Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: Posterior epistaxis is commonly seen in which of the following conditions?

Hypertension. **Explanation:** Epistaxis is classified into anterior and posterior based on the site of bleeding. **Posterior epistaxis** originates from the posterior part of the nasal cavity, most commonly from the **Woodruff’s plexus** (located over the posterior end of the middle turbinate). **Why Hypertension is Correct:** Hypertension is the most common systemic cause of posterior epistaxis, particularly in elderly patients. Chronic high blood pressure leads to **arteriosclerosis** of the sphenopalatine artery and its branches. These brittle vessels lose their ability to contract effectively when ruptured, leading to severe, spontaneous bleeding that often requires packing or surgical intervention. **Analysis of Incorrect Options:** * **A. Children with ethmoidal polyps:** Ethmoidal polyps typically present with nasal obstruction and anosmia; while they may cause blood-tinged discharge, they are not a classic cause of frank posterior epistaxis. * **B. Foreign bodies:** These usually cause unilateral, foul-smelling, purulent nasal discharge in children. While they can cause minor bleeding, it is typically anterior and localized. * **D. Nose picking:** This is the most common cause of **anterior epistaxis** in children and young adults, occurring at **Little’s area (Kiesselbach’s plexus)** on the anterior nasal septum. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of Epistaxis:** Little’s area (Anterior). * **Most common site of Posterior Epistaxis:** Woodruff’s plexus. * **Artery of Epistaxis:** Sphenopalatine artery (a branch of the Maxillary artery). * **Management:** Anterior bleeding is usually managed by Trotter’s method or chemical cautery; posterior bleeding often requires **Post-nasal packing** or endoscopic ligation of the sphenopalatine artery.

Q: What is the presenting symptom of nasal myiasis?

Severe irritation with sneezing. **Explanation:** **Nasal Myiasis** (Peenash) is a condition caused by the infestation of nasal cavities by the larvae of flies, most commonly *Chrysomyia bezziana*. It is typically seen in patients with poor hygiene, atrophic rhinitis, or leprosy. 1. **Why Option A is correct:** The **earliest presenting symptom** of nasal myiasis is intense, severe irritation in the nose accompanied by persistent sneezing. This is a physiological reaction to the movement of the larvae and the toxins they secrete upon entering the nasal vestibule. This stage precedes the more visible signs of infestation. 2. **Why other options are incorrect:** * **Option B (Maggots):** While the presence of maggots is the hallmark of the disease, they are a **sign** (observed by the clinician or patient later) rather than the initial presenting symptom. * **Option C (Nasal pain):** Pain and headache occur later as the larvae invade the paranasal sinuses and cause tissue destruction/secondary infection. * **Option D (Impaired olfaction):** While destruction of the olfactory epithelium can occur in advanced stages, it is not the primary or presenting complaint. **High-Yield Clinical Pearls for NEET-PG:** * **Commonest Fly:** *Chrysomyia bezziana*. * **Predisposing factor:** Atrophic rhinitis (due to the wide nasal room and foul-smelling discharge attracting flies). * **Clinical Features:** Serosanguinous (blood-stained) discharge, foul "putrid" odor, and eventually palatal perforation or orbital complications. * **Management:** * **Initial:** Instillation of **Chloroform and Turpentine oil** (ratio 1:4) to stupefy the maggots. * **Definitive:** Manual removal of maggots using forceps. * **Medical:** Oral **Ivermectin** is highly effective.

Q: What is the commonest site of an ivory osteoma?

Frontal-ethmoidal region. **Explanation:** **Osteomas** are the most common benign tumors of the paranasal sinuses. They are slow-growing, encapsulated bony tumors composed of mature bone. **1. Why the Frontal-ethmoidal region is correct:** Statistically, the **frontal sinus** is the most common site for paranasal sinus osteomas (approx. 75-80%), followed by the **ethmoid air cells**. The "ivory" subtype refers to a dense, hard, and mature bone composition (as opposed to the "cancellous" type). These tumors typically arise near the fronto-ethmoidal suture line. While often asymptomatic, they can cause symptoms by obstructing the frontal sinus drainage pathway, leading to secondary sinusitis or a mucocele. **2. Why the other options are incorrect:** * **Mandible & Maxilla:** While osteomas can occur in the gnathic bones (often associated with **Gardner’s Syndrome**), they are significantly less common here than in the paranasal sinuses. * **Sphenoid:** The sphenoid sinus is the rarest site for a paranasal sinus osteoma. **Clinical Pearls for NEET-PG:** * **Radiology:** On a CT scan, an ivory osteoma appears as a very dense, homogeneous, "stone-like" radiopaque mass with well-defined margins. * **Gardner’s Syndrome:** If a patient presents with multiple osteomas (especially of the mandible), always look for **colonic polyposis** (premalignant), soft tissue tumors, and dental abnormalities. * **Management:** Small, asymptomatic osteomas are managed by observation. Surgical excision (Endoscopic or External/Lynch-Howarth) is indicated if the tumor is symptomatic, enlarging, or causing obstruction.

