Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: Perforation of the nasal septum is not seen in which of the following conditions?

Rhinosporidiosis. **Explanation:** The correct answer is **Rhinosporidiosis** because it is a chronic granulomatous disease characterized by the formation of **friable, leafy, strawberry-like vascular polypoidal masses** that bleed on touch. Unlike other granulomatous conditions, Rhinosporidiosis typically involves the mucous membrane of the septum or turbinates without causing necrosis or destruction of the underlying cartilage or bone; therefore, it does **not** lead to septal perforation. **Analysis of Incorrect Options:** * **Tuberculosis (Lupus Vulgaris):** Typically involves the **cartilaginous** part of the septum. It causes indolent ulceration that eventually leads to perforation. * **Syphilis:** Classically involves the **bony** part of the septum (vomer). Tertiary syphilis (gumma) is highly destructive and is a notorious cause of large septal perforations and "saddle nose" deformity. * **Leprosy:** Primarily affects the anterior cartilaginous septum. Atrophic changes and secondary infections lead to crusting, ulceration, and eventual perforation. **Clinical Pearls for NEET-PG:** * **Most common cause of septal perforation:** Trauma (specifically post-surgical, e.g., SMR or Septoplasty). * **Rhinosporidiosis:** Caused by *Rhinosporidium seeberi* (now classified as a Mesomycetozoea, not a fungus). It is associated with bathing in stagnant pond water. Histology shows characteristic **sporangia** containing endospores. * **Wegener’s Granulomatosis:** Another high-yield cause of septal perforation, often associated with c-ANCA positivity.

Q: Which of the following statements regarding fungal sinusitis is true?

Surgery is required for treatment.. **Explanation:** Fungal sinusitis is broadly classified into **non-invasive** (Fungal ball, Allergic Fungal Rhinosinusitis - AFRS) and **invasive** (Acute fulminant, Chronic, and Granulomatous) forms. **Why Option A is Correct:** In almost all forms of fungal sinusitis, **surgical debridement** (usually via Functional Endoscopic Sinus Surgery - FESS) is the definitive treatment. For non-invasive types like a Fungal Ball or AFRS, surgery is required to remove the "allergic mucin" and debris to prevent recurrence. For invasive types, urgent surgical debridement of necrotic tissue is life-saving to limit the spread to the orbit or brain. **Analysis of Incorrect Options:** * **Option B:** The most common organism associated with fungal sinusitis (especially AFRS and Fungal Ball) is **Aspergillus fumigatus**, not *Aspergillus niger*. * **Option C:** While Amphotericin B is used for invasive fungal sinusitis, the **Liposomal** form is preferred over conventional IV Amphotericin B to reduce nephrotoxicity. Furthermore, surgery remains the primary requirement before or alongside antifungal therapy. * **Option D:** On imaging (CT/X-ray), fungal sinusitis typically shows **hyperdense areas** (due to calcium phosphate and manganese deposits) rather than a simple hazy appearance. A "hazy appearance" is more characteristic of viral or bacterial sinusitis. **High-Yield Clinical Pearls for NEET-PG:** * **AFRS:** Characterized by "peanut-butter" like allergic mucin, Charcot-Leyden crystals on histology, and Type I & III hypersensitivity. * **Double Density Sign:** A classic CT scan finding in AFRS (hyperdense central area surrounded by hypodense mucosa). * **Mucormycosis:** A medical emergency seen in diabetics/immunocompromised patients; presents with black eschar on the turbinates. Treatment is Liposomal Amphotericin B + aggressive debridement.

Q: Allergic fungal sinusitis is typically seen in which patient population?

Immunocompetent patients. **Explanation:** **Allergic Fungal Sinusitis (AFS)** is a non-invasive form of fungal rhinosinusitis. The underlying pathophysiology is a **Type I and Type III hypersensitivity reaction** to fungal antigens (most commonly *Bipolaris*, *Curvularia*, or *Aspergillus*) rather than an active infection. Because it is an exaggerated immune response, it typically occurs in **immunocompetent patients**, often young adults with a history of atopy, asthma, or nasal polyposis. **Analysis of Options:** * **Option A (Correct):** Immunocompetent individuals have the robust immune system necessary to mount the hypersensitivity reaction that characterizes AFS. * **Option B & C (Incorrect):** Immunocompromised and diabetic patients are specifically predisposed to **Invasive Fungal Sinusitis** (e.g., Mucormycosis or Invasive Aspergillosis). In these patients, the fungus invades tissues and blood vessels due to a lack of immune containment, which is the clinical opposite of the localized allergic reaction seen in AFS. **NEET-PG High-Yield Pearls:** * **Bent and Kuhn Criteria:** Used for the diagnosis of AFS. Key features include nasal polyposis, Type I hypersensitivity (elevated IgE/Skin test), and characteristic CT findings. * **CT Appearance:** Shows "Hyperdense" or "Double Density" signals due to the presence of heavy metals (iron/manganese) and calcium salts within the fungal debris. * **Pathology:** Presence of **"Allergic Mucin"**—thick, peanut-butter-like mucus containing Charcot-Leyden crystals and eosinophils. * **Treatment:** Functional Endoscopic Sinus Surgery (FESS) to clear the mucin, followed by long-term **post-operative steroids** to prevent recurrence. Antifungals are generally not required.

