Overview-rhinology, allergy, immunology Flashcards
1
Q
What cells contribute to the formation of the nose
during the 4th week of embryogenesis?
A
Neural crest cells
2
Q
Before closure during embryogenesis, what are the
following spaces called?
● Between the frontal and nasal bones
● Between the frontal and ethmoid bones
● Between the nasal bones and nasal capsule
A
Fronticulus nasofrontalis
Foramen cecum
Prenasal space
3
Q
What embryologic structures form within the thickened ectoderm of the nasal placodes of the frontonasal process and after dividing each placode into medial and lateral nasal processes become the early nasal cavities?
A
Nasal pits
4
Q
Into what structures do the (1) medial and (2)
lateral processes of the nasal pits and the (3)
maxillary process of the maxilla develop?
A
● Medial: Nasal septum (from the globular processes of
His), philtrum, premaxilla
● Lateral: Nasal alae
● Maxillary process: Lateral nasal wall
5
Q
What embryologic membrane separates the nasal and oral cavities, and normally degenerates to allow open passages as the choanae are formed by the deepening olfactory pits during development?
A
Nasobuccal membrane
6
Q
The nasal bones attach to what structures within
the facial skeleton?
A
Frontal bone, nasal process of the maxilla, upper lateral
cartilages, contralateral nasal bone, perpendicular plate of
the ethmoid, and cartilaginous septum
7
Q
What are the three different regions of the paired lower lateral cartilages of the nose?
A
● Medial crus
● Intermediate crus
● Lateral crus
8
Q
What is the name of the area that connects the
lower lateral cartilages with the upper lateral
cartilages?
A
Scroll region
9
Q
What are the boundaries of the internal nasal
valve?
A
● Caudal septum
● Head of the inferior turbinate
● Remainder of tissues around the piriform aperture
● Upper lateral cartilage, distal end
10
Q
What structure does the frontal process of the
maxilla, nasal floor, and lateral fibrofatty tissue
form?
A
Piriform aperture
11
Q
What are the boundaries of the external nasal
valve?
A
● Caudal septum
● Lower lateral cartilage (caudal edge of the lateral crus,
junction with the upper lateral cartilage)
● Piriform aperture
12
Q
Name the components of the nasal septum.
A
● Perpendicular plate of the ethmoid bone ● Quadrangular cartilage ● Vomer ● Maxillary crest ● Palatine bone
13
Q
What is the blood supply of the nasal septum?
A
● Anterior and posterior ethmoid arteries (superior sep-
tum)
● Sphenopalatine artery branches/posterior septal branch
(posterior/inferior septum)
14
Q
Most cases of epistaxis arise in what area?
A
Kiesselbach plexus (Little area), anterior septum
15
Q
The uncinate process is an extension of
what bone?
A
Ethmoid bone
16
Q
What are the three most common superior attach-
ment points for the uncinate?
A
● Lamina papyracea
● Skull base
● Middle turbinate
17
Q
How does the superior attachment of the uncinate process relate to the drainage of the frontal sinus outflow tract?
A
When attached to the lamina papyracea, the frontal sinus usually drains medial to the uncinate, and when it is attached to the skull base or middle turbinate, it often drains lateral to the uncinate.
18
Q
What is the opening to the space between the
uncinate process and the ethmoid bulla called?
A
Semilunar hiatus
19
Q
The uncinate process covers the medial aspect of which space that provides a common drainage pathway for some of the anterior sinuses?
A
(Ethmoidal) Infundibulum
20
Q
True or False. The uncinate attaches to the ethmoid
crest of the maxilla, the lacrimal bone, the
ethmoidal process of the inferior turbinate bone,
and the palatine bone via the lamina perpendicularis.
A
True
21
Q
The lamina papyracea is formed by which bone?
A
Ethmoid bone
22
Q
The nasolacrimal duct empties under
what structure in the nose?
A
Inferior turbinate (via the Hasner valve)
23
Q
What is the name for a pneumatized middle turbinate, which is an extension of the ethmoid bone?
