BoardVitals Flashcards
55yo M with a painless mass in his nose. Biopsy shows “foamy histiocytes,” w/a “moth-eaten” cytoplasm and large plasma cells w/birefringent inclusions. Most likely diagnosis?
Rhinoscleroma
Rhinoscleroma is caused by ___.
Klebsiella Rhinoscleromatis.
Foamy histiocytes (vacuoled macrophages) of Rhinoscleroma are called ___.
Mikulicz cells
Bloated plasma cells of Rhinoscleroma are referred to as ___.
Russell bodies
A ___ presents in teenage males and histopath shows numerous thin-walled vessels, bland epithelium, and fibrous stroma that become fibrotic and less vascular with maturity.
JNA
A JNA presents in teenage males and histopath showing numerous ___(1)___, ___(2)___, and ___(3)___ that become fibrotic and less vascular with maturity.
(1) thin-walled vessels
(2) bland epithelium
(3) fibrous stroma
Churg Strauss syndrome is a small vessel vasculitis that causes _____.
angiitis and allergic granulomatosis
___ is a small vessel vasculitis is that causes angiitis and allergic granulomatosis.
Churg Strauss syndrome
What is true regarding the use of an image guidance system during endoscopic sinus surgery?
The AAOHNS endorses the use of image guidance systems for disease abutting the skull base.
An 85yo M for recurrent expistaxis and nasal congestion. On PE, a pigmented lesion is seen in the R NC. A biopsy frozen section shows small round blue cells. The final path report shows: HMB 45 (+), Cytokeratine (-), Neuron specific enclose (-), S-100 (+), Deamin (-). What is the likely diagnosis?
Melanoma
Also typically melan-A positive
Which sinonasal tumor is: HMB 45 (-), Cytokeratine (+), Neuron specific enclose (+), S-100 (-), Deamin (-)
Sinonasal undifferentiated carcinoma
Which sinonasal tumor is: HMB 45 (-), Cytokeratine (-), Neuron specific enclose (+), S-100 (-), Deamin (-)
Ewing Sarcoma
Which sinonasal tumor is: HMB 45 (-), Cytokeratine (-), Neuron specific enclose (-), S-100 (-), Desmin (+)
Rhabdomyosarcoma
Which Two sinonasal tumors are Neuron specific enolase (+)
- Ewing Sarcoma
- Esthesioneuroblastoma
Due to normal anatomical variance, the Frontal Sinus will drain ___ to the uncinate and into the ___ in approximately 20% of people
Lateral to the uncinate and into the infindibulum
In 20% of patients the uncinate attaches to the ___.
Skull base or Middle turbinate.
In 20% of patients the uncinate attaches to the skull base or middle turbinate, causing the frontal sinus to drain:
Directly into the ethmoid infindibulum.
In 80% of people, the uncinate process attaches to the ____.
Lamina papyracea
The uncinate attaches to the lamina papyracea in 80% of cases and drainage from the frontal sinus is
Medial to the uncinate and into the infindibulum.
A 49yo M undergoes endoscopic sinus surgery for isolated sphenoid sinusitis. A wide b/l sphenoid osteotomy is performed and the sinus is debrided. A pulsation is visible along the L lateral wall at which point a bony dehiscence over the ___ is noted.
Carotid artery
A 49yo M undergoes endoscopic sinus surgery for isolated sphenoid sinusitis. A wide b/l sphenoid osteotomy is performed and the sinus is debrided. A pulsation is visible along the L lateral wall at which point a bony dehiscence over the carotid artery is noted. What segment of the carotid artery is this?
Cavernous segment - 5 segments within the cavernous sinus as it makes two turns
7 segments of the ICA
“C’mon Please Learn Carotid Clinical Organizing Classification”
C: cervical segment P: petrous segment L: lacerum segment C: cavernous segment C: clinoid segment O: ophthalmic segment C: communicating segment
What is the most common cause of anosmia?
Obstructive and inflammatory nasal disease
A 25yo M presents with painful inflamed folliculitis on the nasal tip. What nerve transmits pain from this region?
