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Diplomate exam > Rhinology And Allergology > Flashcards

Rhinology And Allergology Flashcards

1
Q

How to perform endoscopic sphenopalatine ligation?

A
  • ff middle turbinate to posterior aspect
  • vertical incision 7-8mm anterior to the posterior end of middle turbinate
  • crista ethmoidalis seen and marks anterior sphenopalatine foramen; vessels posterosuperior, clip or cauterize
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2
Q

How to ligate ethmoid aa?

A
  • lynch incision
  • anterior lacrimal crest of maxilla frontal process to anterior ethmoid foramen 22-24mm distance.

Anterior ethmoid to posterior ethmoid foramina 12-15mm

Posterior ethmoid aa foramen and optic canal 3-7mm

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3
Q

Definition of ars? Subacute ars? Chronic? Recurrent?

A

Less than 4 weeks with complete resolution

Between 4 and 12 weeks

More than 12 weeks

> 4episodes a year lasting >7-10days with complete resolution in between episodes

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4
Q

4 cardinal symptoms of crs?

A
  • Anterior or posterior purulent nasal discharge
  • Nasal obstruction
  • face pain/pressure
  • hyposmia or anosmia
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5
Q

Dx of crs is 2 of the carinal symptoms accompanied by:

A
  • endoscopic evidence of mucosal inflammation
  • polyp in nasal cavity or middle meatus
  • radiologic evidence of mucosal inflammation
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6
Q

5 criteria of Bent and Kuhn for allergic fungal rhinosinusitis?

A
  1. Eosinophilic mucin (charcot-leyden crystals)
  2. Non invasive fungal hyphae
  3. Nasal polyposis
  4. Characteristic radiologic findings
    (Ct - rim of hypointensity with hyperdense central material (allergic mucin)
  5. Type 1 hypersensitivity reaction
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7
Q

Is acute allergic fungal rhinosinusitis unilateral or bilateral?

A

Unilateral

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8
Q 
Fungal ball in sinus.
Mc location?
Mc fungus?
Immunocompetent/immunocompromised?
Treatment?
A

Maxillary sinus
Aspergillus fumigatus
Immunocompetent
Surgical removal

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9
Q

Chronic invasive fungal rhinosinusitis.
How many weeks duration?
Immunocompetent/compromised?
Etiologic agent?

A

> 4 weeks with minimal inflammatory response
Immunocompetent
Aspergillus fumigates

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10
Q 
Chronic granulomatous fungal rhinosinusitis.
How long?
Immunocompetent or compromised?
Histologic findings?
Etiologic agent?
A

> 4 weeks with mucosal inflammatory cell infiltrate
Immunocompetent
-multinucleated giant cell granulomas centered on eosinophilic material surrounded by fungus
-aspergillus flavus

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11
Q

What is another name for the valveless veins in the nasal area?

A

Veins of Breschet

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12
Q

What is the Chandler classification for ophthalmic complications due to rhinosinusitis?

A

A. Preseptal cellulitis - inflammatory edema with no limitation of eom

B. Orbital cellulitis - chemosis, impairment of eom, proptosis, possible visual impairment

C. Subperiosteal abscess - pus collection between media periorbita and bone; chemosis, exophthalmos, eom impaired, visual impairment worsening

D. Orbital abscess - pus collection in orbital tissue, complete ophthalmoplegia with severe visual impairment

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13
Q

What is the superior orbital fissure syndrome?

A

Cn 3,4,V1 and 6

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14
Q

What is the orbital apex syndrome?

A

Cn 2,3,4,V1 and 6

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15
Q

What is pott puffy tumor?

A

Frontal bone osteomyelitis to erosion of the anterior bony table

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16
Q

Effective first line surgical procedure for children ages 13 or younger with crs?

A

Adenoidectomy

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17
Q

Microorganism responsible for atrophic rhinitis?

A

Klebsiella ozaenae

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18
Q

Mc histology of pns malignancy?