Q: A child has a retained disc battery in the nose. What is the most important consideration in its management?

The battery substance can leak and cause tissue damage.. **Explanation:** A disc battery (button battery) in the nasal cavity is a **surgical emergency**. Unlike inert foreign bodies, disc batteries cause rapid and extensive tissue destruction through three primary mechanisms: 1. **Leakage of alkaline contents:** The caustic substance (usually potassium or sodium hydroxide) causes liquefactive necrosis. 2. **Electrical current:** The moist mucosa completes an electrical circuit, leading to electrolysis and the generation of hydroxide ions at the negative pole. 3. **Pressure necrosis:** Direct physical pressure on the delicate nasal mucosa and septum. **Analysis of Options:** * **Option A (Correct):** This is the most critical consideration because the chemical leakage and electrochemical reactions can lead to **septal perforation** and synechiae formation within hours. * **Option B:** While any foreign body carries a theoretical risk, tetanus is not the primary or most urgent concern in nasal battery impaction. * **Option C:** While specialist removal is necessary, it is a management step, not the "most important consideration" or the underlying pathological reason for the urgency. * **Option D:** **Contraindicated.** Instilling nasal drops or irrigation can liquefy the battery contents and accelerate the electrical conduction, worsening the chemical burn. **High-Yield Clinical Pearls for NEET-PG:** * **Imaging:** A lateral X-ray shows a **"Double Contour" or "Step-off" sign**, distinguishing a battery from a coin. * **Urgency:** Removal should ideally occur within **2–4 hours** to prevent permanent septal damage. * **Complications:** Septal perforation, saddle nose deformity, and orbital complications. * **Golden Rule:** Never irrigate the nose if a battery is suspected.

Q: Rhinitis medicamentosa is due to which of the following?

Nasal decongestants. **Explanation:** **Rhinitis Medicamentosa (RM)** is a condition of rebound nasal congestion brought on by the prolonged use of **topical nasal decongestants** (Option A). These drugs, typically sympathomimetic amines (e.g., Oxymetazoline, Xylometazoline), work by stimulating alpha-receptors to cause vasoconstriction. However, when used for more than 3–5 days, they lead to a "rebound" phenomenon. The underlying pathophysiology involves the downregulation of alpha-receptors and interstitial edema, resulting in severe compensatory vasodilation and nasal obstruction that is refractory to the original medication. **Analysis of Incorrect Options:** * **B. Steroids:** Topical nasal steroids (e.g., Fluticasone) are actually the **treatment of choice** for Rhinitis Medicamentosa. They do not cause rebound congestion and help reduce mucosal inflammation. * **C. Antihistamines:** These are used to treat allergic rhinitis by blocking H1 receptors. They do not affect the vasomotor tone of nasal mucosa in a way that leads to RM. * **D. Surgery:** While chronic mucosal hypertrophy (from long-term RM) might eventually require surgical reduction of turbinates, surgery itself is a treatment modality, not the cause of the condition. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** A patient with a history of chronic cold/allergy who reports that their nasal spray "no longer works" or that they need to use it more frequently to breathe. * **Examination:** The nasal mucosa appears **beefy red**, swollen, and granular (unlike the pale/bluish mucosa seen in allergic rhinitis). * **Management:** Immediate cessation of the decongestant, initiation of topical/systemic steroids, and saline douches. * **Key Duration:** Advise patients never to use topical decongestants for more than **5 consecutive days**.

Q: Anterior bowing of the posterior maxillary wall is described as which sign?