External nasal branch of anterior ethmoidal nerve (branch of V1)
A 20yo M presents w/a 7mo h/o unilateral nasal obstruction, change in voice pitch, and R-sided sinus pressure. CT w/o con reveals a mass filling the posterior R nasal cavity extending posteriorly into the nasopharynx. Endoscopic exam reveals a bluish vascular smooth mass in the R nasal cavity. What is the next appropriate diagnostic study to delineate the extent of the mass into the infra-temporal space?
MRI w/con
A 20yo M presents w/a 7mo h/o unilateral nasal obstruction, change in voice pitch, and R-sided sinus pressure. CT w/o con reveals a mass filling the posterior R nasal cavity extending posteriorly into the nasopharynx. Endoscopic exam reveals a bluish vascular smooth mass in the R nasal cavity. What is the preferred initial study for this mass?
CT w/con (this is most likely a JNA
A 20yo M presents w/a 7mo h/o unilateral nasal obstruction, change in voice pitch, and R-sided sinus pressure. CT w/o con reveals a mass filling the posterior R nasal cavity extending posteriorly into the nasopharynx. Endoscopic exam reveals a bluish vascular smooth mass in the R nasal cavity. What is the diagnosis?
JNA
A 20yo M presents w/a 7mo h/o unilateral nasal obstruction, change in voice pitch, and R-sided sinus pressure. CT w/o con reveals a mass filling the posterior R nasal cavity extending posteriorly into the nasopharynx. Endoscopic exam reveals a bluish vascular smooth mass in the R nasal cavity. The diagnosis of JNA is made. What study should be performed w/in 24hrs of surgical excision?
Angiography - to embolize the tumor and decrease intraoperative blood loss
Which neurotransmitter acts to dilate the nasal microvasculature?
Acetylcholine
What is represented by the asterisk, according to the Kuhn classification?
Type IV Kuhn Cell
What is the Kuhn classification?
This describes 4 pneumatization patterns of the frontal sinus, and recess cells
What is Type 1 of the Kuhn classification of fronto-ethmoidal cells
A single cell superior to the agger nasi.
What is Type II of the Kuhn classification of fronto-ethmoidal cells
A tier of 2 or more cells above the agger nasi cell. (The asterisk indicates an Agger nasi cell)
What is Type III of the Kuhn classification of fronto-ethmoidal cells
A single cell extending from the Agger cell into the frontal sinus (the * indicates an Agger nasi cell)
What is Type IV of the Kuhn classification of fronto-ethmoidal cells
An isolated cell within the frontal sinus
A 48yo M with a history of chronic nasal obstruction presents with concern for persistent septal deviation, despite prior septoplasty. On exam, he is noted to have a R septal deflection and a spur of the maxillary crest region obstructing the R nasal floor. Advantages of an endoscopic vs. traditional extracorporeal approach include all of the following except:
A. Improved visualization of the posterior bony septum
B. Ability to perform incision posterior lumbar
C. Decreased rate of septal perforations
D. Excellent teaching tool
Decreased rate of septal perforations.
The distance of the anterior lacrimal crest to the anterior ethmoid artery is ___mm.
24mm
The distance of the anterior ethmoid artery to the posterior ethmoid artery is ___mm.
12 mm
The distance of the posterior ethmoid artery to the optic canal is ___mm.
6mm
A 30yo F from Kentucky is found to have findings on CT scan suspicious of allergic fungal sinusitis. What RF is most closely associated with allergic fungal sinusitis?
A history of atopy (eg, asthma). This is thought to be an allergic response to a fungal antigen.
A 25yo F who is 10 weeks pregnant presents with complaints of clear rhinorrhea and nasal congestion for the last 2 weeks. After a thorough hx and nasal endoscopy, a dx of rhinitis of pregnancy is made. She is interested in a topical nasal spray, but is concerned about side effects and harm to fetus. What intranasal corticosteroid sprays have been shown to cause congenital malformations.
Triamcinolone (associated with congenital respiratory tract defects)
A 72yo presents for eval of anosmia. His UPSIT (Smell Identification Test) reveals a score of 14. Endoscopic exam reveals no evidence of sinonasal pathology. He denies any trauma and reportedly, his outside MRI is unremarkable. What physical exam finding may elucidate the cause of this patient’s symptoms?
