Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/109

Click to flip

109 Cards in this Set

  • Front
  • Back
The nose develops from ___________ cells
neural crest cells

migration of neural crest cells around the 4th week of gestation
During development of the nose, what are the 3 potential spaces forming between bone and cartilage?
Fonticulus nasofrontalis: space between frontal and nasal bone

Prenasal space: space between nasal bones and nasal capsule

Foramen cecum: space between frontal and ethmoid bone
During nose development, which membrane separates the nasal and oral cavities?
nasobuccal membrane
Anatomy

What are the bones of the nose?
two paired nasal bones, attaching laterally to the nasal process of maxilla
Anatomy

What are the cartilages of the nose?
Paired upper lateral cartilages
Paired lower lateral cartilages
Accessory sesamoid cartilages
Anatomy

What structures make up the nasal septum?
BONE:
Vomer
Palatine bone
Perperndicular plate of ethmoid bone
Maxillary crest

CARTILAGE:
Quadrangular cartilage
What do the following meati drain?

Inferior meatus:
Middle meatus:
Superior meatus:
Inferior meatus: nasolacrimal duct

Middle meatus: maxillary, anterior ethmoid and frontal sinuses

Superior meatus: posterior ethmoid sinuses
Anatomy

What is the blood supply to the external nose?
Primary supply from external cartoid artery to facial artery

Superior labial a: columella and lateral nasal wall

Angular a: nasal side wall, nasal tip, and nasal dorsum
Anatomy

The nasal cavity is supplied by the external and internal carotid arteries.

Which external branches?
External carotid artery system: internal maxillary artery:

- sphenopalatine artery via sphenopalatine foramen: divides into lateral nasal artery, supplying lateral nasal wall; and posterior septal artery, supplying posterior aspect of septum
- Descending palatine artery: forms the greater and lesser palatine arteries; supplies lower portion of the nasal cavity
- Greater palatine artery: passes inferiorly through greater palatine canal and foramen, travels within hard palate mucosa; bilateral arteries meet in midline and travel through single incisive foramen back into nasal cavity
Anatomy

The nasal cavity is supplied by the external and internal carotid arteries.

Which internal branches?
Ophthalmic artery enters orbit and gives off anterior and posterior ethmoid arteries; courses via ant and post ethmoidal canal, takes an intracranial course and then turns inferiorly over the cribriform plate.

- anterior ethmoid artery: supplies lateral and anterior one-third of nasal cavity; anastomoses with sphenopalatine artery (AKA nasopalatine artery; most common artery injuried in septoplasty surgery, causing hematomas)

- posterior ethmoid artery: supplies small portion of superior turbinate and posterior septum
Anatomy

Which vessels supply Kiesselbach's plexus (Little's area)?
1) Septal branches of sphenopalatine artery
2) Anterior ethmoidal artery
3) Greater palatine artery
4) Septal branches of superior labial artery
Anatomy

Which vessels supply Woodruff's plexus (naso-nasopharyngeal plexus)?
posterior nasal a.
posterior ethmoid a.
sphenopalatine a.
ascending pharyngeal a.
Anatomy

Where do the following veins drain into?

Sphenopalatine vein:
Ethmoidal vein:
Anterior facial vein:
Angular vein:
Venous system is valveless

Sphenopalatine vein: via sphenopalatine foramen into pterygoid plexus
Ethmoidal vein: into superior ophthalmic vein
Anterior facial vein: through common facial vein to internal jugular vein; also communicates with cavernous sinus via ophthalmic veins, infraorbital and deep facial veins and the pterygoid plexus
Angular vein: drains external nose via ophthalmic vein to cavernous sinus
Anatomy

What is the lymphatic drainage of the nose?
anterior portion of the nose drains toward external nose in the subQ tissue to the facial vein and submandibular nodes

Others pass posterior to tonsillar region and drain into upper deep cervical nodes

Most drain into pharyngeal plexus and then to the retropharyngeal nodes
Anatomy

Describe the nasociliary nerve, its branches and innervations
Nasociliary nerve is a branch of ophthalmic division of CN V (CN V1)
Gives off two branches after it enters the orbit:

