Rhinology And Allergology Flashcards
(176 cards)
1
Q
How to perform endoscopic sphenopalatine ligation?
A
- ff middle turbinate to posterior aspect
- vertical incision 7-8mm anterior to the posterior end of middle turbinate
- crista ethmoidalis seen and marks anterior sphenopalatine foramen; vessels posterosuperior, clip or cauterize
2
Q
How to ligate ethmoid aa?
A
- lynch incision
- anterior lacrimal crest of maxilla frontal process to anterior ethmoid foramen 22-24mm distance.
Anterior ethmoid to posterior ethmoid foramina 12-15mm
Posterior ethmoid aa foramen and optic canal 3-7mm
3
Q
Definition of ars? Subacute ars? Chronic? Recurrent?
A
Less than 4 weeks with complete resolution
Between 4 and 12 weeks
More than 12 weeks
> 4episodes a year lasting >7-10days with complete resolution in between episodes
4
Q
4 cardinal symptoms of crs?
A
- Anterior or posterior purulent nasal discharge
- Nasal obstruction
- face pain/pressure
- hyposmia or anosmia
5
Q
Dx of crs is 2 of the carinal symptoms accompanied by:
A
- endoscopic evidence of mucosal inflammation
- polyp in nasal cavity or middle meatus
- radiologic evidence of mucosal inflammation
6
Q
5 criteria of Bent and Kuhn for allergic fungal rhinosinusitis?
A
- Eosinophilic mucin (charcot-leyden crystals)
- Non invasive fungal hyphae
- Nasal polyposis
- Characteristic radiologic findings
(Ct - rim of hypointensity with hyperdense central material (allergic mucin) - Type 1 hypersensitivity reaction
7
Q
Is acute allergic fungal rhinosinusitis unilateral or bilateral?
A
Unilateral
8
Q
Fungal ball in sinus. Mc location? Mc fungus? Immunocompetent/immunocompromised? Treatment?
A
Maxillary sinus
Aspergillus fumigatus
Immunocompetent
Surgical removal
9
Q
Chronic invasive fungal rhinosinusitis.
How many weeks duration?
Immunocompetent/compromised?
Etiologic agent?
A
> 4 weeks with minimal inflammatory response
Immunocompetent
Aspergillus fumigates
10
Q
Chronic granulomatous fungal rhinosinusitis. How long? Immunocompetent or compromised? Histologic findings? Etiologic agent?
A
> 4 weeks with mucosal inflammatory cell infiltrate
Immunocompetent
-multinucleated giant cell granulomas centered on eosinophilic material surrounded by fungus
-aspergillus flavus
11
Q
What is another name for the valveless veins in the nasal area?
A
Veins of Breschet
12
Q
What is the Chandler classification for ophthalmic complications due to rhinosinusitis?
A
A. Preseptal cellulitis - inflammatory edema with no limitation of eom
B. Orbital cellulitis - chemosis, impairment of eom, proptosis, possible visual impairment
C. Subperiosteal abscess - pus collection between media periorbita and bone; chemosis, exophthalmos, eom impaired, visual impairment worsening
D. Orbital abscess - pus collection in orbital tissue, complete ophthalmoplegia with severe visual impairment
13
Q
What is the superior orbital fissure syndrome?
A
Cn 3,4,V1 and 6
14
Q
What is the orbital apex syndrome?
A
Cn 2,3,4,V1 and 6
15
Q
What is pott puffy tumor?
A
Frontal bone osteomyelitis to erosion of the anterior bony table
16
Q
Effective first line surgical procedure for children ages 13 or younger with crs?
A
Adenoidectomy
17
Q
Microorganism responsible for atrophic rhinitis?
A
Klebsiella ozaenae
18
Q
Mc histology of pns malignancy?
A
Scc
19
Q
Location of pns cancer locations?
A
Maxillary sinus (55%)
Nasal passage (35%)
Ethmoids (10%)
Frontal and sphenoid sinuses (<1%)
20
Q
Mc symptom of pns tumor? (1 and 2)
A
Mc nasal obstruction
2nd: neck lymphadenopathy
21
Q
Sinonasal undifferentiated carcinoma (SNUC) histopathologic markers?
A
Cytokeratin (CK), epithelial membrane antigen (EMA), weak neuron specific enolase (NSE)
22
Q
Sinonasal neuroendocrine carcinoma (SNEC) histopathologic markers?
