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ENT > Rhinology > Flashcards

Rhinology Flashcards

1
Q

What drains to what meatus?

A

PS FAMM N
Posterior ethmoids, sphenoid
Frontal, ant ethmoids, middle ethmoids, maxillary
Nasolacrimal duct

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2
Q

Where can the sphenopalatine foramen be found?

A

It lies behind the posterior attachment of the middle turbinate, just deep to the crista ethmoidalis

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3
Q

What are the frontal cells?

A

Anterior ethmoid cells that may obstruct the frontal recess

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4
Q

What teeth are medial to the maxillary sinus?

A

Second bicuspid and first/second molars

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5
Q

Where are the agger nasi cells?

A

The most anterior ethmoidal cells

They are anterior to the frontal recess

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6
Q

Where is the ethmoid bulla?

A

Superior to the ethmoid infundubulum/semilunar hiatus. Anterior ethmoid artery courses along the roof of the bulla.

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7
Q

What separates the anterior & posterior ethmoids?

A

Basal lamella of the middle turbinate

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8
Q

Where are Onodi cells found?

A

Posterior ethmoids that lie posterior or lateral to the sphenoid face

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9
Q

Where are Haller cells?

A

Ethmoids that extend into the medial or inferior orbital walls. May obstruct maxillary ostium.

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10
Q

What are the nasal cartilages?

A

Upper lateral
Lower lateral alar (lateral & medial crura)
Lesser alar

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11
Q

What composes the internal nasal valve?

A

Upper lateral cartilage
Septum
Inferior turbinate

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12
Q

What arteries supply Little’s area?

A

aka Kiesselbach’s plexus: SAGS

  • Superior labial
  • Anterior ethmoid
  • Greater palatine
  • Sphenopalatine
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13
Q

What is the histology of the nasal cavity & sinuses?

A

Ciliated, pseudostratified columnar epithelium

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14
Q

What types of drugs can cause nasal congestion?

A 
Antihypertensives
Psychotropics
OCP's
Afrin (rhinitis medicamentosa)
Cocaine/Tobacco/Marijuana
Antithyroid
ASA
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15
Q

What is rhinophyma?

Who gets it?

A

Hypertrophy of sebaceous glands on nose (form of acne rosacea)
40-60y males get it

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16
Q

What conditions are associated with nasal polyposis?

A

Samter’s triad (ASA, asthma, polyps)
Cystic fibrosis
CRS
Allergic rhinitis

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17
Q

What are the three histologic subtypes of nasal polyps?

A

Edematous
Inflammatory
Fibrous

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18
Q

What is an antrochoanal polyp?

A

Large, single pedunculated polyp from maxillary sinus extending all the way to the choana.

There are also sphenochoanal polyps

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19
Q

What benign tumors are found in the nose?

A 
Keratotic/Shneiderian papilloma
Inverted papilloma
JNA
Hemangioma
Pyogenic granuloma
Hemangiopericytoma
Osteoma
Chordoma
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20
Q

What causes keratotic papilloma?

A

HPV 6,11

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21
Q

What are the subtypes of keratotic papilloma?

A

Fungiform (septum)
Inverted
Cylindrical (nasal wall)

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22
Q

Where are IP’s located?

A

Inverted papillomas are typically on the lateral nasal wall. Unilateral.

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23
Q

What is the histology of IP?

A

Endophytic growth of epithelium

Cristae-laden senescent mitrochondria

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24
Q

What percent of IP’s will become malignant?

A

10%

Otherwise they are just locally infiltrative

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25
Q

Where are JNA’s found?

A

At the sphenopalatine foramen or in the nasopharynx

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26
Q

Most common benign salivary glad tumor of the nose?

A

Pleomorphic adenoma

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27
Q

What percent of hemangiopericytomas will turn malignant?

A

10%

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28
Q

Treatment of nasal osteomas

A

Observation

May excise if obstructive

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29
Q

What granulomatous diseases can affect the nose?

A

Sarcoidosis
GPA
Langerhans Cell Histiocytosis
NK/T Cell Lymphoma

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30
Q

What is the Cottle maneuver?

