Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: In Chevallet fracture of the nasal bone, what is the typical mechanism of trauma?

Blow from the side. **Explanation:** The **Chevallet fracture** is a specific type of nasal injury involving the **nasal septum**. It is characterized by a **vertical fracture** of the septal cartilage. 1. **Why Option A is Correct:** The mechanism of a Chevallet fracture is a **lateral blow (blow from the side)**. When a force is applied to the side of the nose, it causes a vertical fracture line in the cartilaginous septum. This often results in a significant deviation of the septum, leading to nasal obstruction and external deformity. 2. **Why Options B and C are Incorrect:** * **Blow from below:** This typically results in a **Jarjavay fracture**. This is a **horizontal fracture** of the septum, often involving the vomer and the maxillary crest, where the cartilage is dislocated from its bony groove. * **Blow from the front:** A direct frontal blow usually causes a "telescoping" injury, comminuted fractures of the nasal bones, or a "saddle nose" deformity due to the crushing of the septal support. 3. **Clinical Pearls for NEET-PG:** * **Chevallet = Vertical fracture** (Lateral force). * **Jarjavay = Horizontal fracture** (Basal force/Blow from below). * **Septal Hematoma:** Always rule this out in nasal trauma. If present, it requires urgent incision and drainage to prevent septal necrosis and a subsequent saddle nose deformity. * **Management:** Most nasal fractures are managed by closed reduction under local or general anesthesia within 7–14 days before the bones unite.

Q: A patient with a sinus infection develops chemosis, bilateral proptosis, and fever. What is the most likely diagnosis?

Cavernous sinus thrombosis. **Explanation:** The clinical triad of **chemosis (conjunctival edema), bilateral proptosis, and fever** following a sinus infection is the classic presentation of **Cavernous Sinus Thrombosis (CST)**. **1. Why Cavernous Sinus Thrombosis is correct:** The cavernous sinuses are paired venous structures located on either side of the sella turcica. They receive venous drainage from the face (via the ophthalmic veins) and the paranasal sinuses (ethmoid and sphenoid). An infection in these areas can lead to septic thrombosis. * **Proptosis and Chemosis:** Occur due to impaired venous drainage from the orbit. * **Bilateral Involvement:** This is the hallmark of CST. Because the two cavernous sinuses communicate via the intercavernous sinuses, an infection starting on one side rapidly spreads to the other. **2. Why other options are incorrect:** * **Lateral Sinus Thrombosis:** Usually a complication of chronic suppurative otitis media (CSOM). It presents with "Griesinger's sign" (edema over the mastoid) and a "picket-fence" fever, but not proptosis or chemosis. * **Frontal Lobe Abscess:** Presents with features of raised intracranial pressure (headache, vomiting, papilledema) and altered mental status, but lacks the specific orbital signs seen here. * **Meningitis:** Presents with fever, neck stiffness, and photophobia. While it can coexist with CST, it does not explain the mechanical orbital findings (proptosis). **Clinical Pearls for NEET-PG:** * **Nerves involved:** Cranial nerves III, IV, V1, V2, and VI pass through the cavernous sinus. **CN VI (Abducens)** is usually the first to be affected (lateral rectus palsy). * **Danger area of the face:** Infections here (e.g., furuncles) can lead to CST due to the **valveless** nature of the facial and ophthalmic veins. * **Treatment:** High-dose intravenous antibiotics and management of the primary source (sinus drainage).

Q: What is the management of maggots in a child's nose?

