateral disease
  • More likely to grow Curvularia and Bipolaris (vs. aspergillus more likely in adults)
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17
Q

Bent and Kuhn Classification for AFRS

A
  1. History of atopy (type I sensitivity)
  2. Nasal polyposis
  3. CT showing hyperdense central mucin surrounded by rim of hypodense material, with radio opaque areas representing fungal elements. MRI T1 AND T2 show hypointense central areas with hyperintense rims.
  4. Eusinophilic mucin with Charcot Leiden crystals
  5. Positive fungal stain for non invasive disease
  • Typically seen in AA patients, lower socioeconomic status.
  • Lower rate of asthma interestingly as compared to CRSwNP due to defect in TLR-4 innate immunity pathway.
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19
Q

What is HHT (Osler Weber Rendu)?

A

AD with variable penetrance
Hereditary hemorrhagic telangiactesia
-Telangiactesia, AV malformations, aneurysms
-Think with recurrent epistaxis and telangiactesias

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19
Q

Contents of Vidian Canal

A
  • Vidian nerve (confluence of greater superficial petrosal nerve and deep petrosal nerve
  • Vidian artery (from ICA)
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20
Q

Superior orbital fissure contents and syndrome SX

A

Contents: CN 3, 4, V1, superior orbital vein, superior opthalmic vein, lacrimal/meningeal anastamosis
Syndrome: Involved III, IV, V1

-Orbital pain, photophobia, proptosis , ophthalmoplegia ,
upper eyelid ptosis/paralysis, nonreactive dilated pupil, anesthesia over
ipsilateral forehead, loss of corneal sensation. Ptosis.Visual acuity intact.
Often from sphenoid sinusitis.

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21
Q

When do the sinuses develop?

A

Maxillary - First to develop. Develop ~ 3 years, + 7-18
Ethmoids - Developed at birth
Sphenoid - Not present at birth. Develop through teens
Frontals - Not present at birth, develop until age 20

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22
Q

Distance of ant., post. ethmoid arteries and optic nerve from lacrimal crest (ant to posterior)

A

24 mm to anterior ethmoid art. THEN
12 mm to posterior ethmoid art. THEN
6 mm to optic nerve

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23
Q

Keros Classification I-III

A

Depth of olfactory groove
I - 1-3 mm, II - 4-7 mm, III - 8-16 mm

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24
Q

Anatomical boundaries of the frontal recess?

