Rhinology Flashcards
What drains to what meatus?
PS FAMM N
Posterior ethmoids, sphenoid
Frontal, ant ethmoids, middle ethmoids, maxillary
Nasolacrimal duct
Where can the sphenopalatine foramen be found?
It lies behind the posterior attachment of the middle turbinate, just deep to the crista ethmoidalis
What are the frontal cells?
Anterior ethmoid cells that may obstruct the frontal recess
What teeth are medial to the maxillary sinus?
Second bicuspid and first/second molars
Where are the agger nasi cells?
The most anterior ethmoidal cells
They are anterior to the frontal recess
Where is the ethmoid bulla?
Superior to the ethmoid infundubulum/semilunar hiatus. Anterior ethmoid artery courses along the roof of the bulla.
What separates the anterior & posterior ethmoids?
Basal lamella of the middle turbinate
Where are Onodi cells found?
Posterior ethmoids that lie posterior or lateral to the sphenoid face
Where are Haller cells?
Ethmoids that extend into the medial or inferior orbital walls. May obstruct maxillary ostium.
What are the nasal cartilages?
Upper lateral
Lower lateral alar (lateral & medial crura)
Lesser alar
What composes the internal nasal valve?
Upper lateral cartilage
Septum
Inferior turbinate
What arteries supply Little’s area?
aka Kiesselbach’s plexus: SAGS
- Superior labial
- Anterior ethmoid
- Greater palatine
- Sphenopalatine
What is the histology of the nasal cavity & sinuses?
Ciliated, pseudostratified columnar epithelium
What types of drugs can cause nasal congestion?
Antihypertensives Psychotropics OCP's Afrin (rhinitis medicamentosa) Cocaine/Tobacco/Marijuana Antithyroid ASA
What is rhinophyma?
Who gets it?
Hypertrophy of sebaceous glands on nose (form of acne rosacea)
40-60y males get it
What conditions are associated with nasal polyposis?
Samter’s triad (ASA, asthma, polyps)
Cystic fibrosis
CRS
Allergic rhinitis
What are the three histologic subtypes of nasal polyps?
Edematous
Inflammatory
Fibrous
What is an antrochoanal polyp?
Large, single pedunculated polyp from maxillary sinus extending all the way to the choana.
There are also sphenochoanal polyps
What benign tumors are found in the nose?
Keratotic/Shneiderian papilloma Inverted papilloma JNA Hemangioma Pyogenic granuloma Hemangiopericytoma Osteoma Chordoma
What causes keratotic papilloma?
HPV 6,11
What are the subtypes of keratotic papilloma?
Fungiform (septum)
Inverted
Cylindrical (nasal wall)
Where are IP’s located?
Inverted papillomas are typically on the lateral nasal wall. Unilateral.
What is the histology of IP?
Endophytic growth of epithelium
Cristae-laden senescent mitrochondria
What percent of IP’s will become malignant?
10%
Otherwise they are just locally infiltrative
Where are JNA’s found?
At the sphenopalatine foramen or in the nasopharynx
Most common benign salivary glad tumor of the nose?
Pleomorphic adenoma
What percent of hemangiopericytomas will turn malignant?
10%
Treatment of nasal osteomas
Observation
May excise if obstructive
What granulomatous diseases can affect the nose?
Sarcoidosis
GPA
Langerhans Cell Histiocytosis
NK/T Cell Lymphoma
What is the Cottle maneuver?
Pull laterally on medial maxillary skin while inhaling
If it improves obstruction, internal nasal valve collapse is present. Modified cottle (using instrument) is better.
Options for internal nasal valve collapse
Butterfly graft
Inferior turbinate reduction
Septoplasty
Options for external nasal valve collapse
Cartilaginous spreader graft
Columellar strut
Onlay Batten graft
Options for septal perforation
Nasal hygiene
Silastic button
Mucoperichondrial flaps +/- fascial graft (must be <2cm)
What does scoring on the UPSIT test indicate?
Univ. of Pennsylvania Smell Identification Test
<6 = malingering 6-18 = total anosmia >33 = normal
Most common causes of anosmia
1) Sinus disease
2) URI
3) Trauma
What is seen in Kallman syndrome?