Most causes of hyposmia and anosmia in the older populations are idiopathic in nature, however, if bulbar symptoms or motor exam findings are noted, a diagnosis of Parkinson’s or other neurodegenerative condition must be excluded.
A patient with an esthesioneuroblastoma presents for Tx. Her tumor involves the nasal cavity and paranasal sinuses, with extension beyond the paranasal sinuses, but no evidence of distant mets or involvement of the regional LNs. What Kadish group does she fall in?
Kadish Group C (tumor extends beyond the nasal cavity and paranasal sinuses (skull base, intracranial compartment, orbit, or cribiform).
What is Kadish Group A?
Staging of sinonasal and ventral skull base malignancies.
A: tumor limited to the nasal cavity
Kadish Group B
Staging of sinonasal and ventral skull base malignancies.
B: tumor limited to the nasal cavity and paranasal sinuses
What is Kadish Group C?
Staging of sinonasal and ventral skull base malignancies.
C: tumor extends beyond the nasal cavity and paranasal sinuses (base of skull, intracranial compartment, orbit, or cribiform).
What is Kadish Group D?
Staging of sinonasal and ventral skull base malignancies.
D: cervical nodal or distant metastases
Fill in the blank.
Anterior septal branch of the Anterior Ethmoidal Artery
Fill in the blank.
Septal branch of the Posterior ethmoidal a.
Fill in the blank.
Posterior septal branch of sphenopalatine a.
Fill in the blank.
Greater palatine artery
Fill in the blank.
Nasal septal branch of superior labial branch of facial a.
A 38yo F is referred for 2 weeks of rhinorrhea. She indicates it is almost exclusively R-sided and persistent. When she goes to the bathroom, the rate of rhinorrhea increases. She denies any recent head trauma. She denies a h/o allergies. Given her likely diagnosis, what would be the blood supply for the septal flap which could be useful in treating her?
Posterior septal branches of the Sphenopalatine a.
A 38yo F is referred for 2 weeks of rhinorrhea. She indicates it is almost exclusively R-sided and persistent. When she goes to the bathroom, the rate of rhinorrhea increases. She denies any recent head trauma. She denies a h/o allergies. What is her most likely diagnosis?
Spontaneous CSF leak
Endoscopic exam reveals a pale, polyploid lesion emanating from the middle meatus, obstructing the view of the middle turbinate. Biopsy of the mass is concerning for an ___.
Inverted Papilloma
From which sinonasal site does an inverted papilloma most frequently arise?
Lateral Nasal wall (in the fontanelle area)
Which sinus is the most commonly affected sinus by an inverted papilloma?
Maxillary sinus
Which of the following arteries does NOT contribute to the vascular plexus on the anterior nasal septum?
A. Ophthalmic B. Facial C. Descending palatine D. Maxillary E. Lesser palatine
E. Lesser palatine
A CT scan is performed on a 52yo F. What symptom most likely prompted this CT scan, showing this benign, osteogenic tumor?
This patient has an osteoma of the ethmoid sinuses. While many are found incidentally on CT scans of the brain, face, or orbits, when a symptom prompts ordering the scan, it is most commonly a HEADACHE.
The opthalmic division of the trigeminal nerve (CN V1) divides into 3 main branches: ___.
Frontal n., Lacrimal n., and Nasociliary n.
Which nerve(s) gives rise to branches that provide sensory innervation to the medial alae of the nose?
The nasociliary branch of the opthalmic n. (V1) innervates the ciliary body, iris, cornea, and conjunctiva. It’s terminal branch is the Anterior Ethmoidal n., which innervates the medial nasal alae via the external nasal n.
Any patient presenting with an osteoma of the sinuses should be evaluated for ___.
Gardener’s syndrome (affects 10% of individuals with familial adenomatous polyposis (FAP).
Gardener’s syndrome is associated with ___, ___, and ___.
- Osteomas of the head & neck
- Adenomatous polyposis
- Supernumerary teeth
The survival rate for invasive fungal sinusitis in a DKA patient is up to ___ in diabetic patients b/c DKA is reversible. The survival rate is less than ___ in non-diagnostic patients.
