Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: Atrophy of the nasal mucosa, with extensive encrustations and a woody hard external nose, is seen in which of the following conditions?

Atrophic Rhinitis (Ozena). **Atrophic Rhinitis (Ozena)** - **Atrophy of nasal mucosa**, extensive **encrustations**, and a **woody hard external nose** are hallmark features of Ozena, a severe form of atrophic rhinitis. - This condition is characterized by chronic inflammation leading to mucosal degeneration, dilation of capillaries, and malodorous discharge. *Allergic rhinitis with nasal polyps* - **Allergic Rhinitis** primarily involves allergic inflammation, leading to sneezing, rhinorrhea, and nasal congestion, without significant mucosal atrophy or a woody external nose. - **Nasal polyps** are benign growths, commonly associated with chronic inflammation, but they do not cause the described atrophy or encrustations. *Chronic sinusitis with mucosal thickening* - **Chronic sinusitis** is characterized by persistent inflammation of the paranasal sinuses, often leading to mucosal thickening, but not atrophy or a woody hard external nose. - While it can cause nasal discharge and crusting, the extensive atrophy and the pathognomonic external nasal changes described are not typical. *Nasal septal perforation with crusting* - **Nasal septal perforation** is a hole in the nasal septum, which can cause crusting, bleeding, and whistling noises. - However, it does not typically lead to generalized mucosal atrophy of the entire nasal cavity or a "woody hard" external nose.

Q: An elderly patient with dementia is brought by family members who report concerns about self-neglect. On examination, you notice atrophic, dry nasal mucosa, extensive encrustations, and a woody, hard external nose. The family attributes these findings to poor hygiene due to cognitive decline. Which of the following is the most appropriate next step in management?

Rhinoscleroma. ***Rhinoscleroma*** - This is a chronic granulomatous disease caused by *Klebsiella rhinoscleromatis* characterized by progressive **fibrosis and sclerosis** of the respiratory tract - The description of a **"woody, hard external nose"** with extensive encrustations and atrophic changes is **pathognomonic for rhinoscleroma** - Often leads to significant nasal deformity and represents a serious chronic infection requiring systemic antibiotics - In elderly patients with cognitive decline, this condition may be misattributed to poor hygiene, delaying proper diagnosis *Nasal polyposis* - Presents with **boggy, edematous, grape-like masses** in the nasal cavity - The symptoms described (woody, hard external nose with atrophic mucosa) are **not typical for nasal polyposis** - Usually causes nasal obstruction and anosmia but does not cause hardening of the external nose *Atrophic rhinitis* - Involves progressive **atrophy of the nasal mucosa** and turbinates with **fetid odor (ozena)**, crusting, and nasal dryness - While this shares some features (atrophy, crusting), it does **not cause a woody, hard external nose** - The external nasal deformity is the key distinguishing feature pointing to rhinoscleroma *Chronic sinusitis* - Characterized by persistent inflammation of the paranasal sinuses with nasal discharge and congestion - Does **not cause atrophic, dry nasal mucosa** or a **woody, hard external nose** - Typically presents with facial pain, purulent discharge, and pressure symptoms

Q: A 30-year-old man presents with a 6-month history of nasal discharge, facial pain, and fever. On antibiotic therapy, the fever subsides. After 1 month, he again experiences symptoms of mucopurulent discharge from the middle meatus, and the mucosa of the meatus appears congested and oedematous. The next best investigation would be:

Non-Contrast CT of the nose and para-nasal sinuses. ***Non-Contrast CT of the nose and para-nasal sinuses*** - A **non-contrast CT scan** is the **gold standard** for diagnosing chronic rhinosinusitis due to its excellent anatomical detail of bony structures and paranasal sinuses. - It helps in identifying **mucosal thickening**, **obstruction**, and **bony remodelling** indicative of chronic inflammation, guiding further management and potential surgical planning. *MRI of the sinuses* - While MRI provides superior soft tissue resolution, it is **less effective than CT** in visualizing bony anatomy and subtle calcifications or bone thickness changes in the sinuses. - It is often reserved for suspected **intracranial extension**, **orbital complications**, or differentiating between inflammatory processes and tumors, which are not the primary concern here. *Plain x-ray of the para-nasal sinuses* - Plain X-rays have **limited sensitivity and specificity** for diagnosing chronic rhinosinusitis due to superimposed structures and poor resolution. - They can show gross opacification but **cannot adequately delineate** detailed sinus anatomy or the extent of mucosal disease. *Inferior meatus puncture* - Inferior meatus puncture is an **invasive procedure** primarily used for **sinus aspiration** or **lavage** in cases of acute purulent sinusitis for diagnostic culture and therapeutic drainage. - It is **not a primary diagnostic imaging tool** for evaluating chronic sinus disease or anatomical variations.