A

Pull laterally on medial maxillary skin while inhaling

If it improves obstruction, internal nasal valve collapse is present. Modified cottle (using instrument) is better.

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31
Q

Options for internal nasal valve collapse

A

Butterfly graft
Inferior turbinate reduction
Septoplasty

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32
Q

Options for external nasal valve collapse

A

Cartilaginous spreader graft
Columellar strut
Onlay Batten graft

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33
Q

Options for septal perforation

A

Nasal hygiene
Silastic button
Mucoperichondrial flaps +/- fascial graft (must be <2cm)

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34
Q

What does scoring on the UPSIT test indicate?

A

Univ. of Pennsylvania Smell Identification Test

<6 = malingering
6-18 = total anosmia
>33 = normal
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35
Q

Most common causes of anosmia

A

1) Sinus disease
2) URI
3) Trauma

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36
Q

What is seen in Kallman syndrome?

A

Hypogonadotropic hypogonadism

Anosmia

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37
Q

What should patients with anosmia be counseled?

A

Install smoke & gas detectors

Check expiration dates on food

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38
Q

What arteries are the most common source of posterior epistaxis?

A

Woodruff’s plexus:
Sphenopalatine
Ascending pharyngeal

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39
Q

What herbal medications can predispose patients to bleeding?

A

Garlic
Ginkgo
Ginseng

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40
Q

What are the common causes of epistaxis?

A

Anterior: Trauma and mucosal drying
Posterior: Hypertension

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41
Q

What is the treatment for epistaxis associated with hereditary hemorrhagic telangiectasia?

A

AKA Osler-Weber-Rendu

Septodermoplasty: Resection of telangiectatic mucosa & STSG placement.

Can also use repeated laser or cautery ablation

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42
Q

What are the preferred operative vascular ligations for recalcitrant epistaxis?

A

Anterior epistaxis: Anterior and posterior ethmoid arteries

Posterior epistaxis: Sphenopalatine artery ligation

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43
Q

Where do the anterior and posterior ethmoid arteries cross into the nasal cavity?

A

Anterior ethmoid: 14–18 mm posterior to frontoethmoid suture
Posterior ethmoid: 10 mm behind anterior ethmoidal
Optic nerve is 4-5 mm behind posterior ethmoidal

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44
Q

What the cytokines favor IgE production?

A

IL-4 & IL-13

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45
Q

What are the types of immune reactions?

A 
ACID: 
Anaphylactic (type I)
Cytotoxic (type II)
Immune complex mediated (type III)
Delayed (type IV)
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46
Q

What cell type is the hallmark of an allergic response?

A

Eosinophils

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47
Q

What are the visible facial changes of allergic rhinitis?

A

Allergic shiners
Allergic salute
Adenoid facies

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48
Q

What is the immediate treatment for anaphylaxis?

A 
ABC's
0.3 mL of epinephrine IM
Benadryl 50 mg
Decadron
H2 blocker IV
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49
Q

What are the side effects of nasal corticosteroids?

A

Epistaxis
Candidiasis
Drying

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50
Q

What are the side effects of oral corticosteroids?

A 
Increased gastric acid production
Hypertension
May mask infection
Insomnia/psychosis
Aseptic necrosis of femoral head
Cushing's syndrome
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51
Q

What are the signs and symptoms of Churg-Strauss?

A

AKA allergic granulomatosis angiitis

Asthma
Eosinophilia
Pulmonary infiltrates
Allergic rhinosinusitis
Late: Vasculitis &amp; Neuropathies
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52
Q

What causes Rhinoscleroma?

A

Klebsiella rhinoscleromatis

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53
Q

Symptoms of Rhinoscleroma

A
  1. Persistent purulent rhinorrhea
  2. Granulomatous inflammation on upper resp tract, glottis, and subglottis, destruction of septum
  3. Fibrosis & scarring
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54
Q

What is seen on histology with Rhinoscleroma?

A

Mikulicz cells

Russell bodies

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55
Q

How does Rhinosporidiosis present?