Conservative treatment with oil followed by removal. **Explanation:** The management of nasal myiasis (maggots in the nose) focuses on the safe and complete extraction of larvae while preventing tissue trauma. **Why Option C is Correct:** The primary challenge in treating nasal myiasis is that maggots possess hooks that allow them to anchor firmly into the nasal mucosa, making forceful extraction painful and damaging. The standard protocol involves instilling **Turpentine oil** (or liquid paraffin/chloroform water) into the nasal cavity. This acts as an irritant and an asphyxiating agent, forcing the maggots to release their grip and crawl out or become sluggish. Once immobilized, they can be safely removed using forceps. **Why Other Options are Incorrect:** * **Option A (Manual removal by hand picking):** Attempting to pull live maggots without prior immobilization is difficult and traumatic. Their hooks can tear the delicate nasal mucosa, leading to severe bleeding and secondary infection. * **Option B (Surgical removal):** Surgery is rarely the first line of treatment. It is reserved only for cases where maggots have migrated into deep, inaccessible areas like the intracranial space or the orbit. * **Option D (Irrigation with warm saline):** Saline is ineffective at dislodging maggots and may push them deeper into the posterior choana or sinuses, increasing the risk of aspiration. **Clinical Pearls for NEET-PG:** * **Causative Agent:** Most commonly the larvae of the fly *Chrysomya bezziana*. * **Predisposing Factors:** Atrophic rhinitis (due to the foul smell attracting flies), leprosy, and poor hygiene. * **Complications:** Palatal perforation, septal destruction, and orbital cellulitis. * **Medical Management:** In severe cases, oral **Ivermectin** is considered an effective systemic treatment to kill the larvae.

Q: Which is the most common tumor of the nasal cavity?

Papilloma. **Explanation:** The most common benign tumor of the nasal cavity is the **Schneiderian Papilloma**. These are true epithelial neoplasms arising from the Schneiderian membrane (the ectodermally derived schneiderian mucosa lining the nose and paranasal sinuses). Among the three types of Schneiderian papillomas—**Inverted**, **Fungiform (Exophytic)**, and **Oncocytic**—the Inverted Papilloma is the most clinically significant. It is characterized by its tendency to grow endophytically (into the underlying stroma), its high rate of recurrence, and its potential for malignant transformation into Squamous Cell Carcinoma (approx. 10%). **Analysis of Incorrect Options:** * **A. Adenoma:** These are rare glandular tumors. While Pleomorphic Adenoma is the most common benign salivary gland tumor, it rarely occurs in the nasal cavity (usually arising from the septum). * **C. Myxoma:** This is a rare mesenchymal tumor of the head and neck, more commonly found in the mandible or maxilla rather than the nasal cavity proper. * **D. Adamantinoma:** This is an old term for Ameloblastoma. It is an odontogenic tumor of the jaw (mandible > maxilla) and does not primarily arise from the nasal cavity. **High-Yield Clinical Pearls for NEET-PG:** * **Inverted Papilloma (Ringertz Tumor):** Most commonly arises from the **lateral wall** of the nose (middle meatus). * **Gold Standard Treatment:** Endoscopic Medial Maxillectomy. * **Radiology:** Look for "bony remodeling" or focal hyperostosis at the site of origin on CT scans. * **Etiology:** Strongly associated with **HPV types 6 and 11**.

Q: What is the commonest complication of Caldwell-Luc operations?

Infraorbital nerve injury. **Explanation:** The **Caldwell-Luc operation** involves creating a window in the anterior wall of the maxilla through the canine fossa to access the maxillary sinus. **1. Why Infraorbital Nerve Injury is Correct:** The infraorbital nerve exits the infraorbital foramen, which is located just superior to the canine fossa. During the elevation of the periosteum or while creating the bony window (antrostomy), the nerve is highly susceptible to stretching or direct trauma. This leads to **cheek numbness or paresthesia**, which is documented as the most frequent postoperative complication (occurring in up to 10-20% of cases). **2. Analysis of Incorrect Options:** * **Oroantral fistula (A):** While a potential risk due to the sublabial incision, it is relatively uncommon if the incision is closed properly in layers. * **Hemorrhage (C):** Bleeding from the sphenopalatine artery or its branches can occur, but it is rarely the "most common" complication compared to sensory nerve changes. * **Orbital cellulitis (D):** This is a rare complication resulting from accidental penetration of the orbital floor (roof of the maxillary sinus). **3. High-Yield Clinical Pearls for NEET-PG:** * **Indications:** Removal of foreign bodies (e.g., root of a tooth), management of Oroantral Fistula (OAF), and access for orbital decompression (Graves' ophthalmopathy). * **Anatomy:** The incision is made in the **gingivolabial sulcus** above the roots of the premolar teeth. * **Modern Context:** Caldwell-Luc has largely been replaced by **FESS** (Functional Endoscopic Sinus Surgery) but remains high-yield for its anatomical complications. * **Dental Injury:** Damage to the roots of the teeth or the superior alveolar nerves is the second most common complication.

