Term
| What percentage of patients have a dehiscent carotid in the sphenoid? |
|
Definition
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|
Term
What are the critical histopathalogic markers for the following pathologies?
1) Melanoma
2) Sinonasal undifferentiated carcinoma
3) Ewing sarcoma
4) Rhabdomyosarcoma
5) Esthesioneuroblastoma |
|
Definition
1) HMB 45+, S100+
2) CK+
3) Neuron specific enolase+
4) Desmin+
5) Neuron specific enolase+ |
|
|
Term
| What is the most useful staging system for Esthesioneuroblastoma in terms of prognosis prediction? |
|
Definition
Kadish
1) Nasal cavity
2) Paranasal sinuses
3) Beyond paranasal sinuses (intracranial but not intradural, orbital, skull base) but without distant mets and cervical LNA
4) Distant mets or cervical LNA |
|
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Term
| How can you differentiate between sinonasal glioma and encephalocele |
|
Definition
| Encephaloceles will change size with jugular venous compression (Furstenburg) |
|
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Term
| What is the comparative data on transphenoidal versus transotic drainage of cholesterol granulomas of the petrous apex? |
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Definition
| For those that abut the sphenoid sinus, recurrence rates are lower for transphernoidal and there is lower morbidiity |
|
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Term
| What are the 5 ethmoid lamellae and where does the anterior ethmoidal artery typically locate? |
|
Definition
Between the second and third. Remember don't embolize as it comes off the ophthalmic which is internal carotid
1) Uncinate
2) Ethmoid Bulla
3) Ground/bala lamella
4) Superior turbinate
5) Supreme turbinate |
|
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Term
| What are the anatomic boundaries of the frontal recess? |
|
Definition
Posterior: ethmoid bulla
Lateral: lamina papyrecia
Anterior: Aggar nasi
Medial: Middle turbinate |
|
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Term
| What is the blood supply to the nasal cavity? |
|
Definition
- Anterior/posterior ethmoidal off of opthalmic
- Sphenopalatine
- Greater palatine
- Superior labial |
|
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Term
| Describe the development of the ethmoturbinals and furrows and their resulting structures |
|
Definition
- Ethmoturbinal 1 becomes the aggar nasi (ascending) and uncinate (descending.
- Furrow between 1 and 2 becomes middle meatus, hiatus semilunaris and ethmoid infundibulum
- Ethmoturbinal 2 becomes the middle turbinate
- Furrow between 2 and 3 becomes the superior meatus
- Turbinal 3 becomes the superior turbinate
- Turbinal 4/5 fuse and becomes the spreme turbinate |
|
|
Term
| What are the most common sites of iatrogenic csf leak after sinus surgery? |
|
Definition
1) Fovea ethmoidalis/roof of ethmoid
2) Cribriform plate
3) Lateral lamella of cribriform plate |
|
|
Term
| how does the primary treatment of IFS related to mucormycosis differ from aspergillus? |
|
Definition
1) Aspergillis- septate 45 degree- Voriconazole
2) Mucormycosis- 90 degree non-septated, IV amphotericin |
|
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Term
| True or false: IFS due to diabetes has a better prognosis compared to immunosuppression |
|
Definition
True- diabetes is reversible.
If secondary to DKA, survival is 80% versus <50% in non-diabetic patients
higher serum iron has decreased survival |
|
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Term
| What are the anatomic boundaries of the internal nasal valve and what contribution does it make to total nasal resistance? |
|
Definition
50%
Septum medially, anterior edge of inferior turbinate inferolaterally, caudal edge of upper lateral cartilage superolaterally |
|
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Term
| What is the blood supply and typical histologic findings of a JNA? Where do they typically grow from? |
|
Definition
1) Imax off of ECA
2) Normal-sized vessels lacking musclaris layer amidst mature connective tissue (fragile), also rich in androgen receptors (only found in men)
3) Commonly grow off of nasal sidewall near sphenopalatine canal, leading to pushing of the posterior maxillary wall anteriorly (Holman-Miller sign) |
|
|
Term
| What is the origin of Rhinophyma, leading to massive nasal hypertophy and hyperplasia of sebaceous glands? |
|
Definition
Final stage of uncontrolled Acne Rosacea
Also associated with the mite Demodex folliculorum, though unclear pathogenic role |
|
|
Term
| What is the cause and histopathology of Rhinoscleroma |
|
Definition
Presents as painless mass in nose.