A

Slow-growing, friable, Painless, Vascular polypoid lesion of nose, tongue, or external eye

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56
Q

Treatment of rhinosporidiosis

A

Excision

Oral antifungals

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57
Q

What is NARES?

A

Non-Allergic Rhinitis with Eosinophilia Syndrome

58
Q

What is the formal term for nasal cavity drying and crusting?

A

Rhinitis sicca anterior

59
Q

What is seen with anhidrotic ectodermal dysplasia?

How is it acquired?

A

Triad: Anhidrosis, hypotrichosis, anodontia
Atrophic rhinitis

It is X-linked

60
Q

How is vasomotor rhinitis diagnosed?

A

Clear watery rhinorrhea
Morning rhinorrhea
Diagnosis of exclusion

61
Q

What is the treatment for vasomotor rhinitis?

A

Anticholinergic, steroid, saline sprays

Vidian neurectomy

62
Q

What is the path of the vidian nerve?

A

Greater petrosal + deep petrosal
Floor of sphenoid sinus
Pterygopalatine ganglion
Parasympathetic to nose, lacrimal gland, palate

63
Q

Timeframe of ARS vs. CRS

A 
<4w = acute
4-12w = subacute
>12w = chronic
64
Q

What qualifies as recurrent acute sinusitis?

A

4 or more discrete episodes of ABRS in a year

65
Q

Criteria for ARS

A

<4w of purulent nasal discharge

plus nasal obstruction and/or facial pain/pressure

66
Q

Criteria for ABRS

A

ARS with either:
Severe symptoms/high fever
Symptoms lasting >10d
Double worsening

67
Q

What are the indications for sinus cultures?

A

Treatment failure
Complicated infection (intracranial, orbital)
Immunocompromised

68
Q

What antibiotic duration can be attempted for CRS?

A

3-6 weeks

69
Q

What is the typical presentation of mycetoma?

A

Recurrent sinusitis/infection of ONE sinus (typically maxillary)

70
Q

What is the histology of Aspergillus?

A

45 degree septations

Y-shaped

71
Q

Treatment for mycetoma

A

Surgical removal +/- antifungals

72
Q

How does allergic fungal rhinosinusitis present?

A

CRS with allergic symptomatology

Nasal polyps

73
Q

How is allergic fungal rhinosinusitis diagnosed?

A 
Allergic evaluation for fungi/molds
Mucin staining (Charcot-Leyden crystals, hyphae without invasion)
74
Q

What is the treatment for allergic fungal rhinosinusitis?

A

Surgical debridement
Topical and oral steroids
+/- antifungals

75
Q

What fungi are most commonly seen in invasive fungal sinusitis?

A

Aspergillus (most common)
Mucor
Rhizopus
Absidia

76
Q

How do fungi appear on MRI?

A

T2 hyperintense (they have metallic elements to them)

77
Q

Presentation of acute invasive fungal sinusitis

A 
Nasal congestion
Orbital swelling
Cranial nerve deficits
Facial numbness
Blackened turbinates or soft palate
78
Q

What is the histology of mucormycosis?

A

Non-septated, 90° broad branching hyphae

79
Q

Who gets chronic invasive fungal rhinosinusitis?

A

Anyone. Immunocompetent people can get it

80
Q

What symptoms define sinobronchial syndrome?

A

Rhinitis

Chronic cough with normal lung sounds

81
Q

Are seen in rhinosinusitis of the HIV patient?

A

CD4 > 200 = normal pathogens

CD4 < 200: mucormycisis, CMV, Pseudomonas, mycobacteria, Pneumocystis jirovecii

82
Q

What sinuses are more likely to contain a mucocele?

A

Frontal > ethmoid > maxillary > sphenoid

83
Q

What is an infected mucocele called?

A

Mucopyocele

84
Q

What is a mucocele?

A

Mucus that cannot escape a sinus and fills the sinus, causing sinus expansion

85
Q

What is a mucous retention cyst?

A

Serous or mucinous submucosal collection of fluid. Caused by a blocked gland.

