Rhinology Flashcards
1
Q
What drains to what meatus?
A
PS FAMM N
Posterior ethmoids, sphenoid
Frontal, ant ethmoids, middle ethmoids, maxillary
Nasolacrimal duct
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
3
Q
What are the frontal cells?
A
Anterior ethmoid cells that may obstruct the frontal recess
4
Q
What teeth are medial to the maxillary sinus?
A
Second bicuspid and first/second molars
5
Q
Where are the agger nasi cells?
A
The most anterior ethmoidal cells
They are anterior to the frontal recess
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.
7
Q
What separates the anterior & posterior ethmoids?
A
Basal lamella of the middle turbinate
8
Q
Where are Onodi cells found?
A
Posterior ethmoids that lie posterior or lateral to the sphenoid face
9
Q
Where are Haller cells?
A
Ethmoids that extend into the medial or inferior orbital walls. May obstruct maxillary ostium.
10
Q
What are the nasal cartilages?
A
Upper lateral
Lower lateral alar (lateral & medial crura)
Lesser alar
11
Q
What composes the internal nasal valve?
A
Upper lateral cartilage
Septum
Inferior turbinate
12
Q
What arteries supply Little’s area?
A
aka Kiesselbach’s plexus: SAGS
- Superior labial
- Anterior ethmoid
- Greater palatine
- Sphenopalatine
13
Q
What is the histology of the nasal cavity & sinuses?
A
Ciliated, pseudostratified columnar epithelium
14
Q
What types of drugs can cause nasal congestion?
A
Antihypertensives Psychotropics OCP's Afrin (rhinitis medicamentosa) Cocaine/Tobacco/Marijuana Antithyroid ASA
15
Q
What is rhinophyma?
Who gets it?
A
Hypertrophy of sebaceous glands on nose (form of acne rosacea)
40-60y males get it
16
Q
What conditions are associated with nasal polyposis?
A
Samter’s triad (ASA, asthma, polyps)
Cystic fibrosis
CRS
Allergic rhinitis
17
Q
What are the three histologic subtypes of nasal polyps?
A
Edematous
Inflammatory
Fibrous
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
19
Q
What benign tumors are found in the nose?
A
Keratotic/Shneiderian papilloma Inverted papilloma JNA Hemangioma Pyogenic granuloma Hemangiopericytoma Osteoma Chordoma
20
Q
What causes keratotic papilloma?
A
HPV 6,11
21
Q
What are the subtypes of keratotic papilloma?
A
Fungiform (septum)
Inverted
Cylindrical (nasal wall)
22
Q
Where are IP’s located?
A
Inverted papillomas are typically on the lateral nasal wall. Unilateral.
23
Q
What is the histology of IP?
A
Endophytic growth of epithelium
Cristae-laden senescent mitrochondria
24
Q
What percent of IP’s will become malignant?
A
10%
Otherwise they are just locally infiltrative
25
Where are JNA's found?
At the sphenopalatine foramen or in the nasopharynx
26
Most common benign salivary glad tumor of the nose?
Pleomorphic adenoma
27
What percent of hemangiopericytomas will turn malignant?
10%
28
Treatment of nasal osteomas
Observation
| May excise if obstructive
29
What granulomatous diseases can affect the nose?
Sarcoidosis
GPA
Langerhans Cell Histiocytosis
NK/T Cell Lymphoma
30
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.
31
Options for internal nasal valve collapse
Butterfly graft
Inferior turbinate reduction
Septoplasty
32
Options for external nasal valve collapse
Cartilaginous spreader graft
Columellar strut
Onlay Batten graft
33
Options for septal perforation
Nasal hygiene
Silastic button
Mucoperichondrial flaps +/- fascial graft (must be <2cm)
34
What does scoring on the UPSIT test indicate?
Univ. of Pennsylvania Smell Identification Test
```
<6 = malingering
6-18 = total anosmia
>33 = normal
```
35
Most common causes of anosmia
1) Sinus disease
2) URI
3) Trauma
36
What is seen in Kallman syndrome?