Hypogonadotropic hypogonadism
Anosmia
What should patients with anosmia be counseled?
Install smoke & gas detectors
Check expiration dates on food
What arteries are the most common source of posterior epistaxis?
Woodruff’s plexus:
Sphenopalatine
Ascending pharyngeal
What herbal medications can predispose patients to bleeding?
Garlic
Ginkgo
Ginseng
What are the common causes of epistaxis?
Anterior: Trauma and mucosal drying
Posterior: Hypertension
What is the treatment for epistaxis associated with hereditary hemorrhagic telangiectasia?
AKA Osler-Weber-Rendu
Septodermoplasty: Resection of telangiectatic mucosa & STSG placement.
Can also use repeated laser or cautery ablation
What are the preferred operative vascular ligations for recalcitrant epistaxis?
Anterior epistaxis: Anterior and posterior ethmoid arteries
Posterior epistaxis: Sphenopalatine artery ligation
Where do the anterior and posterior ethmoid arteries cross into the nasal cavity?
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
What the cytokines favor IgE production?
IL-4 & IL-13
What are the types of immune reactions?
ACID: Anaphylactic (type I) Cytotoxic (type II) Immune complex mediated (type III) Delayed (type IV)
What cell type is the hallmark of an allergic response?
Eosinophils
What are the visible facial changes of allergic rhinitis?
Allergic shiners
Allergic salute
Adenoid facies
What is the immediate treatment for anaphylaxis?
ABC's 0.3 mL of epinephrine IM Benadryl 50 mg Decadron H2 blocker IV
What are the side effects of nasal corticosteroids?
Epistaxis
Candidiasis
Drying
What are the side effects of oral corticosteroids?
Increased gastric acid production Hypertension May mask infection Insomnia/psychosis Aseptic necrosis of femoral head Cushing's syndrome
What are the signs and symptoms of Churg-Strauss?
AKA allergic granulomatosis angiitis
Asthma Eosinophilia Pulmonary infiltrates Allergic rhinosinusitis Late: Vasculitis & Neuropathies
What causes Rhinoscleroma?
Klebsiella rhinoscleromatis
Symptoms of Rhinoscleroma
- Persistent purulent rhinorrhea
- Granulomatous inflammation on upper resp tract, glottis, and subglottis, destruction of septum
- Fibrosis & scarring
What is seen on histology with Rhinoscleroma?
Mikulicz cells
Russell bodies
How does Rhinosporidiosis present?
Slow-growing, friable, Painless, Vascular polypoid lesion of nose, tongue, or external eye
Treatment of rhinosporidiosis
Excision
Oral antifungals
What is NARES?
Non-Allergic Rhinitis with Eosinophilia Syndrome
What is the formal term for nasal cavity drying and crusting?
Rhinitis sicca anterior
What is seen with anhidrotic ectodermal dysplasia?
How is it acquired?
Triad: Anhidrosis, hypotrichosis, anodontia
Atrophic rhinitis
It is X-linked
How is vasomotor rhinitis diagnosed?
Clear watery rhinorrhea
Morning rhinorrhea
Diagnosis of exclusion
What is the treatment for vasomotor rhinitis?
Anticholinergic, steroid, saline sprays
Vidian neurectomy
What is the path of the vidian nerve?
Greater petrosal + deep petrosal
Floor of sphenoid sinus
Pterygopalatine ganglion
Parasympathetic to nose, lacrimal gland, palate
Timeframe of ARS vs. CRS
<4w = acute 4-12w = subacute >12w = chronic
What qualifies as recurrent acute sinusitis?
4 or more discrete episodes of ABRS in a year
Criteria for ARS
<4w of purulent nasal discharge
plus nasal obstruction and/or facial pain/pressure
Criteria for ABRS
ARS with either:
Severe symptoms/high fever
Symptoms lasting >10d
Double worsening
What are the indications for sinus cultures?
Treatment failure
Complicated infection (intracranial, orbital)
Immunocompromised
What antibiotic duration can be attempted for CRS?
3-6 weeks
What is the typical presentation of mycetoma?
Recurrent sinusitis/infection of ONE sinus (typically maxillary)
What is the histology of Aspergillus?