A

Scc

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19
Q

Location of pns cancer locations?

A

Maxillary sinus (55%)
Nasal passage (35%)
Ethmoids (10%)
Frontal and sphenoid sinuses (<1%)

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20
Q

Mc symptom of pns tumor? (1 and 2)

A

Mc nasal obstruction

2nd: neck lymphadenopathy

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21
Q

Sinonasal undifferentiated carcinoma (SNUC) histopathologic markers?

A

Cytokeratin (CK), epithelial membrane antigen (EMA), weak neuron specific enolase (NSE)

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22
Q

Sinonasal neuroendocrine carcinoma (SNEC) histopathologic markers?

A

Chromogranin (CHR)
NSE
Synaptophysin (SYN)
Epithelial markers (CK)

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23
Q

Top 3 most common location of osteoma?

A
  1. Frontal sinus
  2. Ethmoid
  3. Maxillary
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24
Q

Sinonasal papilloma (3) most common types:

A
  1. Septal papilloma (50%)
  2. Inverted papilloma (47%) from lateral nasal wall
  3. Cylindrical papilloma (3%) from lateral nasal wall
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25
Q

Inverted papilloma _____ of malignancy?

A

3-9%

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26
Q

Epicenter of JNA?

A

Sphenopalatine area

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27
Q

Ct scan in JNA shows expansion of what area?

A

Pterygopalatine fossa

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28
Q

Primary blood supply of JNA?

A

Int. max

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29
Q

Scc comprises ______ of all paranasal sinus cancers.

A

70-80%

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30
Q

Olfactory groove tumors from most to least aggressive.

A
  1. Scc of the skull base
  2. Sinonasal undifferentiated ca
  3. Sn neuroendocrine ca
  4. Esthesioneuroblastoma
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31
Q

Malignant mucosal melanoma of the pns survival in 2 years?

A

25%

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32
Q

Physaliferoys cells with soap bubble appearance on pathology?

A

Clival chordoma

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33
Q

Kadish system for ENB?

A

A: tumor of nasal fossa
B: ext to PNS
C: ext beyond PNS
D: ext into or beyond dura

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34
Q

TNM ENB staging system?

A

T1 : inv nasal cavity/PNS (x sphenoid), sparing most superior ethmoid cells

T2: inv nasal cavity/PNS (inc sphenoid), with extension to or erosion of the cribriform plate

T3: extending into orbit or protruding into anterior cranial fossa, without dural invasion

T4: inv brain or dura

N0: no cervical LN inv
N1: any cervical LN inv

M: no mets
M1: distant mets

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35
Q

ENB Hyams histopathological grading?

A

Grade 1-2: homer wright pseudorosette
Grade 3-4: flexner wintersteiner rosettes

Based in mitosis, necrosis, pleomorphism, type of tissue architecture

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36
Q

Pns malignancy with worst prognosis? Best?

A

Mucosal melanoma

Minor salivary gland tumors, low-grade sarcoma

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37
Q 
Paranasal sinus treatment complications most common site?
Venous bleeding?
Arterial bleeding?
Intradural nerve injury?
Extradural nerve injury?
Positive margins?
A
  • Cavernous sinus or pterygoid plexus
  • Ethmoid or internal maxillary arteries
  • CN II
  • CN I
  • lateral supraorbital dura
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38
Q

What nerves are responsible to experience odor?

A

Cn 1, 5, 9, 10

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39
Q

At physiologic air flow rates, what percent of air flows through the olfactory region?

A

15%

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40
Q

Best olfactory ability is noted at what times?

A

Times of upper respiratory infection, when the epithelium is moderately congested, red, and wet. Olfactory seems to improve with narrow nasal chambers

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41
Q

Where does the mucus of the olfactory region come from?

A

Bowman’s glands (serous type) and adjacent respiratory mucosa goblet cells.

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42
Q

Where is the olfactory epithelium located?

A

7cm inside the nasal cavity, protected in a 1mm wide crevice.

