--- title: Most Missed Question in ABIM Prep – Rhinosinusitis with Nasal Polyps description: "Most Missed Question (ABIM): Rhinosinusitis with nasal polyps (CRSwNP) - key signs, associations (asthma/aspirin‑exacerbated), and initial management." image: https://challengercme.com/hubfs/nasal-polyps.jpg --- [![Med-Challenger-green-logo-1024x244](https://challengercme.com/hubfs/Med-Challenger-green-logo-1024x244.webp) ](https://challengercme.com/) - [SHOP EXAM PREP & CME ](https://challengercme.com/blog/most-missed-question-in-abim-prep-rhinosinusitis-with-nasal-polyps#) ### [EMERGENCY MEDICINE](https://challengercme.com/emergency-medicine-exam-review-cme-course) [ABEM exam prep](https://challengercme.com/emergency-medicine-exam-review-cme-course), [MyEMCert](https://challengercme.com/emergency-medicine-myemcert-exam-review-course), etc. ### [FAMILY MEDICINE](https://challengercme.com/family-medicine-exam-review-cme-course) [ABFM exam prep](https://challengercme.com/family-medicine-exam-review-cme-course), [ABFM KSA](https://challengercme.com/family-medicine-moc-ksa-course), etc. ### [INTERNAL MEDICINE ABIM exam prep, MOC points, etc.](https://challengercme.com/internal-medicine-exam-review-cme-course) ### [OBGYN ABOG exam prep, CREOG, etc.](https://challengercme.com/obgyn-exam-review-cme-course) ### [PEDIATRICS ABP exam prep, MOCA-PEDS, etc.](https://challengercme.com/pediatric-medicine-exam-review-cme-course) ### [PEDIATRIC EM](https://challengercme.com/pediatric-emergency-medicine-3rd-edition) [ABP/ABEM exam prep Ed.3](https://challengercme.com/pediatric-emergency-medicine-3rd-edition), [Ed.2](https://challengercme.com/pediatric-emergency-medicine-pack2), etc. ### [SPECIAL PURPOSE / SPEX FSMB exam prep, etc.](https://challengercme.com/special-purpose-exam-review-spex-exam-preparation-course) ### [PHYSICIAN ASSISTANT](https://challengercme.com/physician-assistant-exam-review-cme-course) [PANCE / PANRE](https://challengercme.com/physician-assistant-exam-review-cme-course), [CAQ-EM](https://challengercme.com/pa-caq-em-review-course), etc ### [NURSE PRACTITIONER](https://challengercme.com/family-nurse-practitioner-exam-review-cme-course) [FNP](https://challengercme.com/family-nurse-practitioner-exam-review-cme-course), [ENP](https://challengercme.com/emergency-nurse-practitioner-exam-review-cne-course), [AGNP](https://challengercme.com/adult-gerontology-nurse-practitioner-exam-review-cne-course), [PNCB/CPNP](https://challengercme.com/pediatric-nurse-practitioner-exam-review-cne-course), etc. ### [NURSING / NCLEX NCLEX, CNE, etc.](https://challengercme.com/nursing-certification-nclex-exam-review-cne-courses) ### [STATE-REQUIRED CME / CE State CME requirements, etc.](https://challengercme.com/state-required-cme) ### [JOINT COMMISSION CME](https://challengercme.com/stroke-center-ce-review-course) [Stroke](https://challengercme.com/stroke-center-ce-review-course), [Cardiac](https://challengercme.com/cardiac-center-ce-review-course), [Trauma](https://challengercme.com/trauma-center-ce-review-course), [ALS](https://challengercme.com/advanced-life-support-and-resuscitation-center-ce-review-course), etc. ### [PROFESSIONALISM CME Professionalism review with CME](https://challengercme.com/professionalism-review-course) ### [DERMATOLOGY CME Dermatology review with CME](https://challengercme.com/dermatology-review-course) ### [USMLE STEP 2CK / STEP 3 USMLE exam prep, etc.](https://challengercme.com/usmle-certification-exam-review-clerkship-exams-shelf-exam-review) - [INSTITUTIONS ](https://challengercme.com/atlas-pro-inst) - [BLOG ](https://challengercme.com/blog) - [SUPPORT ](https://support.challengercme.com/knowledge) [SIGN IN ](https://fuse.challengercme.com/sign-in?redirectURL=%2Fuserdash) internal medicine # Most Missed Question in ABIM Prep – Rhinosinusitis with Nasal Polyps Most Missed Question (ABIM): Rhinosinusitis with nasal polyps (CRSwNP) - key signs, associations (asthma/aspirin‑exacerbated), and initial management. 