Q: Which of the following is NOT true about rhinocerebral mucormycosis?

Treatment with voriconazole. **Explanation:** Rhinocerebral Mucormycosis is a fulminant, life-threatening fungal infection caused by fungi of the order Mucorales (e.g., *Rhizopus*, *Mucor*). It primarily affects immunocompromised patients, particularly those with uncontrolled diabetes mellitus (ketoacidosis) or neutropenia. **Why Option B is the correct answer (False statement):** The drug of choice for Mucormycosis is **Liposomal Amphotericin B**. **Voriconazole**, while effective against *Aspergillus*, has **no activity** against Mucorales. Using voriconazole in a suspected case of mucormycosis is a common clinical pitfall and a high-yield exam point. Surgical debridement is also mandatory for survival. **Analysis of other options:** * **Option A (Also known as mucormycosis):** This is a true statement. Rhinocerebral is the most common clinical form of the disease. * **Option C (Angioinvasive):** This is a hallmark feature. The fungi invade blood vessel walls, leading to thrombosis, distal ischemia, and tissue infarction. * **Option D (Black necrotic turbinates):** Due to the angioinvasive nature and subsequent tissue necrosis, patients typically present with a characteristic **black eschar** on the nasal turbinates or the hard palate. **Clinical Pearls for NEET-PG:** * **Risk Factor:** Diabetic Ketoacidosis (acidosis allows the fungus to thrive by releasing iron from transferrin). * **Diagnosis:** Definitive diagnosis is made via biopsy showing **broad, ribbon-like, non-septate hyphae** branching at **right angles (90°)**. * **Management:** "Reverse the underlying cause + Aggressive surgical debridement + IV Amphotericin B." * **Second-line agents:** Posaconazole or Isavuconazole can be used as salvage therapy or step-down treatment.

Q: Caldwell-Luc operation is indicated for which condition?

Maxillary sinusitis. The **Caldwell-Luc operation** is a classic surgical procedure designed to provide direct access to the **maxillary sinus**. It involves creating an opening in the canine fossa (above the premolar teeth) to enter the sinus, followed by the creation of an intranasal antrostomy for drainage. ### Why Maxillary Sinusitis is Correct: The procedure is specifically indicated for chronic maxillary sinusitis that is unresponsive to conservative management or endoscopic approaches. It allows for the complete removal of irreversible diseased mucosa, polyps, or foreign bodies (like a displaced tooth root) from the maxillary antrum. It is also the approach used for biopsy of maxillary tumors and for the **Denker’s operation** (an extension for reaching the nasopharynx). ### Why Other Options are Incorrect: * **Frontal Sinusitis:** Managed via procedures like the Lynch-Howarth operation, Trephination, or more commonly, Functional Endoscopic Sinus Surgery (FESS). * **Ethmoid Sinusitis:** Addressed via internal or external ethmoidectomy (e.g., Patterson’s or Jansen-Horgan approach). * **Sphenoid Sinusitis:** Accessed via transnasal or transethmoidal routes, often using endoscopic techniques. ### High-Yield Clinical Pearls for NEET-PG: * **Key Indications:** Chronic maxillary sinusitis with irreversible changes, Oro-antral fistula closure, and removal of **Antrochoanal polyps** (to prevent recurrence by removing the base). * **Common Complication:** Numbness of the cheek or upper teeth due to injury to the **infraorbital nerve**. * **Current Status:** Largely replaced by **FESS** (Functional Endoscopic Sinus Surgery), which is more physiological and less invasive. * **Landmark:** The incision is made in the gingivolabial sulcus, lateral to the frenulum.

Q: Which of the following are features of congenital syphilis?