A
Chromogranin (CHR)
NSE
Synaptophysin (SYN)
Epithelial markers (CK)
23
Q
Top 3 most common location of osteoma?
A
- Frontal sinus
- Ethmoid
- Maxillary
24
Q
Sinonasal papilloma (3) most common types:
A
- Septal papilloma (50%)
- Inverted papilloma (47%) from lateral nasal wall
- Cylindrical papilloma (3%) from lateral nasal wall
25
Inverted papilloma _____ of malignancy?
3-9%
26
Epicenter of JNA?
Sphenopalatine area
27
Ct scan in JNA shows expansion of what area?
Pterygopalatine fossa
28
Primary blood supply of JNA?
Int. max
29
Scc comprises ______ of all paranasal sinus cancers.
70-80%
30
Olfactory groove tumors from most to least aggressive.
1. Scc of the skull base
2. Sinonasal undifferentiated ca
3. Sn neuroendocrine ca
4. Esthesioneuroblastoma
31
Malignant mucosal melanoma of the pns survival in 2 years?
25%
32
Physaliferoys cells with soap bubble appearance on pathology?
Clival chordoma
33
Kadish system for ENB?
A: tumor of nasal fossa
B: ext to PNS
C: ext beyond PNS
D: ext into or beyond dura
34
TNM ENB staging system?
T1 : inv nasal cavity/PNS (x sphenoid), sparing most superior ethmoid cells
T2: inv nasal cavity/PNS (inc sphenoid), with extension to or erosion of the cribriform plate
T3: extending into orbit or protruding into anterior cranial fossa, without dural invasion
T4: inv brain or dura
N0: no cervical LN inv
N1: any cervical LN inv
M: no mets
M1: distant mets
35
ENB Hyams histopathological grading?
Grade 1-2: homer wright pseudorosette
Grade 3-4: flexner wintersteiner rosettes
Based in mitosis, necrosis, pleomorphism, type of tissue architecture
36
Pns malignancy with worst prognosis? Best?
Mucosal melanoma
| Minor salivary gland tumors, low-grade sarcoma
37
```
Paranasal sinus treatment complications most common site?
Venous bleeding?
Arterial bleeding?
Intradural nerve injury?
Extradural nerve injury?
Positive margins?
```
- Cavernous sinus or pterygoid plexus
- Ethmoid or internal maxillary arteries
- CN II
- CN I
- lateral supraorbital dura
38
What nerves are responsible to experience odor?
Cn 1, 5, 9, 10
39
At physiologic air flow rates, what percent of air flows through the olfactory region?
15%
40
Best olfactory ability is noted at what times?
Times of upper respiratory infection, when the epithelium is moderately congested, red, and wet. Olfactory seems to improve with narrow nasal chambers
41
Where does the mucus of the olfactory region come from?
Bowman’s glands (serous type) and adjacent respiratory mucosa goblet cells.
42
Where is the olfactory epithelium located?
7cm inside the nasal cavity, protected in a 1mm wide crevice.
43
Type of epithelium of olfactory epithelium?
Pseudostratified columnar with no submucosa
44
4 main types of cells in the olfactory area?
1. Ciliated olfactory receptors
2. Microvillar cells
3. Supporting (sustentacular) cells - do not directly influence the transduction process
4. Basal cells - globus basal cells seem to be responsible for continuous replacement of olfactory receptor cells. Replication cycle is 3-7weeks
45
Number of olfactor cells in humans?
6M
46
First relay station in the olfactory pathway?
Olfactory bulb
47
Have the largest gene family in the entire genome?
Olfactory receptors
48
Odor memory lasts how long?
At least a year. (Visual memory only a few months)
49
Number of molecules needed to stimulate a receptor?
9
50
Threshold levels for stimulation?
40 receptors
51
Most widely used test substances for smell?
Pyridine and n-butyl alcohol
52
How to identify malingering patients (anosmia)?
Place coffee granules on the tongue. An anosmic px would only taste a bitter taste but not coffee. A malingerer will identify the taste as coffee, yet will be unable to recognize it when passed in front of the nose.
53
________ have better olfactory ability both in threshold and identification.
Women
54
Adaptation and habituation takes how long?
1-5mins
55
Total anosmia occurs with blows to the?
Occiput
56
Best known type of congenital hyposmia.
