Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: Following Caldwell-Luc operation, a patient develops hypoesthesia. Which nerve is likely damaged?

Infraorbital nerve. ### Explanation **1. Why the Correct Answer is Right:** The **Caldwell-Luc operation** involves creating a window in the anterior wall of the maxilla through the canine fossa to access the maxillary sinus. The **infraorbital nerve** (a branch of the maxillary division of the trigeminal nerve) exits through the infraorbital foramen, which is located just superior to the canine fossa. During the surgical incision or retraction of the soft tissues of the cheek, this nerve is highly vulnerable to traction, compression, or direct injury. Damage to this nerve leads to **hypoesthesia** (numbness) of the cheek, upper lip, and upper gingiva. **2. Why the Other Options are Wrong:** * **Supraorbital nerve:** This is a branch of the frontal nerve (Ophthalmic division, V1). It exits through the supraorbital notch/foramen above the eye and supplies the forehead and scalp; it is not involved in maxillary sinus surgery. * **Maxillary nerve (V2):** While the infraorbital nerve is a branch of V2, the main trunk of the maxillary nerve lies deeper in the pterygopalatine fossa. A standard Caldwell-Luc procedure affects the peripheral branch (infraorbital) rather than the main trunk. * **Mandibular nerve (V3):** This nerve supplies the lower jaw, teeth, and tongue. It is anatomically distant from the surgical site of the maxillary sinus. **3. Clinical Pearls for NEET-PG:** * **Indications for Caldwell-Luc:** Removal of foreign bodies (e.g., root of a tooth) from the sinus, management of Oro-antral fistula, and as an approach to the pterygopalatine fossa (Lynch’s procedure). * **Most common complication:** Cheek swelling and numbness (infraorbital nerve injury). * **Anatomical Landmark:** The incision is made in the gingivolabial sulcus above the roots of the premolar teeth, avoiding the canine tooth to prevent dental denervation.

Q: Which of the following statements about nasal glioma is FALSE?

It is transilluminating.. **Explanation:** Nasal glioma is a rare, benign congenital anomaly consisting of ectopic glial tissue that has lost its intracranial connection. Understanding its clinical features is crucial for differentiating it from other midline nasal masses like encephaloceles. **Why Option D is the Correct (False) Statement:** Unlike an **encephalocele**, which contains a patent connection to the subarachnoid space and is filled with cerebrospinal fluid (CSF), a nasal glioma is a solid mass of glial tissue and fibrous stroma. Because it lacks a fluid-filled sac, it **does not transilluminate**. Transillumination is a classic feature of encephaloceles. **Analysis of Other Options:** * **Option A (MRI):** MRI is the gold standard investigation. It is essential to rule out any intracranial extension or "stalk" before surgical intervention to prevent CSF leaks or meningitis. * **Option B (Surgical Excision):** The definitive treatment is complete surgical excision, usually via an external approach (like a lateral rhinotomy) or endoscopic approach, depending on the location. * **Option C (Non-pulsatile):** Since nasal gliomas are isolated from the intracranial space, they do not exhibit pulsations or expansion upon crying/straining (negative Furstenberg’s test), unlike encephaloceles. **High-Yield Clinical Pearls for NEET-PG:** 1. **Furstenberg’s Test:** Positive in Encephalocele (mass expands on compression of internal jugular vein); Negative in Nasal Glioma. 2. **Location:** 60% are extranasal (on the bridge of the nose), 30% are intranasal, and 10% are both. 3. **Origin:** They are essentially "sequestered" encephaloceles that failed to recede during development. 4. **Biopsy Warning:** Never biopsy a midline nasal mass in a child until an intracranial connection has been ruled out by imaging.

Q: A female who underwent laparoscopic appendectomy for acute appendicitis developed difficulty in breathing and a swelling in the anterior part of the nasal septum after bumping her nose on a table on post-operative day 2. What is the next line of management?