Holman Miller sign. **Explanation:** The **Holman-Miller sign** (also known as the antral sign) is a classic radiological feature of **Juvenile Nasopharyngeal Angiofibroma (JNA)**. JNA is a benign but locally aggressive, highly vascular tumor that typically arises in the sphenopalatine foramen of adolescent males. As the tumor grows, it expands into the pterygopalatine fossa, creating pressure that pushes the posterior wall of the maxillary sinus forward. This characteristic **anterior bowing** is best visualized on a lateral skull X-ray or CT scan and is considered pathognomonic for JNA. **Analysis of Incorrect Options:** * **Hennebert sign:** This is a clinical sign seen in Otology. It refers to the occurrence of nystagmus or vertigo triggered by pressure changes in the external auditory canal (e.g., using a Siegel’s speculum). It is typically seen in Meniere’s disease or syphilis (due to a hypermobile stapes). * **Holsky sign / Honeybell sign:** These are distractors and do not represent recognized clinical or radiological signs in ENT. **High-Yield Clinical Pearls for JNA:** * **Demographics:** Almost exclusively seen in adolescent males (10–20 years). * **Triad:** Profuse recurrent epistaxis, nasal obstruction, and a mass in the nasopharynx. * **Diagnosis:** Diagnosis is primarily clinical and radiological. **Biopsy is contraindicated** due to the risk of life-threatening hemorrhage. * **Staging:** Often involves the Fisch or Radkowski classification systems. * **Treatment:** Surgical excision (e.g., Transpalatal or Endoscopic approach) preceded by preoperative embolization to reduce blood loss.

Q: In a nasal smear, the number of eosinophils is increased in which of the following conditions?

Non-allergic eosinophilic rhinitis. **Explanation:** The presence of increased eosinophils in a nasal smear (nasal cytology) is a hallmark of Type I hypersensitivity or specific eosinophilic inflammatory processes. **Why Option D is Correct:** **Non-allergic Rhinitis with Eosinophilia Syndrome (NARES)**, or Non-allergic eosinophilic rhinitis, is characterized by symptoms of perennial rhinitis (sneezing, itching, rhinorrhea) in patients who have **negative** skin prick tests and normal serum IgE levels. Despite the lack of a specific allergen trigger, the nasal smear characteristically shows **>10-20% eosinophils**, making it the defining diagnostic feature of this condition. **Why other options are incorrect:** * **A. Viral Rhinitis:** This is characterized by an acute inflammatory response where the nasal smear predominantly shows **neutrophils** and sloughed epithelial cells, not eosinophils. * **B. Rhinitis Medicamentosa:** This results from the rebound congestion caused by the overuse of topical decongestants (e.g., Oxymetazoline). The pathology involves squamous metaplasia and loss of ciliary function; eosinophilia is not a feature. * **C. Vasomotor Rhinitis:** This is a non-allergic, non-inflammatory condition caused by autonomic instability (parasympathetic overactivity). Nasal cytology is typically **normal** or shows very few cells; eosinophils are absent. **High-Yield Clinical Pearls for NEET-PG:** * **Nasal Smear Eosinophilia:** Seen in Allergic Rhinitis, NARES, and Nasal Polyposis (especially those associated with Aspirin sensitivity/Samter’s Triad). * **NARES vs. Allergic Rhinitis:** Both present with eosinophilia, but NARES has negative allergy testing (IgE/Skin Prick). * **Hansel’s Stain:** The preferred stain for identifying eosinophils in nasal secretions. * **Normal Nasal Smear:** Usually contains few cells; eosinophils >10% is considered pathological.

Q: An 18-year-old boy presented with repeated epistaxis and a mass arising from the lateral wall of his nose extending into the nasopharynx. Surgical intervention is planned. All of the following statements regarding his management are true, except which one?

A transpalatal approach is typically employed.. ***A transpalatal approach is typically employed.*** - While it provides access to the nasopharynx, the **transpalatal approach** is considered inadequate because it offers poor visualization of **lateral tumor extensions** into the infratemporal fossa. - It is associated with complications like **palatal fistulae** and is largely obsolete in favor of **endoscopic** or wider **transmaxillary** approaches for Juvenile Nasopharyngeal Angiofibroma (JNA). *Adequate blood transfusion should be arranged.* - JNA is a **highly vascular** tumor composed of irregular vessels lacking a muscular coat, making them prone to **torrential hemorrhage** during surgery. - Preparation for **massive blood loss** and preoperative **embolization** are mandatory safety measures in the surgical management of this condition. *A lateral rhinotomy approach may be utilized.* - **Lateral rhinotomy** is a classic external surgical approach that provides excellent exposure for tumors involving the **nasal cavity** and **ethmoid sinuses**. - It allows the surgeon to directly visualize and control the blood supply and margins of larger JNA tumors that extend into the **paranasal sinuses**. *A transmaxillary approach can be considered.* - The **transmaxillary approach** (or its modifications like the **Weber-Fergusson** incision) is useful for tumors extending into the **pterygopalatine** or **infratemporal fossa**. - It provides the necessary wide access to the **sphenopalatine foramen**, which is the primary site of origin for these angiofibromas.