Kallman’s syndrome
57
Distortion of inhaled odors. Perception of smell without an odorant in the environment?
Parosmia, phantosmia
58
Conjure memories based on odors in such a dramatic way.
Marcel proust syndrome
59
Useful for the detection of the nasal cycle.
Rhinostereometry
60
Shows the volume of the nasal cavity?
Acoustic rhinometry
61
Sign to assess the effect of the nasal valve, the pxs cheek is drawn back to see whether a significant decrease in obstruction occurs.
Cottle sign
62
In rhinomanometry, it determines what?
Nasal patency
63
In rhinomanometry, what is referred to by the ff terms?
Ratio of pressure to flow
Ratio of flow to pressure
Mean pressure x flow
Resistance
Conductance
Work
64
Advantages of acoustic rhinometry?
-better for studies of rapidly changing microvascular conditions and nasal volume changes
- provides more precise anatomic information
- less variable results
- useful for the evaluation of patients.
65
What does the “I” notch in rhinometry signify?
Isthmus nasi, first dip
66
What does the “C” notch in rhinometry signify?
Concha, 2nd dip, which corresponds to the anterior tip of the inferior turbinate.
67
What is the normal notch pattern in rhinomanometry?
In patients with allergic rhinitis and with habitual snoring?
“Climbing w”
“Descending w”
68
What is the international standard of resistance?
150 Pa
69
For allergic patients, the MCA (minimal cross sectional area) is at the _________ and not at the usual i notch.
C notch
70
What is a clear indication for surgery?
Constant stenosis and total flow of 700 cm3/sec
71
Normal MCA (minimal cross sectional area) in acoustic rhinometry?
For the total airway?
0. 72-0.73 cm2 before decongestion,
0. 92-0.95cm2 after congestion,
1. 46cm2 before congestion
1. 88cm2 after congestion
72
Most important determinant of patient’s wellbeing?
Total resistance
73
Slit like opening between the caudal edge of the lateral cartilage and the nasal septum coined by Mink, considered to be the narrowest part of the nasal airway, aka nasal valve, os internum, limen vestibule, limen nasi, luminal valve, luminal chink?
Ostium internum
74
What are the three types of sphenoid sinuses as described by Hamberger?
1. Sellar (67-76%): Sella turcica bulges into a well-developed sinus.
2. Presellar (23-28%): Cancellous bone extends from under the sella to the anterior aspect of the floor.
3. Conchal (0-5%): Sphenoid sinus is entirely filled with cancellous bone.
75
What is the foramen of Morgagni?
Gap between superior constrictor muscle and skull base.
76
What passes through the foramen spinosum?
Meningeal branch of V3
77
Passes through infraorbital foramen?
Terminal branch of V2
78
Passes through foramen ovale?
Accessory meningeal artery and terminal branch of V3
79
Passes through sphenopalatine foramen?
Sphenopalatine artery
80
Passes through superior orbital fissure?
CN 3, 4, 6 and V1
81
Passes through foramen rotundum?
V2
82
Where does Dorello's canal pass and what structures does it contain?
Lies between the petrous tip and sphenoid bone and contains the CN 6 and inferior petrosal sinus.
83
What are the nuclei of the vagus nerve?
Nucleus ambiguus,dorsal motor nucleus, and the nucleus of the solitary tract.
84
What are the diagnostic criteria for Acute Fungal Sinusitis according to Bent and Khun?
Allergic mucin
Nasal polyposis
CT scan findings consistent with chronic rhinosinusitis
Positive fungal histology or culture
Type I hypersensitivity diagnosed by history, positive skin test, or serology.
85
What is the most common organism cultured from an intracerebral abscess resulting from rhinosinusitis?
Streptococcus milleri (commensal found in the mouth, vagina, and feces).
86
Vomeronasal organ located on the anteroinferior nasal septum?
Jacobson organ
87
Orthonasal stimulation is detected?
Nose
88
Retronasal stimulation is detected?
Posterior choanae
89
Most frequent cause of olfactory loss?
Frontal blow
90
Rate of recovery from an olfactory blow?
<10%
91
Mechanism of injury to olfactory epithelium?
Shearing of olfactory nerve at cribriform plate
| Contusion of olfactory bulb or other central processing areas
92
At what age does olfactory identification drop?
60-70 yrs old
93
Mucus travels what speed?