1) Infratrochlear nerve - supplies skin at the medial angle of eyelid

2) Anterior ethmoidal nerve - leaves orbit with anterior ethmoidal artery; supplies anterior superior nasal cavity, anterior ends of middle and inferior turb and corresponding septum; also region anterior to the superior turb; leaves nasal cavity and supplies skin on dorsum of the tip of nose
Anatomy

Describe the maxillary nerve, its branches and innervations
Maxillary nerve (CN V2) exits middle cranial fossa via foramen rotundum

- Lateral posterior superior nasal branch - posterior portion of superior and middle turbs; post ethmoid cells
- Medial posterior superior nasal branch - ant sphenoid, posterior septum and roof of nasal cavity
- Nasoplatine nerve - ant hard palate
- Greater palatine nerve - inf turb, middle and inferior meatus

Infraorbital branch - supplies portion of vestibule of the nose; anterior portion of inferior meatus; part of floor of nasal cavity
Anatomy

What are the preganglionic nerves of the pterygopalatine ganglion?
The autonomic innervation of the nose is derived from the pterygopalatine/sphenopalatine ganglion

Preganglionic fibers of the nose are originate from the superior salivatory nucleus in the medulla oblongata --> CN VII --> ggreater superficial p...
The autonomic innervation of the nose is derived from the pterygopalatine/sphenopalatine ganglion

Preganglionic fibers of the nose are originate from the superior salivatory nucleus in the medulla oblongata --> CN VII --> ggreater superficial petrosal nerve at the geniculate ganglion --> vidian nerve --> pterygopalatine ganglion
Anatomy

What are the postganglionic nerves of the pterygopalatine ganglion?
The autonomic innervation of the nose is derived from the pterygopalatine/sphenopalatine ganglion

Arise in ganglion and join sympathetic and sensory fibers
Travel with branches of sphenopalatine nerve and provide secretomotor fibers to mucous glands in nasal mucosa & lacrimal glands
Cause vasodilation
Anatomy

What are the sympathetic fibers of the nose?
From thoracic spinal nerve (T1-T3)

Postganglionic fibers from superior cervical ganglion and travel with the ICA
Leave this plexus as deep petrosal nerve and join the greater superficial petrosal nerve to form vidian nerve (nerve of pterygoid ...
From thoracic spinal nerve (T1-T3)

Postganglionic fibers from superior cervical ganglion and travel with the ICA
Leave this plexus as deep petrosal nerve and join the greater superficial petrosal nerve to form vidian nerve (nerve of pterygoid canal)
Causes vasoconstriction
Anatomy

What is the histology of the nasal vestibule?
Keratinized squamous epithelium with vibrissae, sweat and sebaceous glands
Anatomy

What is the histology of the anterior 1/3 of nasal cavity & anterior portions of inferior and middle turbs?
squamous and transitional cell epithelium
Anatomy

What is the histology of the posterior nasal cavity?
Pseudostratified columnar epithelium
Anatomy

Describe the layers of the mucous blanket
Two layers: gel and sol phase

Gel phase: superficial layer, produced by goblet and submucosal glands; traps particulate matter

Sol phase: deep layer, produced by microvilli; provides fluid that facilitates ciliary movement

Other component...
Two layers: gel and sol phase

Gel phase: superficial layer, produced by goblet and submucosal glands; traps particulate matter

Sol phase: deep layer, produced by microvilli; provides fluid that facilitates ciliary movement

Other components: mucoglycoproteins, immunoglobulins, interferon and inflammatory cells
Describe the two physiologic nasal reflexes?
Nasal reflexes - multiple that causes periodic nasal congestion, rhinorrhea or sneezing

Postural reflex - increased congestion with supine position; congestion on the side of dependence upon lying on the side

Hot or cold temperature reflex - sneezing upon sudden exposure of skin to dramatic temperature extremes
List the functions of the nose
Airway: conduit for air
Filtration: trap and remove airborne particulate matter
Humidification: increases relative humidity
Heating: provides radiant heat of inspired air
Nasal reflexes: postural, and hot or cold temp reflexes
Chemosensation: detects irritants and temp changes
Olfaction
Describe the change in nasal airflow resistance throughout the day
Cycle occurring every 2-7 hours

