BAILEY CHAPTER 2

91 – 110
91 . A patient complains of nasal allergies during the spring
season. A multi prick device is used to apply eight skin prick
tests consisting of a positive and negative control and six local
antigenic trees. At 20 minutes, all eight skin sites have
developed 7-mm wheals.
Which is the best interpretation?
A. The patient has allergic sensitivity to all six trees tested.
B. The patient is exhibiting a hypersensitivity to the glycerin.
C. The patient has recently taken an antihistamine, which
interferes with the results .
D . Although the patient denies any previous skin conditions,
he or she likely has psoriasis.
Answer: B
Some patients develop a wheal response and
skin erythema from glycerin, which is used as a
preservative and diluent for allergen extracts .
Multiple uniform-sized wheals in this patient
suggest glycerin sensitivity.
This case highlights the value of using a negative
glycerin control in all skin testing.
PAGE 4 1 5
92. Which of these branching patterns does the
most recent classification of chronic rhinosinusitis
(CRS) use?
A. Eosinophilic vs noneosinophilic, then polypoid vs
nonpolypoid
B. Polypoid vs nonpolypoid, then eosinophilic vs
noneosinophilic
C. Polypoid vs nonpolypoid, then neutrophilic vs
nonneutrophilic
D. Neutrophilic vs nonneutrophilic, then polypoid vs
nonpolypoid
Answer: B
The current classification of CRS distinguishes
between polypoid and nonpolypoid disease.
A further subdivision distinguishes between
cases with eosinophilic or noneosinophilic
inflammation.
There are important treatment implications to
this subdivision.
PAGE 536
93. A 43-year-old man presents with a 3-week history of
facial pain, nasal congestion, and purulent nasal drainage.
Symptoms are slowly improving after being placed on
antibiotics for 10 days, but are persistent. Which of the
following statements is the most correct?
A. A CT scan at this time is necessary to determine the
sites of involvement.
B. An MRI would be appropriate to determine the
potential for complicated sinusitis.
C. A CT with contrast would be helpful to assess for nasal
polyposis.
D. Imaging is not indicated at this time.
Answer: D
Imaging is not indicated in uncomplicated acute
sinusitis.
PAGE 422
94. Which of the following methods is most
commonly used to make the diagnosis of
nasal polyp disease?
A. Biopsy
B. MR imaging
C. History and examination
D. Flow cytometry
Answer: C
The definitive diagnosis of nasal polyp requires
histologic examination of a tissue biopsy.
However, in practice the diagnosis is usually
made based on the patient's history and
examination or endoscopy findings .
The finding of unilateral polyp disease should
raise the suspicion of neoplasm.
PAGE 526
9 5 . Which of the following is most true about the relationship
of allergy and chronic rhinosinusitis (CRS) with nasal polyposis?
A. Studies have consistently found that nasal polyp patients with
allergy have more severe
disease.
B. Allergen-specific immunotherapy has been shown to induce
nasal polyp regression.
C. Dysregulated IgE metabolism in nasal polyps is demonstrated
by elevated antigenspecific and total IgE within nasal polyp
tissue.
D. Eosinophils in nasal polyps are a result of late-phase allergic
inflammation .
Answer: C
The importance of allergy in CRS with nasal polyps
is unclear.
Allergy may be a disease-modifying factor, but is
not considered a "cause II of nasal polyp disease.
Immunotherapy is not a proven treatment for nasal
polyp disease. Some nasal polyps have high levels
of antigen-specific IgE, and dysregulated IgE
metabolism may play a role in the disease.
PAGES 530-531
96 . Which of the following etiologies of
cerebrospinal fluid ( CSF) rhinorrhea is associated
with highest risk of recurrence?
A. Tumor
B. Traumatic
c. Spontaneous
D . Congenital
Answer: C
Spontaneous CSF leaks are often due to elevated
intracranial pressure.
Patients with elevated intracranial pressure may
develop delayed recurrent leaks or develop new
sites of CSF leak over time.
PAGE 665
97 . Th2 cells secrete all of the following
cytokines except:
A. INF-y
B. IL-4
C. IL-6
D. IL- 13
Answer: A
IFN-y is one of the characteristic Th1 cytokines .
PAGE 385
98 . Which of the following i s an imaging
characteristic o f most malignancies?
A. CT high density
B. Tl hyperintense
C. T2 hypointense
D. Orbital invasion
Answer: C
Solid tumors are hypointense on T2-weighted MR
images and often isointense on T1 images .
With contrast administration, malignancies may
appear hyperintense on T1 -weighted images .
CT cannot reliably differentiate soft tissue and
secretions; however,high density on CT is often a
sign of dense inspissated secretions or a fungus ball
PAGE 437
99. The agger nasi cell is identified on a coronal
CT scan as:
A. Cell extending into the frontal sinus
B. Cell attached to the lamina papyracea
C. Cell anterior to the attachment of middle
turbinate
D. Cell pneumatizing into middle turbinate
Answer: C
The agger nasi cell is intimately related to the
nasolacrimal sac and the anterior attachment of
the middle turbinate to the lateral nasal wall.
PAGE 677
100. What is the best explanation for the
pathophysiologic link between chronic rhinosinusitis
and asthma?
A. Nasobronchial reflex
B. Pharyngobronchial reflex
C. Posterior nasal drainage of inflammatory
mediators
D. Shared (systemic) inflammation
Answer: D
Upper and lower respiratory inflammatory
diseases like allergic rhinitis and asthma worsen
and improve in tandem.