A
Concha bullosa
24
Q
The middle turbinate attaches superiorly to the lateral aspect of the cribriform plate, laterally to the lamina papyracea/maxillary sinus, posteriorly to the lateral wall just anterior to the crista ethmoidalis of the palatine bone, and anteriorly near the agger nasi to what structure, which is a
part of the frontal process of the maxilla?
A
Cristal ethmoidalis of the maxilla
25
What structure separates the anterior and
| posterior ethmoid sinuses?
Ground or basal lamella
26
What are the five ethmoturbinals, and
| what do they become?
First → Agger nasi (ascending portion) and uncinate process
(descending portion)
Second → Middle turbinate
Third → Superior turbinate
Fourth and fifth fuse → supreme turbinate
27
List the first four ethmoid lamellae.
● Uncinate process
● Ethmoid bulla
● Basal lamella of the middle turbinate
● Lamella of the superior turbinate
28
What is the horizontal plate of the ethmoid bone
that forms the roof of the ethmoid sinus and
separates the ethmoid air cells from the anterior
cranial fossa called?
Fovea ethmoidalis
29
What are the three infundibular cells that are
| anterior ethmoid air cells?
● Agger nasi cells
● Terminal cell (recessus terminalis)
● Suprainfundibular cell
30
Which cell type is the most anterior of the
ethmoid cells and forms near the attachment of
the middle turbinate to the lateral nasal wall?
Agger nasi cell(s)
31
After removing the uncinate process, the ethmoid
bulla typically sets just anterior to the basal
lamella. Where does this sinus drain?
Suprabullar or retrobullar recess (sinus lateralis)
32
What arterial structure typically runs
| through the roof of the ethmoid bulla?
Anterior ethmoid artery
33
The middle meatus, uncinate, infundibulum,
anterior ethmoid cells, and ostia (frontal, ethmoid,
maxillary) collectively are referred to as what?
Ostiomeatal complex
34
What is the name of the infraorbital ethmoid air
cells that pneumatize into the maxillary sinus and
can narrow the maxillary sinus ostium?
Haller cells
35
In the adult, the posterior ethmoidal complex
consists of one to five cells, which typically drain
into which space?
Superior or supreme meatus
36
Air cells that pneumatize lateral or posterior to
the anterior wall of the sphenoid sinus are called
what?
Onodi cells (sphenoethmoidal cell)
37
What is the first sinus to develop embryologically?
Maxillary sinus
38
What structure must be removed to visualize the
| natural ostium of the maxillary sinus?
Uncinate process
39
Where is the most common location for the
| maxillary ostium within the infundibulum?
Inferior third (65%)
40
Where are the anterior and posterior nasal
| fontanelles located?
Located anterior and posterior to the inferior aspect of the
| uncinate process
41
What structure runs through the roof of the
| maxillary sinus?
Infraorbital nerve
42
A series of three or four frontal furrows arise out
of the ventral middle meatus and give rise to
what?
● First frontal furrow = agger nasi cell
● Second frontal furrow = frontal sinus
● Third and fourth furrow = anterior ethmoid cells
43
What is the last sinus to fully develop, and at
| what age has it typically reached full size?
Frontal sinus. Late teens
44
The frontal sinus drains via the frontal sinus
| outflow tract or frontal recess into which space?
Ethmoid infundibulum (most common)
45
The frontal or frontoethmoidal cells are located superior to the agger nasi cell and can have quite variable pneumatization. Describe the four Kuhn types of pneumatization.
● Type I: Single cell superior to the agger nasi but not
extending into the frontal sinus
● Type II: Tier of two or more cells above the agger nasi but
below the orbital roof
● Type III: Single cell extending from the agger nasi into the
frontal sinus
● Type IV: Isolated cell within the frontal sinus
46
What type of cell can be found posterior to the
| frontal sinus and superior to the orbit?
Supraorbital ethmoid cells
47
The spread of frontal sinus infections intracranially
is commonly thought to pass through what
structures?