Hypogonadotropic hypogonadism
| Anosmia
37
What should patients with anosmia be counseled?
Install smoke & gas detectors
| Check expiration dates on food
38
What arteries are the most common source of posterior epistaxis?
Woodruff's plexus:
Sphenopalatine
Ascending pharyngeal
39
What herbal medications can predispose patients to bleeding?
Garlic
Ginkgo
Ginseng
40
What are the common causes of epistaxis?
Anterior: Trauma and mucosal drying
Posterior: Hypertension
41
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
42
What are the preferred operative vascular ligations for recalcitrant epistaxis?
Anterior epistaxis: Anterior and posterior ethmoid arteries
| Posterior epistaxis: Sphenopalatine artery ligation
43
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
44
What the cytokines favor IgE production?
IL-4 & IL-13
45
What are the types of immune reactions?
```
ACID:
Anaphylactic (type I)
Cytotoxic (type II)
Immune complex mediated (type III)
Delayed (type IV)
```
46
What cell type is the hallmark of an allergic response?
Eosinophils
47
What are the visible facial changes of allergic rhinitis?
Allergic shiners
Allergic salute
Adenoid facies
48
What is the immediate treatment for anaphylaxis?
```
ABC's
0.3 mL of epinephrine IM
Benadryl 50 mg
Decadron
H2 blocker IV
```
49
What are the side effects of nasal corticosteroids?
Epistaxis
Candidiasis
Drying
50
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
```
51
What are the signs and symptoms of Churg-Strauss?
AKA allergic granulomatosis angiitis
```
Asthma
Eosinophilia
Pulmonary infiltrates
Allergic rhinosinusitis
Late: Vasculitis & Neuropathies
```
52
What causes Rhinoscleroma?
Klebsiella rhinoscleromatis
53
Symptoms of Rhinoscleroma
1. Persistent purulent rhinorrhea
2. Granulomatous inflammation on upper resp tract, glottis, and subglottis, destruction of septum
3. Fibrosis & scarring
54
What is seen on histology with Rhinoscleroma?
Mikulicz cells
| Russell bodies
55
How does Rhinosporidiosis present?
Slow-growing, friable, Painless, Vascular polypoid lesion of nose, tongue, or external eye
56
Treatment of rhinosporidiosis
Excision
| Oral antifungals
57
What is NARES?
Non-Allergic Rhinitis with Eosinophilia Syndrome
58
What is the formal term for nasal cavity drying and crusting?
Rhinitis sicca anterior
59
What is seen with anhidrotic ectodermal dysplasia?
| How is it acquired?
Triad: Anhidrosis, hypotrichosis, anodontia
Atrophic rhinitis
It is X-linked
60
How is vasomotor rhinitis diagnosed?
Clear watery rhinorrhea
Morning rhinorrhea
Diagnosis of exclusion
61
What is the treatment for vasomotor rhinitis?
Anticholinergic, steroid, saline sprays
| Vidian neurectomy
62
What is the path of the vidian nerve?
Greater petrosal + deep petrosal
Floor of sphenoid sinus
Pterygopalatine ganglion
Parasympathetic to nose, lacrimal gland, palate
63
Timeframe of ARS vs. CRS
```
<4w = acute
4-12w = subacute
>12w = chronic
```
64
What qualifies as recurrent acute sinusitis?
4 or more discrete episodes of ABRS in a year
65
Criteria for ARS
<4w of purulent nasal discharge
| plus nasal obstruction and/or facial pain/pressure
66
Criteria for ABRS
ARS with either:
Severe symptoms/high fever
Symptoms lasting >10d
Double worsening
67
What are the indications for sinus cultures?
Treatment failure
Complicated infection (intracranial, orbital)
Immunocompromised
68
What antibiotic duration can be attempted for CRS?
3-6 weeks
69
What is the typical presentation of mycetoma?
Recurrent sinusitis/infection of ONE sinus (typically maxillary)
70
What is the histology of Aspergillus?