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43
Q

Type of epithelium of olfactory epithelium?

A

Pseudostratified columnar with no submucosa

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44
Q

4 main types of cells in the olfactory area?

A
  1. Ciliated olfactory receptors
  2. Microvillar cells
  3. Supporting (sustentacular) cells - do not directly influence the transduction process
  4. Basal cells - globus basal cells seem to be responsible for continuous replacement of olfactory receptor cells. Replication cycle is 3-7weeks
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45
Q

Number of olfactor cells in humans?

A

6M

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46
Q

First relay station in the olfactory pathway?

A

Olfactory bulb

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47
Q

Have the largest gene family in the entire genome?

A

Olfactory receptors

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48
Q

Odor memory lasts how long?

A

At least a year. (Visual memory only a few months)

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49
Q

Number of molecules needed to stimulate a receptor?

A

9

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50
Q

Threshold levels for stimulation?

A

40 receptors

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51
Q

Most widely used test substances for smell?

A

Pyridine and n-butyl alcohol

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52
Q

How to identify malingering patients (anosmia)?

A

Place coffee granules on the tongue. An anosmic px would only taste a bitter taste but not coffee. A malingerer will identify the taste as coffee, yet will be unable to recognize it when passed in front of the nose.

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53
Q

________ have better olfactory ability both in threshold and identification.

A

Women

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54
Q

Adaptation and habituation takes how long?

A

1-5mins

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55
Q

Total anosmia occurs with blows to the?

A

Occiput

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56
Q

Best known type of congenital hyposmia.

A

Kallman’s syndrome

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57
Q

Distortion of inhaled odors. Perception of smell without an odorant in the environment?

A

Parosmia, phantosmia

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58
Q

Conjure memories based on odors in such a dramatic way.

A

Marcel proust syndrome

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59
Q

Useful for the detection of the nasal cycle.

A

Rhinostereometry

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60
Q

Shows the volume of the nasal cavity?

A

Acoustic rhinometry

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61
Q

Sign to assess the effect of the nasal valve, the pxs cheek is drawn back to see whether a significant decrease in obstruction occurs.

A

Cottle sign

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62
Q

In rhinomanometry, it determines what?

A

Nasal patency

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63
Q

In rhinomanometry, what is referred to by the ff terms?
Ratio of pressure to flow
Ratio of flow to pressure
Mean pressure x flow

A

Resistance
Conductance
Work

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64
Q

Advantages of acoustic rhinometry?

A

-better for studies of rapidly changing microvascular conditions and nasal volume changes

  • provides more precise anatomic information
  • less variable results
  • useful for the evaluation of patients.
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65
Q

What does the “I” notch in rhinometry signify?

A

Isthmus nasi, first dip

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66
Q

What does the “C” notch in rhinometry signify?

A

Concha, 2nd dip, which corresponds to the anterior tip of the inferior turbinate.

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67
Q

What is the normal notch pattern in rhinomanometry?

In patients with allergic rhinitis and with habitual snoring?

A

“Climbing w”

“Descending w”

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68
Q

What is the international standard of resistance?

A

150 Pa

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69
Q

For allergic patients, the MCA (minimal cross sectional area) is at the _________ and not at the usual i notch.

A

C notch

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70
Q

What is a clear indication for surgery?

A

Constant stenosis and total flow of 700 cm3/sec

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71
Q

Normal MCA (minimal cross sectional area) in acoustic rhinometry?

For the total airway?

A
  1. 72-0.73 cm2 before decongestion,
  2. 92-0.95cm2 after congestion,
  3. 46cm2 before congestion
  4. 88cm2 after congestion
72
Q

Most important determinant of patient’s wellbeing?

A

Total resistance

73
Q

Slit like opening between the caudal edge of the lateral cartilage and the nasal septum coined by Mink, considered to be the narrowest part of the nasal airway, aka nasal valve, os internum, limen vestibule, limen nasi, luminal valve, luminal chink?