86
Q

What is seen with Kartagener’s syndrome?

A 
Chronic rhinosinusitis
Otitis media
Bronchiectasis
Situs inversus
Sperm dysmotility
87
Q

how does sinus surgery differ for patience with Kartagener’s?

A

Antrostomies should be gravity dependent, rather than functional

88
Q

What conditions are associated with nasal polyps?

A

Asthma
Cystic fibrosis
Allergic fungal sinusitis
Aspirin intolerance

89
Q

What cranial nerve defect maybe seen in orbital cellulitis?

A

Afferent pupillary defect

Extra ocular muscles may be limited

90
Q

What pathogens are most commonly seen in cavernous sinus thrombosis?

A

Staph aureus

Strep

91
Q

Symptoms of cavernous sinus thrombosis

A

Picket fence fevers
Contralateral eye symptoms
CN III, IV, V2, VI
Proptosis and chemosis

92
Q

What clinical test can demonstrate lateral sinus thrombosis?

A

Tobey-Ayer or Queckenstedt’s test

Ipsilateral IJ compression: no change in CSF pressure
Contralateral hi J compression: increased pressure

93
Q

What are the foramina of Breschet?

A

Venous drainage foramina of the frontal sinus

Can facilitate direct intracranial extension of infection

94
Q

Treatment of CST

A

IV antibiotics
+/- anticoagulants
Delayed sinus surgery

95
Q

Complications of CST

A

Meningitis
Septic metastasis
Death

96
Q

What is the most common intracranial complication from rhinosinusitis?

A

Meningitis

97
Q

What sinuses have the highest risk of meningitis when infected?

A

Sphenoid and ethmoid sinusitis

98
Q

What sinus carries the highest risk of intracranial abscess formation?

A

Frontal sinus

Holds true for epidural abscess, Subdural abscess, and intraparenchymal abscess

99
Q

How is osteomyelitis of the skull base diagnosed?

A

Diagnose with technetium

Follow with gallium

100
Q

What is Pott’s puffy tumor?

A

Osteomyelitis or subperiosteal abscess of the frontal bone. Caused by invasion through the diploic veins.

101
Q

What is seen in superior orbital fissure syndrome?

A

CN III, IV, V1, VI palsy

102
Q

What is seen in orbital apex syndrome?

A

CN II, III, IV, V1, VI palsy

103
Q

What is the normal order of procedures in FESS?

A 
Medialize the middle turbinate
Uncinate resection
Maxillary antrostomy
Anterior then posterior ethmoidectomy
Sphenoidotomy
Frontal recess
104
Q

What is a Draf I?

A

Frontal sinusotomy

Leaves roof of the agger nasi and highest suprabullar cell

105
Q

What is a Draf IIa?

A

Frontal sinusotomy

Removes roof of the agger nasi and highest suprabullar cell

106
Q

What is a Draf IIb?

A

Frontal sinusotomy

Removes roof of the agger nasi the the the the, highest suprabullar cell, and head of the middle turb

107
Q

What is a Draf III?

A

AKA Modified Lothrop

Removes entire floor of frontal sinus as well as anterosuperior septum

108
Q

Where on the sphenoid face does the ostium typically lie?

A

1.5 CM above the choanal floorr
8 mm below the skull base
Typically superior to the posterior attachment of the superior turb

109
Q

How far back is the sphenoid ostium typically found?

A

6-8 cm posterior to the anterior nasal spine

110
Q

Which side are you more likely to get into the orbit?

A

The right side with a right-handed surgeon

111
Q

Treatment for a retrobulbar hematoma

A

Ophthalmology consult
Mannitol
Lateral canthotomy

112
Q

What should be analyzed on a preop sinus CT?

A 
Cribriform plate
Lamina papyracea
Onodi cells
Sphenoid sinus pneumatization
Ethmoidal artery (anterior)
113
Q

What are the types of frontal cells?

A

Type 1: single cells above the agger nasi cell
Type 2: consist of 2+ small cells above the agger nasi cell Type 3: a large cell above the agger nasi cell with extension into the frontal sinus
Type 4: rare frontoethmoidal cells that are entirely contained within the frontal sinus

114
Q

What are the cutoffs for the Keros classification?