Q: What can a rhinolith cause?

All the above. **Explanation:** A **rhinolith** is a calcareous concretion formed by the gradual deposition of mineral salts (calcium and magnesium) around an endogenous or exogenous foreign body in the nasal cavity. Its clinical presentation is typically characterized by unilateral, foul-smelling nasal discharge. **Why "All the Above" is correct:** 1. **Nasal Obstruction (Option A):** As the rhinolith grows over time, it acts as a space-occupying lesion, physically blocking the nasal passage. This is the most common presenting symptom. 2. **Epistaxis (Option B):** The rough, irregular surface of the stone causes constant irritation and pressure necrosis of the surrounding nasal mucosa and septum, leading to ulceration and bleeding. 3. **Epiphora (Option C):** Large rhinoliths located in the inferior meatus can compress or obstruct the opening of the **nasolacrimal duct**, preventing tear drainage and resulting in a watery eye (epiphora). **Clinical Pearls for NEET-PG:** * **Composition:** Primarily Calcium phosphate, Calcium carbonate, and Magnesium phosphate. * **Common Site:** Usually found on the floor of the nose, between the inferior turbinate and the septum. * **Diagnosis:** While clinical examination (anterior rhinoscopy) is key, a **CT scan** is the investigation of choice to determine the extent and rule out bony destruction. On X-ray, it appears as a radio-opaque mass. * **Differential Diagnosis:** Must be differentiated from osteoma, calcified nasal polyp, or malignancy. * **Treatment:** Surgical removal, usually via an endonasal approach. Large stones may require lithotripsy (crushing) before removal.

Q: The main vascular supply of Little's area is all, except?

Palatal branch of sphenopalatine artery. **Explanation:** Little’s area (located in the anteroinferior part of the nasal septum) is the most common site for epistaxis. It contains **Kiesselbach’s Plexus**, an arterial anastomosis where branches from both the internal and external carotid systems meet. **Why Option D is correct:** The **Greater Palatine Artery** (a branch of the maxillary artery) contributes to the plexus by passing through the incisive canal. However, there is no "Palatal branch of the sphenopalatine artery" that supplies this area. The sphenopalatine artery itself terminates as posterior septal branches, not a specific "palatal branch" for Little's area. **Analysis of Incorrect Options:** * **A. Septal branch of superior labial artery:** A branch of the Facial artery (External Carotid system). It supplies the anteroinferior septum. * **B. Nasal branch of sphenopalatine artery:** Specifically the **Posterior Septal branch** of the Sphenopalatine artery (External Carotid system). It is often considered the "Artery of Epistaxis." * **C. Anterior ethmoidal artery:** A branch of the Ophthalmic artery (**Internal Carotid system**). It is the only internal carotid contribution to the plexus. **High-Yield Clinical Pearls for NEET-PG:** * **Woodruff’s Plexus:** Located over the posterior end of the middle turbinate (nasopharynx); the most common site for **posterior epistaxis**, primarily supplied by the Sphenopalatine artery. * **Trottter’s Triad:** Associated with Nasopharyngeal Carcinoma (Conductive hearing loss, Palatal palsy, Ipsilateral facial pain). * **Management:** Most anterior bleeds in Little's area can be managed by **Trotter’s Method** (pinching the nose and leaning forward) or chemical cautery (Silver Nitrate).

Q: The nasal mucosa is supplied by which artery?