Mucosal vasculature is under sympathetic tone
- when tone DECREASES = vessels engorge = increased airflow resistance
What are the 3 regions of nasal resistance?
nasal vestibule
nasal valve 
nasal cavum
nasal vestibule
nasal valve
nasal cavum
What are the 3 borders of the nasal valve?
Nasal valve is the narrowest point of nasal airway resistance

Borders: lower edge of upper lateral cartilage, anterior end of inferior turbinates, and nasal septum
Nasal valve is the narrowest point of nasal airway resistance

Borders: lower edge of upper lateral cartilage, anterior end of inferior turbinates, and nasal septum
Where are the various locations of olfactory epithelium?
Located in upper edge of nasal chamber adjacent to cribriform plates

Superior nasal septum

Superior lateral nasal wall
What are the two layers of the olfactory epithelium?
Olfactory mucosa
Lamina propria
Congenital Anomalies

What are the four basic theories of choanal atresia?
1) Persistence of buccopharyngeal membrane
2) Abnormal persistence of bucconasal membrane
3) Abnormal mesoderm forming adhesions in nasochoanal region
4) Misdirection of neural crest cell migration
Congenital Anomalies

What percentage of pt's with choanal atresia also have other associated congenital anomalies?
20-50%
Congenital Anomalies

What congenital anomalies are associated with choanal atresia?
CHARGE (coloboma, heart dz, MR, genital hypoplasia, ear anomalies)

Apert syndrome, Crouzon dz, Treacher-Collins syndrome
Congenital Anomalies

What is the timing of presentation between unilateral and bilateral choanal atresia?
Bilateral - presents in newborn with airway distress at birth since newborns are obligate nasal breathers; classic presentation is cyclic cyanosis relieved by crying (paradoxical cyanosis)

Unilateral - presents between 5-24mo with unilateral obstruction and nasal discharge
Congenital Anomalies

What are the treatments for choanal atresia?
Bilateral = immediate management - airway stabilization with oral airway, McGovern nipple

Surgical approaches = tranpalatal, transnasal, endoscopic
Congenital Anomalies

List the thee congenital midline nasal masses
Dermoid sinus cyst (most common)
Glioma
Encephalocele

Tx of all is surgical excision
Congenital Anomalies

What is the presentation of a dermoid sinus cyst?
Present as a midline nasal pit, fistula, or infected mass located anywhere from the glabella to the nasal columella. May present as intranasal, intracranial or extranasal masses along the nasal dorsum

Mass is nontender, noncompressible, and fir...
Present as a midline nasal pit, fistula, or infected mass located anywhere from the glabella to the nasal columella. May present as intranasal, intracranial or extranasal masses along the nasal dorsum

Mass is nontender, noncompressible, and firm; do not transilluminate
Congenital Anomalies

What is the pathophysiology behind dermoid nasal cysts?
During development, projection of dura protrudes through fonticulus frontalis or inferiorly into prenasal space; the projetion normal regresses and if it does not, the dura can remain attached to the epidermis, causing trapping of ectodermal elements

Have a tendency for repeated infections

Tx - surgical excision of entire cyst & tract; I&D is discouraged
Congenital Anomalies

What is the presentation of a nasal glioma?
Gliomas are made of neuroglial elements consisting of glial cells in a connective tissue matrix with or without a fibrous connection to the dura.  Abnormal closure of the fonticulus frontalis can lead to an ectopic rest of glial tissue .

There ...
Gliomas are made of neuroglial elements consisting of glial cells in a connective tissue matrix with or without a fibrous connection to the dura. Abnormal closure of the fonticulus frontalis can lead to an ectopic rest of glial tissue .

There is no fluid filled space connected to the subarachnoid space. These lesions usually present as a red or bluish lump at or along the nasomaxillary suture, or as an intranasal mass.

They are characteristically firm, noncompressible, do not increase in size with crying, and do not transilluminate. The overlying skin may have telangiectasias.

They can be associated with a widened nose or with hypertelorism secondary to growth of the mass. Intranasal gliomas most often arise from the lateral wall of the nose or less often from the nasal septum.

60% are extranasal, 30% intranasal, and 10% are both. Overall, 15% are connected to the dura. The intranasal type is more often associated with dural attachment (35%) than the extranasal type (9%).