Diabetic - 80%
Non-Diabetic - <50%
A sinus infection from which bacterial organism is most likely to resolve without antibiotics?
Moraxella catarrhalis
Chandler’s classic action I
Preseptal cellulitis (edema of the preseptal tissues and NO ocular involvement)
Chandler’s Classification II
Orbital Cellulitis:
- chemosis (swelling of bulbar conjunctiva)
- EOM impairment
- possible visual impairment
Chandler’s Classification III
Subperiosteal abscess:
- worsening chemosis (swelling of bulbar conjunctiva
- exopthalmos
- EOM and visual impairment
What are the boundaries of the frontal recess?
Anterior: agger nasi,
Posterior: ethmoid bulla + basal lamella
Lateral: middle turb
Medial: lamina paprecia
A 35 M presents w/recurrent nosebleeds and is found to have palatal lesions seen in image.
- Dx?
- Associated finding?
- Hereditary hemorrhagic telangiectasia
- Pulmonary AV malformation
In what percent of patients is the carotid a dehiscent in the sphenoid sinus?
21-30% (specifically, 23%).
Which is the most common site of intraoperative iatrogenic CSF leak?
Fovea ethmoidalis/roof of ethmoid.
(other sites: cribiform plate, lateral lamella)
Ethmoturbinals are a serious of _____, that begin to develop ~week 8 of gestation.
Folds on the lateral nasal wall.
The ascending portion of the 1st ethmoturbinal forms the ___ descending portion forms the ___.
- Agger Nasi cell
- Uncinate process.
The 2nd ethmoturbinal forms the ___.
Middle turbinate.
The 3rd ethmoturbinal forms the ___.
Superior turbinate.
The 4th and 5th ethmoturbinals fuse to form the ___.
Supreme turbinate.
The Tobey-Ayer/Queckenstedt’s test, is (+) when _____.
external compression of an IJV ipsilateral to a site of thrombosis does not cause an increase in CSF pressure, but compression of the contralateral (nonobstructed) IJV does cause an increase in CSF pressure
What is the etiology of this patient’s condition?
This is the final stage of acne Rosacea progression.
- caused by pathogen: Demodex folliculorum
Lund-Mackey scoring:
0 = _____
1 = partial opacification
2 = complete opacification or blockage of the OMC
Lund-Mackey scoring:
0 = No opacification
1 = partial opacification
2 = complete opacification or blockage of the OMC
Lund-Mackey scoring:
0 = opacification
1 =
2 = complete opacification or blockage of the OMC
Lund-Mackey scoring:
0 = No opacification
1 = partial opacification
2 = complete opacification or blockage of the OMC
Lund-Mackey scoring:
0 = opacification
1 = partial opacification
2 = ___
Lund-Mackey scoring:
0 = No opacification
1 = partial opacification
2 = complete opacification or blockage of the OMC
Bony structures of the nasal septum:
- Perpendicular plate of ethmoid bone
- Vomer
- Nasal crest of the Palatine bone
- Nasal crest of the Maxilla
Cartilaginous structures of nasal septum:
- Alar cartilage
- Vomeronasal cartilage
What is the most common presenting symptom of a patient with an esthesioneuroblastoma?
Nasal obstruction.
(Very rare: <3% of all NC tumors)
An esthesioneuroblastoma is a rare sinonasal tumor that arises from ___.
Basal neural cells of olfactory mucosa.
The ___ artery is the most frequent feeding vessel for a JNA.
Internal maxillary artery
What is the indicated structure?
Anterior ethmoid artery.
List the structures indicated on CT axial/sagittal view (anterior to posterior):
Anterior to Posterior:
- Anterior ethmoid artery
- Middle ethmoid artery
- Posterior ethmoid artery
The _____ is the landmark access to the sphenoidal sinus
Posterior ethmoidal artery.
(View is of the L ant skull base: PO = periorbita, SS, = sphenoid sinus, PS = plenum sphenoidale, ER = ethmoid roof)
The frontal sinus is supplied by which vessels?