Q: Which of the following parts of the nasal septum is the most common site for epistaxis?

Anteroinferior part of nasal septum. ***Anteroinferior part of nasal septum*** - This region contains **Kiesselbach's plexus** (also known as Little's area), a highly vascularized area located in the anteroinferior nasal septum where four major arteries anastomose (anterior ethmoidal, sphenopalatine, greater palatine, and superior labial arteries). - Due to its **superficial location** and **rich blood supply**, Kiesselbach's plexus is the most common site for **epistaxis** (nosebleeds), accounting for approximately 90% of anterior nosebleeds. - This area is easily accessible and prone to trauma from nose picking, dry air, and minor injuries. *Anterosuperior part of nasal septum* - While part of the anterior septum, this region does not contain the dense vascular network of Kiesselbach's plexus. - It is less commonly associated with epistaxis compared to the anteroinferior region. *Posterosuperior part of nasal septum* - This area is supplied by branches of the **sphenopalatine artery** (Woodruff's plexus) and is associated with **posterior epistaxis**, which is less common but potentially more severe. - Posterior nosebleeds account for only about 10% of all epistaxis cases and typically occur in elderly patients or those with hypertension. *Posteroinferior part of nasal septum* - This region has a relatively less dense vascular supply compared to the anteroinferior or posterosuperior parts. - It is not a primary site for epistaxis and is less clinically significant for nasal bleeding.

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

Premalignant. ***Premalignant*** - **Antrochoanal polyps are benign growths** and typically do not carry any **premalignant potential**. - They are **inflammatory or edematous mucosal outgrowths**, not neoplastic lesions. - This is the **FALSE statement**, making it the correct answer to this EXCEPT question. *Typically unilateral* - **Antrochoanal polyps** almost exclusively originate from the **maxillary antrum** on one side, making them characteristically **unilateral**. - While ethmoidal nasal polyps can be bilateral, antrochoanal polyps are **distinctly unilateral**. *Arises from the maxillary antrum* - The defining characteristic of an **antrochoanal polyp** is its origin from the **mucosa of the maxillary sinus** (antrum). - It then extends through the **maxillary ostium** into the nasal cavity and often prolapses into the **nasopharynx** or **oropharynx**. *Does not cause malignancy* - **Antrochoanal polyps** are benign lesions and are **not known to undergo malignant transformation**. - Their primary clinical concerns relate to **nasal obstruction**, **mouth breathing**, and **snoring** due to their mechanical effects.

Q: In a typical nasal bone fracture from lateral trauma, the fracture line is usually

Horizontal. ***Horizontal*** - Lateral trauma to the nasal bones typically causes a **horizontal fracture line** along the nasal bridge, often involving the nasal septum. - This is due to the force being applied from the side, pushing the nasal bones inwards and leading to a fracture that runs **perpendicular to the long axis** of the nasal bones. *Oblique* - An oblique fracture line would involve a force applied at an **angle** to the nasal bones, which is less common in typical lateral trauma scenarios. - While possible, it is not the most common or typical fracture pattern for this specific mechanism of injury. *Comminuted* - A comminuted fracture involves **multiple fragments** or more severe crushing, which usually results from a higher-energy impact or a direct frontal blow, not a typical lateral trauma. - While comminution can occur with any fracture, it is not the **primary characteristic** of a typical lateral nasal bone fracture. *Vertical* - A vertical fracture line would suggest a force applied more directly from **above or below**, along the long axis of the nasal bones, which is inconsistent with lateral trauma. - Such a fracture pattern is less common in isolated nasal bone injuries and rare following a lateral impact.