Foramina of Breschet (small venules that drain the frontal sinus mucosa to the dural veins)
48
How is the sphenoid sinus formed during
| development?
Nasal mucosa invaginates into the cartilaginous nasal
capsule, which forms the cupolar recess. The wall of this
recess becomes ossified later in development into the
ossiculum Bertini. The cartilage is resorbed in the 2nd and
3rd years of life, and the ossiculum attaches to the
sphenoid bone. Pneumatization then progresses and is
complete in the 9th to the 12th years.
49
What is the most posterior paranasal
| sinus, and where does its natural ostium drain?
Sphenoid sinus; sphenoethmoidal recess (between the superior turbinate and the anterior wall of the sphenoid sinus)
50
Describe four surgical landmarks to help safely
| identify the natural ostium of the sphenoid sinus.
● 6.2 to 8.0 cm from the anterior nasal spine
● 30 to 40 degrees from the nasal floor
● Medial to the posterior end of the superior turbinate
(85%)
● ~ Halfway up the anterior sphenoid wall
51
The carotid artery is reported to be dehiscent in the sphenoid sinus in what percent of patients?
~ 15%
52
What are the main types of sphenoid pneumatization in the Hamberger classification?
● Conchal type: No pneumatization
● Presellar type: Pneumatization restricted anterior to a
vertical plane passing through the anterior clinoid
process
● Sellar type: Well-pneumatized, most common (90%); can
be complete or incomplete depending on whether the
pneumatization extends to the clivus
53
When removing the intersinus septum within a
sphenoid sinus, attachment of this septation to
what critical structure must be considered?
Internal carotid artery
54
What is the space between the internal carotid
artery and the optic nerve within the sphenoid
sinus called?
Opticocarotid recess
55
What portion of the internal carotid artery can be seen within the sphenoid sinus?
(Inter)cavernous portion:
● Presellar: Anterior vertical segment and anterior bend
● Infrasellar: Short horizontal segment
● Retrosellar: Posterior bend and posterior vertical segment
56
What neurovascular structures set within the
| parasellar cavernous sinus?
● Internal carotid artery
● Cranial nerves III, IV, and VI
● Cranial nerves V1 and V2
57
What anatomical structures pass through the optic canal?
● Optic nerve
● Ophthalmic artery
● Ophthalmic vein
58
The vidian nerve is formed by which two nerves
before it runs through the vidian canal and exits into
the pterygopalatine fossa?
● Greater superficial petrosal nerve from the geniculate
ganglion of the facial nerve (parasympathetic fibers from
the superior salivary nucleus)
● Deep petrosal nerve from the sympathetic plexus of the
internal carotid artery (sympathetic fibers)
59
What is the lateral craniopharyngeal canal that may persist in the adult patient anad lead to
encephalocele formation and cerebrospinal fluid
(CSF) leak and most commonly is noted in patients with significant lateral pneumatization of the sphenoid sinus?
Sternberg canal
60
The cribriform plate lies medially within the
| anterior skull base, surrounded laterally by what structure?
Fovea ethmoidalis (roof of the ethmoid sinuses): Joins the
cribriform plate via the lateral lamella of the cribriform
plate, which is often quite thin
61
According to Keros et al (Laryngol Rhinol Otol,
1965), the anterior skull base can be described
based on the depth of the cribriform plate in
relation to the fovea ethmoidalis according to
which three classifications?
● Type I: 1 to 3 mm
● Type II: 4 to 7 mm
● Type III: 8 to 16 mm (highest risk for iatrogenic injury)
62
Describe the slope of the anterior skull base from
| anterior to posterior.
Highest anteriorly, lowest posteriorly
63
What major branches of the internal maxillary
| artery provide arterial blood supply to the nose?
● Sphenopalatine artery
● Descending palatine artery → greater and lesser palatine
arteries
64
The sphenopalatine foramen is located posterior to
the attachment of the middle turbinate to the
lateral nasal wall, may have several foramina, and
almost always is demarcated by what small, raised,
bony crest just anterior or anteroinferior to the
foramen?