45 degree septations
| Y-shaped
71
Treatment for mycetoma
Surgical removal +/- antifungals
72
How does allergic fungal rhinosinusitis present?
CRS with allergic symptomatology
| Nasal polyps
73
How is allergic fungal rhinosinusitis diagnosed?
```
Allergic evaluation for fungi/molds
Mucin staining (Charcot-Leyden crystals, hyphae without invasion)
```
74
What is the treatment for allergic fungal rhinosinusitis?
Surgical debridement
Topical and oral steroids
+/- antifungals
75
What fungi are most commonly seen in invasive fungal sinusitis?
Aspergillus (most common)
Mucor
Rhizopus
Absidia
76
How do fungi appear on MRI?
T2 hyperintense (they have metallic elements to them)
77
Presentation of acute invasive fungal sinusitis
```
Nasal congestion
Orbital swelling
Cranial nerve deficits
Facial numbness
Blackened turbinates or soft palate
```
78
What is the histology of mucormycosis?
Non-septated, 90° broad branching hyphae
79
Who gets chronic invasive fungal rhinosinusitis?
Anyone. Immunocompetent people can get it
80
What symptoms define sinobronchial syndrome?
Rhinitis
| Chronic cough with normal lung sounds
81
Are seen in rhinosinusitis of the HIV patient?
CD4 > 200 = normal pathogens
| CD4 < 200: mucormycisis, CMV, Pseudomonas, mycobacteria, Pneumocystis jirovecii
82
What sinuses are more likely to contain a mucocele?
Frontal > ethmoid > maxillary > sphenoid
83
What is an infected mucocele called?
Mucopyocele
84
What is a mucocele?
Mucus that cannot escape a sinus and fills the sinus, causing sinus expansion
85
What is a mucous retention cyst?
Serous or mucinous submucosal collection of fluid. Caused by a blocked gland.
86
What is seen with Kartagener's syndrome?
```
Chronic rhinosinusitis
Otitis media
Bronchiectasis
Situs inversus
Sperm dysmotility
```
87
how does sinus surgery differ for patience with Kartagener's?
Antrostomies should be gravity dependent, rather than functional
88
What conditions are associated with nasal polyps?
Asthma
Cystic fibrosis
Allergic fungal sinusitis
Aspirin intolerance
89
What cranial nerve defect maybe seen in orbital cellulitis?
Afferent pupillary defect
| Extra ocular muscles may be limited
90
What pathogens are most commonly seen in cavernous sinus thrombosis?
Staph aureus
| Strep
91
Symptoms of cavernous sinus thrombosis
Picket fence fevers
Contralateral eye symptoms
CN III, IV, V2, VI
Proptosis and chemosis
92
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
93
What are the foramina of Breschet?
Venous drainage foramina of the frontal sinus
Can facilitate direct intracranial extension of infection
94
Treatment of CST
IV antibiotics
+/- anticoagulants
Delayed sinus surgery
95
Complications of CST
Meningitis
Septic metastasis
Death
96
What is the most common intracranial complication from rhinosinusitis?
Meningitis
97
What sinuses have the highest risk of meningitis when infected?
Sphenoid and ethmoid sinusitis
98
What sinus carries the highest risk of intracranial abscess formation?
Frontal sinus
Holds true for epidural abscess, Subdural abscess, and intraparenchymal abscess
99
How is osteomyelitis of the skull base diagnosed?
Diagnose with technetium
| Follow with gallium
100
What is Pott's puffy tumor?
Osteomyelitis or subperiosteal abscess of the frontal bone. Caused by invasion through the diploic veins.
101
What is seen in superior orbital fissure syndrome?
CN III, IV, V1, VI palsy
102
What is seen in orbital apex syndrome?
CN II, III, IV, V1, VI palsy
103
What is the normal order of procedures in FESS?
```
Medialize the middle turbinate
Uncinate resection
Maxillary antrostomy
Anterior then posterior ethmoidectomy
Sphenoidotomy
Frontal recess
```
104
What is a Draf I?
