Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: Sudden death during maxillary irrigation is most likely due to which of the following complications?

Air embolism. **Explanation:** **Correct Answer: A. Air Embolism** Sudden death during maxillary antral irrigation (Proof puncture) is a rare but catastrophic complication, most commonly attributed to **air embolism**. This occurs when air is accidentally introduced into the venous system. During the procedure, if the trocar tip displaces the sinus mucosa or enters a bony canal, air can be forced into the **pterygoid venous plexus** or the facial veins. From there, it travels to the right heart and then to the pulmonary circulation (causing right heart failure) or through a patent foramen ovale to the cerebral circulation, leading to immediate circulatory collapse and death. **Why other options are incorrect:** * **B. Maxillary artery thrombosis:** While the maxillary artery is in proximity, its injury would typically lead to severe hemorrhage rather than sudden, instantaneous death. Thrombosis is a slower process. * **C. Hemorrhage:** Injury to the sphenopalatine or maxillary artery can cause significant epistaxis, but it is rarely immediately fatal as it does not cause the instantaneous cardiac arrest seen in air embolism. * **D. Meningitis:** This is an inflammatory/infectious complication that develops over days. It cannot cause sudden death during the procedure. **Clinical Pearls for NEET-PG:** * **Prevention:** To prevent air embolism, always ensure the syringe is filled with saline (not air) and **never** use air to "clear" the sinus after irrigation. * **Positioning:** If air embolism is suspected, place the patient in the **Durant’s position** (Left lateral decubitus and Trendelenburg) to trap the air in the apex of the right ventricle. * **Other Complications:** Other risks of antral puncture include orbital injury, cheek hematoma (most common), and vasovagal syncope.

Q: A patient presents with multiple bilateral nasal polyps and radiographic evidence of paranasal sinus opacities. Which of the following treatments would NOT be indicated?

Amphotericin B. ### Explanation **Correct Answer: C. Amphotericin B** **1. Why Amphotericin B is the Correct Answer:** The clinical presentation of multiple bilateral nasal polyps and sinus opacities is characteristic of **Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP)**. This condition is primarily an inflammatory process, often associated with Type 2 helper T-cell (Th2) inflammation. **Amphotericin B** is a potent antifungal medication used for invasive fungal infections (like Mucormycosis) or Allergic Fungal Rhinosinusitis (AFRS) in specific surgical contexts. However, it is **not** a standard or indicated treatment for routine bilateral nasal polyps, as these are non-infectious inflammatory growths. **2. Analysis of Other Options:** * **B. Corticosteroids:** These are the **mainstay of treatment**. They reduce the size of polyps by decreasing mucosal edema and suppressing the inflammatory cascade. Both topical (sprays) and systemic steroids are used. * **D. Antihistamines:** These are indicated if the nasal polyps are associated with underlying allergic rhinitis, helping to control symptoms like sneezing and rhinorrhea. * **A. Epinephrine:** While not a long-term treatment, topical epinephrine (or other sympathomimetics) is used as a **decongestant** to shrink the nasal mucosa during clinical examination or endonasal surgery to improve visualization. **3. High-Yield Clinical Pearls for NEET-PG:** * **Ethmoidal Polyps:** Usually bilateral, multiple, and pearly white. They are common in adults. * **Antrochoanal Polyps:** Usually unilateral, single, and originate from the maxillary sinus. Common in children. * **Samter’s Triad:** Aspirin sensitivity, Asthma, and Nasal Polyposis (High-yield association). * **Kartagener’s Syndrome:** Situs inversus, Bronchiectasis, and Sinusitis/Polyps due to ciliary dyskinesia. * **Investigation of Choice:** Non-contrast CT scan of the Paranasal Sinuses (Coronal view).

Q: Malignant tumors are commonest in which of the following paranasal sinuses?