A

Ostium internum

74
Q

What are the three types of sphenoid sinuses as described by Hamberger?

A
  1. Sellar (67-76%): Sella turcica bulges into a well-developed sinus.
  2. Presellar (23-28%): Cancellous bone extends from under the sella to the anterior aspect of the floor.
  3. Conchal (0-5%): Sphenoid sinus is entirely filled with cancellous bone.
75
Q

What is the foramen of Morgagni?

A

Gap between superior constrictor muscle and skull base.

76
Q

What passes through the foramen spinosum?

A

Meningeal branch of V3

77
Q

Passes through infraorbital foramen?

A

Terminal branch of V2

78
Q

Passes through foramen ovale?

A

Accessory meningeal artery and terminal branch of V3

79
Q

Passes through sphenopalatine foramen?

A

Sphenopalatine artery

80
Q

Passes through superior orbital fissure?

A

CN 3, 4, 6 and V1

81
Q

Passes through foramen rotundum?

82
Q

Where does Dorello’s canal pass and what structures does it contain?

A

Lies between the petrous tip and sphenoid bone and contains the CN 6 and inferior petrosal sinus.

83
Q

What are the nuclei of the vagus nerve?

A

Nucleus ambiguus,dorsal motor nucleus, and the nucleus of the solitary tract.

84
Q

What are the diagnostic criteria for Acute Fungal Sinusitis according to Bent and Khun?

A

Allergic mucin
Nasal polyposis
CT scan findings consistent with chronic rhinosinusitis
Positive fungal histology or culture
Type I hypersensitivity diagnosed by history, positive skin test, or serology.

85
Q

What is the most common organism cultured from an intracerebral abscess resulting from rhinosinusitis?

A

Streptococcus milleri (commensal found in the mouth, vagina, and feces).

86
Q

Vomeronasal organ located on the anteroinferior nasal septum?

A

Jacobson organ

87
Q

Orthonasal stimulation is detected?

88
Q

Retronasal stimulation is detected?

A

Posterior choanae

89
Q

Most frequent cause of olfactory loss?

A

Frontal blow

90
Q

Rate of recovery from an olfactory blow?

91
Q

Mechanism of injury to olfactory epithelium?

A

Shearing of olfactory nerve at cribriform plate

Contusion of olfactory bulb or other central processing areas

92
Q

At what age does olfactory identification drop?

A

60-70 yrs old

93
Q

Mucus travels what speed?

A

2-10 mm/hr

94
Q

Ciliary beat frequency?

A

8 hz normal temp

12 hz at 37 degrees c

95
Q

Primary screening for primary ciliary dyskinesia?

A

Nasal nitric oxide. Tenfold decrease in pcd.

96
Q

Three types of wegener’s granulomatosis?

A

Type 1: limited form. Urti lasting several weeks, unresponsive to antibiotics associated with serosangiunous nasal drainage and pain

Type 2: sicker patients with more systemic symptoms

Type 3: widely disseminatd, with involvement of multiple airway, pulmonary, renal and cutaneous lesions

97
Q

How to dx WG?

98
Q

Treatment of WG?

A

Oral cyclophosphamide 2mg/kg/day for 1 year and prednisone 1mg/kg/day for 1 month. Trimethoprim-smx

99
Q

3 dx criteria for sarcoidosis?

A

Clinical and radiologic presentation typical of sarcoidosis
Nasal biopsy materal should demonstrate non caseating granulomas
Other causes of granulomatous changes excluded

100
Q

Is mucosal destruction seen in wg or cgs?

101
Q

3 phases of churg strauss syndrome?

A
  1. Prodromal pjase
  2. Peripheral blood and tissue eosinophilia, chronic eosinophilic pneumonia, eosinophilic gastroenteritis
  3. Life threatening systemic vasculitis
102
Q

Treatment of churg strauss syndrome?

A

Corticosteroids

103
Q

3 stages for the development of rhinoscleroma?