Supratrochlear a, Supraorbital a, Superior Ophthalmic a.
Cavernous sinuses receive venous blood supply from which Valveless Veins
- Superior/Inferior ophthalmic veins
- Sphenoid vein
- Middle cerebral veins
A Thornwaldt’s cyst is a benign nasopharyngeal cyst that arises from a _____.
Pharyngeal notochord remnant.
Identify the structure:
See image.
Identify the structure:
See image.
Identify the structure:
See image.
Identify the structure:
See image.
Identify the structure.
Foramen Rotundum (contains Maxillary a. V2)
The rate of dehiscence of the anterior ethmoid a. can be up to ___%, making it vulnerable to damage.
40%
The location of the anterior ethmoid a is between the ___ and ___ lamella.
2nd and 3rd lamella.
The ___ vein is a recipient of blood drainage from the posterior pterygoid plexus.
Maxillary vein.
The ___ vein is a recipient of blood drainage from the anterior pterygoid plexus.
Facial vein.
What is the Lund Mackey score of this image?
Right:
M - 1
OMC - 2
E - 1
Left:
M - 2
OMC - 2
E - 0
Total = 8.
The internal nasal valve is bordered by the _____, _____, and _____.
Nasal septum, head of inferior turbinate, caudal edge of upper lateral cartilage.
The sphenoid os is located:
- ___cm from the anterior nasal spine
- 30 degrees from the nasal floor and adjacent to the nasal septum
- 11mm inferior to the skull base
- 1.5-2cm above choanal roof
The sphenoid os is located:
- 7cm from the anterior nasal spine
- 30 degrees from the nasal floor and adjacent to the nasal septum
- 11mm inferior to the skull base
- 1.5-2cm above choanal roof
The sphenoid os is located:
- 7cm from the anterior nasal spine
- ___ degrees from the nasal floor and adjacent to the nasal septum
- 11mm inferior to the skull base
- 1.5-2cm above choanal roof
The sphenoid os is located:
- 7cm from the anterior nasal spine
- 30 degrees from the nasal floor and adjacent to the nasal septum
- 11mm inferior to the skull base
- 1.5-2cm above choanal roof
The sphenoid os is located:
- 7cm from the anterior nasal spine
- 30 degrees from the nasal floor and adjacent to the nasal septum
- ___mm inferior to the skull base
- 1.5-2cm above choanal roof
The sphenoid os is located:
- 7cm from the anterior nasal spine
- 30 degrees from the nasal floor and adjacent to the nasal septum
- 11mm inferior to the skull base
- 1.5-2cm above choanal roof
The sphenoid os is located:
- 7cm from the anterior nasal spine
- 30 degrees from the nasal floor and adjacent to the nasal septum
- 11mm inferior to the skull base
- ___cm above choanal roof
The sphenoid os is located:
- 7cm from the anterior nasal spine
- 30 degrees from the nasal floor and adjacent to the nasal septum
- 11mm inferior to the skull base
- 1.5-2cm above choanal roof
Identify the structure:
See Image.
Identify the structure:
See Image.
Identify the structures:
Foramen Ovale (V3, accessory meningeal a., LSPN, emmissary v.)
Foramen Spinosum (middle meningeal a., meningeal branch of V3)
Identify the structure:
See image.
Identify the structures:
See Image.
A _____ mass would demonstrate skull base erosion and would most likely be pulsatile.
Meningoencephalocele.
A ___ is an expansitile level mass, so the bone is remodeled and you can see the maxillary sinus posterior wall pushed anteriorly.
JNA
A CT scan of _____ shows a rim of hypointensity w/hyperdense central material (allergic mucin) + speckled areas of increased attenuation (due to ferromagnetic elements).
Allergic fungal sinusitis.
Kuhn for the diagnosis of allergic fungal sinusitis includes criteria (mneumonic shown in image):
“Mr. KUHN”
M - mucous (eosinophilia, Charcot Leyden crystals)
K - KOH mount (fungal smear, noninvasive fungal hyphae)
Uno - ONE (type 1 hypersensitivity)
Head - characteristic CT findings
N - Nasal polyp
JNA originates in the lateral wall of the nasal cavity, close to the superior border of the ___.