Q: Atrophic dry nasal mucosa, extensive encrustations, and a woody hard external nose are suggestive of:

Atrophic rhinitis. ***Atrophic rhinitis*** - **Atrophic dry nasal mucosa**, extensive **encrustations**, and a **woody hard external nose** are classic presentations of atrophic rhinitis, especially the primary form (ozena). - This condition involves progressive atrophy of the nasal mucosa and turbinates. *Nasal obstruction due to foreign body* - A **foreign body** in the nose typically causes unilateral foul-smelling discharge, obstruction, and sometimes pain, not generalized dryness or extensive encrustations. - It does not lead to a "woody hard" external nose. *Chronic rhinosinusitis* - Characterized by **mucopurulent discharge**, facial pain/pressure, and nasal obstruction, usually without the extreme dryness or global mucosal atrophy seen in the question. - Encrustations can occur, but typically not to the extent or with the atrophic changes described. *Nasal polyps* - **Nasal polyps** cause nasal obstruction, anosmia (loss of smell), and often runny nose, but they do not typically cause atrophic mucosa or a woody hard external nose. - They are soft, movable growths, distinct from the features presented.

Q: Most common presentation of adult rhinosporidiosis is?

Polypoidal mass. ***Polypoidal mass*** - The most common presentation of adult rhinosporidiosis is a **friable, reddish, polypoidal or sessile mass** in the nasal cavity. - These masses are often described as having a **strawberry-like appearance** due to multiple white dots, which are sporangia. *Halitosis* - While rhinosporidiosis can cause symptoms like **nasal obstruction** and discharge, **fetid breath (halitosis)** is not typically the primary or most common presentation. - Halitosis is more commonly associated with other dental or systemic issues, or with severe secondary infections. *Pain* - **Pain is rare** in rhinosporidiosis unless there is significant secondary infection or involvement of adjacent structures. - The lesions are generally asymptomatic until they cause mechanical obstruction or bleeding. *Anosmia* - **Anosmia (loss of smell)** can occur due to mechanical obstruction of the nasal passages by the polypoidal mass. - However, it is a **secondary symptom** resulting from the mass effect, not the most common initial or direct presentation of the disease itself.

Q: Atrophic dry nasal mucosa, extensive encrustations, and foul-smelling nasal discharge are suggestive of which condition?

Atrophic Rhinitis. ***Atrophic Rhinitis*** - This condition is characterized by progressive atrophy of the **nasal mucosa and turbinates**, leading to dryness, extensive crusting, and a characteristic **foul odor (ozena)**. - The **wide nasal cavities** due to turbinate atrophy and the **paradoxical nasal obstruction** despite patent airways are classic features. - The **foul-smelling discharge with green-brown crusts** is pathognomonic for atrophic rhinitis. *Rhinoscleroma* - This is a chronic granulomatous disease caused by **Klebsiella rhinoscleromatis**, presenting in three stages: atrophic, granulomatous, and sclerotic. - The sclerotic stage produces a characteristic **woody hard induration** of the nose and upper airways. - While crusting can occur, the primary features are **nasal obstruction, granuloma formation**, and progressive fibrosis, not the extensive atrophy and foul odor seen in atrophic rhinitis. *Wegener's Granulomatosis* - This is a systemic vasculitis (now called Granulomatosis with Polyangiitis) that can affect the upper respiratory tract. - Features include **bloody crusting, epistaxis, and saddle nose deformity** due to cartilage destruction. - **Systemic symptoms** (kidney involvement, pulmonary nodules) and positive **c-ANCA** help differentiate it from isolated atrophic rhinitis. *Nasal Tuberculosis* - Nasal tuberculosis is rare and typically presents with **granulomatous ulcerative lesions**, nasal obstruction, and sometimes **septal perforation**. - The **generalized atrophy, extensive crusting, and characteristic foul odor** are not primary features of nasal TB. - Usually associated with **pulmonary tuberculosis** and responds to anti-tubercular therapy.

Q: Treatment of choice for carcinoma of the maxillary sinus with T3N0M0?