Q: Which of the following is a known complication of acute sinusitis?

Potts puffy tumor. **Explanation:** **Potts Puffy Tumor** is a classic, high-yield complication of **acute frontal sinusitis**. It is characterized by subperiosteal abscess and overlying soft tissue edema of the forehead. The underlying mechanism is **osteomyelitis of the frontal bone**, which occurs due to the spread of infection through the diploic veins (veins of Breschet) or by direct extension. It presents as a fluctuant, tender swelling on the forehead. **Analysis of Options:** * **Orbital Cellulitis (Option A):** While this is a common complication of ethmoid sinusitis, Potts Puffy Tumor is specifically associated with frontal bone osteomyelitis, making it a more distinct "named" complication often tested in exams. * **Conjunctival Chemosis (Option C):** This is a clinical sign (swelling of the conjunctiva) seen in orbital complications or cavernous sinus thrombosis, but it is not a primary diagnosis or a specific "tumor-like" complication. * **Subdural Abscess (Option D):** This is an intracranial complication. While acute sinusitis can lead to intracranial spread, Potts Puffy Tumor is the specific extracranial complication involving the bone and soft tissue. **NEET-PG High-Yield Pearls:** * **Most common sinus involved in orbital complications:** Ethmoid sinus (due to the thin *lamina papyracea*). * **Most common sinus involved in intracranial complications:** Frontal sinus. * **Chandler’s Classification:** Used to stage orbital complications of sinusitis (Stage I: Preseptal cellulitis to Stage V: Cavernous sinus thrombosis). * **Management of Potts Puffy Tumor:** Requires IV antibiotics and surgical drainage (often via a trephination or endoscopic approach).

Question 1

While playing football, an 18-year-old boy sustained a blow to the nose, resulting in deviation of the nose. On examination, the nasal septum was not deviated. Which of the following statements is true about the patient?

Accepted Answer

He should be taken for closed reduction as soon as the overlying edema subsides.

Answer

He should be taken up for open reduction one week later.

Answer

Septoplasty should be done in the same sitting.

Answer

He is having a Jarjavay fracture.

Question 2

Perforation of the nasal septum is not seen in which of the following conditions?

Accepted Answer

Rhinosporidiosis

Answer

Tuberculosis

Answer

Syphilis

Answer

Leprosy

Question 3

Which of the following statements regarding fungal sinusitis is true?

Accepted Answer

Surgery is required for treatment.

Answer

The most common organism is Aspergillus niger.

Answer

Amphotericin B IV is used for invasive fungal sinusitis.

Answer

A hazy appearance on X-ray with radio-opacity is seen.

Question 4

Allergic fungal sinusitis is typically seen in which patient population?

Accepted Answer

Immunocompetent patients

Answer

Immunocompromised patients

Answer

Diabetic patients

Answer

None of the above

Question 5

A child has a retained disc battery in the nose. What is the most important consideration in its management?

Accepted Answer

The battery substance can leak and cause tissue damage.

Answer

It can lead to tetanus.

Answer

Refer the child to a specialist for removal of the battery.

Answer

Instill nasal drops.

Question 6

Rhinitis medicamentosa is due to which of the following?

Accepted Answer

Nasal decongestants

Answer

Steroids

Answer

Antihistamines

Answer

Surgery

Question 7

Anterior bowing of the posterior maxillary wall is described as which sign?

Accepted Answer

Holman Miller sign

Answer

Hennebert sign

Answer

Holsky sign

Answer

Honeybell sign

Question 8

In a nasal smear, the number of eosinophils is increased in which of the following conditions?

Accepted Answer

Non-allergic eosinophilic rhinitis

Answer

Viral rhinitis

Answer

Rhinitis medicamentosa

Answer

Vasomotor rhinitis

Question 9

An 18-year-old boy presented with repeated epistaxis and a mass arising from the lateral wall of his nose extending into the nasopharynx. Surgical intervention is planned. All of the following statements regarding his management are true, except which one?

Accepted Answer

A transpalatal approach is typically employed.

Answer

Adequate blood transfusion should be arranged.

Answer

A lateral rhinotomy approach may be utilized.

Answer

A transmaxillary approach can be considered.

Question 10

Which of the following is a known complication of acute sinusitis?

Accepted Answer

Potts puffy tumor

Answer

Orbital cellulitis

Answer

Conjunctival chemosis

Answer

Subdural abscess

Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses — MCQs

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