Incision and drainage. **Explanation:** The clinical presentation of post-traumatic nasal obstruction and a swelling in the anterior nasal septum is diagnostic of a **Septal Hematoma**. This occurs when trauma causes blood to collect between the septal cartilage and its overlying mucoperichondrium. **Why Incision and Drainage is correct:** A septal hematoma is a surgical emergency. The septal cartilage depends entirely on the overlying perichondrium for its blood supply (via diffusion). The pressure from the hematoma strips the perichondrium away, leading to **ischemic necrosis** of the cartilage. If not drained immediately via **Incision and Drainage (I&D)**, it can result in a septal abscess, septal perforation, or a "Saddle Nose" deformity due to loss of structural support. **Why other options are incorrect:** * **Oral/IV Antibiotics (B & D):** While antibiotics are given post-procedure to prevent secondary infection (abscess formation), they cannot evacuate the collected blood. Without drainage, the cartilage will necrose regardless of antibiotic use. * **Observation (C):** Waiting is contraindicated. A hematoma will not resolve spontaneously fast enough to save the underlying cartilage. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Sign:** On examination, a septal hematoma appears as a smooth, soft, fluctuant, cherry-red swelling. It does not shrink with topical vasoconstrictors (unlike turbinate hypertrophy). * **Site of Incision:** A small horizontal/hemitransfixion incision is made at the most dependent part. * **Post-Op Care:** After drainage, **bilateral nasal packing** is essential to prevent re-accumulation of blood. * **Complication:** If left untreated, it can progress to a **Septal Abscess**, which carries a risk of cavernous sinus thrombosis due to retrograde venous spread.

Q: A 60-year-old male complains of right-sided nasal obstruction and nasal discharge, which is sometimes blood-tinged. Biopsy findings are shown below. What is your diagnosis?

Rhinosporidiosis. ***Rhinosporidiosis*** - Characterized by **large sporangia** containing **endospores** on histopathology, which is pathognomonic for this fungal infection caused by *Rhinosporidium seeberi*. - Presents with **unilateral nasal obstruction** and **blood-tinged discharge** along with characteristic **polypoidal masses** in the nasal cavity. *Rhinoscleroma* - Histopathology shows **Mikulicz cells** (large foamy macrophages) containing **Donovan bodies** (*Klebsiella pneumoniae* subsp. *rhinoscleromatis*). - Typically presents with **progressive nasal deformity** and **nodular lesions** rather than polypoidal masses. *Wegener's granulomatosis* - Biopsy reveals **necrotizing granulomatous inflammation** with **multinucleated giant cells** and **vasculitis**. - Associated with **c-ANCA positivity** and systemic involvement including lungs and kidneys, not isolated nasal symptoms. *Stewart's granuloma* - Histopathology shows **lymphomatous infiltrate** with **atypical lymphoid cells** and **plasma cells**. - Represents a **midline destructive lesion** with aggressive tissue destruction, unlike the benign polypoidal growth pattern described.

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

Air embolism. ### Explanation **Correct Answer: C. Air Embolism** **Mechanism:** Air embolism is a rare but catastrophic complication of maxillary sinus irrigation (Antral wash-out). It occurs when air is accidentally introduced into the venous system. During the procedure, the trocar may injure the rich venous plexus of the maxillary sinus mucosa or enter a bony dehiscence. If air is insufflated into the sinus (often to check for patency or to clear the cannula) before or after irrigation, it can enter these damaged veins, travel to the right heart, and subsequently to the pulmonary circulation or through a patent foramen ovale to the brain, leading to sudden cardiovascular collapse or stroke. **Analysis of Incorrect Options:** * **A. Fat Embolism:** This typically occurs following fractures of long bones or orthopedic surgeries where bone marrow fat enters the circulation. It is not associated with sinus procedures. * **B. Pulmonary Embolism:** This usually results from deep vein thrombosis (DVT) in the lower extremities. While an air embolism can lodge in the pulmonary artery, "Pulmonary Embolism" as a standalone term traditionally refers to thromboembolism. * **D. Maxillary Artery Thrombosis:** While the maxillary artery is in proximity, its thrombosis would lead to localized ischemia or necrosis rather than sudden systemic death. **High-Yield Clinical Pearls for NEET-PG:** * **Prevention:** Always ensure the syringe is filled with saline (not air) and **never** use air to "blow out" the remaining fluid from the sinus. * **Positioning:** If air embolism is suspected, place the patient in the **Durant’s position** (Left lateral decubitus with Trendelenburg) to trap air in the apex of the right ventricle. * **Other Complications of Antral Wash-out:** Vasovagal attack (most common), orbital injury, and hemorrhage.