2-10 mm/hr
94
Ciliary beat frequency?
8 hz normal temp
| 12 hz at 37 degrees c
95
Primary screening for primary ciliary dyskinesia?
Nasal nitric oxide. Tenfold decrease in pcd.
96
Three types of wegener's granulomatosis?
Type 1: limited form. Urti lasting several weeks, unresponsive to antibiotics associated with serosangiunous nasal drainage and pain
Type 2: sicker patients with more systemic symptoms
Type 3: widely disseminatd, with involvement of multiple airway, pulmonary, renal and cutaneous lesions
97
How to dx WG?
C anca
98
Treatment of WG?
Oral cyclophosphamide 2mg/kg/day for 1 year and prednisone 1mg/kg/day for 1 month. Trimethoprim-smx
99
3 dx criteria for sarcoidosis?
Clinical and radiologic presentation typical of sarcoidosis
Nasal biopsy materal should demonstrate non caseating granulomas
Other causes of granulomatous changes excluded
100
Is mucosal destruction seen in wg or cgs?
Wg
101
3 phases of churg strauss syndrome?
1. Prodromal pjase
2. Peripheral blood and tissue eosinophilia, chronic eosinophilic pneumonia, eosinophilic gastroenteritis
3. Life threatening systemic vasculitis
102
Treatment of churg strauss syndrome?
Corticosteroids
103
3 stages for the development of rhinoscleroma?
Catarrhal - foul smelling discharge weeks/months
Atrophic stage - large nasal plaques or crusts foul smelling and stimulate the lesions in atrophic rhinitis
Granulomatous - multiple granulomatous nodules, which enlarge and coalesce
Fibrosis and stenosis - sometimes extending into the nasopharynx and trachea
104
Dx of rhinoscleroma?
Eosin staining russel bodies
| Hallmark of vacuolated mikulicz cells
105
Treatment of rhinoscleroma?
Streptomycin 1g/day for 4 weeks
| Tetracycline 2g/day
106
Site in nasal cavity most affected by TB?
Nasal septum
| Anterior portion of nasal turbinates
107
Causative agent of rhinosporidius, usual in asian and african countries?
Rhinosporidium seeberi
108
How to dx mucormycosis?
Periodic acid schiff stain or
| Grocott-gomori methenamine silver nitrate stain
109
Survival rate of mucormycosis?
50%
110
How to differentiate WG and t cell lymphoma?
1. Distribution of ulceration is focal, localized and explosive in t-cell lymphomas
2. Systemic features and lung infiltrates are similar, but otologic, renal, and tracheal involvement is uncommon in t-cell
3. Main differences are found on morphologic examination
111
```
Supplies septum:
Anterior inferior
Superior posterior
Superior anterior
Anterior
Posterior?
```
```
Greater palatine aa
Posterior ethmoid aa (also supplies lateral wall)
Superior anterior: anterior ethmoid aa
Anterior: superior labial from facial aa
Posterior: sphenopalatine
```
112
Transfusion threshold for epistaxis?
9mg/dL
113
At how many mins will phenylephrine decongest? Anesthetize?
6mins and 9mins
114
Longest and most anterior branch of the sphenopalatine artery?
Posterior lateral nasal branch. Clipped and ligated to locate the nasopalatine branch to the palate
115
Where is anterior ethmoid found? Most common?
Always between 2nd and 3rd lamella.
| Subrabullar recess.
116
Temperature of hot water irrigation for epistaxis?
52 degree celsius (122 degrees f) for 3 mins.
117
When do traumatic epistaxis take place?
7 weeks post injury
118
Connects ica and eca through branch of the sphenopalatine.
Vidian artery
119
1st branch of the internal carotid aa?
Ophthalmic aa
120
How long should nasal pack in epistaxis be left in place?
12-24hrs
121
How to ligate anterior ethmoid aa accdg to stammerger?
1-2mm behind junction of posterior wall of frontal recess and anterior ethmoid
122
How to locate anterior ethmoid aa accdg to simon?
From posterior wall of frontal recess, 11mm (6-15mm)
123
Where does transnasal endoscopic sphenopalatine artery ligation (TESPAL) ligate?
At the posterolateral attachment of the middle turbinate where the sphenopalatine foramen leaves the sphenopalatine foramen.
124
Contraindication for embolization in epistaxis?
Identified bleeding froming from eca supply. Cannot be for ica because causes blindness.