A

Medial: middle turbinate, cribriform plate

Lateral: lateral papyracea

Posterior: ethmoid bulla

Anterior: agger nasi , uncinate , beak, etc

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25
What are the Draf I-III procedures?
Draf I removal of ethmoid bulla Draf IIa removal of agger nasi and frontal recess cells Draf IIb removal of frontal floor from orbit to middle turb Draf III Modified lothrop , remove ISS, superior septum, some middle turb
26
What are the different types of frontal cells (1-4)?
• Type 1 – Single ethmoid cell above agger nasi • Type 2 – Tier of 2 or more cells in frontal recess above agger nasi • Type 3 – Single massive cell pneumatizing into frontal • Type 4 – (Kuhn) floating cell within frontal sinus
27
What is orbital apex syndrome?
Orbital Apex Syndrome: SOF syndrome + **loss of vision**. Involves **II**, III, IV, VI, V1
28
What is cavernous sinus thrombosis syndrome?
Involves III, IV, VI, V1, V2. Ophthalmoplegia , chemosis, proptosis, nonreactive pupil, anesthesia over ipsilateral, forehead and cheek (often Due to tumors 35% of time, can be from ethmoiditis . 80% fatal (not as much these days)
29
Sympathetic pathway for sinuses?
Superior cervical ganglion --\> postganglionic with ICA, split off with **deep petrosal nerve** , join GSPN --\> **vidian nerve** (nerve of the pterygoid canal where it joins ascending sphenoidal branch from otic ganglion). Provides **vasoconstrictor** tone to arteries and capacitance veins.
30
Parasympathetic pathway for sinuses?
Superior salivatory nucleus --\> nervus intermedius --\> geniculate ganglion --\> GSPN --\> **vidian nerve** --\> pterygopalatine ganglion --\> travel with trigeminal. **Controls secretions and dilates resistance vessels**
31
External nasal valve vs internal nasal valve anatomy?
External: nasal alar cartilage, columella , and nasal sill Internal: septum, anterior edge of the inferior turbinate, and caudal edge of upper lateral cartilage; narrowest segment (50% of total nasal resistance)
32
Blue Cell Tumors Mnemonic
MR SLEEP ## Footnote Melanoma/Merkel cell; Rhabdo ;SNUC/small cell (SNUC); Lymphoma; Ewing’s; Esthesio ; PNET (primitive neuroectodermal tumor)/plasmocytoma
33
Encephalocele vs Glioma
Encephalocele - failed migration of neural crest cells results in ependymal lined meninges herniation though the base of skull; **communicates with subarachnoid space** SSx : soft, masses that change with straining and crying , transilluminates Dx : CT or MRI reveals a bony defect, Furstenburg test (compression of the jugular vein causes increase in the size of the mass from increased CSF pressure) Glioma ––“pinched off” encephalocele. SSx : intranasal or extranasal firm, nonpulsatile mass (typically not midline), skin covered, **does not change in size with straining** , broad nasal dorsum. Dx : CT or MRI to evaluate for intracranial extension
34
Dermoid Cyst of Sinus Features?
Pathophysiology : defective obliteration of dural tissue in **prenasal space or fronticulus frontalis**, forms an epithelial lined cyst (may contain hair and adnexal tissue). Presents at birth.
35
Features of Inverted Papilloma?
HPV 6, 11, 16, 18 M\>F, 5th-6th decades Typically presents on lateral nasal wall DX - CT Histopath - **cristae-laden** senescent mitochondria, inflammatory cells throughout epithelium, **endophytic growth** of epithelium into underlying stroma. Complications: 5-10% malignant degeneration from lateral wall lesions extension into sinuses, orbit, nasolacrimal duct, or skull base Rx: excision with drilling of bone at root
36
What is the Hollman Miller sign?
Anterior bowing of posterior maxilla and enlargement of superior orbital fissure. Seen with JNAs.
37
Features of Esthesioneuroblastoma (age distribution, stain, TX, histopath)?
Rare, Bimodal peak in 2 nd and 6 th decades of life Stain for S100 Presents as a pink or brown friable nasal mass, excellent prognosis if confined to nasal cavity Rx : surgical excision with postoperative radiation treatment of choice Pathology: Homer Wright pseudorosettes 30% of cases, Flexner Wintersteiner (true) rosettes ––(Grade III) 5% of cases
38
Rhinosporidiosis Bacteria, SX, Histopath, TX
Rhinosporidium seeberi, India, Pakistan, Africa SSx : friable, “strawberry” red (vascular) polypoid nasal lesion (epistaxis, Dx : culture and biopsy Histopathology : **pseudoepitheliomatous hyperplasia** , submucosal cysts, fungal sporangia with chitinous shells Rx : surgical excision with cauterization of the base and oral antifungal agents, corticosteroid injections, may consider dapsone ![]()
39
TX for Allergic Fungal Rhinosinusitus
Rx : surgical debridement, **topical and oral corticosteroids**, abx (co bacterial infection) , consider adjuvant antifungal medications or immunotherapy ![]()
40
Blood supply to vestibular organs (2)?
