Rhinology And Allergology Flashcards
How to perform endoscopic sphenopalatine ligation?
- 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
How to ligate ethmoid aa?
- 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
Definition of ars? Subacute ars? Chronic? Recurrent?
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
4 cardinal symptoms of crs?
- Anterior or posterior purulent nasal discharge
- Nasal obstruction
- face pain/pressure
- hyposmia or anosmia
Dx of crs is 2 of the carinal symptoms accompanied by:
- endoscopic evidence of mucosal inflammation
- polyp in nasal cavity or middle meatus
- radiologic evidence of mucosal inflammation
5 criteria of Bent and Kuhn for allergic fungal rhinosinusitis?
- Eosinophilic mucin (charcot-leyden crystals)
- Non invasive fungal hyphae
- Nasal polyposis
- Characteristic radiologic findings
(Ct - rim of hypointensity with hyperdense central material (allergic mucin) - Type 1 hypersensitivity reaction
Is acute allergic fungal rhinosinusitis unilateral or bilateral?
Unilateral
Fungal ball in sinus. Mc location? Mc fungus? Immunocompetent/immunocompromised? Treatment?
Maxillary sinus
Aspergillus fumigatus
Immunocompetent
Surgical removal
Chronic invasive fungal rhinosinusitis.
How many weeks duration?
Immunocompetent/compromised?
Etiologic agent?
> 4 weeks with minimal inflammatory response
Immunocompetent
Aspergillus fumigates
Chronic granulomatous fungal rhinosinusitis. How long? Immunocompetent or compromised? Histologic findings? Etiologic agent?
> 4 weeks with mucosal inflammatory cell infiltrate
Immunocompetent
-multinucleated giant cell granulomas centered on eosinophilic material surrounded by fungus
-aspergillus flavus
What is another name for the valveless veins in the nasal area?
Veins of Breschet
What is the Chandler classification for ophthalmic complications due to rhinosinusitis?
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
What is the superior orbital fissure syndrome?
Cn 3,4,V1 and 6
What is the orbital apex syndrome?
Cn 2,3,4,V1 and 6
What is pott puffy tumor?
Frontal bone osteomyelitis to erosion of the anterior bony table
Effective first line surgical procedure for children ages 13 or younger with crs?
Adenoidectomy
Microorganism responsible for atrophic rhinitis?
Klebsiella ozaenae
Mc histology of pns malignancy?
Scc
Location of pns cancer locations?
Maxillary sinus (55%)
Nasal passage (35%)
Ethmoids (10%)
Frontal and sphenoid sinuses (<1%)
Mc symptom of pns tumor? (1 and 2)
Mc nasal obstruction
2nd: neck lymphadenopathy
Sinonasal undifferentiated carcinoma (SNUC) histopathologic markers?
Cytokeratin (CK), epithelial membrane antigen (EMA), weak neuron specific enolase (NSE)
Sinonasal neuroendocrine carcinoma (SNEC) histopathologic markers?
Chromogranin (CHR)
NSE
Synaptophysin (SYN)
Epithelial markers (CK)
Top 3 most common location of osteoma?
- Frontal sinus
- Ethmoid
- Maxillary
Sinonasal papilloma (3) most common types:
- Septal papilloma (50%)
- Inverted papilloma (47%) from lateral nasal wall
- Cylindrical papilloma (3%) from lateral nasal wall
Inverted papilloma _____ of malignancy?
3-9%
Epicenter of JNA?
Sphenopalatine area
Ct scan in JNA shows expansion of what area?
Pterygopalatine fossa
Primary blood supply of JNA?
Int. max
Scc comprises ______ of all paranasal sinus cancers.
70-80%
Olfactory groove tumors from most to least aggressive.
- Scc of the skull base
- Sinonasal undifferentiated ca
- Sn neuroendocrine ca
- Esthesioneuroblastoma
Malignant mucosal melanoma of the pns survival in 2 years?