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[START IM REVIEW](https://fuse.challengercme.com/fulltrial/212) --- ### Share this article [mailto:?subject=Check%20out%20https://challengercme.com/blog/most-missed-question-in-abim-prep-rhinosinusitis-with-nasal-polyps&utm_medium=social&utm_source=email%20&body=Check%20out%20https://challengercme.com/blog/most-missed-question-in-abim-prep-rhinosinusitis-with-nasal-polyps&utm_medium=social&utm_source=email](mailto:?subject=Check%20out%20https://challengercme.com/blog/most-missed-question-in-abim-prep-rhinosinusitis-with-nasal-polyps&utm_medium=social&utm_source=email%20&body=Check%20out%20https://challengercme.com/blog/most-missed-question-in-abim-prep-rhinosinusitis-with-nasal-polyps&utm_medium=social&utm_source=email) ### Subscribe ### Subscribe ![A 76‑year‑old woman — case review](https://challengercme.com/hubfs/nasal-polyps.jpg) Chronic rhinosinusitis with nasal polyps (CRSwNP). Key point — association with asthma/aspirin‑exacerbated respiratory disease; first‑line management includes intranasal corticosteroids and ENT referral if refractory. [![Want more control over your program's outcomes? Learn about Institutional Programs](https://no-cache.hubspot.com/cta/default/9106197/interactive-194510541423.png) ](https://challengercme.com/hs/cta/wi/redirect?encryptedPayload=AVxigLLilN5Od9flYtBXUnLLfNcK%2BljyGm5NSGiZWNZMoYWowhD7iMG7LjVYRCp7iKZY1C56vBbiD84r%2FWeuet5K1FEmHJMjwYTOuDTIoALZr0IuKXexom9YSZbHMDNcQmYtD1JSODVrB7lfxVOT2xjk3a0vCuL25uecf7JAQlcaObA5rHgTjBlsa%2FTQOfl6Jg%3D%3D&webInteractiveContentId=194510541423&portalId=9106197) ## **Question - Aspirin Triad** A 40-year-old man presents to you with what he calls a "cold," which he says has lasted for many months followed by the gradual onset of blockage of his right nasal passage. He has had asthma for about 10 years, which he says occurs unpredictably. He uses aspirin and, on occasion, nonsteroidal anti-inflammatory drugs. He tells you that recently his sense of smell has decreased. Upon examination, he has a pronounced nasal voice. Vital signs are normal. Examination of the right nasal passage with a speculum reveals a gray, cyst-like mass protruding into the nasal cavity. The remainder of the head, eyes, ears, nose, and throat examination is normal. Which of the following may be found in patients with chronic sinusitis? **Answers:** A. asthma and nasal polyps B. asthma and eosinophilic pneumonia C. hyperplastic eosinophilic sinusitis and aspirin sensitivity D. asthma and gastro-esophageal reflux disease (GERD)   *This item is commonly missed because it blends clinical clues to chronic rhinosinusitis with nasal polyps (CRSwNP)—nasal obstruction, hyponosmia/anosmia, pale gray polypoid tissue—with asthma and NSAID exposure, priming you to recall the classic triad of aspirin-exacerbated respiratory disease (AERD). Many examinees overthink the stem and choose a more esoteric pairing (e.g., “hyperplastic eosinophilic sinusitis and aspirin sensitivity”) instead of the board-favored association: asthma plus nasal polyps. On exam day, prioritize pattern recognition: adult-onset or worsening asthma, recurrent nasal polyps, and NSAID sensitivity co-cluster (AERD/Samter triad). Contemporary guidance (European Position Paper on Rhinosinusitis and Nasal Polyps, EPOS 2020; Global Initiative for Asthma, GINA 2024) emphasizes that CRSwNP is a distinct endotype often linked to type 2 inflammation and that anosmia is particularly characteristic in CRSwNP.*   ## **Why This Question Is Often Missed** - The stem tempts a “pathology-word salad” choice (hyperplastic eosinophilic sinusitis) over the simpler, canonical association tested on boards: asthma + nasal polyps. - Test-takers conflate common comorbidities (e.g., asthma + GERD) with causally or phenotypically linked disease (AERD). - Anosmia is under-recognized as a strong CRSwNP clue, pushing examinees away from the AERD triad.   ## **What the Distractors Indicate** | **Option** | **What It Tests / Implies** | **Why It’s Wrong Here** | | --- | --- | --- | | asthma and nasal polyps | Recognizing CRSwNP’s classic association and AERD pattern | Correct: CRSwNP commonly coexists with asthma; NSAID sensitivity is frequent (AERD). | | asthma and eosinophilic pneumonia | Overgeneralization of “eosinophilia” in airway disease | Eosinophilic pneumonia is not a typical comorbidity of chronic sinusitis/CRSwNP. | | hyperplastic eosinophilic sinusitis and aspirin sensitivity | Anchoring on histopathologic jargon and NSAID clues | Mixes a histologic subtype term with association; boards expect the clinical triad recognition (polyps + asthma ± NSAID sensitivity), not this pairing as the best answer. | | asthma and GERD | Common but nonspecific comorbidity | GERD may coexist with asthma but does not define CRSwNP or explain anosmia/polyps. |   ## **Internal Medicine High-Yield Pearl** > Adult with nasal obstruction, anosmia, pale polyps, asthma, and NSAID exposure = think CRSwNP with AERD; choose “asthma + nasal polyps.”   ## **Core Learning Objectives** ### 1. Recognize the clinical phenotype and associations of CRSwNP, especially the AERD (Samter) triad: asthma, nasal polyps, and NSAID sensitivity. 2. Distinguish CRSwNP from look-alikes and select appropriate first-line evaluation/management steps per EPOS 2020 and GINA 2024. ## **The Exam “Test Trick” at Play** The test writers juxtapose a high-utility clinical association (asthma + nasal polyps) with a more esoteric, jargon-heavy distractor. Boards reward identification of the straightforward triad rather than overfitting to path terms. [![Want more control over your program's outcomes? Learn about Institutional Programs](https://no-cache.hubspot.com/cta/default/9106197/interactive-194510541423.png) ](https://challengercme.com/hs/cta/wi/redirect?encryptedPayload=AVxigLLilN5Od9flYtBXUnLLfNcK%2BljyGm5NSGiZWNZMoYWowhD7iMG7LjVYRCp7iKZY1C56vBbiD84r%2FWeuet5K1FEmHJMjwYTOuDTIoALZr0IuKXexom9YSZbHMDNcQmYtD1JSODVrB7lfxVOT2xjk3a0vCuL25uecf7JAQlcaObA5rHgTjBlsa%2FTQOfl6Jg%3D%3D&webInteractiveContentId=194510541423&portalId=9106197) ## Additional ABIM Exam Practice Questions and Remediation for CRSwNP/AERD --- ### **Internal Medicine Practice Question 1 — Classic triad clue ** A 38-year-old with adult-onset asthma develops progressive nasal obstruction and loss of smell after taking ibuprofen. Nasal endoscopy shows bilateral pale polyps. Which association is most characteristic? A. Aspirin-exacerbated respiratory disease B. Primary ciliary dyskinesia C. Allergic bronchopulmonary aspergillosis D. Chronic neutropenic sinusitis E. Granulomatosis with polyangiitis Answer and Remediation - A — Correct response!: Asthma + CRSwNP + NSAID reactions is classic AERD (Samter triad) per EPOS 2020/GINA 2024. - B — Review: Causes chronic sinusitis, but links to infertility/situs inversus rather than NSAID-triggered bronchospasm. - C — Review: ABPA links to asthma/bronchiectasis with Aspergillus sensitization, not NSAID sensitivity or nasal polyps. - D — Review: Neutropenia predisposes to infections, not type 2 polypoid disease with NSAID reactivity. - E — Review: GPA features necrotizing granulomas/vasculitis, epistaxis, and systemic signs; not classic for anosmia with pale polyps. ### Internal Medicine Practice Question 2 — First-line therapy A 45-year-old man with CRSwNP and asthma reports recurrent obstruction and anosmia. Best initial pharmacologic therapy? A. Intranasal corticosteroid spray B. Long-term oral antibiotics C. Antihistamine monotherapy D. Systemic corticosteroids indefinitely E. Immediate aspirin desensitization for all Answer and Remediation - A — Correct response!: Intranasal steroids are first-line for CRSwNP; short oral steroid bursts only for flares (EPOS 2020). - B — Review: Prolonged antibiotics are not first-line in CRSwNP absent acute infection. - C — Review: Antihistamines help allergic rhinitis, not primary CRSwNP pathology. - D — Review: Chronic systemic steroids have unacceptable toxicity; reserve brief courses. - E — Review: Aspirin desensitization is for confirmed AERD when benefits outweigh risks, not universally applied. ### Internal Medicine Practice Question 3 — Diagnostic step Which test best confirms the presence of nasal polyps in suspected CRSwNP? A. Serum total IgE B. Nasal endoscopy C. MRI of paranasal sinuses D. Skin-prick testing E. Sweat chloride test Answer and Remediation - A — Review: IgE may reflect atopy but does not confirm polyps. - B — Correct response!: Endoscopy directly visualizes polyps and is recommended to confirm diagnosis (EPOS 2020). - C — Review: CT, not MRI, is typical for mapping extent preoperatively; imaging is not required to “confirm” polyps when endoscopy is available. - D — Review: Allergy testing may guide comorbidity management, not polyp confirmation. - E — Review: Cystic fibrosis testing is for selected cases (e.g., children), not standard adult CRSwNP