Maxillary. **Explanation:** The correct answer is **A. Maxillary**. **1. Why Maxillary Sinus is Correct:** The maxillary sinus is the largest of the paranasal sinuses and is the most common site for both benign and malignant neoplasms. Statistically, approximately **80% of all paranasal sinus malignancies** occur in the maxillary sinus. The most common histological type found here is **Squamous Cell Carcinoma (SCC)**. These tumors often present late because the sinus is a large, hollow space, allowing the tumor to grow significantly before causing symptoms like cheek swelling, nasal obstruction, or epistaxis. **2. Why Other Options are Incorrect:** * **Ethmoidal Sinus:** This is the second most common site (approx. 10-15%). Adenocarcinoma is notably associated with the ethmoid sinuses, particularly in workers exposed to wood dust. * **Frontal Sinus:** Malignancies here are rare (approx. 1-2%). This sinus is more commonly associated with benign osteomas. * **Sphenoidal Sinus:** This is the rarest site for primary paranasal malignancies (<1%). Due to its deep location, tumors here often present with cranial nerve palsies or headache. **3. NEET-PG High-Yield Pearls:** * **Ohngren’s Line:** A theoretical line connecting the medial canthus of the eye to the angle of the mandible. Tumors **posterosuperior** to this line have a worse prognosis due to early involvement of the skull base and orbit. * **Most common histology:** Squamous Cell Carcinoma (overall). * **Woodworkers/Furniture industry:** Strongly associated with **Adenocarcinoma** of the Ethmoid sinus. * **Nickel/Leather workers:** Increased risk of Sinonasal Squamous Cell Carcinoma. * **Inverting Papilloma:** A benign but locally aggressive tumor (lateral wall of nose) with a high risk of malignant transformation into SCC.

Q: Which of the following is FALSE regarding a nasolabial cyst?

It is odontogenic in origin. ### Explanation **Nasolabial Cyst (Klestadt’s Cyst)** The correct answer is **B**, as nasolabial cysts are **non-odontogenic** in origin. **1. Why Option B is False (The Correct Answer):** Nasolabial cysts are developmental, non-odontogenic cysts. They arise from the remnants of the **nasolacrimal duct** or from trapped epithelial remnants at the junction of the globular, lateral nasal, and maxillary processes. Since they do not originate from tooth-forming tissues (the dental lamina), they are classified as soft-tissue cysts, not odontogenic cysts. **2. Analysis of Other Options:** * **Option A (Klestadt’s Cyst):** This is the eponymous name for a nasolabial cyst. It is a classic synonym frequently tested in PG entrance exams. * **Option C (Treated by excision):** The standard treatment is surgical excision, typically via a **sublabial approach** (Caldwell-Luc type incision). Small asymptomatic cysts may be observed, but symptomatic ones require removal. * **Option D (Region of the nasolabial fold):** These cysts are characteristically located in the soft tissue of the nasolabial fold, deep to the ala of the nose. **3. Clinical Pearls for NEET-PG:** * **Presentation:** Typically presents as a slow-growing, painless swelling in the nasolabial region, causing **ala flare** and loss of the nasolabial fold. * **Demographics:** Most common in females (4:1 ratio) in the 4th to 6th decades of life. * **Radiology:** Unlike odontogenic cysts, these are **soft-tissue cysts**. Therefore, they usually do not show any bony changes on X-ray, though they may cause pressure erosion (scalloping) of the underlying maxilla in chronic cases. * **Physical Exam:** Bimanual palpation reveals a fluctuant swelling with one finger in the labial sulcus and the other in the nasal vestibule.

Q: A black necrotic mass is seen in the nose of an elderly diabetic patient. What is the most probable diagnosis?

Mucormycosis. **Explanation:** The clinical presentation of a **black necrotic mass** (eschar) in the nasal cavity of an **elderly diabetic patient** is a classic hallmark of **Rhinocerebral Mucormycosis**. **1. Why Mucormycosis is correct:** Mucormycosis is an opportunistic fungal infection caused by fungi of the order Mucorales. It predominantly affects patients with uncontrolled diabetes (especially those in ketoacidosis) or immunosuppression. The fungus is **angioinvasive**, meaning it invades blood vessel walls, leading to thrombosis and subsequent tissue infarction. This ischemia results in the characteristic **painless black eschar** on the turbinates, palate, or skin. **2. Why other options are incorrect:** * **Lupus vulgaris:** This is a progressive form of cutaneous tuberculosis. It typically presents with "apple-jelly" nodules on the face, not acute necrotic masses in the nose. * **Aspergillosis:** While it can cause fungal sinusitis, the invasive form is less common than Mucormycosis in diabetics and usually doesn't present with the rapid, hallmark black necrotic eschar. * **Pseudomonas infection:** This typically causes greenish-blue purulent discharge (e.g., in malignant otitis externa) rather than a dry, black necrotic mass. **Clinical Pearls for NEET-PG:** * **Diagnosis:** Confirmed by KOH mount or biopsy showing **broad, ribbon-like, non-septate hyphae** branching at **right angles (90°)**. * **Management:** This is a surgical emergency. Treatment involves aggressive surgical debridement and intravenous **Liposomal Amphotericin B**. * **Risk Factor:** Diabetic Ketoacidosis (DKA) is the strongest risk factor because the fungus thrives in acidic, glucose-rich environments.