25%
Physaliferoys cells with soap bubble appearance on pathology?
Clival chordoma
Kadish system for ENB?
A: tumor of nasal fossa
B: ext to PNS
C: ext beyond PNS
D: ext into or beyond dura
TNM ENB staging system?
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
ENB Hyams histopathological grading?
Grade 1-2: homer wright pseudorosette
Grade 3-4: flexner wintersteiner rosettes
Based in mitosis, necrosis, pleomorphism, type of tissue architecture
Pns malignancy with worst prognosis? Best?
Mucosal melanoma
Minor salivary gland tumors, low-grade sarcoma
Paranasal sinus treatment complications most common site? Venous bleeding? Arterial bleeding? Intradural nerve injury? Extradural nerve injury? Positive margins?
- Cavernous sinus or pterygoid plexus
- Ethmoid or internal maxillary arteries
- CN II
- CN I
- lateral supraorbital dura
What nerves are responsible to experience odor?
Cn 1, 5, 9, 10
At physiologic air flow rates, what percent of air flows through the olfactory region?
15%
Best olfactory ability is noted at what times?
Times of upper respiratory infection, when the epithelium is moderately congested, red, and wet. Olfactory seems to improve with narrow nasal chambers
Where does the mucus of the olfactory region come from?
Bowman’s glands (serous type) and adjacent respiratory mucosa goblet cells.
Where is the olfactory epithelium located?
7cm inside the nasal cavity, protected in a 1mm wide crevice.
Type of epithelium of olfactory epithelium?
Pseudostratified columnar with no submucosa
4 main types of cells in the olfactory area?
- Ciliated olfactory receptors
- Microvillar cells
- Supporting (sustentacular) cells - do not directly influence the transduction process
- Basal cells - globus basal cells seem to be responsible for continuous replacement of olfactory receptor cells. Replication cycle is 3-7weeks
Number of olfactor cells in humans?
6M
First relay station in the olfactory pathway?
Olfactory bulb
Have the largest gene family in the entire genome?
Olfactory receptors
Odor memory lasts how long?
At least a year. (Visual memory only a few months)
Number of molecules needed to stimulate a receptor?
9
Threshold levels for stimulation?
40 receptors
Most widely used test substances for smell?
Pyridine and n-butyl alcohol
How to identify malingering patients (anosmia)?
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.
________ have better olfactory ability both in threshold and identification.
Women
Adaptation and habituation takes how long?
1-5mins
Total anosmia occurs with blows to the?
Occiput
Best known type of congenital hyposmia.
Kallman’s syndrome
Distortion of inhaled odors. Perception of smell without an odorant in the environment?
Parosmia, phantosmia
Conjure memories based on odors in such a dramatic way.
Marcel proust syndrome
Useful for the detection of the nasal cycle.
Rhinostereometry
Shows the volume of the nasal cavity?
Acoustic rhinometry
Sign to assess the effect of the nasal valve, the pxs cheek is drawn back to see whether a significant decrease in obstruction occurs.
Cottle sign
In rhinomanometry, it determines what?
Nasal patency
In rhinomanometry, what is referred to by the ff terms?
Ratio of pressure to flow
Ratio of flow to pressure
Mean pressure x flow
Resistance
Conductance
Work
Advantages of acoustic rhinometry?
-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.
What does the “I” notch in rhinometry signify?
Isthmus nasi, first dip
What does the “C” notch in rhinometry signify?
Concha, 2nd dip, which corresponds to the anterior tip of the inferior turbinate.
What is the normal notch pattern in rhinomanometry?
In patients with allergic rhinitis and with habitual snoring?
“Climbing w”
“Descending w”
What is the international standard of resistance?
150 Pa
For allergic patients, the MCA (minimal cross sectional area) is at the _________ and not at the usual i notch.
C notch
What is a clear indication for surgery?
Constant stenosis and total flow of 700 cm3/sec