Perforation in the cartilaginous part of the nose. **Explanation:** Congenital syphilis is divided into early (manifesting before 2 years of age) and late (manifesting after 2 years) stages. **Why Option B is Correct:** Syphilis is characterized by an affinity for the **cartilaginous structures**. In congenital syphilis, the inflammatory process (gummatous destruction) specifically targets the **cartilaginous part of the nasal septum**. This leads to perforation and the subsequent collapse of the nasal bridge. **Analysis of Incorrect Options:** * **A. Snuffles:** This is a highly infectious nasal discharge (syphilitic rhinitis) and is an **early** manifestation, typically appearing within the first few weeks of life. * **C. Mulberry Molars:** These are permanent first molars with multiple poorly developed cusps. While seen in congenital syphilis, they are a **late** manifestation (appearing after age 2), and the question specifically highlights the cartilaginous involvement as a primary pathological feature. * **D. Saddle Nose Deformity:** While this is a classic sign of congenital syphilis, it results from the destruction of the **bony** part of the nasal bridge (the bridge itself), whereas the primary pathological perforation occurs in the **cartilaginous** septum. **High-Yield Clinical Pearls for NEET-PG:** * **Hutchinson’s Triad:** Interstitial keratitis, Hutchinson’s teeth (notched incisors), and 8th nerve deafness. * **Early Signs:** Snuffles, Condyloma lata, Pemphigus syphiliticus (bullous lesions on palms/soles), and Osteochondritis (Wimberger’s sign). * **Late Signs:** Clutton’s joints (painless knee swelling), Sabre shin (anterior bowing of tibia), and Rhagades (linear scars around the mouth). * **Screening:** VDRL/RPR are used for screening; TPHA/FTA-ABS are confirmatory. Treatment of choice is **Penicillin G**.

Q: What is the treatment of Rhinitis Medicamentosa?

Withdrawal of nasal drops with a short course of steroids. **Explanation:** **Rhinitis Medicamentosa** is a condition of rebound nasal congestion caused by the prolonged use (typically >5–7 days) of topical nasal decongestants (e.g., Oxymetazoline, Xylometazoline). These drugs cause vasoconstriction; however, chronic use leads to tachyphylaxis, interstitial edema, and secondary vasodilation, resulting in a "rebound" phenomenon where the patient feels more congested than before. **Why Option A is Correct:** The primary goal of treatment is to break the cycle of dependency. 1. **Withdrawal:** Immediate cessation of the offending topical decongestant is mandatory to allow the nasal mucosa to recover. 2. **Steroids:** Systemic or topical corticosteroids are used to reduce the underlying mucosal inflammation and edema, making the withdrawal process tolerable for the patient. **Why Other Options are Incorrect:** * **Option B (Antibiotics):** Rhinitis Medicamentosa is a drug-induced physiological change, not a bacterial infection. Antibiotics have no role unless there is a secondary bacterial sinusitis. * **Option C (Polypectomy):** This is a surgical procedure for nasal polyps. While chronic rhinitis can lead to mucosal hypertrophy, the initial management is medical withdrawal, not surgery. * **Option D (Increasing the dose):** This would exacerbate the condition, leading to further mucosal damage and worsening the rebound congestion. **High-Yield NEET-PG Pearls:** * **Pathophysiology:** Chronic use leads to the loss of vascular tone and permanent damage to the ciliary epithelium. * **Clinical Presentation:** The patient often describes a "red, beefy" nasal mucosa on examination. * **Management Tip:** To ease withdrawal, some clinicians suggest stopping the drops in one nostril at a time (the "one-nostril-at-a-time" method) while starting intranasal steroid sprays.

Q: A 32-year-old female patient underwent extraction of an upper first molar on the right side, resulting in a 0.3 mm perforation of the sinus wall. Oroantral communication is predominantly seen during the extraction of which teeth?

Maxillary first molars. **Explanation:** The **maxillary first molar** is the most common tooth associated with the formation of an oroantral communication (OAC). This is primarily due to the anatomical proximity of its roots to the floor of the maxillary sinus (antrum of Highmore). In many adults, only a thin layer of bone—or sometimes just the sinus mucosa—separates the trifurcated roots of the first molar from the sinus cavity. During extraction, the divergent nature of these roots increases the risk of fracturing the thin antral floor. **Analysis of Options:** * **Maxillary First Molar (Correct):** Statistically the most frequent site for OAC because its roots are the longest and most closely related to the lowest point of the sinus floor. * **Maxillary Second Molar:** While also in close proximity to the sinus, it is the second most common site. The roots are often less divergent than the first molar. * **Maxillary Premolars:** The second premolar is frequently near the sinus, but the first premolar is usually further anterior, making OAC less common. * **Maxillary Paramolar:** These are supernumerary teeth. While they can cause complications, they are rare compared to the standard dentition. **Clinical Pearls for NEET-PG:** * **Definition:** An OAC is a physical communication between the oral cavity and maxillary sinus. If it persists and becomes epithelialized, it is termed an **Oroantral Fistula (OAF)**. * **Management Rule of Thumb:** * ** 6 mm:** Requires surgical closure (e.g., **Berger’s Buccal Advancement Flap** or Palatal Rotation Flap). * **Diagnosis:** Positive **nose-blowing test** (escape of air/bubbles through the socket).