Crista ethmoidalis of the palatine bone
65
The sphenopalatine artery can exit the foramen in
up to 10 separate branches, what are the most
common branches and their distribution?
● Lateral nasal artery: Lateral nasal wall including the
turbinates
● Posterior septal artery: Posterior/inferior septum
66
When ligating the anterior ethmoid artery via an
| external approach, the vessel can be found running in what suture line?
Frontoethmoid suture
67
What is the distance between the anterior lacrimal crest of the maxilla’s frontal process to the anterior ethmoid artery?
20 to 25 mm
68
What is the average distance between the anterior
| and posterior ethmoid arteries?
10 to 19 mm
69
What is the average distance from the posterior
| ethmoid artery to the optic nerve?
3 to 7 mm
70
What intranasal vessels are branches of the internal
| carotid artery?
Anterior and posterior ethmoid arteries
71
What is the blood supply to the nasal septum?
● Superior labial artery (anteriorly)
● Greater palatine artery (posteriorly)
● Anterior and posterior ethmoid arteries (superiorly)
● Posterior septal artery (posterior and inferiorly)
72
What arterial plexus is formed along the
posterior lateral nasal wall just under the inferior
turbinate by branches from the ascending
pharyngeal, posterior ethmoid, sphenopalatine,
and lateral nasal arteries?
Woodruff plexus
73
True or False. Venules within the respiratory
mucosa of the nasal and paranasal cavities do
not have valves.
True
74
Where do the (1) sphenopalatine, (2) ethmoid,
| (3) angular, and (4) anterior facial veins drain?
Pterygoid plexus
● Superior ophthalmic vein
● Ophthalmic vein → cavernous sinus
● Common facial vein → internal jugular vein
75
What is the primary blood supply to the
| external nose?
```
Angular artery (facial artery)
● Superior labial artery (facial artery)
```
76
What arterial supply contributes to the formation
| of the Kiesselbach plexus (the Little area)?
● Posterior septal artery (sphenopalatine artery, external
carotid artery)
● Anterior ethmoid artery (ophthalmic artery, internal
carotid artery)
● Greater palatine artery (internal maxillary artery, external
carotid artery)
● Septal branches of the superior labial artery (facial artery,
external carotid artery)
77
```
What major nerve branches arise from the
nasociliary nerve (V1), and what regions of the
nose do they supply?
```
● Infratrochlear nerve → medial eyelid skin
● Anterior ethmoid nerve → anterior/superior nasal cavity,
lateral nasal wall, and septum, external skin of nasal tip
78
After exiting the foramen rotundum, the maxillary
nerve (V2) contributes fibers to the pterygopalatine
(sphenopalatine) ganglion, which then supplies
innervation to the nose via which branches?
● Infraorbital nerve → anterior area of inferior meatus,
anterior nasal floor, nasal vestibule
● Superior nasal branches (medial/lateral posterior) →
posterior superior/middle turbinates, posterior ethmoid
sinuses, face of the sphenoid, nasal vault, posterior septum
● Nasopalatine nerve → anterior hard palate
● Greater palatine nerve → middle/inferior meatus, poste-
rior aspect of inferior turbinate
79
Where do the parasympathetic fibers that provide
vasodilation and secretomotor stimulation to
mucous glands synapse?
● Pterygopalatine (sphenopalatine) ganglion
● Superior salivatory nucleus → nervus intermedius →
geniculate ganglion → vidian nerve → pterygopalatine
ganglion → sphenopalatine nerve branches → vaso-
dilation/secretomotor function
80
Postganglionic sympathetic fibers that ultimately
control vasoconstriction in the nose arise from
what ganglion?
● Superior cervical ganglion
● T1–T3 → superior cervical ganglion → internal carotid
artery plexus → join greater superficial petrosal nerve →
vidian nerve → pterygopalatine ganglion → sphenopala-
tine nerve branches → vasoconstriction
81
Where do olfactory neurons synapse?
● Olfactory bulb
● Olfactory receptor neurons → unmyelinated axons →
myelinated fascicles → olfactory fila/cribriform plate/→
olfactory bulb → olfactory tract
82
Name the bones of the orbit.