Different from rhinophyma (Rosacia, mites), and rhinosporidiosis.
Rhinoscleroma caused by Klebsiella Rhinoscleromatis and diagnosed on biopsy showing foamy histiocytes (Mikulicz cell) and pseudoepitheliomatous hyperplasia and bloated plasma cells (Russel Bodies).
Treatment is tetracycline or ciprofloxacin |
|
|
Term
| What form of chronic rhinosinusitis is associated strongly with staph aureus? |
|
Definition
SA enterotoxin acts as superantigen in CRSwNP.
Associated with high IgE subset, nasal polyposis, asthma and AERD. |
|
|
Term
| What is the most common cause of acute bacterial sinusitis in patients with allergies? |
|
Definition
S. pneumo
S. aureus is common in patients with CRSwNP, but not as common as strep in acute bacterial sinusitis |
|
|
Term
| Which cause of acute bacterial rhinosinusitis is most likely to resolve without antibiotic treatment? |
|
Definition
|
|
Term
What is the topical nasal steroid of choice for rhinitis of pregnancy?
What topical agent is associated birth abnormalities? |
|
Definition
1) Budesonide is choice
2) Triamcinolone is associated with respiratory defects
Flonase and Mometasone are likely safe, but data is somewhat lacking. |
|
|
Term
| How many days of symptoms must occur before diagnosis of bacterial rhinosinusitis can be made? |
|
Definition
10 days
Acute < 4 weeks
Subacute 4-12 weeks
Chronic >12 weeks |
|
|
Term
| ANC below what number is a poor prognostic indicator in transplant patients or those with hematologic malignancies who develop IFS? |
|
Definition
|
|
Term
| Distinguish which nerves are involved in cavernous sinus syndrome, superior orbital fissure syndrome and orbital apex syndrome |
|
Definition
1) Cavernous sinus= III, IV, V1/2, VI, sympathetics. Can be bilateral
2) Superior orbital fissure= III, IV, V1 +/- V2, VI. Unilateral
3) Orbital Apex syndrome= II, III, IV, V1/2, VI (usually due to trauma) |
|
|
Term
| What are the branches of the opthalmic division of the trigeminal nerve? |
|
Definition
Frontal, Lacrimal and Nasociliary
Terminal branch of nasociliary nerve is anterior ethmoidal nerve which innervates the medial nasal alae via the external nasal nerve. |
|
|
Term
| What is the risk of oncologic transformation in Inverted Papilloma? |
|
Definition
Associated with HPV 16/18
10%, risk to SCC |
|
|
Term
| What neurologic conditions is hyposmia/anosmia an early sign of? |
|
Definition
| Parkinson's, Alzheimers, MS, Depression, Schizophrenia |
|
|
Term
| What is the clearest prognostic indicator of survival in mucosal melanoma? |
|
Definition
Site of origin in the head and neck
5 year survival nasal cavity is 15-30%
12% for oral cavity
0.5% for paranasal sinuses |
|
|
Term
| What is the most common microbe involved in cavernous sinus thrombosis? |
|
Definition
|
|
Term
| Describe the action of the vidian nerve in the nasal cavities |
|
Definition
- Forms as joining of GSPN (pre-ganglionic parasympathetics) and deep petrosal (post-ganglionic sympathetics) in vidan canal and joins branches of sphenopalatine nerve.
- Parasympathetic: ACh, VIP, leads to dilation, mast cell degranulation
- Sympathetic noradrenaline and neuropeptide Y leades to constriction |
|
|
Term
| What are the keros classification of the skull base? |
|
Definition
Evaluation of skull base height in anterior ethmoid
1) 1-3mm depth to olfactory fossa
2) 4-7mm
3) 8-12mm |
|
|
Term
| What are the most common microbes involved in allergic fungal sinusitis? |
|
Definition
Dermatiaceous molds (Alternaria, Bipolaris, Curvularia etc).