They are more common in males by a 3:1 ratio although the significance of this has not been established.

Tx: surgical excision
Congenital Anomalies

What is the presentation of an encephalocele?
Encephalocele is a congenital herniation of the CNS tissue through skull base defects; either meningocele (meninges only) or meningoencephaloceles (meninges + glial tissue)

Mass is often bluish or red, soft, compressible and TRANSilluminates; p...
Encephalocele is a congenital herniation of the CNS tissue through skull base defects; either meningocele (meninges only) or meningoencephaloceles (meninges + glial tissue)

Mass is often bluish or red, soft, compressible and TRANSilluminates; pulsatile and expands with crying or straining
Congenital Anomalies

What is a positive Furstenberg test?
nasal mass expands with compression of internal jugular veins = encephalocele
Congenital Anomalies

Where are the locations of encephaloceles?
Occipital (most common - 75%)

Sincipital - also called frontoethmoidal encephaloceles, with defect at foramen cecum, just anterior to cribriform plate

Basal - defect in floor of anterior cranial fossa between cribriform plate and clinoid process
Congenital Anomalies

What are the subtypes of sincipital encephaloceles?
Sincipital encephaloceles AKA frontoethmoidal encephaloceles

Present as an external mass over nose, glabella or forehead

Subtypes:
1) Nasofrontal
2) Nasoethmoidal
3) Naso-orbital
Sincipital encephaloceles AKA frontoethmoidal encephaloceles

Present as an external mass over nose, glabella or forehead

Subtypes:
1) Nasofrontal
2) Nasoethmoidal
3) Naso-orbital
Congenital Anomalies

What are the subtypes of basal encephaloceles?
Present as internal intranasal or nasopharyngeal mass

Subtypes:
1) Transethmoidal
2) Trans-sphenoidal
3) Sphenoethmoidal
4) Sphenomaxillary
Present as internal intranasal or nasopharyngeal mass

Subtypes:
1) Transethmoidal
2) Trans-sphenoidal
3) Sphenoethmoidal
4) Sphenomaxillary
Head and neck teratomas account for what percentage of all teratomas?
2-3%
What is the most common site for a head & neck teratoma?
Cervical teratoma, followed by nasopharyngeal teratoma
Cervical teratoma, followed by nasopharyngeal teratoma
Describe the location and presentation of Rathke's Pouch Cyst
Rathke's pouch is an invagination of the nasopharyngeal epithelium in the posterior midline; the anterior pituitary gland develops from this in fetal life.
Remnants of this pouch may persist forming a cyst or tumor

Rathke's pouch cyst:
1) Ben...
Rathke's pouch is an invagination of the nasopharyngeal epithelium in the posterior midline; the anterior pituitary gland develops from this in fetal life.
Remnants of this pouch may persist forming a cyst or tumor

Rathke's pouch cyst:
1) Bening cyst in the sella turcica
2) Usually assx but may cause mass effect on pituitary gland or optic chiasm
3) Usually present in 5th or 6th decade of life; F > M
4) MRI is modality of choice

Tumor of Rathke's pouch = craniopharyngioma
Describe the presentation of Thornwaldt's Cyst
Benign nasopharyngeal cyst
Develops from remnant of notochord

Sx: postnasal drip, haliotosis, aural fullness, serous otitis media, and cervical pain

Examination: smooth submucosal midline mass in nasopharynx

Tx: none if assx; if sx, mars...
Benign nasopharyngeal cyst
Develops from remnant of notochord

Sx: postnasal drip, haliotosis, aural fullness, serous otitis media, and cervical pain

Examination: smooth submucosal midline mass in nasopharynx

Tx: none if assx; if sx, marsupialization through surgical correction via endoscopic approach
Describe the presentation of Intra-Adenoidal Cysts
Occlusion of adenoid crypts, leading to retention cysts in adenoids
Asymptomatic
Present in midline, rhomboid shape on imaging
Which branchial arches form a branchial cleft cyst?
first or second branchial arches
Explain the sensitization phenomenon in allergic rhinitis
Initial exposure to antigen causes antigen-processing cells (macs & dendritic cells) present the processed peptides to T-helper cells.