45 degree septations
Y-shaped
Treatment for mycetoma
Surgical removal +/- antifungals
How does allergic fungal rhinosinusitis present?
CRS with allergic symptomatology
Nasal polyps
How is allergic fungal rhinosinusitis diagnosed?
Allergic evaluation for fungi/molds Mucin staining (Charcot-Leyden crystals, hyphae without invasion)
What is the treatment for allergic fungal rhinosinusitis?
Surgical debridement
Topical and oral steroids
+/- antifungals
What fungi are most commonly seen in invasive fungal sinusitis?
Aspergillus (most common)
Mucor
Rhizopus
Absidia
How do fungi appear on MRI?
T2 hyperintense (they have metallic elements to them)
Presentation of acute invasive fungal sinusitis
Nasal congestion Orbital swelling Cranial nerve deficits Facial numbness Blackened turbinates or soft palate
What is the histology of mucormycosis?
Non-septated, 90° broad branching hyphae
Who gets chronic invasive fungal rhinosinusitis?
Anyone. Immunocompetent people can get it
What symptoms define sinobronchial syndrome?
Rhinitis
Chronic cough with normal lung sounds
Are seen in rhinosinusitis of the HIV patient?
CD4 > 200 = normal pathogens
CD4 < 200: mucormycisis, CMV, Pseudomonas, mycobacteria, Pneumocystis jirovecii
What sinuses are more likely to contain a mucocele?
Frontal > ethmoid > maxillary > sphenoid
What is an infected mucocele called?
Mucopyocele
What is a mucocele?
Mucus that cannot escape a sinus and fills the sinus, causing sinus expansion
What is a mucous retention cyst?
Serous or mucinous submucosal collection of fluid. Caused by a blocked gland.
What is seen with Kartagener’s syndrome?
Chronic rhinosinusitis Otitis media Bronchiectasis Situs inversus Sperm dysmotility
how does sinus surgery differ for patience with Kartagener’s?
Antrostomies should be gravity dependent, rather than functional
What conditions are associated with nasal polyps?
Asthma
Cystic fibrosis
Allergic fungal sinusitis
Aspirin intolerance
What cranial nerve defect maybe seen in orbital cellulitis?
Afferent pupillary defect
Extra ocular muscles may be limited
What pathogens are most commonly seen in cavernous sinus thrombosis?
Staph aureus
Strep
Symptoms of cavernous sinus thrombosis
Picket fence fevers
Contralateral eye symptoms
CN III, IV, V2, VI
Proptosis and chemosis
What clinical test can demonstrate lateral sinus thrombosis?
Tobey-Ayer or Queckenstedt’s test
Ipsilateral IJ compression: no change in CSF pressure
Contralateral hi J compression: increased pressure
What are the foramina of Breschet?
Venous drainage foramina of the frontal sinus
Can facilitate direct intracranial extension of infection
Treatment of CST
IV antibiotics
+/- anticoagulants
Delayed sinus surgery
Complications of CST
Meningitis
Septic metastasis
Death
What is the most common intracranial complication from rhinosinusitis?
Meningitis
What sinuses have the highest risk of meningitis when infected?
Sphenoid and ethmoid sinusitis
What sinus carries the highest risk of intracranial abscess formation?
Frontal sinus
Holds true for epidural abscess, Subdural abscess, and intraparenchymal abscess
How is osteomyelitis of the skull base diagnosed?
Diagnose with technetium
Follow with gallium
What is Pott’s puffy tumor?
Osteomyelitis or subperiosteal abscess of the frontal bone. Caused by invasion through the diploic veins.
What is seen in superior orbital fissure syndrome?
CN III, IV, V1, VI palsy
What is seen in orbital apex syndrome?
CN II, III, IV, V1, VI palsy
What is the normal order of procedures in FESS?
Medialize the middle turbinate Uncinate resection Maxillary antrostomy Anterior then posterior ethmoidectomy Sphenoidotomy Frontal recess
What is a Draf I?
Frontal sinusotomy
Leaves roof of the agger nasi and highest suprabullar cell
What is a Draf IIa?
Frontal sinusotomy
Removes roof of the agger nasi and highest suprabullar cell
What is a Draf IIb?
Frontal sinusotomy
Removes roof of the agger nasi the the the the, highest suprabullar cell, and head of the middle turb
What is a Draf III?