Surgery and Radiotherapy. ***Surgery and Radiotherapy*** - For **T3N0M0 maxillary sinus carcinoma**, a multidisciplinary approach involving both **surgery** (for primary tumor resection) and **postoperative adjuvant radiotherapy** is the preferred treatment. - This combined modality offers the best chance for **local control** and improved survival due to the aggressive nature and potential for microscopic residual disease in T3 tumors. *Surgery* - While surgery is crucial for removing the primary tumor, it alone may not be sufficient for **T3 tumors** due to the high risk of **microscopic residual disease** at the margins. - **Single modality treatment** with surgery for T3 tumors often results in higher rates of **local recurrence**. *Radiotherapy* - **Radiotherapy alone** is generally reserved for unresectable tumors or in cases where surgery is contraindicated due to comorbidities. - It may not achieve adequate **tumor eradication** as a primary standalone treatment for a T3 tumor without the benefit of surgical debulking. *Surgery and chemotherapy* - **Chemotherapy** is often considered in the context of **neoadjuvant** or **concurrent chemoradiation** for advanced head and neck cancers, or for metastatic disease. - For localized T3N0M0 maxillary sinus carcinoma, the primary adjuvant modality after surgery is **radiotherapy**, with chemotherapy reserved for specific scenarios or advanced stages.

Question 1

Atrophy of the nasal mucosa, with extensive encrustations and a woody hard external nose, is seen in which of the following conditions?

Accepted Answer

Atrophic Rhinitis (Ozena)

Answer

Chronic sinusitis with mucosal thickening

Answer

Allergic rhinitis with nasal polyps

Answer

Nasal septal perforation with crusting

Question 2

An elderly patient with dementia is brought by family members who report concerns about self-neglect. On examination, you notice atrophic, dry nasal mucosa, extensive encrustations, and a woody, hard external nose. The family attributes these findings to poor hygiene due to cognitive decline. Which of the following is the most appropriate next step in management?

Accepted Answer

Rhinoscleroma

Answer

Nasal polyposis

Answer

Atrophic rhinitis

Answer

Chronic sinusitis

Question 3

A 30-year-old man presents with a 6-month history of nasal discharge, facial pain, and fever. On antibiotic therapy, the fever subsides. After 1 month, he again experiences symptoms of mucopurulent discharge from the middle meatus, and the mucosa of the meatus appears congested and oedematous. The next best investigation would be:

Accepted Answer

Non-Contrast CT of the nose and para-nasal sinuses

Answer

MRI of the sinuses

Answer

Plain x-ray of the para-nasal sinuses

Answer

Inferior meatus puncture

Question 4

Which of the following parts of the nasal septum is the most common site for epistaxis?

Accepted Answer

Anteroinferior part of nasal septum

Answer

Anterosuperior part of nasal septum

Answer

Posterosuperior part of nasal septum

Answer

Posteroinferior part of nasal septum

Question 5

All of the following are true about antrochoanal polyp except which of the following?

Accepted Answer

Premalignant

Answer

Does not cause malignancy

Answer

Typically unilateral

Answer

Arises from the maxillary antrum

Question 6

In a typical nasal bone fracture from lateral trauma, the fracture line is usually

Accepted Answer

Horizontal

Answer

Oblique

Answer

Comminuted

Answer

Vertical

Question 7

Atrophic dry nasal mucosa, extensive encrustations, and a woody hard external nose are suggestive of:

Accepted Answer

Atrophic rhinitis

Answer

Nasal obstruction due to foreign body

Answer

Chronic rhinosinusitis

Answer

Nasal polyps

Question 8

Most common presentation of adult rhinosporidiosis is?

Accepted Answer

Polypoidal mass

Answer

Halitosis

Answer

Pain

Answer

Anosmia

Question 9

Atrophic dry nasal mucosa, extensive encrustations, and foul-smelling nasal discharge are suggestive of which condition?

Accepted Answer

Atrophic Rhinitis

Answer

Nasal Tuberculosis

Answer

Rhinoscleroma

Answer

Wegener's Granulomatosis

Question 10

Treatment of choice for carcinoma of the maxillary sinus with T3N0M0?

Accepted Answer

Surgery and Radiotherapy

Answer

Surgery

Answer

Radiotherapy

Answer

Surgery and chemotherapy

Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses — MCQs

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