Upon subsequent exposure to the same Ag, these cells are stimulated to diffentiated into more T-helper cells or B cells.

B cells further differentiate into plasma cells and produce IgE specific to that Ag. Allergen-specific IgE molecules then bind to the surface of mast cells, sensitizing them.
Explain the early and phase responses in allergic rhinitis, including symptoms
Early phase response - starts within 5-15min
- mast cells degranulate, releasing histamine, heparin and tryptase
- degranulation also triggers formation of prostaglandin PGD2, leukotrienes LTC4, LTD4, LTE4 and platelet activating factor (PAF)
- Sx - sneezing, rhinorrhea, congestion and pruritis

Late phase response - starts 2-4hrs later
- caused by newly arrived inflammatory cells recruited by cytokines
- EOS, neutrophils and basophils prolong the earlier reactions and lead to chronic inflammation
How do you differentiate allergic vs nonallergic rhinitis?
Nonallergic has same sx as allergic rhinitis except for nasal and ocular pruritis
What are the possible triggers for nonallergic rhinitis?
strong fragrances
tobacco smoke
changes in temperature
cleaning products
What are the various classifications of nonallergic rhinitis?
1) Infectious rhinitis
2) Vasomotor rhinitis
3) Hormonal rhinitis
4) Occupational rhinitis
5) Drug-induced rhinitis
6) Rhinitis medicamentosa
7) Gustatory rhinitis
8) Nonallergic rhinitis of eosinophilia syndrome (NARES)
What is the pathophysiology of vasomotor rhinitis?
Predominance of the parasympathetic system leading to vasodilation and mucosal edema.
Cold air and strong odors exacerbate sx
Which drugs are responsible for drug-induced nonallergic rhinitis?
Antihypertensives: ACEI and beta blockers

NSAIDS

Oral contraceptives
What is the pathophysiology of gustatory rhinitis?
Watery rhinorrhea due to vasodilation after eating, especially with spicy or hot foods
What are the Sx of nonallergic rhinitis of eosinophilia syndrome (NARES)?
Rhinitis with approximately 10-20% EOS on nasal smears

Sx of nasal congestion, rhinorrhea, sneezing, pruritis, and hyposmia
Discuss the cause and sx of atrophic rhinitis
AKA Rhinitis Sicca or Ozena
Mucosal colonization with klebsiella ozaenae and other organisms

Nasal mucosa degenerates and loses mucociliary fnct

May be either primary or secondary (ie. d/t trauma or nasal surgery (empty nose syndrome))

P...
AKA Rhinitis Sicca or Ozena
Mucosal colonization with klebsiella ozaenae and other organisms

Nasal mucosa degenerates and loses mucociliary fnct

May be either primary or secondary (ie. d/t trauma or nasal surgery (empty nose syndrome))

Presentation - foul smell as well as yellow or green nasal crusting with atrophy and fibrosis of mucosa
What is the triad of Wegener's Granulomatosis?
Triad:
1) Necrotizing granulomas of respiratory tract
2) Vasculitis
3) Glomerulonephritis
What are the nasal presentations of Wegener's Granulomatosis and what are the diagnostic studies?
Sinonasal sx usually manifest early with severe nasal crusting, epistaxis, rhinorrhea and secondary rhinosinusitis

+cANCA
+anti-Myeloperoxidase and anti-Proteinase 3

Tx: saline irrigation, nasal moisturization and topical Abx
What are the nasal presentations of sarcoidosis?
Multisystem inflammatory dz with noncaseating granulomas

Sinonasal manifestations: nasal obstruction, postnasal drainage, recurrent sinusitis

Serum ACE levels may be elevated
Describe the general facts of rhinoscleroma
Chronic granulomatous dz due to Klebsiella rhinoscleromatis
Endemic to Africa, central America, or Southeast Asia
Usually affects nasal cavity, but may also affect the larynx, nasopharynx, or paranasal sinuses
What are the three stages of rhinoscleroma dz progression?