confirmation. ### Internal Medicine Practice Question 4 — Medication strategy in AERD In AERD with persistent symptoms despite intranasal steroids, which adjunct is most likely to improve upper and lower airway symptoms? A. Inhaled anticholinergic B. Intranasal antihistamine only C. Leukotriene receptor antagonist D. Daily macrolide therapy E. Antifungal nasal irrigations Answer and Remediation - A — Review: Anticholinergics help COPD/bronchospasm but do not target leukotriene-driven AERD. - B — Review: May reduce rhinorrhea but not core polyp/inflammatory pathway. - C — Correct response!: Leukotriene modifiers target overactive leukotriene pathway central to AERD pathophysiology (EPOS 2020). - D — Review: Macrolides have niche roles in non–type 2 CRS; evidence in CRSwNP/AERD is limited. - E — Review: Antifungals are not recommended for CRSwNP. ### **Internal Medicine Practice Question 5 — Imaging decision ** A 42-year-old with CRSwNP fails maximal medical therapy and is referred for surgery. Which imaging is appropriate preoperatively? A. Chest CT B. MRI brain with contrast C. Plain sinus radiographs D. Non-contrast CT of the paranasal sinuses E. PET-CT Answer and Remediation - A — Review: Not relevant to surgical planning for polyps. - B — Review: MRI may complement if complications suspected, but CT is standard for anatomy. - C — Review: Obsolete for surgical planning; poor sensitivity/specificity. - D — Correct response!: Non-contrast sinus CT maps anatomy and disease extent before endoscopic sinus surgery (EPOS 2020). - E — Review: Not indicated in CRSwNP.   ## **Mini Case Discussion Prompt** > Compare management strategies for (1) CRSwNP with confirmed AERD (history of NSAID-induced bronchospasm) versus (2) CRSwNP with atopic rhinitis but no NSAID sensitivity—discuss roles of leukotriene modifiers, brief oral steroid tapers, endoscopic evaluation, sinus CT for surgical planning, aspirin desensitization, and when to consider biologics (e.g., dupilumab) after failure of standard therapy.   ## **Mini-FAQ** - How do ABIM-style questions signal CRSwNP? Look for bilateral pale polyps, nasal obstruction, and especially anosmia in an adult with asthma. - Do boards expect me to order imaging to “diagnose” polyps? No—nasal endoscopy confirms polyps; CT is for extent/surgical planning (EPOS 2020). - What’s the board-favored initial treatment? Intranasal corticosteroids, saline irrigation, brief oral steroids for severe flares; add leukotriene modifiers in AERD (EPOS 2020, GINA 2024). - When is aspirin desensitization tested? In confirmed AERD with ongoing need for aspirin/NSAIDs or refractory symptoms under specialist care; not as first-line for all CRSwNP. **** --- This question appears in [Med-Challenger Internal Medicine Review with CME](https://challengercme.com/internal-medicine-exam-review-cme-course) [Try for free and save](https://fuse.challengercme.com/fulltrial/212). Ace your exams and meet your CME/MOC requirements for just $35 a month! 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All rights reserved [Privacy Policy](https://support.challengercme.com/knowledge/what-are-your-terms-of-service-privacy-policy-user-agreement) ```json { "@context" : "https://schema.org", "@id" : "https://challengercme.com/blog#webpage", "@type" : "WebPage", "description" : "The Challenger Medical Education Blog offers informative patient cases, medical certification exam preparation courses and board exam review tips.", "inLanguage" : "en", "isPartOf" : { "@type" : "WebSite", "name" : "Med-Challenger", "url" : "https://challengercme.com/" }, "mainEntityOfPage" : { "@id" : "https://challengercme.com/blog", "@type" : "WebPage" }, "name" : "Challenger Medical Education Blog", "primaryImageOfPage" : { "@type" : "ImageObject", "url" : "https://challengercme.com/hubfs/Webpage%20Featured%20Images/Medical%20Education%20Blog%20-%20Free%20CME%20resources%2c%20certification%20exam%20tips%2c%20clinical%20challenge%20questions%20and%20more.png" }, "publisher" : { "@type" : "Organization", "name" : "Challenger Corporation", "url" : "https://challengercme.com/" }, "url" : "https://challengercme.com/blog" } ``` ```json { "@context" : "https://schema.org", "@type" : "BlogPosting", "about" : [ "Chronic rhinosinusitis with nasal polyps (CRSwNP)", "Aspirin-exacerbated