A

Keros I: < 4mm
Keros II: 4-7mm
Keros III: > 7mm

115
Q

Criteria for ARS

A

Nasal discharge or blockage
AND
Facial pain/pressure or hyposmia

116
Q

Criteria for CRS

A 
More than 12w
2 or more of:
Obstruction/congestion
Discharge
Facial pain/pressure
Hyposmia
AND: CT or scope purulence
117
Q

Criteria for recurrent acute sinusitis

A

4 or more episodes of ARS per year

118
Q

What vitamin is often deficient in CRSwNP patients?

A

Vitamin D

119
Q

Contributions to the nasal septum

A

Vomer
Perpendicular plate (ethmoid)
Quadrangular cartilage
Maxillary crest

120
Q

What is the crista ethmoidalis?

A

Fibrous attachment of basal lamella to the ascending palatine bone (lateral nasal wall)

121
Q

What is the relationship of the crista ethmoidalis to the SPA?

A

SPA lies 1mm anterosuperior to the CE

122
Q

Where does the anterior ethmoid artery come out in the nose?

A

One cell behind the frontal ostium

123
Q

Between which EOM does the anterior ethmoidal artery cross in the eye?

A

Superior oblique and medial rectus

124
Q

What are the external landmarks to the anterior and posterior ethmoid artery?

A

Relative to frontoethmoid suture line and lacrimal sac:
AEA is 24mm posterior
PEA is another 12mm posterior
Optic nerve is another 6mm posterior

125
Q

What is the typical direction of the anterior ethmoid artery in the nasal cavity?

A

Posterolateral to anteromedial

126
Q

What landmark sits at the approximate height of the sphenoid ostium?

A

Roof of the maxillary sinus

127
Q

Where is the natural maxillary sinus ostium in relation to the middle turbinate?

A

Lower 1/3 of middle turb approximates maxillary sinus os

128
Q

What portion of the middle turbinate should be preserved?

A

Horizontal portion

Helps to stabilize the middle turbinate and preserves a branch of the SPA

129
Q

Where can inverted papillomas arise?

A

Lateral nasal wall (90%)

Maxillary, frontal, ethmoid sinuses

130
Q

Where is the Schneiderian membrane? What is it?

A

Lines the nasal cavity & PNS’s

Ciliated columnar epithelium from the ECTODERM

131
Q

Where are the most common sites for nasal SCCa?

A 
Maxillary sinus (70%)
Nasal cavity (12%)
Remainder of sinuses (18%)
132
Q

What are the sinonasal malignancies?

A 
SCC (80% of sinonasal Ca)
IP (10% SCC)
Adenoid cystic (10% of sinonasal Ca)
Adenocarcinoma
Melanoma
SNUC
Esthesioneuroblastoma
Lymphoma
Other salivary gland tumors
133
Q

Treatment for adenoid cystic carcinoma of the nose

A

Surgery

Radiation if perineural/perivascular invasion found (60% of cases)

134
Q

Which sinonasal tumor is associated with fume inhalation?

A

Adenocarcinoma is associated with wood dust, lacquers, and other organic compounds

135
Q

Where is Ohngren’s line?

A

Lateral canthus to angle of jaw

Posterosuperior to this plane suggests poor prognosis for SNM

136
Q

What age group typically gets esthesioneuroblastoma?

A

Bimodal (teens and elderly)

137
Q

What percent of verrucous carcinoma harbors classical SCCa?

A

20%

Classical SCCa much more likely to metastasize

138
Q

What causes NK/T-cell lymphoma of the nose?

A

EBV infection

139
Q

How does NK/T-cell lymphoma of the nose present?

A

Midline destructive lesion of the nose

140
Q

What is the most common pediatric SNM?

A

Sarcomas

Especially rhabdomyosarcoma.

141
Q

What is the role of antihistamines in CRS?

A

Only if concurrent allergic rhinitis also present

ENT (10 decks)

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