How do you tx the dz?
1) Catarrhal or atrophic: rhinitis, purulent rhinorrhea, and nasal crusting

2) Granulomatous or hypertrophic: small painless granulomatous lesions in upper respiratory tract that block nasal passages

3) Sclerotic: sclerosis and fibrosis narr...
1) Catarrhal or atrophic: rhinitis, purulent rhinorrhea, and nasal crusting

2) Granulomatous or hypertrophic: small painless granulomatous lesions in upper respiratory tract that block nasal passages

3) Sclerotic: sclerosis and fibrosis narrowing nasal passages

Tx - long-term Abx, biopsy, debridement
What are two histologic findings of rhinoscleroma?
1) Mikulicz cells: large macrophage with clear cytoplasm containing bacilli

2) Russel bodies in plasma cells (large eosinophilic inclusions)
1) Mikulicz cells: large macrophage with clear cytoplasm containing bacilli

2) Russel bodies in plasma cells (large eosinophilic inclusions)
Describe the general facts about rhinosporidiosis, sx, histopathology and tx
Rhinosporidiosis is a chronic granulomatous infection caused by Rhinosporidium seeberi
Endemic to Africa, Pakistan, Sri Lanka, or India

Sx - friable red nasal polyps, nasal obstruction, and epistaxis

Histiopathology - pseudoepitheliomatous ...
Rhinosporidiosis is a chronic granulomatous infection caused by Rhinosporidium seeberi
Endemic to Africa, Pakistan, Sri Lanka, or India

Sx - friable red nasal polyps, nasal obstruction, and epistaxis

Histiopathology - pseudoepitheliomatous hyperplasia, presence of R. seeberi

Tx - surgical excision
Epistaxis

How is an IMAX ligation performed?
Caldwell-Luc to enter maxillary sinus
Enter posterior wall, vessels clipped
Caldwell-Luc to enter maxillary sinus
Enter posterior wall, vessels clipped
Epistaxis

How is an endoscopic sphenopalatine ligation performed?
- Follow middle turb to posterior aspect
- Make vertical incision approximately 7-8mm anterior to the posterior end of middle turbinate
- Crista ethmoidalis seen and marks anterior sphenopalatine foramen; vessels are posterosuperior to this
- C...
- Follow middle turb to posterior aspect
- Make vertical incision approximately 7-8mm anterior to the posterior end of middle turbinate
- Crista ethmoidalis seen and marks anterior sphenopalatine foramen; vessels are posterosuperior to this
- Clip or cauterize vessels at this site and replace flap
What are the sx of rhinosinusitis?
Symptoms (2 or more)
A) one of which should be nasal blockage or obstruction or congestion or nasal discharge (anterior OR posterior nasal drip)
B) +/- facial pain or pressure
C) +/- hyposmia or anosmia
What are the five classifications of rhinosinusitis?
1) Acute RS (ARS) - Sx lasting <4 weeks with complete resolution

2) Subacute RS - Sx lasting between 4-12 weeks

3) Chronic RS (CRS) with OR w/o polyps - sx lasting >12 weeks w/o complete resolution of sx

4) Recurrent ARS - 4 or more episodes per year, each lasting >7-10 days WITH complete resolution in between episodes

5) Acute exacerbation of CRS - sudden worsening of baseline CRS with return to baseline after tx
Acute Rhinosinusitis

What are the most common agents in acute viral rhinosinusitis?
rhinovirus and influenzae
Sx lasts <14 days
Acute Rhinosinusitis

What are the three cardinal sx for diagnosis of acute bacterial rhinosinusitis?
1) Purulent nasal discharge
2) Face pain or pressure
3) Nasal obstruction

+/- anosmia, fever, aural fullness, cough, and headache
Acute Rhinosinusitis

What is the pathophysiology of acute rhinosinusitis?
Anatomic abnormalities may predispose on to ARS: septal deviation and spur, turbinate hypertrophy, prominent ethmoidal bulla, concha bullosa, pneumatization and inversion of uncinate process.

Acute viral resp infection affects nasal and sinus mucosa leading to obstruction of sinus outflow

Other factors: allergies, nasal packing, sinonasal tumors, trauma and dental infections
Chronic Rhinosinusitis

What are the four cardinal sx of CRS?
1) Anterior or posterior purulent nasal drainage
2) Nasal obstruction
3) Face pain or pressure
4) Hyposmia or anosmia
What are the criteria to make a diagnosis of CRS?
At least two of the four cardinal sx + ONE of the following?