Q: All of the following are true of antrochoanal polyp except?

Bleeds on touch. **Explanation:** Antrochoanal polyps (Killian's polyp) are benign, non-neoplastic growths that arise from the mucosa of the maxillary sinus, exit through the accessory ostium, and extend into the choana and nasopharynx. **Why "Bleeds on touch" is the correct answer (False statement):** Antrochoanal polyps are typically **translucent, pearly white, or grayish-pink** in appearance. They are relatively avascular and smooth. Unlike malignant tumors (like inverted papilloma or squamous cell carcinoma) or vascular tumors (like Juvenile Nasopharyngeal Angiofibroma), they **do not bleed on touch**. If a nasal mass bleeds easily, a clinician should suspect malignancy or a vascular lesion rather than a simple polyp. **Analysis of other options:** * **A. Common in young:** True. These polyps are most frequently seen in children and young adults, unlike ethmoidal polyps which are more common in older adults. * **B. Single and unilateral:** True. Antrochoanal polyps are characteristically solitary and affect only one side. Bilateral presentation is extremely rare. * **D. Treatment involves FESS:** True. Functional Endoscopic Sinus Surgery (FESS) is the gold standard. The goal is to remove the polyp and its stalk from the maxillary sinus to prevent recurrence. **High-Yield Clinical Pearls for NEET-PG:** * **Components:** It has three parts—Antral, Nasal, and Choanal. * **Radiology:** On X-ray/CT, it shows opacification of the maxillary sinus with a soft tissue mass extending into the nasopharynx. * **Differential Diagnosis:** Must be differentiated from **Angiofibroma** (which occurs in adolescent males and bleeds profusely). * **Historical Note:** The Caldwell-Luc operation was previously used but has been largely replaced by FESS.

Question 1

Posterior epistaxis is commonly seen in which of the following conditions?

Accepted Answer

Hypertension

Answer

Children with ethmoidal polyps

Answer

Foreign bodies of the nose

Answer

Nose picking

Question 2

What is the presenting symptom of nasal myiasis?

Accepted Answer

Severe irritation with sneezing

Answer

Maggots

Answer

Nasal pain

Answer

Impaired olfaction

Question 3

What is the commonest site of an ivory osteoma?

Accepted Answer

Frontal-ethmoidal region

Answer

Mandible

Answer

Maxilla

Answer

Sphenoid

Question 4

Which of the following is NOT true about rhinocerebral mucormycosis?

Accepted Answer

Treatment with voriconazole

Answer

Also known as mucormycosis

Answer

Angioinvasive

Answer

Black necrotic turbinates

Question 5

Caldwell-Luc operation is indicated for which condition?

Accepted Answer

Maxillary sinusitis

Answer

Frontal sinusitis

Answer

Ethmoid sinusitis

Answer

Sphenoid sinusitis

Question 6

Which of the following are features of congenital syphilis?

Accepted Answer

Perforation in the cartilaginous part of the nose

Answer

Snuffles is a late manifestation

Answer

Mulberry molars

Answer

Saddle nose deformity

Question 7

What is the treatment of Rhinitis Medicamentosa?

Accepted Answer

Withdrawal of nasal drops with a short course of steroids

Answer

Antibiotics

Answer

Polypectomy

Answer

Increasing the dose of the nasal drops

Question 8

A 32-year-old female patient underwent extraction of an upper first molar on the right side, resulting in a 0.3 mm perforation of the sinus wall. Oroantral communication is predominantly seen during the extraction of which teeth?

Accepted Answer

Maxillary first molars

Answer

Maxillary premolars

Answer

Maxillary second molar

Answer

Maxillary paramolar

Question 9

Regarding nasal syphilis, which of the following statements is true, except?

Accepted Answer

Secondary syphilis is the common association.

Answer

Perforation can occur in the nasal septum.

Answer

Saddle nose deformity may develop.

Answer

In newborns, the condition presents as snuffles.

Question 10

All of the following are true of antrochoanal polyp except?

Accepted Answer

Bleeds on touch

Answer

Common in young

Answer

Single and unilateral

Answer

Treatment involves FESS

Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses — MCQs

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