A

Catarrhal - foul smelling discharge weeks/months
Atrophic stage - large nasal plaques or crusts foul smelling and stimulate the lesions in atrophic rhinitis
Granulomatous - multiple granulomatous nodules, which enlarge and coalesce
Fibrosis and stenosis - sometimes extending into the nasopharynx and trachea

104
Q

Dx of rhinoscleroma?

A

Eosin staining russel bodies

Hallmark of vacuolated mikulicz cells

105
Q

Treatment of rhinoscleroma?

A

Streptomycin 1g/day for 4 weeks

Tetracycline 2g/day

106
Q

Site in nasal cavity most affected by TB?

A

Nasal septum

Anterior portion of nasal turbinates

107
Q

Causative agent of rhinosporidius, usual in asian and african countries?

A

Rhinosporidium seeberi

108
Q

How to dx mucormycosis?

A

Periodic acid schiff stain or

Grocott-gomori methenamine silver nitrate stain

109
Q

Survival rate of mucormycosis?

110
Q

How to differentiate WG and t cell lymphoma?

A
  1. Distribution of ulceration is focal, localized and explosive in t-cell lymphomas
  2. Systemic features and lung infiltrates are similar, but otologic, renal, and tracheal involvement is uncommon in t-cell
  3. Main differences are found on morphologic examination
111
Q 
Supplies septum:
Anterior inferior
Superior posterior
Superior anterior
Anterior
Posterior?
A 
Greater palatine aa
Posterior ethmoid aa (also supplies lateral wall)
Superior anterior: anterior ethmoid aa
Anterior: superior labial from facial aa
Posterior: sphenopalatine
112
Q

Transfusion threshold for epistaxis?

113
Q

At how many mins will phenylephrine decongest? Anesthetize?

A

6mins and 9mins

114
Q

Longest and most anterior branch of the sphenopalatine artery?

A

Posterior lateral nasal branch. Clipped and ligated to locate the nasopalatine branch to the palate

115
Q

Where is anterior ethmoid found? Most common?

A

Always between 2nd and 3rd lamella.

Subrabullar recess.

116
Q

Temperature of hot water irrigation for epistaxis?

A

52 degree celsius (122 degrees f) for 3 mins.

117
Q

When do traumatic epistaxis take place?

A

7 weeks post injury

118
Q

Connects ica and eca through branch of the sphenopalatine.

A

Vidian artery

119
Q

1st branch of the internal carotid aa?

A

Ophthalmic aa

120
Q

How long should nasal pack in epistaxis be left in place?

121
Q

How to ligate anterior ethmoid aa accdg to stammerger?

A

1-2mm behind junction of posterior wall of frontal recess and anterior ethmoid

122
Q

How to locate anterior ethmoid aa accdg to simon?

A

From posterior wall of frontal recess, 11mm (6-15mm)

123
Q

Where does transnasal endoscopic sphenopalatine artery ligation (TESPAL) ligate?

A

At the posterolateral attachment of the middle turbinate where the sphenopalatine foramen leaves the sphenopalatine foramen.

124
Q

Contraindication for embolization in epistaxis?

A

Identified bleeding froming from eca supply. Cannot be for ica because causes blindness.

125
Q

How to perennial ar?

A

> 2 hours a day

>9 months/year

126
Q

Most suggestive symptom of allergy?

127
Q

Mast cell degranulation releases?

A

Histamin
Tryptase
PGD2
Cysteneil leukotrienes

128
Q

What is local allergic rhinitis?

A

Localized nasal allergy
Allergy testing negative (skin or serologic)
(-) systemic atopy

129
Q

H1 antihistamine effective within?

130
Q

Name an intranasal antihistamine

A

Azelastine

131
Q

First line treatment for AR?

A

Intranasal corticosteroid

132
Q

Principal s/e of icns?

A

Local nasal irritation

133
Q

Mc pathophysiology of atrophic rhinitis?

A

Before antibiotics, klebsiella ozaenae. Now secondary to surgery.