1) Endoscopic evidence of mucosal inflammation: purulent mucus or edema in middle meatus or ethmoid region
2) Polyps in nasal cavity or middle meatus
3) Radiologic evidence of mucosal inflammation
What are the 3 subtypes of chronic rhinosinusitis?
1) CRS with polyps
2) CRS w/o polyps (mc type, 60-65%)
3) Allergic fungal rhinosinusitis
What are the five criteria of Bent & Kuhn for allergic fungal rhinosinusitis?
1) Eosinophilic mucin (Charcot-Leyden crystals)
2) Noninvasive fungal hyphae
3) Nasal polyposis
4) Characteristic radiologic findings
5) Type 1 hypersensitivity by history, skin tests or serology
What are the characteristic CT & MRI radiologic findings of allergic fungal rhinosinusitis?
CT findings
1) rim of hypointensity with hyperdense central material (allergic mucin)
2) speckled areas of increased attenuation due to ferromagnetic fungal elements

MRI findings
1) peripheral hyperintensity with central hypointensity on bot...
CT findings
1) rim of hypointensity with hyperdense central material (allergic mucin)
2) speckled areas of increased attenuation due to ferromagnetic fungal elements

MRI findings
1) peripheral hyperintensity with central hypointensity on both T1 and T2
2) central "void" on T2
What are the typical agents responsible for allergic fungal rhinosinusitis?
Dematiaceous fungi (alternaria, bipolaris, curvularia, cladosporium, dreschlera)
Is allergic fungal rhinosinusitis typically unilateral or bilateral?
unilateral
Allergic fungal rhinosinusitis has a high association with which disease process?
asthma
Up to ___% of CRS pt's have asthma
50%
Explain staphylococcal superantigens and their role in CRS
Staph superantigen is an exotoxin secreted by certain S. aureus strains; they activate T cells by linking T-cell receptors with MHC II surface molecule on antigen presenting cells (APC's)
Staph superantigen is an exotoxin secreted by certain S. aureus strains; they activate T cells by linking T-cell receptors with MHC II surface molecule on antigen presenting cells (APC's)
Explain which granulomatous vasculitis may cause CRS?
Churg-Strauss syndrome: CRSwNP, asthma, peripheral eosinophilia, pulmonary infiltrates, systemic eosinophilic vasculitis, and peripheral neuropathy
What are the two main categories of fungal rhinosinusitis (nonallergic)
Invasive & noninvasive
What are the three types of invasive fungal rhinosinusitis?
acute invasive (aka acute fulminant fungal rhinosinusitis)
chronic invasive
chronic granulomatous
What are the three types of noninvasive fungal rhinosinusitis?
sinus fungal ball
saprophytic fungal infestation (SFI)
allergic fungal rhinosinusitis
Noninvasive Fungal Rhinosinusitis

Sinus fungal ball is usually bilateral or unilateral?

What is the most common fungal agent?
unilateral

Aspergillus fumigates
unilateral

Aspergillus fumigates
Noninvasive Fungal Rhinosinusitis

Does sinus fungal ball typically present in immunocompromised or immunocompetent pt's?

What is the tx?
Immunocompetent pt's

surgical removal
Invasive Fungal Rhinosinusitis

What are the sx of acute invasive fungal rhinosinusitis?
Nasal painless ulcer or eschar
Periorbital or facial swelling
Ophthalmoplegia
Invasive Fungal Rhinosinusitis

Does acute invasive fungal rhinosinusitis affect immunocompromised or immunocompitent pt's?
Immunocompromised
Invasive Fungal Rhinosinusitis

Which organisms are involved in acute invasive fungal rhinosinusitis?
Septate - Aspergillus, 45* branching

Nonseptate - Mucorales (Rhizopus, Rhizomucor, Absidia, Mucor, Cunninghamella, Mortierella, Saksenaea, Aopohysomyces, and Zygomycosis). 90* branching, necrotic background, serpiginous (Most common in DKA pt's)
Invasive Fungal Rhinosinusitis