Need 5 criteria:
- eosinophilic mucin
- atopy type 1 hypersensitivity
- polyps
- fungal stain or culture
- CT evidence (usually dramatic bony expansion, rim of hypointensity with hyperdense center)Whta |
|
|
Term
| What is the hypothesized pathogenesis of AERD? |
|
Definition
Dysregulated eicosanoid synthesis
AA is normally cleaved by PDA2 and shunted to the LKE (via lipoxygenase) or PGE (via cyclooxygenase) pathways.
In AERD there is overproduction of LKEs.
ASA shunts further LKE by inhibiting cyclooxygenase and decreasing PGE2 production in favor of LKE production
Polyps in AERD typically are more refractive to treatment and recurrent with high eosinophilic load |
|
|
Term
| True or false, treatment of CRS in asthmatic patients can improve asthma? |
|
Definition
| True. CRSwNP is considered "asthma" of the upper airway |
|
|
Term
| What percentage of anterior ethmoid arteries and cavernous carotid arteries are dehiscent? |
|
Definition
|
|
Term
| Where is the most common site of persistent sinus disease following ESS? |
|
Definition
|
|
Term
| When does the sphenoid sinus begin pneumatization embryologically? |
|
Definition
|
|
Term
| What is the differential for a congenital midline nasal mass? |
|
Definition
1) Dermoid- does not transilluminate, firm, painless and non-compressible. Surgical excision. Need MRI and CT.
2) Glioma: ectopic glial tissue (15-20% with IC connection). Firm, non-tender, does not transilluminate. Complete surgical excision.
3) Encephalocele (occipital common vs. sincipital)
- bluish, soft, compressible, transilluminates. Surgery needed
4) Teratoma
5) Rathke Pouch or Thornwald Cyst |
|
|
Term
Which of the following is not part of the early phase of allergic rhinitis?
1) Mast cell degranulation
2) Histamine release
3) Tryptase release
4) Eosinophil activation |
|
Definition
Eosinophil activation
Early (5-15 minutes): sneezing, rhinorrhea, congestion, pruritis
Late (2-4 hours): inflammatory cells recruited by cytokines. Seasonal allergies, Perennial allergies |
|
|
Term
| What disease process is assocaited with rhinitis with 10-20% eosinophils on nasal smear with negative allergy assesment? |
|
Definition
| Nonallergic rhinitis of eosinophilia syndrome (NARES). Topical nasosteroids used to treat |
|
|
Term
| What is the most common organism associated with atrophic rhinitis? |
|
Definition
. Foul smell and yellow/green nasal crusting with atrophy and fibrosis of mucosa.
- Klebsiella ozaenae
Treat with nasal saline irrigation, antibiotics, surgery can reduce nasal cavity size |
|
|
Term
| What is the treatment for rhinosporidiosis? |
|
Definition
Rhinosporidium seeberi leading to chronic granulomatous infection.
Associated with pseudoepitheliomatous hyperplasia.
Treat with surgical excision. |
|
|
Term
| Criteria for recurrent ARS |
|
Definition
| 4 or more episodes per year, each lasting 7-10 years, with complete resolution of symptoms between. |
|
|
Term
| How does the immunologic mechanism of CRSwNP differ from CRSsNP? |
|
Definition
CRSwNP is neutrophillic
CRSsNP is eosinophillic |
|
|
Term
| What is an appropriate first-line surgical procedure for children <13 with CRS? |
|
Definition
Adenoidectomy
Also make sure to treat GERD |
|
|
Term
Which antibiotics are appropriate for management of CRS without nasal polyps?
What about with polyps? |
|
Definition
1) Macrolide antibiotic (Azithromycin) for >12 weeks along with nasal steroids and saline irrigations
2) If polyps, systemic corticosteroids for 10 days with taper in addition to above |
|
|
Term
What is the most common cancer of the paranasal sinuses and the most common location it is found within the sinuses?
What is the most common presenting symptom? |
|
Definition
SCC, Maxillary sinus (second is nasal passage).