Q: All of the following are diagnostic criteria of allergic fungal sinusitis (AFS) EXCEPT?

Orbital invasion. **Explanation:** Allergic Fungal Sinusitis (AFS) is a non-invasive fungal disease of the paranasal sinuses. The diagnosis is based on the **Bent and Kuhn criteria**, which emphasize that the disease process remains extramucosal. **1. Why "Orbital Invasion" is the correct answer:** AFS is characterized by the absence of tissue invasion. While the accumulated fungal debris and pressure can cause **bone erosion** and expansion (leading to proptosis or telecanthus), the fungus does **not** invade the orbital soft tissues or the brain. If tissue invasion is present, the diagnosis shifts to Invasive Fungal Sinusitis (e.g., Mucormycosis or Chronic Invasive Aspergillosis). **2. Why the other options are incorrect (Diagnostic Criteria):** * **Areas of high attenuation on CT scan:** This is a classic feature. The "double density" sign occurs because of the accumulation of heavy metals (iron, manganese) and calcium salts within the fungal mucin. * **Allergic eosinophilic mucin:** This is the hallmark of AFS. It is a thick, "peanut-butter" like secretion containing eosinophils, Charcot-Leyden crystals, and scattered fungal hyphae (demonstrated by Gomori Methenamine Silver stain). * **Type 1 Hypersensitivity:** AFS is an immunologic reaction, not an infection. Patients typically have an IgE-mediated allergy to the offending fungus, confirmed by skin prick tests or elevated serum IgE. **Clinical Pearls for NEET-PG:** * **Bent and Kuhn Criteria:** 1. Type 1 Hypersensitivity, 2. Nasal Polyposis, 3. Characteristic CT findings, 4. Eosinophilic mucin, 5. Positive fungal stain/culture. * **Most common fungus:** *Bipolaris spicifera* (followed by *Curvularia* and *Aspergillus*). * **Treatment:** Surgical debridement (FESS) followed by **post-operative steroids** (to control the allergic response). Antifungals are generally not required.

Q: A 20-year-old female presents with nasal obstruction and crusting of the nose. Examination revealed an infiltrating lesion involving the nasal vestibule and upper lip with broadening of the nasal dorsum. What is the likely diagnosis?

Rhinoscleroma. **Explanation:** The clinical presentation of nasal obstruction, crusting, and an infiltrating lesion involving the nasal vestibule and upper lip, combined with the characteristic **"broadening of the nasal dorsum" (Hebra nose)**, is pathognomonic for **Rhinoscleroma**. **Rhinoscleroma** is a chronic granulomatous disease caused by *Klebsiella rhinoscleromatis* (Frisch bacillus). It typically progresses through three stages: 1. **Atrophic stage:** Mimics atrophic rhinitis (crusting, foul smell). 2. **Granulomatous/Proliferative stage:** Formation of painless, non-ulcerative granulomatous nodules. This stage causes the characteristic woody-hard swelling and broadening of the nose. 3. **Cicatricial stage:** Extensive fibrosis and stenosis. **Why other options are incorrect:** * **Rhinosporidiosis:** Caused by *Rhinosporidium seeberi*, it presents as a leafy, friable, strawberry-like vascular polyp, usually following bathing in stagnant water. It does not typically involve the upper lip or cause nasal broadening. * **Fungal Granuloma:** (e.g., Aspergillosis or Mucormycosis) Usually presents with bone destruction, necrotic debris, or invasive features in immunocompromised patients, rather than the specific "Hebra nose" deformity. * **Nasal Diphtheria:** Presents with an adherent greyish-white membrane and excoriation of the nares/upper lip due to discharge, but does not cause granulomatous infiltration or nasal broadening. **High-Yield Pearls for NEET-PG:** * **Causative Agent:** *Klebsiella rhinoscleromatis* (Gram-negative diplobacillus). * **Histopathology:** Look for **Mikulicz cells** (foamy macrophages containing bacilli) and **Russell bodies** (eosinophilic hyaline inclusions in plasma cells). * **Drug of Choice:** Streptomycin and Tetracycline (Long-term therapy). * **Biopsy** is the gold standard for diagnosis.