What is the tx for acute invasive fungal rhinosinusitis?
aggressive surgical debridement
systemic antifungals
correct underlying immunosuppressed states

(poor prognosis)
Invasive Fungal Rhinosinusitis

Which species are involved in chronic invasive fungal rhinosinusitis?
Aspergillus fumigates common
Mucor
Alternaria
Curvularia
Bipolaris
Candida
Drechslera
Invasive Fungal Rhinosinusitis

Does chronic invasive fungal rhinosinusitis affect immunocompromised or immunocompetent pt's?
immunocompetent pts
Invasive Fungal Rhinosinusitis

What is the pathogenesis of chronic invasive fungal rhinosinusitis?
Tissue invasion by fungal elements >4wks with minimal inflammatory responses
Invasive Fungal Rhinosinusitis

What is the tx for chronic invasive fungal rhinosinusitis?
Surgical debridement
Systemic antifungals

(poor prognosis)
Invasive Fungal Rhinosinusitis

What is the pathogenesis of chronic granulomatous fungal rhinosinusitis?
Tissue invasion by fungal elements >4wks with inflammatory responses (remember, chronic invasive has minimal inflammatory response)

Multinucleated giant cell granulomas centered on eosinophilic materal surrounded by fungus
Invasive Fungal Rhinosinusitis

Does chronic granulomatous fungal rhinosinusitis affect immunocompromised or immunocompetent pt's?
immunocompetent pts
Invasive Fungal Rhinosinusitis

Which species are involved in chronic granulomatous fungal rhinosinusitis?
Aspergillus flavus
What are the various ways that rhinosinusitis can spread and cause complications?
Hematogenous spread: retrograde thrombophlebitis through valveless veins (veins of Breschet)

Direct spread: through lamina papyracea, osteomyelitis
What are mucoceles and what is the tx?
- Collection of sinus secretions trapped due to obstruction of sinus outflow tract; expansile process

- Mucopyoceles: infected mucocele

Tx - endoscopic marsupialization
What are some ophthalmologic complications of rhinosinusisits?

What are the Chandler's classifications?
Chandler's classifications
1) Preseptal cellulitis: inflammatory edema; no limitation of extraocular movements (EOM)
2) Orbital cellulitis: chemosis, impairment of EOM, proptosis, possible visual impairment
3) Subperiosteal abscess: pus collect...
Chandler's classifications
1) Preseptal cellulitis: inflammatory edema; no limitation of extraocular movements (EOM)
2) Orbital cellulitis: chemosis, impairment of EOM, proptosis, possible visual impairment
3) Subperiosteal abscess: pus collection between medial periorbita and bone; chemosis, exophthalmos, EOM impaired, visual impairment worsening
4) Orbital abscess: pus collection in orbital tissue; complete ophthalmoplegia with severe visual impairement
- Sup. orbital fissure syndrome (CN 3, 4, V1, 6)
- Orbital apex syndrome (CN 2, 3, 4, V1, 6)
5) Cavernous sinus thrombosis: bilateral ocular sx
List 4 neurologic complications of rhinosinusitis
1) Meningitis
2) Epidural abscess
3) Subdural abscess
4) Brain abscess
List 2 bony complications of rhinosinusitis
1) Osteomyelitis: thrombophlebitic spread via diploic veins

2) Pott's puffy tumor: subperiosteal abscess (frontal bone osteomyelitis to erosion of the anterior bony table)
1) Osteomyelitis: thrombophlebitic spread via diploic veins

2) Pott's puffy tumor: subperiosteal abscess (frontal bone osteomyelitis to erosion of the anterior bony table)
You placed a pt with acute rhinosinusitis on Abx. How many days after starting tx would you want to change the ABx if there has been to improvement?
72 hours after starting Abx
What is the recommended medical tx of CRS without nasal polyps?
1) Long-term oral Abx (>12 wks), usually macrolide
2) Topical nasal steroids
3) Nasal saline irrigation
What is the recommended medical tx of CRS with nasal polyps?
1) Topical nasal corticosteroids (drops better than sprays)
2) Systemic corticosteroids: 1mg/kg initial dose and taper over 10 days
3) Nasal irrigations
Long-term oral Abx
4) long-term oral Abx (>12wks), usually macrolide