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ENT Written Board Prep > Rhinology > Flashcards

Rhinology Flashcards

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1
Q

What are the predominant cells found in acute sinusitis? CRS?

A 
ARS = neutrophils 
CRS = eosinophils
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2
Q

Name the 4 lamellae

A

1: uncinate process
2: ethmoid bulla
3: basal/ground lamella
4: superior turbinate

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3
Q

Name the organisms most commonly involved in atrophic rhinitis and rhinoscleroma.

A

AR: Klebsiella ozeanae
Rhino: Klebsiella rhinoscleromatis

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4
Q

Name the organisms most commonly involved in rhinoscleroma and rhinosporidiosis.

A

Rhinoscl: Klebsiella rhinoscleromatis
Rhinosp: Rhinosporidium seebri (fungi have spores)

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5
Q

Name the organisms most commonly involved in ABRS.

A

Moraxella, Strep pneumoa, H flu

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6
Q

Name the organisms most commonly involved in mycetoma, ARS, AIFS, CIFS

A

mycetoma – aspergillus fumigatus
AFRS – demitaceous
acute invasive – aspergillus fumigatus, mucor (Rhizopus)
chronic invasive - aspergillus flavus

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7
Q

Name the arterial contributions to Kisselbach’s plexus. Woodruff’s?

A

Kisselbach’s – SPA, greater palatine, ant ethmoid, superior labial
Woodruff’s – SPA, posterior ethmoid, ascending pharyngeal

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8
Q

What are the nasal manifestations, histology, and lab testing for GPA?

A

GPA – (mnemonics based on “c” for c-ANCA) crusting, caseating granulomas, c-ANCA

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9
Q

Describe the differences (physical exam, embryology origin) between nasal dermoids, gliomas, and encephaloceles.

A

Dermoid – trapped ectoderm (skin, hair, sweat glands); abnormal closure of fonticulus frontalis, firm masses that don’t transilluminate or compress

Glioma – trapped glial elements; abnormal closure of fonticulus frontalis, firm masses that don’t transilluminate or compress

Encephalocele – trapped CNS from abnormal closure of foramen cecum or other areas of skull base; blue/red, soft compressible masses that DO transilluminate; positive Furstenburg sign (expansion w IJV compression)

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10
Q

Most common site of CSF leak?

A

Lateral lamellae of the cribiform (also – this is part of the ethmoid bone, while the fovea ethmoidalis (2nd most common CSF leak site) is part of the frontal bone)

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11
Q

Second most common site of CSF leak?

A

Fovea ethmoidalis (first is lateral lamellae of cribriform)

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12
Q

5 ethmoturbinals and 3 furrows - what do they become?

A

Ethmoturbs: 1st- aggar nasi and uncinate; 2nd - middle turb; 3rd- superior turb; 4th&5th - supreme turb. Furrows:

Furrows: 1st - ethmoidal infundibulum & frontal recess; 2nd - superior meatus; 3rd supreme meatus

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13
Q

The four lamellae?

A

Uncinate; ethmoid bulla; ground lamella; superior turb

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14
Q

Most common site of attachment for the uncinate process?

A

lamina paparycea

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15
Q

Boundaries of the ethmoidal infundibulum?

A

Ethmoidal infundibulum: uncinate medial, ethmoid bulla posterior, maxilla /lacrimal bone anterior, lamina paparycea lateral.

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16
Q

Boundaries of the frontal recess?

A

Frontal recess: suprabullar recess posterior, aggar nasi anterior, middle turb medial, lamina paparycea lateral

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17
Q

What are the keros classifications and their significance? Which is highest risk?

A

Height of the lateral lamella of the cribriform plate: Keros I 1-3mm, Keros II 4-7mm, Keros III >7mm. Keros III highest risk for CSF leak

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18
Q

Histological differences between ARS and CRS? Difference in predominant inflammatory cell for ARS vs CRS? Which one is Th2 mediated?

A

ARS: exudative process; neutrophils. CRS: proliferative process; eosinophils. CRS with polyps is Th2 mediated. CRS without polyps thought to be more Th1 mediated, triggers (tobacco, environmental pollutants/irritants, genetic predisposition to G- infections?)

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19
Q

Bent + Kuhn major diagnostic criteria for AFRS (there are five)?

A

characteristic CT findings, culture-proven fungus, Type I hypersensitivity to that fungus, eosinophilic mucin, nasal polyposis.

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20
Q

Classically implicated family of fungi in AFRS?

A

Dematiaceous family.

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21
Q

What is Samter’s triad? Implicated inflammatory mediator?

A

Nasal polyposis, aspirin sensitivity, asthma. Leukotrienes.

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22
Q

Role of aspirin in the arachidonic acid pathway? How does it lead imbalance in inflammatory response in Samter’s triad?

A

Blocks prostaglandin E synthesis, thereby leading to overproduction of leukotrienes in the arachidonic acid pathway due to loss of negative feedback loop. Arachidonic acid can go towards 5-lipoxygenase (leukotrienes) or cyclooxygenase pathways (PGE2).

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23
Q

Diagnostic criteria for CRS?

