Prepared by John Seyerle, MD, Ohio State University

1. Allergic rhinitis affects what proportion of the population in Westernized countries?
A. 5 percent
B. 10 percent
C. 20 percent
D. 50 percent

2. Which of the following is most likely to cause rhinitis medicamentosa?
A. Corticosteroids
B. Anti-histamines
C. Catecholamines
D. Imidazoles

3. What infectious agent is most associated with primary atrophic rhinitis?
A. Staphylococcus
B. Nocardia
C. Candida
D. Klebsiella

4. What is the most common cause of secondary atrophic rhinitis?
A. Nasal catecholamines
B. Allergic rhinitis
C. Nasal surgery
D. Infections

5. What percentage of allergy sufferers report feeling tired frequently or sometimes during the allergy season?
A. 20 percent
B. 40 percent
C. 60 percent
D. 80 percent

6. In the United States, Allergic Rhinitis is responsible for how many lost work days every year?
A. 1.5 million
B. 2.5 million
C. 3.5 million
D. 4.5 million

7. In the United States, Allergic Rhinitis is responsible for how many lost school days every year?
A. 1 million
B. 2 million
C. 3 million
D. 4 million

8. Which of the following symptoms would you expect to manifest first following nasal allergen provocation?
A. Nasal discharge
B. Sneezing
C. Congestion
D. Sinusitis

9. Which of the following cells are derived from cKIT+CD34+ pluripotent bone marrow stem cells?
A. Mast cells
B. Basophils
C. Eosinophils
D. T lymphocytes

10. Which of the following interleukins is most likely to cause differentiation of basophils?
A. IL-2
B. IL-3
C. IL-4
D. IL-5

Answers
1. C, page 975
Large population-based studies indicate that nearly a quarter of the population may suffer from allergic rhinitis.
2. C, page 978
While both catecholamines and inidazoles can cause rhinitis medicamentosa, the most troublesome of these is a-adrenorecptor agonsits, a catecholamine.
3. D, page 978
Primary atrophic rhinitis is caused by infection of the nasal cavity by Klebsiella ozanae and other bacteria.
4. C, page 978
Nasal and sinus surgery can result in stripping and loss of nasal mucosa, thereby sacrificing the ability of the lining to provide moisture and clear any debris.
5. D, page 979
An ‘Allergies in America' survey showed 80 percent of sufferers felt tired frequently or sometimes during allergy season.
6. C, page 979
Allergic Rhinitis is responsible for 3.5 million lost workdays every year in the United States.
7. B, page 979
Allergic Rhinitis is responsible for 2 million lost school days every year in the United States.
8. B, page 980
Following nasal allergen provocation in sensitive subjects, there occurs an early allergic response comprising itching/sneezing within seconds or minutes followed by nasal discharge and congestion that is maximal at 15-30 minutes. A proportion of subjects go on to develop a late-phase response that is maximal at 6-12 hours.
9. A, page 980
Mast cells are tissue-based inflammatory cells derived from cKIT+ CD34+ pluripotent bone marrow stem cells.
10. B, page 981
Basophils develop from CD34+ pluripotent stem cells which circulate to the periphery where IL-3 is the dominant cytokine involved in differentiation of basophils from IL-3 receptor-positive precursors.

Allergy and Immunology Review Corner: Chapter 56 of Middleton's Allergy Principles and Practice, Seventh Edition, edited by N. Franklin Adkinson, et al.

Chapter 56: Nasal Polyps and Rhinosinusitis (Pages 991-1004)

Prepared by Christopher Martin, MD, Walter Reed Army Medical Center

1. The most common sinus site of origin for nasal polyps is?
A. Ethmoidal
B. Maxillary
C. Sphenoidal
D. Frontal

2. A symptom common to nasal polyps that differentiates the condition from chronic sinusitis without polyposis is?
A. Purulent drainage
B. Unilateral diminished hearing
C. Anosmia
D. Buccal parasthesia

3. Which of the following is true regarding aspirin-sensitive rhinosinusitis (ASRS)?
A. A clearly-defined IgE-mediated mechanism
B. No effect of atopy on the development of aspirin sensitivity
C. Normal blood eosinophil counts
D. Decreased cysteinyl-leukotriene levels in the urine

4. Population studies demonstrate the most frequent CFTR mutation causing cystic fibrosis is?
A. Three base insertion encoding phenylalanine at F(509).
B. Three base deletion resulting in failure to encode valine at V(508).
C. Single non-sense mutation in the promoter region for chloride channels.
D. Three base deletion resulting in failure to encode phenylalanine at F(508).

5. Which is the most common form of fungal sinus disease?
A. Acute/fulminant (invasive)
B. Chronic/indolent (invasive)
C. Fungal ball
D. Allergic fungal sinusitis

6. Which of the following is true?
A. Amphotericin B lavage is an effective standard therapy for chronic rhinosinusitis.
B. Long-term steroids are recommended for treatment of allergic fungal rhinosinusitis.
C. There is conclusive evidence that fungal eradication improves nasal polyps and prevents recurrence.
D. Polyps influenced by fungal disease bleed more often due to thinning of the basement membranes in sub-epithelial regions.

7. Which is true regarding the role S. aureus has in nasal polyps?
A. S. aureus lowers local IgE levels resulting in a more severe local eosinophilic inflammation.
B. The rate of S. aureus colonization is constant amongst all atopic groups.
C. Single agent antibiotic therapy (doxycycline) has been shown to be as effective as oral steroids in reducing polyp size.
D. The effects of S. aureus are superantigen-independent.

8. Which is true of rhinosinusitis?
A. Uncomplicated viral URI lead to sinusitis in a majority of cases.
B. A large number of viral URI infections become super-infected with bacteria.
C. Sinusitis has a prevalence of 30 percent to 35 percent in the U.S. population.
D. The most common suspected cause of chronic rhinosinusitis is fungal disease.

9. Which of the following is true when discussing chronic rhinosinusitis and nasal polyps?
A. TGF-B is increased in both CRS and polyp states.
B. TGF-B is decreased in both CRS and polyp states.
C. TGF-B is increased in CRS but decreased in polyp states.
D. TGF-B is decreased in CRS but increased in polyp states.

10. The primary cells present in the sinus fluid of patients undergoing surgery for chronic sinusitis is?
A. Eosinophils
B. Mast cells
C. Activated T-lymphocytes
D. Neutrophils

Answers
1. A, page 992
While all these areas can generate polyps, ethmoidal polyps are the most common. Turbinate polyps are generally rare overall.
2. C, page 992
Symptoms such as hyposmia, congestion and discharge can be common to both conditions. Complete anosmia is strongly associated with polyps.
3. B, page 994
While ASRS is associated with locally high levels of IgE, no clear IgE mediated pathway explaining the pathogenesis exists, and atopy does not appear to affect risk in developing aspirin sensitivity.
4. D, page 995
This mutation is found in 73.2 percent of all CF patients.
5. D, page 995
Allergic fungal sinusitis is the most common of the fungal sinus diseases.
6. B, page 996
7. C, page 998
8. A, pages 998-999
9. C, page 1002
10. D, page 1000