Key takeaway: In adults, chronic rhinosinusitis with nasal polyps frequently coexists with asthma and aspirin/NSAID sensitivity—recognize the AERD (Samter) triad and expect anosmia.
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
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.
| 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. |
Adult with nasal obstruction, anosmia, pale polyps, asthma, and NSAID exposure = think CRSwNP with AERD; choose “asthma + nasal polyps.”
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.
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 diseaseA 45-year-old man with CRSwNP and asthma reports recurrent obstruction and anosmia. Best initial pharmacologic therapy?
A. Intranasal corticosteroid sprayWhich test best confirms the presence of nasal polyps in suspected CRSwNP?
A. Serum total IgEIn AERD with persistent symptoms despite intranasal steroids, which adjunct is most likely to improve upper and lower airway symptoms?
A. Inhaled anticholinergicA 42-year-old with CRSwNP fails maximal medical therapy and is referred for surgery. Which imaging is appropriate preoperatively?
A. Chest CT
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.
This question appears in Med-Challenger Internal Medicine Review with CME
Try for free and save. Ace your exams and meet your CME/MOC requirements for just $35 a month!
No matter your program, no matter the size, Med-Challenger for Groups and Institutions can better prepare your program or group, fulfill industry requirements, and increase test scores.