Nasal obstruction followed by neck LNA |
|
|
Term
| What are the relevant environmental exposures the predispose individuals to sinonasal SCC and adenocarcinoma? |
|
Definition
SCC: nickel, aflatoxin, chromium
Adenocarcinoma: wood dust, woodworking, leather |
|
|
Term
| What are the histopathalogic markers that differentiate esthesioneuroblastoma from sinonasal neuroendocrine carcinoma (SNEC) from sinonasal undifferentiated carcinoma (SNUC) |
|
Definition
1) ENB: not carcinoma, neuronal differentiation. -CK, - EMA, +CHR, +SYN
2) SNEC: neuronal differentiation and carcinoma. +CK, +NSE, + CHR, +SYN
3) SNUC: carcinoma without neuronal diff. +CK, +EMA, weak or neg NSE. |
|
|
Term
| What is the appropriate treatment of a sinonasal hemangiopericytoma? |
|
Definition
Low-grade cancer with low metastatic potential. High local recurrence (30%).
Resection with negative margins, expect bleeding. |
|
|
Term
| Which sinonasal malignancy is associated with "Physaliferous cells with soap bubble appearance"? |
|
Definition
|
|
Term
| What is the Hyams grading system from Esthesioneuroblastoma? |
|
Definition
Histopath (1-4). Based on mitosis, necrosis, pleomorphism
Grade 1-2: Homor Wright pseudorossettes
Grad 3-4: Flexner Wintersteiner rossettes |
|
|
Term
What are the vascular supplies for the following flaps used in sinonasal reconstruction?
1) Pericranial flap
2) Temporoparietal fascia flap
3) Temporalis muscle
4) Free flap options
5) Nasoseptal flap |
|
Definition
1) Supraorbital and supratrochlear arteries. Primary option.
2) STA
3) Deep temporal artery
4) RFF (radial) or ALT (descending branch of lateral circumflex femoral)
5) Sphenopalatine artery. Great option, primary. |
|
|
Term
| Why is it so important to identify Onodi cells during sinus surgery? |
|
Definition
Posterior ethmoid cell with superolateral pneumatization into the sphenoid sinus.
25% of cells will have optic nerve travel in the lateral superior part of the cell. |
|
|
Term
| Where does the middle turbinate attach to the skull base and why is this important? |
|
Definition
The junction of the cribriform plate medially and the fovea ethmoidalis laterally.
Frequent location of CSF leaks |
|
|
Term
| What are the most common sellar tumors and how many are functional? |
|
Definition
| Pituitary adenomas, 30% PAs are prolactinomas |
|
|
Term
| What is the typical appearance of pituitary adenoma on MRI? |
|
Definition
| Microadenomas and most macroadenomas (>1cm) appear hypodense relative to pituitary on T1 and enhance less than pituitary with GAD. |
|
|
Term
| When is petrosal sinus sampling useful in the workup of pituitary adenoma? |
|
Definition
Symptoms of Cushing's disease but with unremarkable MRI.
Collect ACTH levels from bilateral petrosal sinsues |
|
|
Term
| What is the appropriate treatment for prolactinomas? |
|
Definition
Associated with MEN-1.
Treat with dopamine agonist bromocriptine and cabergoline.
Surgery if poorly controlled. |
|
|
Term
| What is a craniopharyngioma, what are the subtypes and how are they treated? |
|
Definition
1) Squamous epithelial remnant of Rathe pouch (different from cyst).
2) Papillary squamous (adult) solidly enhancing lesion in suprasellar region on MRI vs. Adamantinomatous (children).
Treatment is surgical. Though STR with RT vs. GTR are debated. |
|
|
Term
| What is the imaging appearance and treatment for clival chordoma? |
|
Definition
Sometimes difficult to tell apart from Chordoma on imaging. Better prognosis than Chordoma.
1) Midline mass arising from notochord remnants, heterogeneous enhnacement on T2 and hypo or isointense on T1. 100% will show bony destruction and expansion.
2) Surgery + RT. |
|
|
Term
| What is the most common location of spontaneous anterior CSF leak? How does this compare to congenital encephaloceles. |
|
Definition
1) Spontaneous: Lateral sphenoid recess, or Sternberg canal.
2) Congenital: adjacent to vertical attachment of middle turbinate (junction of fovea and cribriform) |
|
|
Term
| What are the most common hypogammaglobulin deficiencies in adults and children? |
|
Definition
1) IgG3 adults
2) IgG2 children- encapsulated infections from haemophilus, klebsiella and strep pneumo |
|
|
Term
| What is the total duration of therapy required for subcutaneous immunotherapy and when does it start to work? |
|
Definition
Starts to work 12 weeks, increases over 1-2 years after treatment.