AKA Modified Lothrop
Removes entire floor of frontal sinus as well as anterosuperior septum
Where on the sphenoid face does the ostium typically lie?
1.5 CM above the choanal floorr
8 mm below the skull base
Typically superior to the posterior attachment of the superior turb
How far back is the sphenoid ostium typically found?
6-8 cm posterior to the anterior nasal spine
Which side are you more likely to get into the orbit?
The right side with a right-handed surgeon
Treatment for a retrobulbar hematoma
Ophthalmology consult
Mannitol
Lateral canthotomy
What should be analyzed on a preop sinus CT?
Cribriform plate Lamina papyracea Onodi cells Sphenoid sinus pneumatization Ethmoidal artery (anterior)
What are the types of frontal cells?
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
What are the cutoffs for the Keros classification?
Keros I: < 4mm
Keros II: 4-7mm
Keros III: > 7mm
Criteria for ARS
Nasal discharge or blockage
AND
Facial pain/pressure or hyposmia
Criteria for CRS
More than 12w 2 or more of: Obstruction/congestion Discharge Facial pain/pressure Hyposmia AND: CT or scope purulence
Criteria for recurrent acute sinusitis
4 or more episodes of ARS per year
What vitamin is often deficient in CRSwNP patients?
Vitamin D
Contributions to the nasal septum
Vomer
Perpendicular plate (ethmoid)
Quadrangular cartilage
Maxillary crest
What is the crista ethmoidalis?
Fibrous attachment of basal lamella to the ascending palatine bone (lateral nasal wall)
What is the relationship of the crista ethmoidalis to the SPA?
SPA lies 1mm anterosuperior to the CE
Where does the anterior ethmoid artery come out in the nose?
One cell behind the frontal ostium
Between which EOM does the anterior ethmoidal artery cross in the eye?
Superior oblique and medial rectus
What are the external landmarks to the anterior and posterior ethmoid artery?
Relative to frontoethmoid suture line and lacrimal sac:
AEA is 24mm posterior
PEA is another 12mm posterior
Optic nerve is another 6mm posterior
What is the typical direction of the anterior ethmoid artery in the nasal cavity?
Posterolateral to anteromedial
What landmark sits at the approximate height of the sphenoid ostium?
Roof of the maxillary sinus
Where is the natural maxillary sinus ostium in relation to the middle turbinate?
Lower 1/3 of middle turb approximates maxillary sinus os
What portion of the middle turbinate should be preserved?
Horizontal portion
Helps to stabilize the middle turbinate and preserves a branch of the SPA
Where can inverted papillomas arise?
Lateral nasal wall (90%)
Maxillary, frontal, ethmoid sinuses
Where is the Schneiderian membrane? What is it?
Lines the nasal cavity & PNS’s
Ciliated columnar epithelium from the ECTODERM
Where are the most common sites for nasal SCCa?
Maxillary sinus (70%) Nasal cavity (12%) Remainder of sinuses (18%)
What are the sinonasal malignancies?
SCC (80% of sinonasal Ca) IP (10% SCC) Adenoid cystic (10% of sinonasal Ca) Adenocarcinoma Melanoma SNUC Esthesioneuroblastoma Lymphoma Other salivary gland tumors
Treatment for adenoid cystic carcinoma of the nose
Surgery
Radiation if perineural/perivascular invasion found (60% of cases)
Which sinonasal tumor is associated with fume inhalation?
Adenocarcinoma is associated with wood dust, lacquers, and other organic compounds
Where is Ohngren’s line?
Lateral canthus to angle of jaw
Posterosuperior to this plane suggests poor prognosis for SNM
What age group typically gets esthesioneuroblastoma?
Bimodal (teens and elderly)
What percent of verrucous carcinoma harbors classical SCCa?
20%
Classical SCCa much more likely to metastasize
What causes NK/T-cell lymphoma of the nose?
EBV infection
How does NK/T-cell lymphoma of the nose present?
Midline destructive lesion of the nose
What is the most common pediatric SNM?
Sarcomas
Especially rhabdomyosarcoma.
What is the role of antihistamines in CRS?
Only if concurrent allergic rhinitis also present