Question 1

What is the treatment of choice in bilateral ethmoidal polyps?

Accepted Answer

Functional Endoscopic Sinus Surgery (FESS)

Answer

Ethmoidectomy

Answer

Endoscopic removal

Answer

Chemotherapy and Radiotherapy

Question 2

A child presents with unilateral, foul smelling nasal discharge. What is the most probable cause?

Accepted Answer

Foreign body

Answer

Acute sinusitis

Answer

Rhinolith

Answer

Nasal synechiae

Question 3

Following Caldwell-Luc operation, a patient develops hypoesthesia. Which nerve is likely damaged?

Accepted Answer

Infraorbital nerve

Answer

Supraorbital nerve

Answer

Maxillary nerve

Answer

Mandibular nerve

Question 4

Which of the following statements about nasal glioma is FALSE?

Accepted Answer

It is transilluminating.

Answer

Intracranial connection is best evaluated by MRI.

Answer

Treatment is primarily surgical excision.

Answer

It is non-pulsatile.

Question 5

A female who underwent laparoscopic appendectomy for acute appendicitis developed difficulty in breathing and a swelling in the anterior part of the nasal septum after bumping her nose on a table on post-operative day 2. What is the next line of management?

Accepted Answer

Incision and drainage

Answer

Oral antibiotics for 7-10 days

Answer

Observation

Answer

Intravenous antibiotics

Question 6

A 60-year-old male complains of right-sided nasal obstruction and nasal discharge, which is sometimes blood-tinged. Biopsy findings are shown below. What is your diagnosis?

Accepted Answer

Rhinosporidiosis

Answer

Rhinoscleroma

Answer

Wegener's granulomatosis

Answer

Stewart's granuloma

Question 7

A 20-year-old male presents with nasal obstruction and nasal discharge. Nasal endoscopy shows a large polyp in the right nostril extending into the nasopharynx. What is the most appropriate management for this patient?

Accepted Answer

Functional Endoscopic Sinus Surgery (FESS)

Answer

Intranasal polypectomy

Answer

Steroids

Answer

Caldwell-Luc procedure

Question 8

Sudden death occurring after maxillary sinus irrigation is most likely due to which of the following complications?

Accepted Answer

Air embolism

Answer

Fat embolism

Answer

Pulmonary embolism

Answer

Maxillary artery thrombosis

Question 9

All of the following are diagnostic criteria of allergic fungal sinusitis (AFS) EXCEPT?

Accepted Answer

Orbital invasion

Answer

Areas of high attenuation on CT scan

Answer

Allergic eosinophilic mucin

Answer

Type 1 hypersensitivity

Question 10

A 20-year-old female presents with nasal obstruction and crusting of the nose. Examination revealed an infiltrating lesion involving the nasal vestibule and upper lip with broadening of the nasal dorsum. What is the likely diagnosis?

Accepted Answer

Rhinoscleroma

Answer

Rhinosporidiosis

Answer

Fungal granuloma

Answer

Nasal diphtheria

Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses — MCQs

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