Anterior vestibular a. - Utricle, SCC, HCC Posterior vestibular a. - Most of saccule
41
Primary sympathetic neurotransmitter and parasympathetic neurotransmitter to nose?
Sympathetic - Norepi Parasympathetic - Ach
42
What medication can improve anosmia?
Budesonide irrigation with olfactory training leads to better olfaction outcomes than concurrent use of plain saline irrigation.
43
Stepwise management for Prolactinoma?
Medical TX first - Cabergoline or Bromocriptine Surgical management reserved for non responders, intolerance to medication, patient choice, apoplexy, cystic components.
44
UPSIT test interpretation?
Anything less than 10 (by chance, anyone should get 10/40) Normal: 34-40 (F), 35-40 (M) 31-34 or 35: Mild 26-30: Moderate 19-25: Severe 6-18: Complete Anosmia
45
What hormones are secreted by the posterior pituitary?
Oxytocin, Vasopressin. Everything else is anterior pituitary.
46
Diagnostic criteria for chronic rhinosinusitus?
12 weeks of 2 major criteria (drainage, obstruction, facial pain, hyposmia/anosmia) AND evidence of inflammation (mucous or edema in middle meatus, nasal polyposis, radiographic evidence of inflammation)
47
What is Ohngren's line and what is it's significance?
Angle of mandible to medial canthus. Tumors above this have poorer prognosis due to increased risk of invading skull base.
48
Axial CT scan of the sinuses with important landmarks (picture on other side)
49
Coronal CT scan of sinuses with landmarks (picture on other side)
50
Contents of Foramen Ovale? Foramen Rotundum? Foramen Spinosum? SOF? Jugular Formen?
Ovale: V3 Rotundum: V2 Spinosum: Middle meningeal artery SOF: III, IV, V1, VI Jugular: IX, X, XI
51
Chandler Classification for JNA (4 total)?
1 - nasopharynx 2- nasal cavity or sphenoid 3 - maxillary, ethmoid, infratemporal fossa, orbit, cheek, cavernous sinus 4- Intracranial extension
52
Krouse T staging for Inverted Papilloma
Stage T1: nasal cavity Stage T2: ostiomeatal complex region, ethmoid, or medial wall of the maxillary sinus Stage T3: involves any wall of the maxillary sinus but medial, frontal sinus, or sphenoid sinus Stage T4: any extranasal or extrasinus extension or presence of a malignant neoplasm
53
Churg Strauss and Treatment
Small/medium cell vasculitis, p-ANCA positive Asthma, eusinophilia (\>10%), allergic rhinosinusitus, pulmonary infiltrates, vasculitis, neuritis TX - Oral steroids, cyclophosphamide/methotrexate and management of sinonasal SX (FESS)
54
Keisselbach's Plexus
Anterior ethmoid a., sphenopalatine a., greater palatine a. (off Imax), septal branch of superior labial a. (off facial)
55
HHT Features
- Autosomal dominant - Curacao criteria: Epistaxis, mucosal telangectasias, visceral lesions (AV malformations), first degree relative) - TX - Treat epistaxis medically and/or surgically as needed Consider brain MRI to rule out brain AV malformation
56
Mechanism of Dubilimab, Omalizumab, Mepolizumab
Duplimab - anti IL-4 and 13 Omalizumab - anti IgE (binds to Fc part) *Also approved for chronic urticaria* Mepolizumab - anti IL-5
57
Samter's Triad
- Polyps, asthma and asthma exacerbated by COX-1 inhibitors - Caused by abnormality in arachodonic acid cascade --\> leads to pro inflammatory cascade - TX for CRS +/- aspirin desensitization \*40-50% of patient with CRS w/NP have asthma
58
Granulomatosis with Polyangitis Features and TX
Small/medium vasculitis, C-ANCA positive SX: chronic inflammation, granulation tissue, concurrent infection, chronic mucosal crusting, septal perforation, saddle nose deformity TX: Oral corticosteroids, immunosuppressants (cyclophosphamide), Bactrim if in remission, FESS if in remission, saline rinses
59
Sarcoidosis Features and TX
-**Noncaseating granulomatous disease** SX: **Bihilar lymphadenopathy** on chest x-ray , fatigue, night sweats, and weight loss, erythema nodosum, Uveitis, Heerfordt’s syndrome (enlarged parotid glands, facial nerve palsy, uveitis, and fever), **severe chronic inflammation and polyps, presence of mucosal nodules and/or cobble stoning of mucosa** TX: Oral corticosteroid, Immunosuppressive agents (cyclophosphamide and methotrexate), Topical saline rinses and steroids for symptomatic relief, FESS in controlled inflammatory disease
60
Mechanism of Montelukast?
Leukotriene receptor antagonist - used for CRS w/NP
61
Features of Kartagener's
- Autosomal RECESSIVE - CRS - Bronchiectasis - Ciliary dyskinesia - Situs Inversus
62
What is this and what MRI features would you see?
90 degree non septate hyphae → Mucor Would see hyperdense rind around dark necrotic (non contrast enhancing) material on MRI Treat with Amphotericin B
63
What test do you use to asses patency of lacrimal valve?
Jones dye test (flourescein)
64
What super antigen is associated with CRS w/NP?
Staphylococcal Enterotoxins
65
What has budesonide shown to improve?