A

2 of 4: facial pain/pressure, nasal discharge, hyposmia/anosmia, nasal congestion for 12 weeks

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24
Q

What subset of CSF leaks have the highest rate of encephaloceles (traumatic, spontaneous, iatrogenic)? Roughly how high is that rate?

A

Spontaneous. >50%

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25
Name 3-4 ways to diagnose a CSF leak
beta-2-transferrin, thin-cut CT, MRI/MR cisternography, CT cisternography with intrathecal contrast
26
How to administer intrathecal fluorescein? What complication can occur at higher doses?
0.1cc of fluorescein in 10cc CSF given over 10 m. Seizures; Also it’s not FDA approved for this
27
What type of anesthesia has been shown to reduce blood loss in FESS? What special anesthesia considerations should be taken for CSF leak case?
TIVA; RSI for CSF leak case and extubate deep to prevent pneumocephalus from bagging
28
What are the Draf procedures and how do they differ? Which one is the same as a modified Lothrop? Which one is good for lateralized middle turbinate/revision?
Draf 1 - frontal recess surgery without involving ostium. Draf 2A is frontal sinusotomy dissection up to but not including the middle turbinate. Draf 2B dissection medial to the middle turbinate with some resection of the anterior attachment of the middle turb. Draf 3 is modified Lothrop and involves posterior septectomy with drilling of the intersinus septum. Draft 2B is good for revision/lateralized middle turbinate.
29
How far below the skull base can the anterior ethmoid artery run? What percent are dehiscent?
4mm below (some say 5mm). 25% dehiscent.
30
Management of an arterial orbital hematoma? Name 2-3 additional non-procedural considerations in management?
Lateral canthotomy/cantholysis. Give mannitol, timolol eye drops, dexamethasone. Ophtho consult. Medial orbital decompression (though this is obviously surgical).
31
Define these potential spaces in nasal embryology: fonticulus nasofrontalis, paranasal space, foramen cecum
fonticulus - between the frontal bone and the nasal bone. paranasal space - between the nasal bone and the nasal capsule. foramen cecum - between the frontal bone and the ethmoid bone
32
5 parts of the nasal septum?
perpendicular plate of ethmoid, vomer, maxillary crest, quadrangular cartilage, palatine bone
33
What structure(s) drain(s)s into the superior, middle, and inferior meati?
superior: posterior ethmoids. middle: ethmoid infundibulum, frontal, anterior ethmoid, maxillary sinuses. inferior meatus: nasolacrimal duct
34
What does the superior labial artery supply? Angular artery?
Superior labial: columella and lateral nasal wall. Angular artery: nasal ala, dorsum, tip
35
Branches of the ICA that supply the nose?
ICA: anterior/posterior ethmoid arteries
36
Branches of the ECA that supply the nose?
ECA (internal maxillary): greater palatine, sphenopalatine artery, descending palatine.
37
Violation of which artery implicated in septal hematomas after septoplasty?
Sphenopalatine artery
38
Vessels in Kiesselbach’s plexus? Woodruff’s plexus? (4 each)
Kiesselbach: superior labial, greater palatine, anterior ethmoid, anterior septal branch of sphenopalatine. Woodruff: sphenopalatine, ascending pharyngeal, posterior nasal artery, posterior ethmoid
39
Parasympathetic and sympathetic autonomic innervation of the nose: a) which ganglion? b) travels with which peripheral nerves? c) function?
a) pterygopalatine ganglion for parasympathetic; T1-T3 superior cervical sympathetic ganglion. b) greater superficial petrosal/nervus intermedius; deep petrosal nerve. c) parasympathetic: mucous secretions, vasodilation. sympathetic: vasoconstriction
40
Difference between gel and sol layers of mucus: a) superficial vs deep? b) produced by which cells? c) function?
a) gel is superficial, sol is deep. b) gel is made by goblet cells/secretory cells; sol is made by microcilia c) gel is supposed to trap particles/antigens, sol helps with ciliary movement
41
Borders of external nasal valve? Borders of internal nasal valve? Narrowest point?
External nasal valve: caudal edge of the upper lateral cartilage, columella, ala. Internal nasal valve: upper lateral cartilage, head of the turb, nasal septum. INV is narrowest point.
42
Normal relationship between upper lateral cartilage and septum?
Normal relationship is 10-15 deg
43
Cell type in olfactory region of the nose? Location?
pseudostratified neuroepithelium. Located in the olfactory cleft adjacent to the cribriform plate.
44
Where do the axons of the olfactory neurons synapse?
They synapse in the olfactory bulb
45
What type of hypersensitivity mediates allergic rhinitis?
allergic rhinitis mediated by type I hypersensitivity.
46
When does the early phase of allergic reaction occur and what cell types/inflammatory mediators are involved?
Early phase within 5-15m, mast cells involved -> histamine release, leukotrienes.
47