134
Q

Pathologic change in atrophic rhinitis?

A

Ciliated respiratory epithelium are converted to non ciliated squamous metaplasia.

135
Q

Fda approved treatment for nares (2)?

A

Fluticasone

Beclomethasone

136
Q

What percent of icns is absorbed?

137
Q

Nasal ciliary beat? Mucus moves?

A

10-15 beats/min

2.5-7.5 ml/min

138
Q

Sympathetic mediation in nose?

A

Norepinephrine, neuropeptide Y - vasoconstriction

139
Q

Parasympathetic mediation in nose?

A

Norepinephine, acth, vip - increased secretion

140
Q

Nasal sensation?

141
Q

Blood supply of columnella and caudal septum?

A

Superior labial aa

142
Q

Shape and angulation of nasal valve?

A

Trapezoidal, 10-15degrees

143
Q

Airflow through nasal valve in adult at rest?

A

16 m/sec linear velocity (decreased by 4 in nasal cavity)

144
Q

Most important variable in nasal flow?

A

Diameter of nasal passage

145
Q

How many neurofibromas will produce malignant transformation (von recklinghausen disease)?

146
Q

What are the intermediate nasal neoplasms?

A

Inverting papilloma
Hemangioma
Meningioma
Hemangiopericytoma

147
Q

Mc cune alright syndrome associated with fibrous dysplasia or ossifying fibroma?

A

Fibrous dysplasia (developmental anomaly)

148
Q

Mc complication of sinus radiation?

A

Cataract formation

149
Q

Sarcomas more often seen in maxilla or mandible?

150
Q

What is the combination of suprabullar and retrobullar recess called?

A

Sinus lateralis. Drains into middle meatus via hiatus semilunaris superior or hiatus semilunaris

151
Q

Where does maxilary ostium drain?

A

Inferior 3rd of infundibulum in 65% of cases

152
Q

Anterior and posterior fontanelle separated by?

A

Uncinate bone

153
Q

Mc technical cause of surgical failure?

A

Lateralizatin of middle turbinate and failure to incorporate natural ostium into middle meatus

154
Q

Mc minor complication ess

155
Q

Mc reported complication ess

A

Perioperative and postoperative hemorrhage

156
Q

Mc orbital complication?

A

Orbital hemorrhage

157
Q

Increased orbital pressure in ess leads to blindness in?

A

60-90 mins

158
Q

Diplopia in ess d/t what muscle?

A

Superior oblique or medial rectus

159
Q

Frontal sinus approach complete removal of anterior frontal sinus wall

160
Q

Floor of frontal sinus, portions of lamina payracea, ehtmoidectomy?

161
Q

Frontal sinus floor and anterior wall ethmoidectomy?

162
Q

Anterior wall frontal sinus based inferiorly retracted and replaced with periosteum intact

A

Osteoplastic

163
Q

Mucus blanket renewed every?

164
Q

Nasal cycle duration

165
Q

Predominant leukotriene from eosinophils

166
Q

___ exposures for sensitization

167
Q

Reason for nasal valve dysfunction with age

A

Cartilage decrease in tensile strength

168
Q

Nipple for bilatral choanal atresia

A

Mcgovern nipple

169
Q

Volume of maxillary sinus, frontal, ethmoid, sphenoid

A

15ml, 4-7ml, 2-3ml, 0.5-8ml

170
Q

Adult nose how many secretions in a day

A

1000ml/day

171
Q

Csf produced at a rate of?

172
Q

Total csf volume?

173
Q

Normal upper limit of csf pressure in infants? In children?

A

40 mmhg

140 mmhg

174
Q

3 arms of failed immunity?

A

Immunodeficiency
Hypersensitivity
Autoimmunity

175
Q

Allergic rhinitis prevalence?

A

40% of general population

176
Q

Primary immune deficiency?

A

1/1200 births. Mc iga def 1/300-500 px

Diplomate exam (7 decks)

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