125
How to perennial ar?
>2 hours a day
| >9 months/year
126
Most suggestive symptom of allergy?
Itching
127
Mast cell degranulation releases?
Histamin
Tryptase
PGD2
Cysteneil leukotrienes
128
What is local allergic rhinitis?
Localized nasal allergy
Allergy testing negative (skin or serologic)
(-) systemic atopy
129
H1 antihistamine effective within?
1 hour
130
Name an intranasal antihistamine
Azelastine
131
First line treatment for AR?
Intranasal corticosteroid
132
Principal s/e of icns?
Local nasal irritation
133
Mc pathophysiology of atrophic rhinitis?
Before antibiotics, klebsiella ozaenae. Now secondary to surgery.
134
Pathologic change in atrophic rhinitis?
Ciliated respiratory epithelium are converted to non ciliated squamous metaplasia.
135
Fda approved treatment for nares (2)?
Fluticasone
| Beclomethasone
136
What percent of icns is absorbed?
20%
137
Nasal ciliary beat? Mucus moves?
10-15 beats/min
| 2.5-7.5 ml/min
138
Sympathetic mediation in nose?
Norepinephrine, neuropeptide Y - vasoconstriction
139
Parasympathetic mediation in nose?
Norepinephine, acth, vip - increased secretion
140
Nasal sensation?
CN 5
141
Blood supply of columnella and caudal septum?
Superior labial aa
142
Shape and angulation of nasal valve?
Trapezoidal, 10-15degrees
143
Airflow through nasal valve in adult at rest?
16 m/sec linear velocity (decreased by 4 in nasal cavity)
144
Most important variable in nasal flow?
Diameter of nasal passage
145
How many neurofibromas will produce malignant transformation (von recklinghausen disease)?
1 in 8
146
What are the intermediate nasal neoplasms?
Inverting papilloma
Hemangioma
Meningioma
Hemangiopericytoma
147
Mc cune alright syndrome associated with fibrous dysplasia or ossifying fibroma?
Fibrous dysplasia (developmental anomaly)
148
Mc complication of sinus radiation?
Cataract formation
149
Sarcomas more often seen in maxilla or mandible?
Mandible
150
What is the combination of suprabullar and retrobullar recess called?
Sinus lateralis. Drains into middle meatus via hiatus semilunaris superior or hiatus semilunaris
151
Where does maxilary ostium drain?
Inferior 3rd of infundibulum in 65% of cases
152
Anterior and posterior fontanelle separated by?
Uncinate bone
153
Mc technical cause of surgical failure?
Lateralizatin of middle turbinate and failure to incorporate natural ostium into middle meatus
154
Mc minor complication ess
Synechiae
155
Mc reported complication ess
Perioperative and postoperative hemorrhage
156
Mc orbital complication?
Orbital hemorrhage
157
Increased orbital pressure in ess leads to blindness in?
60-90 mins
158
Diplopia in ess d/t what muscle?
Superior oblique or medial rectus
159
Frontal sinus approach complete removal of anterior frontal sinus wall
Riedel
160
Floor of frontal sinus, portions of lamina payracea, ehtmoidectomy?
Lynch
161
Frontal sinus floor and anterior wall ethmoidectomy?
Killian
162
Anterior wall frontal sinus based inferiorly retracted and replaced with periosteum intact
Osteoplastic
163
Mucus blanket renewed every?
3-4 hrs
164
Nasal cycle duration
2-4 hrs
165
Predominant leukotriene from eosinophils
Ltc3
166
___ exposures for sensitization
5
167
Reason for nasal valve dysfunction with age
Cartilage decrease in tensile strength
168
Nipple for bilatral choanal atresia
Mcgovern nipple
169
Volume of maxillary sinus, frontal, ethmoid, sphenoid
15ml, 4-7ml, 2-3ml, 0.5-8ml
170
Adult nose how many secretions in a day
1000ml/day
171
Csf produced at a rate of?
20ml/hr
172
Total csf volume?
140ml
173
Normal upper limit of csf pressure in infants? In children?
40 mmhg
| 140 mmhg
174
3 arms of failed immunity?
Immunodeficiency
Hypersensitivity
Autoimmunity
175
Allergic rhinitis prevalence?
40% of general population
176
Primary immune deficiency?
1/1200 births. Mc iga def 1/300-500 px