Sphenopalatine foramen.
In ___, the gross pathology shows a sessile, lobulated, rubbery dark red-tan gray mass that can be large in size - admixture of vascular tissue and fibrous stroma.
JNA.
The lesser palatine artery supplies the ___.
Soft palate.
Blood supply to the nasal cavity includes the:
1.
2. Greater palatine a.
3. Sphenopalatine a.
4. Superior labial a.
Blood supply to the nasal cavity includes the:
1. Anterior/Posterior ethmoid a.
2. Greater palatine a.
3. Sphenopalatine a.
4. Superior labial a.
Blood supply to the nasal cavity includes the:
1. Anterior/Posterior ethmoid a.
2.
3. Sphenopalatine a.
4. Superior labial a.
Blood supply to the nasal cavity includes the:
1. Anterior/Posterior ethmoid a.
2. Greater palatine a.
3. Sphenopalatine a.
4. Superior labial a.
Blood supply to the nasal cavity includes the:
1. Anterior/Posterior ethmoid a.
2. Greater palatine a.
3. ___
4. Superior labial a.
Blood supply to the nasal cavity includes the:
1. Anterior/Posterior ethmoid a.
2. Greater palatine a.
3. Sphenopalatine a.
4. Superior labial a.
Blood supply to the nasal cavity includes the:
1. Anterior/Posterior ethmoid a.
2. Greater palatine a.
3. Sphenopalatine a.
4.
Blood supply to the nasal cavity includes the:
1. Anterior/Posterior ethmoid a.
2. Greater palatine a.
3. Sphenopalatine a.
4. Superior labial a. (Septal branches)
The ___ sinus is the most frequently involved anatomic site of osteoma involvement in the sinonasal tract.
Frontal sinus osteoma.
_____ + _____ are surgical treatments for nonallergic rhinitis that doesn’t respond to medical therapy.
Vidian neurectomy + Posterior nasal nerve cryoablation.
The Vidian nerve is comprised of:
1.
2.
- GSPN
- Deep petrosal n.
Which n. gives rise to branches that provide sensory innervation to the nasal tip?
Nasocilliary nerve (branch of V1 Trigeminal n).
(the external branch of the ant. ethmoidal n provides sensation to nasal tip)
A Caldwell-Luc procedure can be used to access the ___ and ___ directly.
Maxillary sinus + Orbital floor
A vidian neurectomy is a procedure indicated for refractory ___ and tearing w/eating.
vasomotor rhinitis
The semilunar hiatus is a crescent shaped gap between the ___ of the uncinate process and ___ of the ethmoid bulla.
The semilunar hiatus is a crescent shaped gap between the Posterior margin of the uncinate process and Anterior wall of the ethmoid bulla.
A Keros type ___ patient would be in most danger of entering anterior skull base during ethmoidectomy?
Keros type III (8-16mm from cribiform plater to fovea ethmoidalis of frontal bone)
- the taller the lateral lamella, the more at risk of entering ant cranial fossa
What is the diagnosis?
Inverted papilloma.
A Draf I includes a _____ w/removal of any additional obstructing structures, resulting in the creation of a drainage tract from the frontal sinus ostium.
A Draf 1 includes a partial or total ethmoidectomy w/removal of any additional obstructing structures, resulting in the creation of a drainage tract from the frontal sinus ostium.
A Draf II procedure is an extension of Draf I , and involves resection of the _____ from the _____ to the _____.
A Draf 2 procedure is an extension of Draf I , and involves resection of the frontal sinus floor from the middle turbinate to the lamina papyracea
A Draf IIb involves resection of the _____ from the nasal septum to the lamina papyracea.
A Draf IIb involves resection of the **frontal sinus floor **from the nasal septum to the lamina papyracea.
**Draf III **includes Draf IIb bilateral drainage, in addition to the removal of the ___, the ___ portion of the frontal sinus septum, and the frontal sinus ___ bilaterally.
Draf III includes Draf IIb bilateral drainage, in addition to the removal of the superior portion of the nasal septum, the inferior portion of the frontal sinus septum, and the frontal sinus floor bilaterally.