Mainly the external carotid artery. The blood supply to the nasal mucosa is derived from both the **Internal Carotid Artery (ICA)** and the **External Carotid Artery (ECA)** systems. However, the ECA provides the vast majority of the blood flow. ### Why Option C is Correct The nasal cavity receives a dual blood supply, but the **External Carotid Artery** is the primary contributor through its major branches: 1. **Sphenopalatine Artery:** A branch of the Maxillary artery (ECA). Known as the **"Artery of Epistaxis,"** it supplies most of the posterior part of the nasal septum and lateral wall. 2. **Greater Palatine Artery:** Also from the Maxillary artery (ECA). 3. **Superior Labial Artery:** A branch of the Facial artery (ECA). ### Why Other Options are Incorrect * **Options A & B:** These are incorrect because the supply is not exclusive. The ICA contributes via the **Ophthalmic artery**, which gives off the **Anterior and Posterior Ethmoidal arteries**. These supply the roof and upper part of the nasal cavity. * **Option D:** While the ICA supply is clinically significant (especially in ethmoidal surgeries), it is quantitatively much smaller than the extensive network provided by the ECA branches. ### High-Yield Clinical Pearls for NEET-PG * **Little’s Area (Kiesselbach’s Plexus):** Located on the anteroinferior part of the nasal septum, this is the most common site for epistaxis. It is an anastomosis of four arteries: **S**phenopalatine, **A**nterior Ethmoidal, **G**reater Palatine, and **S**uperior Labial (**Mnemonic: SAGS**). * **Woodruff’s Plexus:** Located posteriorly, below the posterior end of the inferior turbinate. Bleeding here is usually from the Sphenopalatine artery and is more common in elderly/hypertensive patients. * **Surgical Note:** In cases of severe, uncontrollable epistaxis, the **Maxillary artery** (ECA branch) or the **External Carotid Artery** itself may be ligated. Note that the ICA is never ligated for epistaxis.

Question 1

In Chevallet fracture of the nasal bone, what is the typical mechanism of trauma?

Accepted Answer

Blow from the side

Answer

Blow from below

Answer

Blow directly from the front

Answer

Any of the above

Question 2

A patient with a sinus infection develops chemosis, bilateral proptosis, and fever. What is the most likely diagnosis?

Accepted Answer

Cavernous sinus thrombosis

Answer

Lateral sinus thrombosis

Answer

Frontal lobe abscess

Answer

Meningitis

Question 3

What is the management of maggots in a child's nose?

Accepted Answer

Conservative treatment with oil followed by removal

Answer

Manual removal by hand picking

Answer

Surgical removal

Answer

Irrigation with warm saline solution

Question 4

Which is the most common tumor of the nasal cavity?

Accepted Answer

Papilloma

Answer

Adenoma

Answer

Myxoma

Answer

Adamantinoma

Question 5

What is the commonest complication of Caldwell-Luc operations?

Accepted Answer

Infraorbital nerve injury

Answer

Oroantral fistula

Answer

Hemorrhage

Answer

Orbital cellulitis

Question 6

What can a rhinolith cause?

Accepted Answer

All the above

Answer

Nasal obstruction

Answer

Epistaxis

Answer

Epiphora

Question 7

The main vascular supply of Little's area is all, except?

Accepted Answer

Palatal branch of sphenopalatine artery

Answer

Septal branch of superior labial artery

Answer

Nasal branch of sphenopalatine artery

Answer

Anterior ethmoidal artery

Question 8

Extraction of a maxillary second molar has resulted in a perforation of the maxillary antrum 0.5 cm in diameter. What is an acceptable procedure?

Accepted Answer

Smoothening the bone margins of the socket and placement of sutures across the socket.

Answer

Caldwell-Luc procedure

Answer

Creation of a nasal antrostomy window for proper aeration and drainage.

Answer

Insertion of iodoform gauze packing into the socket to allow healing by second intention.

Question 9

The nasal mucosa is supplied by which artery?

Accepted Answer

Mainly the external carotid artery

Answer

Only the external carotid artery

Answer

Only the internal carotid artery

Answer

Mainly the internal carotid artery

Question 10

Which of the following statements are true regarding the disease depicted here?

Accepted Answer

The histopathology shows foamy macrophages with intracytoplasmic bacilli and plasma cells with Russell bodies; nasal obstruction is a common complaint; and streptomycin and tetracycline for 4-6 weeks are used in treatment.

Answer

The histopathology shows foamy macrophages with intracytoplasmic bacilli and plasma cells with Russell bodies; it is a case of granulomatosis with polyangiitis; and it is caused by a gram-positive bacillus.

Answer

The histopathology shows foamy macrophages with intracytoplasmic bacilli and plasma cells with Russell bodies; it is caused by a gram-positive bacillus; and streptomycin and tetracycline for 4-6 weeks are used in treatment.

Answer

Nasal obstruction is a common complaint; it is caused by a gram-positive bacillus; and streptomycin and tetracycline for 4-6 weeks are used in treatment.

Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses — MCQs

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