Rhinology Flashcards
What bacteria is rhinophyma associated with?
Demodex Follicularum
What bacteria is rhinoscleroma associated with, Histopath and TX?
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.
Favorable prognostic indicators for acute invasive fungal sinusitis?
Uncontrolled diabetes or hematologic malignancy, surgical intervention, treatment with Amphotericin B.
NEGATIVE prognostic indicators for acute invasive fungal sinusitis?
Advanced age, renal/liver failure, altered mental status, intracranial extension
Risk of malignant transformation for inverted papillomas
10% risk of transformation to a SCC
Most common causes of acute bacterial rhinosinusitis
Strep pneumo > H. flu > Moraxella
Mechanism of Azelastine
H1 receptor antagonist
Used for allergic rhinitis
Mechanism of Ranitidine and use
H2 receptor antagonist used for GERD
T4a maxillary sinus tumor
Invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, nasopharynx or clivus, CN other than V2
T4b maxillary sinus tumor
All of previous plus dura or brain involvement, middle fossa invovlement, orbital apex
Definition of recurrent acute rhinosinusitis
At least 4 episodes per year with asymptomatic episodes in between
Kadish staging for esthesioneuroblastoma?
A - Nasal cavity
B - Sinus
C - Beyond sinuses and nasal cavity
D - Presence of metastases (regional or distant)
Derivitives of the 5 ethmoturbinals? Where does inferior develop from?
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
What do the following innervate:
External br. of anterior ethmoid n.
Interior br. of anterior ehtmoid n.
Infratrochlear n.
Infraorbital n.
sphenopalatine n.
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)
Two common types of fungus you can see in acute invasive, histopath features and treatment for each one?
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
Features of pediatric allergic fungal sinusitus (in comparison to adults)
- 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)
Bent and Kuhn Classification for AFRS
- History of atopy (type I sensitivity)
- Nasal polyposis
- 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.
- Eusinophilic mucin with Charcot Leiden crystals
- 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.
What is HHT (Osler Weber Rendu)?
AD with variable penetrance
Hereditary hemorrhagic telangiactesia
-Telangiactesia, AV malformations, aneurysms
-Think with recurrent epistaxis and telangiactesias
Contents of Vidian Canal
- Vidian nerve (confluence of greater superficial petrosal nerve and deep petrosal nerve
- Vidian artery (from ICA)
Superior orbital fissure contents and syndrome SX
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.
When do the sinuses develop?
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
Distance of ant., post. ethmoid arteries and optic nerve from lacrimal crest (ant to posterior)
24 mm to anterior ethmoid art. THEN
12 mm to posterior ethmoid art. THEN
6 mm to optic nerve
Keros Classification I-III
Depth of olfactory groove
I - 1-3 mm, II - 4-7 mm, III - 8-16 mm
Anatomical boundaries of the frontal recess?
Medial: middle turbinate, cribriform plate
Lateral: lateral papyracea
Posterior: ethmoid bulla
Anterior: agger nasi , uncinate , beak, etc
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
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
What is orbital apex syndrome?
Orbital Apex Syndrome: SOF syndrome + loss of vision. Involves II, III,
IV, VI, V1
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)
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.
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
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)
Blue Cell Tumors Mnemonic
MR SLEEP
Melanoma/Merkel cell; Rhabdo ;SNUC/small cell (SNUC); Lymphoma; Ewing’s; Esthesio ; PNET (primitive neuroectodermal tumor)/plasmocytoma
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
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.
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
What is the Hollman Miller sign?
Anterior bowing of posterior maxilla and enlargement of superior orbital fissure. Seen with JNAs.
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
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
TX for Allergic Fungal Rhinosinusitus
Rx : surgical debridement, topical and oral corticosteroids, abx (co bacterial infection) , consider adjuvant antifungal medications or immunotherapy
Blood supply to vestibular organs (2)?
Anterior vestibular a. - Utricle, SCC, HCC
Posterior vestibular a. - Most of saccule
Primary sympathetic neurotransmitter and parasympathetic neurotransmitter to nose?
Sympathetic - Norepi
Parasympathetic - Ach
What medication can improve anosmia?
Budesonide irrigation with olfactory training leads to better olfaction outcomes than concurrent use of plain saline irrigation.
Stepwise management for Prolactinoma?
Medical TX first - Cabergoline or Bromocriptine
Surgical management reserved for non responders, intolerance to medication, patient choice, apoplexy, cystic components.
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
What hormones are secreted by the posterior pituitary?
Oxytocin, Vasopressin. Everything else is anterior pituitary.
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)
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.
Axial CT scan of the sinuses with important landmarks (picture on other side)
Coronal CT scan of sinuses with landmarks (picture on other side)
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
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
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
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)
Keisselbach’s Plexus
Anterior ethmoid a., sphenopalatine a., greater palatine a. (off Imax), septal branch of superior labial a. (off facial)
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
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
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
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
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
Mechanism of Montelukast?
Leukotriene receptor antagonist - used for CRS w/NP
Features of Kartagener’s
- Autosomal RECESSIVE
- CRS
- Bronchiectasis
- Ciliary dyskinesia
- Situs Inversus
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
What test do you use to asses patency of lacrimal valve?
Jones dye test (flourescein)
What super antigen is associated with CRS w/NP?
Staphylococcal Enterotoxins
What has budesonide shown to improve?
Improved SNOT 22 scores (when used after surgery) and improved olfaction outcomes when used concurrently with saline.
What causes proptosis with grave’s disease?
Proliferation of fibroblasts and lymphocytic infiltration in the extraocular muscles (sometimes need medial orbital wall decompression).
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.
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.
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
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
What does posterior pituitary secrete?
Oxytocin, vasopressin
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
What is the blood supply for a nasoseptal flap?
Nasoseptal banch of posterior nasal artery (from sphenopalatine artery)
What markers is COVID associated with?
IL-6, IL-1, TNF-alpha (inhaled corticosteroids downregular these)
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.
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)
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
Cystic fibrosis inhertience, gene, sx?
-AR
-CFTR issue, chloride ion channel
-Delayed meconium
-Lots of sinus infections
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
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
What cytokine profile is seen in patients with CF?
Nasal polyps are driven by neutrophils, IL-8
Different from the usual CRS!!
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!
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.
MOA of Benralizumab?
Anti IL-5 RECEPTOR alpha Ab. Good for asthma, Wegener’s
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.