When does the late phase of allergic reaction occur and what actors are involved?
Late phase 2-4 hours later, eosinophils/neutrophils/basophils involved -> prolong the early phase reactants.
48
Name 2-3 nonallergic causes of rhinitis. Name 2-3 medications that can cause rhinitis.
vasomotor, hormone, rhinitis medicamentosa, atrophic, infectious, drug-induced. Medications: NSAIDs, ACE inhibitors, OCPs, beta blockers.
49
Colonization with what organism is associated with atrophic rhinitis? What is secondary atrophic rhinitis?
Klebsiella ozeanae. Secondary = postop, traumatic.
50
Necrotizing granulomas of respiratory tract, vasculitis, kidney dysfunction (glomerulonephritis). Diagnosis? Serology?
Wegener’s/PGA. C-ANCA
51
Rhinosclera vs Rhinosporidiosis: Organism? b) Nasal findings/clinical manifestations? c) Treatment?
a) rhinosclera = Klebsiella rhinoscleromatis. rhinosporidiosis = rhinosporidium seeberi. b) Rhinosclera has 3 phases but can cause granulomas. Rhinosporidium causes polyps. c) Rhinosclera = antibiotics, possible debridement. Rhinosporidiosis = surgical excision
52
What is the Lynch incision?
Access to the anterior ethmoidal artery from external approach.
53
What are the relationships between the lacrimal crest, the anterior ethmoidal artery, the posterior ethmoidal artery, and the optic canal?
24-12-6mm
54
Define by duration/frequency: ARS, subacute RS, CRS w/wo nasal polyps, recurrent ARS
ARS < 4 weeks. subacute 4-12, chronic > 12. Recurrent acute = 4 episodes in 12 months with complete resolution in between
55
Cell type mediating CRS with polyps? Cytokines/inflammatory mediators involved in polyposis?
CRS with NP = eosinophils; leukotrienes involved.
56
AFRS: Name 2-3 dematiaceous fungi.
Alternaria, Bipolaris, Curvilaria.
57
What do the speckled areas of increased attenuation on CT correspond to in AFRS? What do the hyperdense areas surrounded by a rim of hypointensity on CT correspond to?
Speckled areas = allergic mucin. Hyperdense = ferromagnetic elements from fungi.
58
What is Churg Strauss?
vasculitis with granulomas of the nose and asthma. also eosinophilia.
59
Fungus ball: most common sinus? most common organism?
Maxillary; Aspergillus fumigatus
60
Mucor vs Aspergillus: septations? angle? background? shape?
Mucor = nonseptations, 90 degrees, tissue background, serpiginous. Aspergillus = +septations, 45 degrees, hyphae background, vermiform
61
Which form(s)of fungal sinusitis are associated with Aspergillus flavus? Aspergillus fumigatus?
flavus associated with granulomatous. AIFS/CIFS with fumigatus
62
What are the Chandler classifications of orbital complications from ARS?
I - preseptal cellulitis; II- orbital cellulitis; III subperiosteal abscess; IV - orbital abscess; V - cavernous sinus thrombosis
63
How is superior orbital fissure syndrome different from orbital apex syndrome?
orbital apex syndrome involves CN II
64
Most common sinonasal malignancy in adults? Pediatrics? b) 3 most commonly involved sites?
SCC in adults, embryonal rhabdomyosarc in peds. b) most commonly involved = nasal cavity, maxillary sinus, ethmoid
65
Name 2-3 exposure risks for SCC vs adenocarcinoma of the sinuses.
SCC - aflatoxins, mustard gases, nickel. adenocarcinoma - woodworking/furniture, leather
66
Histological markers for esthesio vs SNEC vs SNUC?
esthesio - CK negative, neuron-specific enolase positive; SNEC CK+, NSE+; SNUC CK+, NSE weak or -. Chromogranin and synaptophysin also neuroendocrine markers.
67
IP: a) site of origin? b) rate of malignant transformation?
a) lateral nasal wall b) 5-9%
68
JNA: a) radiologic buzzword/eponym? b) major arterial supply (typically)?
a) holman miller / expansion of PPF b) internal max
69
What’s notable about the behavior of adenoid cystic carcinoma?
high rate of perineural spread
70
Histopathological cell type in chordoma?
physalliferous / soap bubble cells
71
What is the Kadish system and what is it used for?
Grading system for esthesioneuroblastoma. A - limited to nasal cavity B - extension to paranasal sinuses C - extension outside of the paranasal sinuses D - intracranial involvement
72
What is Ohngren’s line? What is its clinical significance?
Diagonal line from angle of the mandible to medial canthus. Anterioinferior to that late, prognosis is better
73
Blood supply of the following flaps: a) nasoseptal flap b) pericranial flap c) temporoparietal fascia d) temporalis muscle
a) posterior septal artery b) supratrochlear and supraorbital c) superficial temporal artery d) deep temporal artery
74
Complications: a) most common source of venous bleed? b) arterial bleed? c) intradural nerve injury? d) extradural nerve injury? e) location of positive margins?
a) pterygoid plexus or cavernous sinus b) ethmoidal arteries c) CN II d) CN I e) lateral supraorbital dura
75
Most common presenting symptom of a sinonasal tumor? Second most common presenting symptom?
nasal obstruction; neck mass

ENT Written Board Prep (13 decks)

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