The most likely explanation for this connection is
that these two conditions are separate
manifestations of a systemic inflammatory
disease.
PAGE 554
101 . A 25-year-old man presents to you with severe nasal
pruritus, sneezing, and profuse watery rhinorrhea. He had
previous skin allergy testing, which showed no significant
reactions. You perform a nasal smear, which shows 2 7%
eosinophils. Which of the following is true of this patient's
clinical syndrome?
A. His symptoms were likely preceded by a history of aspirin
sensitivity.
B. The presence of nasal eosinophilia is generally regarded as a
good prognostic indicator for his response to topical nasal
steroids.
C. The pathophysiology of this syndrome is well documented to
be via COX-2 inhibition and leukotriene excess .
D . Saccharin clearance test in this patient will likely be normal .
Answer: B
Nonallergic rhinitis with eosinophilia (NARES ) is
a poorly understood eosinophilic inflammatory
disease of the nose and sinuses .
NARES may be a precursor to aspirin exacerbated
respiratory disease.
As an eosinophilic respiratory disease,
corticosteroids are the recommended treatment.
PAGE 473
102. A patient presents for allergy testing using skin
prick tests. The positive control of histamine shows no
response. Which is the most likely explanation?
A. The allergy nurse forgot to add the histamine to the
diluent.
B. The patient has no allergies, not even to histamine.
C. The patient has anergic skin and should be
evaluated for an immune deficiency.
D. The patient has taken a medication that suppresses
the response.
Answer: D
A lack of skin response to the histamine positive
control prick suggests that histamine receptors
are not functioning normally.
The usual culprit is unknown or accidental
antihistamine use.
PAGE 415
103 . Which of the following is characteristic of the
inflammatory response in allergic rhinitis?
A. Mast cells degranulate upon the first/initial
exposure to antigen/allergen.
B. There is a predominance of Th2 cytokines like
interleukin (IL)-4, IL-5, and IL-13 .
C . The late-phase allergic response occurs 30
minutes after exposure to antigen/allergen.
D . There is a predominance of Th1 cytokines like
interferon gamma, IL-2, and tumor necrosis factor
beta.
Answer: B
Allergic rhinitis is characterized by 11Th2 II
inflammation.
Mast cells will degranulate on repeated exposure
to allergen, not initial exposure.
The late-phase allergic response occurs within
hours of exposure.
PAGE 551
104. Which is not a symptom used to make the
diagnosis of chronic sinusitis?
A. Mucopurulent drainage
B. Nasal obstruction
C. Facial pressure
D . Headache
Answer: D
Headache is not considered to be a cardinal
symptom of chronic sinusitis. The other choices
are.
PAGES 586-587
105 . The diagnosis of allergic rhinitis is primarily
based on:
A. Allergy skin testing
B. Specific IgE levels in serum
C. Thorough history and physical examination
D . Total IgE levels in serum
Answer: C
A thorough history is still considered the best
way to make a diagnosis of allergic disease.
Testing serves a confirmatory role.
PAGES 461 --463
106. Side effects from long-term use of oral
glucocorticoids include:
A. Cataracts
B. Avascular necrosis of the hip
C. Glaucoma
D . All of the above
Answer: D
Both acute and long-term toxicities of oral
glucocorticoids limit their use. All of the side
effects listed may result from chronic use.
PAGE 588
107. Which of the following agents for the
treatment of aspirin-exacerbated respiratory
disease (AERD) targets the primary disease
pathway?
A. Oxymetazoline
B. Fluticasone
C. Montelukast
D. Diphenhydramine
Answer: C
All of these agents may be used in the treatment
of AERD; however, montelukast, a CysLT1
receptor antagonist, directly targets the primary
metabolic derangements in this disease process
(namely, overproduction of leukotrienes) .
PAGE 479
108 . Chronic invasive fungal rhinosinusitis is
clinically distinguished from acute invasive
fungal rhinosinusitis by:
A. Time course of disease
B. Degree of tissue inflammation
C. Causative fungal organism
D. Presence of immunocompromise
Answer: A
The time course of disease separates acute from
chronic invasive fungal sinusitis from a clinical
standpoint.
There are a variety of clinicopathologic differences
between these two conditions, but none of the
other answers provides a distinguishing difference.
PAGE 558
109 . Which of the following is not a technique
to address the internal nasal valve?
A. Spreader grafts
B. Park sutures
C. Splay graft
D. Batten graft
Answer: D
Alar batten grafts support the weak portion of
the nasal ala that contains only fibrofatty tissue.
The ala is the lateral border of the external nasal
valve.
The other techniques address internal nasal
valve narrowing.
PAGES 619-620
110. When comparing subcutaneous
immunotherapy (SCIT) to sublingual
immunotherapy (SLIT) , which of the statements
below is true?
A. SCIT has a lower rate of anaphylaxis than SLIT.
B. SLIT efficacy is superior to SCIT.
C. Sublingual therapy is an option for patients
with an aversion to needles .
D . SCIT requires daily injections.
Answer: C
SLIT almost never causes anaphylaxis and is a
treatment option for patients who do not want
repeated injections.
The relative efficacy of SCIT vs SLIT is inadequately
studied.
SCIT utilizes injections every 1 to 4 weeks .
PAGES 465--466