Q: Which bone is commonly fractured in facial injuries?

Nasal bones. **Explanation:** The **nasal bones** are the most commonly fractured bones in the facial skeleton, accounting for approximately 40–50% of all facial fractures. This high incidence is due to their prominent, central position on the face and the relative fragility of the thin bony plates compared to the more robust surrounding structures. **Analysis of Options:** * **A. Nasal bones (Correct):** Their projection makes them the first point of impact in blunt trauma (e.g., altercations, falls, or sports injuries). * **B. Nasoethmoid bone:** Fractures involving the Naso-Orbito-Ethmoid (NOE) complex are much rarer and require high-velocity impact. They are clinically significant due to potential injury to the lacrimal apparatus and medial canthal ligament (leading to traumatic telecanthus). * **C. Zygomatic bone:** The zygoma is the **second** most common facial bone fractured. Specifically, the "Tripod fracture" (Zygomaticomaxillary complex) is a frequent exam topic. * **D. Mandible:** While a common site of injury, it is less frequently fractured than the nasal bones. It is often described as a "ring-like" structure; hence, fractures often occur at two sites (e.g., symphysis and contralateral condyle). **Clinical Pearls for NEET-PG:** * **Diagnosis:** Nasal fractures are primarily a **clinical diagnosis**. X-rays are often unnecessary as they do not change the immediate management of simple fractures. * **Management:** The most critical immediate assessment in a nasal fracture is to rule out a **Septal Hematoma**. If present, it must be drained urgently to prevent septal necrosis and a subsequent "Saddle Nose" deformity. * **Order of Frequency:** Nasal bones > Zygoma > Mandible > Maxilla (Le Fort).

Question 1

What is true about septal hematoma?

Accepted Answer

Occurs due to trauma, can lead to saddle-nose deformity, and requires conservative treatment.

Answer

Occurs due to trauma, can lead to saddle-nose deformity, and may lead to abscess formation.

Answer

Occurs due to trauma, requires conservative treatment, and may lead to abscess formation.

Answer

Occurs due to trauma and can lead to saddle-nose deformity.

Question 2

A patient presents with an antrochoanal polyp arising from the medial wall of the maxilla. Which of the following is the best management for the patient?

Accepted Answer

FESS with polypectomy

Answer

Medial maxillectomy

Answer

Caldwell-Luc procedure

Answer

Intranasal polypectomy

Question 3

Sudden death during maxillary irrigation is most likely due to which of the following complications?

Accepted Answer

Air embolism

Answer

Maxillary artery thrombosis

Answer

Hemorrhage

Answer

Meningitis

Question 4

Orbital cellulitis is a complication of?

Accepted Answer

Endoscopic sinus surgery

Answer

Parasinusitis

Answer

Faciomaxillary trauma

Answer

All of these

Question 5

A patient presents with multiple bilateral nasal polyps and radiographic evidence of paranasal sinus opacities. Which of the following treatments would NOT be indicated?

Accepted Answer

Amphotericin B

Answer

Epinephrine

Answer

Corticosteroids

Answer

Antihistamines

Question 6

Malignant tumors are commonest in which of the following paranasal sinuses?

Accepted Answer

Maxillary

Answer

Frontal

Answer

Ethmoidal

Answer

Sphenoidal

Question 7

Ohngren's classification of maxillary sinus carcinoma is based on which anatomical landmark or plane?

Accepted Answer

An imaginary plane between the medial canthus of the eye and the angle of the mandible

Answer

An imaginary plane between the lateral canthus of the eye and the angle of the mandible

Answer

Two horizontal lines, one passing through the floor of the orbit and the other through the floor of the antrum

Answer

None of the above

Question 8

Which of the following is FALSE regarding a nasolabial cyst?

Accepted Answer

It is odontogenic in origin

Answer

Also known as a Klestadt cyst

Answer

It is treated by excision

Answer

It is seen in the region of the nasolabial fold

Question 9

A black necrotic mass is seen in the nose of an elderly diabetic patient. What is the most probable diagnosis?

Accepted Answer

Mucormycosis

Answer

Lupus vulgaris

Answer

Aspergillosis

Answer

Pseudomonas infection

Question 10

Which bone is commonly fractured in facial injuries?

Accepted Answer

Nasal bones

Answer

Nasoethmoid bone

Answer

Zygomatic bone

Answer

Mandible

Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses — MCQs

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