respiratory disease (AERD) / Samter triad", "Nasal polyps", "Asthma", "Anosmia / hyposmia", "Intranasal corticosteroids", "Leukotriene receptor antagonists", "Nasal endoscopy", "CT of paranasal sinuses", "Aspirin desensitization", "EPOS 2020", "GINA 2024", "Exam preparation (ABIM practice / medical education)" ], "articleSection" : "Internal Medicine", "author" : { "@type" : "Organization", "name" : "Challenger Corporation" }, "dateModified" : "2025-11-17T20:45:41.404Z", "datePublished" : "2025-10-28T15:01:47.000Z", "description" : "Most Missed Question (ABIM): Rhinosinusitis with nasal polyps (CRSwNP) - key signs, associations (asthma/aspirin‑exacerbated), and initial management.", "headline" : "Most Missed Question in ABIM Prep – Rhinosinusitis with Nasal Polyps", "image" : [ { "@type" : "ImageObject", "description" : "Med-Challenger / Challenger Corporation logo", "url" : "https://challengercme.com/logo.png" } ], "inLanguage" : "en-US", "keywords" : [ "CRSwNP", "nasal polyps", "AERD", "Samter triad", "anosmia", "asthma", "intranasal corticosteroids", "leukotriene receptor antagonist", "aspirin desensitization", "nasal endoscopy", "sinus CT", "ABIM prep", "medical education", "practice questions" ], "mainEntityOfPage" : { "@id" : "https://challengercme.com/blog/most-missed-question-in-abim-prep-rhinosinusitis-with-nasal-polyps", "@type" : "WebPage" }, "publisher" : { "@type" : "Organization", "logo" : { "@type" : "ImageObject", "url" : "https://challengercme.com/logo.png" }, "name" : "Challenger Corporation" } } ``` ```json { "@context" : "https://schema.org", "@type" : "QAPage", "mainEntity" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "A. asthma and nasal polyps — The article explains that chronic rhinosinusitis with nasal polyps (CRSwNP) commonly coexists with asthma and that NSAID sensitivity clusters with adult-onset or worsening asthma and recurrent nasal polyps (AERD/Samter triad). The board-favored association is asthma plus nasal polyps; anosmia and pale/gray polypoid tissue are characteristic clues." }, "name" : "Which association is commonly found in patients with chronic rhinosinusitis with nasal polyps?", "text" : "A 40-year-old man with a months-long nasal \"cold,\" progressive unilateral nasal blockage, adult-onset asthma for 10 years, occasional aspirin/NSAID use, and decreased sense of smell has a gray, cyst-like mass in the nasal cavity consistent with a nasal polyp. Which of the following may be found in patients with chronic sinusitis? A. asthma and nasal polyps B. asthma and eosinophilic pneumonia C. hyperplastic eosinophilic sinusitis and aspirin sensitivity D. asthma and gastro-esophageal reflux disease (GERD)" } } ``` ```json { "@context" : "https://schema.org", "@type" : "ItemList", "description" : "Exam-style review questions based on this article’s teaching points.", "itemListElement" : [ { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Aspirin-exacerbated respiratory disease (AERD): adult-onset asthma + CRSwNP + NSAID reactions (Samter triad)." }, "name" : "Classic triad clue — what diagnosis is most characteristic?" }, "position" : 1 }, { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Intranasal corticosteroid spray — first-line therapy for CRSwNP; short oral steroid bursts are reserved for flares." }, "name" : "Best initial pharmacologic therapy for CRSwNP with anosmia?" }, "position" : 2 }, { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Nasal endoscopy — direct visualization confirms polyps (per EPOS 2020 referenced in the article)." }, "name" : "Which test best confirms the presence of nasal polyps?" }, "position" : 3 }, { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Leukotriene receptor antagonist — targets leukotriene-driven pathway implicated in AERD and may improve upper and lower airway symptoms." }, "name" : "Adjunct most likely to improve symptoms in AERD when intranasal steroids are insufficient?" }, "position" : 4 }, { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Non-contrast CT of the paranasal sinuses — used to map anatomy and disease extent before surgery (EPOS 2020)." }, "name" : "Appropriate preoperative imaging for CRSwNP prior to endoscopic sinus surgery?" }, "position" : 5 } ], "name" : "Practice Questions", "numberOfItems" : 5 } ```