```
● Lacrimal bone
● Ethmoid bone
● Frontal bone
● Maxillary bone
● Sphenoid bone
● Zygomatic bone
● Palatine bone
```
83
What extraocular muscle is at highest risk during
| medial orbital decompression for Graves ophthalmopathy?
Medial rectus muscle
84
What epithelium covers the cribriform
plate bilaterally, extending to the superior and
middle turbinates?
Olfactory neurepithelium: Pseudostratified columnar epi-
thelium containing bipolar spindle-shaped olfactory recep-
tor cells (cranial nerves I and V), columnar sustentacular cells, microvillar cells, and basal cells.
Note: This sets on a vascular lamina propria containing
Bowman (olfactory) glands and no submucosa.
85
What part of the nasal cavity is composed
of stratified keratinizing squamous epithelium,
hair follicles, sebaceous glands, and sweat glands?
Nasal vestibule
86
What ectodermally derived epithelium
| lines most of the nasal and paranasal cavities?
Ciliated pseudostratified columnar (respiratory) epithelium
with ciliated and nonciliated columnar cells, mucoserous
(minor salivary) glands within the submucosa, goblet cells,
and basal cells
Note: Anterior third → squamous and transitional cell
epithelium, posterior two-thirds → pseudostratified col-
umnar epithelium
87
Ciliated columnar cells may contain 50 to 200 cilia per cell with each cilia arranged in a specific
pattern. On electron microscopy, what do you
expect to see for a normal ciliary structure?
“9 + 2” microtubules in doublets (dynein arms)
88
What is another name for the ciliated pseudostratified columnar epithelium that lines the nasal and paranasal cavities?
Schneiderian membrane (ectodermally derived)
89
In normal individuals, the mucosa of one nasal
passageway will be congested compared with the contralateral side owing to cyclic engorgement of
the nasal turbinates. What is this normal physiologic
phenomenon, which may function to optimize
humidification and warming of the air, called?
Nasal cycle
90
What is the length of the average nasal cycle?
What factors can cause an increase or decrease
in “congestion” on a given side?
● Average cycle: 2 to 4 hours
● Decreased exercise, increased heart rate
● Increased: on “down” side when lying on one’s side
91
True or False. The nasal mucosal microvasculature
| is under parasympathetic tone.
False. Sympathetic tone → vasoconstriction → when tone
decreases → increased vasodilation. Changes in tone result
in the normal nasal cycle.
92
What is typically the narrowest area inside the
nose, which creates the area of greatest resistance
to airflow?
Internal nasal valve
93
Without changing nasal resistance, injecting
lidocaine into the nose can result in the sensation
of nasal obstruction, whereas inhaling menthol,
camphor or eucalyptol can result in the sensation
of a more “open” nasal passageway. Why?
Change in the level of activity of cold receptors, located
| predominantly in the nasal vestibule
94
On what is airflow through the nose dependent?
● Cross-sectional area of the nasal passageway
● Pressure differential across the nose
● Laminar vs. turbulent airflow
95
Describe the Bernoulli principle with
| respect to the nasal valve.
The speed of a fluid through a tubular structure is greatest
at the point of smallest diameter. At the point of maximum
velocity, the pressure reaches a nadir. The difference
between intranasal pressure at the nasal valve and
atmospheric pressure leads to potential for collapse.
96
As air moves from the nasal vestibule to the
nasopharynx, the relative humidity increases by
approximately what percent?
95%
97
What nasal structure filters out large
| particles (20 to 30 μm) from the air?
Nasal vibrissae
● Nasal septum and turbinates filter particles 10 to 30 μm.
● Bronchial tree mucosa filters out particles 2 μm in diameter.
● Particles 0.2 to 0.5 μm in diameter tend to remain suspended and are exhaled.
98
The nose filters out particles from the air larger than what size? Particles smaller than this size are able to reach the alveoli of the lungs.