Total treatment is 3-5 years. |
|
|
Term
| How does Azelastine work? |
|
Definition
Second generation H1 receptor antagonist that stabilizes mast cells
Used in allergic and non-allergic rhinitis.
Pregnancy category C |
|
|
Term
| Why are beta blockers contraindicated during allergy testing? |
|
Definition
| If anaphylaxis, it will modulate epinephrine effects and cause un-obstructed alpha response (constriction) |
|
|
Term
| What are examples of type 4 hypersensitivity? |
|
Definition
T-cell delayed type
1) Contact dermatitis (poison ivy)
2) Graft rejection |
|
|
Term
| What is the only food allergy with FDA approval for a sublingual/oral immunotherapy? |
|
Definition
| Palforzia for peanuts. All others its just investigational |
|
|
Term
| What is the "skin end point titration" in intradermal dilution testing? What about the confirmatory wheel? |
|
Definition
5mm is negative and baseline. Endpoint is the first concentration that elicits a progressive response. It is the first POSITIVE wheel that leads to progressive growth.
Ex: 1/256 is 5mm, 1/128 is 7mm, 1/64 is 12mm.
1/128 is the endpoint titration. 1/64 is the confirmatory. |
|
|
Term
Eczema, thrombocytopenia, bacterial infections.
What is the Ig profile? |
|
Definition
WAS: X-linked disorder.
Decreased IgM, elevated IgA and IgE |
|
|
Term
| Which Ig cross the placenta? |
|
Definition
|
|
Term
| What inhibits and stimulates IgE production? |
|
Definition
Found on Basophils
Inhibited by IFN-y
Stimulated by IL-4 (IL5 also involved) |
|
|
Term
| What are the immunologic changes associated with allergy therapy and what profile is pre-treatment predictive of success? |
|
Definition
1) Pre-treatment low levels of total IgE and blood eosinophils, with high specific IgE to total IgE ratio predicts success
2) Shift from Th2 to Th1 response (suppresses memory B cells). Increased IL-10, IL-12, IgG4, IgA, decrease in specific IgE/IgG4 ratio all occur with successful treatment |
|
|
Term
| Describe the basic structure of an antibody |
|
Definition
Two heavy chains and two light chains. Heavy chain determines subclass.
N-terminus (Fab, variable, made from light and heavy chains) binds antigens
terminus (Fc, constant, made from heavy chain) binds complement and other immune cells.
IgE is least common. IgG is most common. IgA predominant in breastmilk but does not cross the placenta (only IgG does) |
|
|
Term
| What is the action of aspirin? |
|
Definition
Inhibits cyclooxygenase which converts AA to PGEs, thereby decreasing PGE production.
AA pathway shifted in favor of LKE production via cleavage by LPO. |
|
|
Term
| If flonase alone is not sufficient to control seasonal allergic rhinitis, what is the next medication that should be added? |
|
Definition
| Intra-nasal antihistamine azelastine |
|
|
Term
| What is the least sedating anti-histamine? |
|
Definition
Fexofenadine (second generation) is less sedating that Cetirizine (second generation).
All first-generation are lipophillic and are more sedating (diphenydramine, chlorpheniramine, hydroxyzine) |
|
|
Term
Which anti-inflammatory drug is safe to use in AERD?
ASA 81, ASA 325, Celecoxib or Ibuprofen? |
|
Definition
| Celecoxib, COX-2 inhibition. |
|
|
Term
| What are the classic seasonal and perrenial allergens? |
|
Definition
Spring= Tree pollen
Summer= Grass
Fall= Ragweed
Winter= None
Perenial= Molds and pets |
|
|
Term
| How do the utility of RAST and skin testing compare? |
|
Definition
1) RAST- more specific, less sensitive, slower, more expensive
2) Skin- more sensitive, less specific, faster, cheeper |
|
|
Term
| which meds do and do not interfere with skin allergy testing? |
|
Definition
Interfere: TCA, theophylline, topical steroid, oral antihistamine
Do not: oral steroids |
|
|
Term
| Which food allergies are least likely to resolve with time? |
|
Definition
| Tree nut (10%), peanut (20%) |
|
|
Term
| How does Omalizumab work and when is it given? |
|
Definition
Allergic rhinitis and allergic asthma
IgE inhibition (prevents free IgE from binding receptors) |
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