Frontal sinusotomy
| Leaves roof of the agger nasi and highest suprabullar cell
105
What is a Draf IIa?
Frontal sinusotomy
| Removes roof of the agger nasi and highest suprabullar cell
106
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
107
What is a Draf III?
AKA Modified Lothrop
| Removes entire floor of frontal sinus as well as anterosuperior septum
108
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
109
How far back is the sphenoid ostium typically found?
6-8 cm posterior to the anterior nasal spine
110
Which side are you more likely to get into the orbit?
The right side with a right-handed surgeon
111
Treatment for a retrobulbar hematoma
Ophthalmology consult
Mannitol
Lateral canthotomy
112
What should be analyzed on a preop sinus CT?
```
Cribriform plate
Lamina papyracea
Onodi cells
Sphenoid sinus pneumatization
Ethmoidal artery (anterior)
```
113
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
114
What are the cutoffs for the Keros classification?
Keros I: < 4mm
Keros II: 4-7mm
Keros III: > 7mm
115
Criteria for ARS
Nasal discharge or blockage
AND
Facial pain/pressure or hyposmia
116
Criteria for CRS
```
More than 12w
2 or more of:
Obstruction/congestion
Discharge
Facial pain/pressure
Hyposmia
AND: CT or scope purulence
```
117
Criteria for recurrent acute sinusitis
4 or more episodes of ARS per year
118
What vitamin is often deficient in CRSwNP patients?
Vitamin D
119
Contributions to the nasal septum
Vomer
Perpendicular plate (ethmoid)
Quadrangular cartilage
Maxillary crest
120
What is the crista ethmoidalis?
Fibrous attachment of basal lamella to the ascending palatine bone (lateral nasal wall)
121
What is the relationship of the crista ethmoidalis to the SPA?
SPA lies 1mm anterosuperior to the CE
122
Where does the anterior ethmoid artery come out in the nose?
One cell behind the frontal ostium
123
Between which EOM does the anterior ethmoidal artery cross in the eye?
Superior oblique and medial rectus
124
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
125
What is the typical direction of the anterior ethmoid artery in the nasal cavity?
Posterolateral to anteromedial
126
What landmark sits at the approximate height of the sphenoid ostium?
Roof of the maxillary sinus
127
Where is the natural maxillary sinus ostium in relation to the middle turbinate?
Lower 1/3 of middle turb approximates maxillary sinus os
128
What portion of the middle turbinate should be preserved?
Horizontal portion
| Helps to stabilize the middle turbinate and preserves a branch of the SPA
129
Where can inverted papillomas arise?
Lateral nasal wall (90%)
| Maxillary, frontal, ethmoid sinuses
130
Where is the Schneiderian membrane? What is it?
Lines the nasal cavity & PNS's
Ciliated columnar epithelium from the ECTODERM
131
Where are the most common sites for nasal SCCa?
```
Maxillary sinus (70%)
Nasal cavity (12%)
Remainder of sinuses (18%)
```
132
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
```
133
Treatment for adenoid cystic carcinoma of the nose
Surgery
Radiation if perineural/perivascular invasion found (60% of cases)
134
Which sinonasal tumor is associated with fume inhalation?
Adenocarcinoma is associated with wood dust, lacquers, and other organic compounds
135
Where is Ohngren's line?
Lateral canthus to angle of jaw
Posterosuperior to this plane suggests poor prognosis for SNM
136
What age group typically gets esthesioneuroblastoma?
Bimodal (teens and elderly)
137
What percent of verrucous carcinoma harbors classical SCCa?
20%
Classical SCCa much more likely to metastasize
138
What causes NK/T-cell lymphoma of the nose?
EBV infection
139
How does NK/T-cell lymphoma of the nose present?
Midline destructive lesion of the nose
140
What is the most common pediatric SNM?
Sarcomas
| Especially rhabdomyosarcoma.
141
What is the role of antihistamines in CRS?
Only if concurrent allergic rhinitis also present