5 μm
99
What are the two mucous layers associated with
| the nasal mucociliary system?
● Upper gel layer: Trap inhaled particle; formed by goblet
cells and submucosal glands
● Lower sol layer; surround cilia of epithelium; formed by
microvilli
100
What cells are responsible for producing
| the airway mucus?
● Goblet cells: Secrete mucins
● Submucosal Seromucous glands: secrete mucins
● Epithelial cells: Hydration of the mucus via active trans-
epithelial transport systems
● Venules: Plasma proteins
101
What factors can contribute to decreased
| mucociliary clearance?
● Dysfunction of cilia: Trauma, environmental damage, genetic disorder (i.e., primary ciliary dyskinesia, Karta-
gener syndrome, cystic fibrosis, etc.)
● Altered mucus production or viscosity: Cystic fibrosis
102
What test can be used to measure mucociliary transport time in the nose?
Saccharin test : A saccharin pellet is placed in the anterior
nasal cavity and dissolves, passing toward the oropharynx
via the mucociliary system and resulting in the sensation of
a sweet taste. Time for placement to sensation: < 20
minutes.
103
What nasal reflex results in congestion/swelling
of the nasal mucosa when lying in a dependent
position?
Postural reflex
104
Which nerves contribute to the overall experience
| of an odor?
● Olfactory nerve
● Trigeminal nerve
● Vagus nerve
● Glossopharyngeal nerve
105
What produces the nasal mucus, a key component
| of olfaction?
Bowman glands found within the lamina propria beneath
the olfactory epithelium and goblet cells and submucous
glands found within the adjacent respiratory epithelium
produce mucus
106
What type of cell is responsible for olfaction?
Olfactory receptor cells are bipolar ciliated neurons.
107
```
What layer(s) must odorants penetrate to reach
the olfactory receptor neurons?
```
Olfactory mucus
108
What organ is often noted in the anteroinferior
nasal septum as a small pit whose function in
humans is unknown but in many other mammals
is thought to be related to the detection of
pheromones?
Vomeronasal organ (Jacobson organ)
109
What characteristics of particles are important
| for their recognition by the olfactory nerves?
For particles to be recognized by the olfactory nerves, the
| particles must be volatile substances that are lipid soluble.
110
What terms are associated with each of the
following?
● Normal olfaction
● Complete loss of smell
● Decreased sense of smell
● Altered perception of smell
● Perception of odor without stimulus present
● Altered perception of an odor in the presence
of an odorant stimulus
```
● Normosmia
● Anosmia
● Hyposmia
● Dysosmia
● Phantosmia
● Parosmia or troposmia
```
111
Describe the two main types of olfactory
| dysfunction.
● Conductive olfactory loss: Occurs secondary to obstruc-
tion of the nasal airflow to the olfactory cleft
● Sensorineural or nonconductive olfactory loss: Occurs
secondary to damage or dysfunction of the olfactory
neurons anywhere along the olfactory system
112
What are common causes of conductive olfactory
| loss?
● Chronic rhinosinusitis (CRS), allergic rhinitis, polyps,
septal deflection, tumors
● Also occurs with diverted airway (tracheostomy or
laryngectomy) from diminished or absent airflow
through the nose
113
What are common causes of sensorineural
| olfactory loss?
Post-upper respiratory tract infection (UTI; viral) loss, CRS
(certain patients), head trauma, toxin exposure, congenital
disorders, dementia, Alzheimer disease, Parkinson disease,
multiple sclerosis
114
How often does olfactory loss occur after head
| trauma, and when does it occur?
5% to 10%
The amount of loss usually correlates with the severity of
trauma. Onset is often immediate but can be delayed for
months.
115
What is the mechanism thought to be associated
with olfactory dysfunction resulting from head
trauma?
Shearing of the olfactory nerve axons, contusion/hemor-
rhage within the olfactory regions of the brain, or structural alteration of the sinonasal tract The most common trauma type is impact to the frontal
region, followed by trauma to the occiput.