Improved SNOT 22 scores (when used after surgery) and improved olfaction outcomes when used concurrently with saline.
66
What causes proptosis with grave's disease?
Proliferation of fibroblasts and lymphocytic infiltration in the **extraocular muscles** (sometimes need medial orbital wall decompression).
67
Indications for DCR and landmarks?
Indications: Primary or secondary nasolacrimal duct obstruction (long standing epiphora) -Axilla of the middle turbinate and the maxillary line, which represents the anterior attachment of the uncinate process. Anatomic studies have shown that the lacrimal sac lies lateral to the nasal wall at the maxillary line with the major portion extending up to 1 cm superior to the level of the insertion of the middle turbinate. Removal of bone to that point will maximize exposure of the superior half of the lacrimal sac.
68
Internal Nasal Valve Components
Septum, inferior turbinate head, caudal edge of upper lateral cartilage, +/- piriform appeture -Most narrow segment of nasal cavity, angle less than 10-15 degrees may lead to nasal valve collapse.
69
What is next step in imaging for positive beta 2 transferrin/rhinorrhea but no evidence of skull base defect on CT scan?
MRI with FLAIR and CISS protocols
70
Encephalocele vs Glioma
Encephalocele - failed migration of neural crest cells results in ependymal lined meninges herniation though the base of skull; **communicates with subarachnoid space** SSx : soft, masses that change with straining and crying , transilluminates Dx : CT or MRI reveals a bony defect, Furstenburg test (compression of the jugular vein causes increase in the size of the mass from increased CSF pressure) Glioma ––“pinched off” encephalocele. SSx : intranasal or extranasal firm, nonpulsatile mass (typically not midline), skin covered, **does not change in size with straining** , broad nasal dorsum. Dx : CT or MRI to evaluate for intracranial extension
71
What does posterior pituitary secrete?
Oxytocin, vasopressin
72
How does CSF appear in MRI T2 CISS vs MRI T2 FLAIR?
T2 CISS- CSF BRIGHT T2 FLAIR - CSF DARK Order if CT scan doesn't localize CSF leak
73
What is the blood supply for a nasoseptal flap?
Nasoseptal banch of posterior nasal artery (from sphenopalatine artery)
74
What markers is COVID associated with?
IL-6, IL-1, TNF-alpha (inhaled corticosteroids downregular these)
75
What is this?
Inverted papilloma, often grows off lateral wall of nasal cavity or inferior turbinate. Pearl: Most sinus malignancies are T2 hypo or isointense which helps to differentiate the tumor from inflammatory mucosa or fluid which is T2 hyperintense.
76
Mechanism of cocaine?
Blocks uptake of norepi and epi in the CNS and systemically (via sodium channel blocking) Vasoconstrictor Do NOT use with Ketamine (arrythmias)
77
What is this (no bony involvement or intracranial extension)?
Thornwald's cyst - the most common congenital nasopharyngeal lesion! Can cause OSA type symptoms High T1 and T2 signal Notochord remnant TX: Observe is asymptomatic, trans oral marsupialization if symptomatic
78
Cystic fibrosis inhertience, gene, sx?
-AR -CFTR issue, chloride ion channel -Delayed meconium -Lots of sinus infections
79
Sarcoidosis mnemonic - A GRUELLING Disease!
Ace increase Granulomas aRthritis Uveitis Erythema nodosum Lymphadenopathy (bilateral hilar) Lupus pernio Idiopathic NON CASEATING Gammaglobulinemia Vit Di increase (hypercalcemia) Sinonasal; Severe inflammatory polyps, crusting, mucosal cobblestoning
80
Coccidiomycosis features, cultures, TX?
Southwest USA/Mexico/South America Usually pulmonary disease but can disseminate to skin (also inside nose polyp like), skin ,etc. TX: Itraconazole (Amphotericin B if in spine, etc.) Cultures: Shows "spherules of C" + granulomatous reaction
81
What cytokine profile is seen in patients with CF?
Nasal polyps are driven by neutrophils, IL-8 Different from the usual CRS!!
82
What sinus SX is associated with Gardener syndrome and what is the inheritence pattern?
Multiple OSTEOMAS (most common benign neoplasm of the sinuses, often in the frontal sinuses) -AD inheritence -Associated with colon polyps too!
83
What is the diagnostic criteria for churg straus?
4 out of 6 features needed to be identified: Asthma, Migratory infiltrates in lung, Paranasal sinus abnormalities, Mono or polyneuropathy, Peripheral blood eosinophilia (greater than 10% total leucocyte count), Eosinophilic tissue infiltrates in the biopsy.
84
MOA of Benralizumab?
Anti IL-5 RECEPTOR alpha Ab. Good for asthma, Wegener's
85
What are the components of the NOSE score?
Five items: nasal congestion, nasal obstruction, trouble breathing through the nose, trouble sleeping, unable to get enough air through the nose during exercise or exertion.

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