116
How does post-traumatic olfactory dysfunction
differ in the pediatric population compared with
that in adults?`
Olfactory dysfunction is less common: 3.2% transient
| dysfunction and 1.2% with permanent dysfunction.
117
What percentage of adults will recover their sense
of smell after experiencing anosmia from a head
trauma?
5 to 10%
118
What is the most common cause of olfactory
| loss?
Persistent olfactory dysfunction after URI. This type of
olfactory loss is more common in women, typically women
older than 50 years (70 to 80% of cases).
119
What proportion of patients will likely recover
their sense of smell following a postviral URI,
regardless of treatment?
~ One-third
120
Olfaction is dependent on the health of the
olfactory neural elements, which are slowly lost
over time, resulting in an age-dependent decline
in olfaction, most noticeable after what decade(s)?
Sixth and seventh
121
Olfactory function can be lost after exposure to
specific toxins, such as formalin or cigarette
smoke. What factors most strongly influence the
olfactory dysfunction?
● Type of toxin
| ● Concentration and duration of exposure
122
In what two neurologic diseases is olfactory loss
| thought to be one of the earliest signs?
Parkinson disease and Alzheimer disease
123
What disorder is associated with anosmia and hypogonadism?
```
Kallmann syndrome (hypogonadotropic hypogonadism);
can be X-linked (KAL 1 gene) or autosomal dominant (KAL 2
gene)
```
124
Describe Kallmann syndrome and its relation to congenital olfactory dysfunction.
Gonadotropin-releasing hormone neurons fail to migrate
from the olfactory placode to the hypothalamus. Magnetic
resonance imaging (MRI) may demonstrate the absence of
olfactory bulbs.
125
In what familial autosomal dominant condition
| do patients develop anosmia, early baldness, and bilateral vascular headaches?
Familial anosmia
126
What advice is critical to relay to patients with
| significantly impaired olfaction?
It is critical to review the risks of inability to smell "warning"
odors, such as smoke, natural gas, and spoiled foods, and to
recommend the use of smoke alarms and natural gas
detectors.
127
Describe the principle of olfactory threshold
| testing and one method of performing it.
```
Absolute threshold of detection is identified, which is the
lowest concentration of an odorant that can be detected
reliably. An odorant in one sniff bottle and water in another
bottle are presented at varying concentrations from weak
to strong (based on distance).
```
128
Describe the principle of odor identification tests.
This is a quantitative test (number of odorants identified).
Odorants are presented at suprathreshold concentrations
to a patient who is asked to identify the odorants.
129
```
Describe the University of Pennsylvania
Identification Test (UPSIT).
```
The UPSIT is a self-administered test with four ‘‘scratch and
sniff’’ booklets, each containing 10 odorants. Each odorant
has a question with four answers. The patient is required to
answer even if he or she does not recognize the odorant.
Random-chance performance would be 10 of 40, so scores
lower than 5 are concerning for malingering. The UPSIT has
been studied extensively, and the reliability of the test is
high.
130
Describe the Cross-Cultural Smell Identification
| Test (CC-SIT).
This test is a variant of the UPSIT. It comprises 12 items
(banana, chocolate, cinnamon, gasoline, lemon, onion,
paint thinner, pineapple, soap, smoke, and turpentine) and
is based on odorants most consistently identified by
subjects representing various countries (China, France,
Germany, Italy, Japan, Russia, and Sweden).
131
What are the most common side effects of
| second-generation histamine type 1 (H1) blockers?
Headache, urinary retention, dry mouth, blurry vision, and
| GI upset
132
What is the most common side effect of
| intranasal steroid sprays?
Epistaxis resulting from incorrect technique
133
What are the most common side effects of
| pseudoephedrine?
Nervousness, hypertension, and urinary retention
134
What is the onset of action of cocaine?
5 to 10 minutes
135
What is the duration of action of cocaine?
6 hours
136
What is the maximum recommended dose of
| cocaine?
Varies between 1 and 3 mg/kg; 3 mg/kg is most common.
Commonly comes in a 4% solution, and it is estimated
that < 40% is truly absorbed.
