Allergic Fungal Sinusitis — MCQs
Best diagnostic test for fungal skin infection –
Which of the following is typically not associated with allergic pulmonary aspergillosis?
The type of allergic reaction seen in allergic fungal sinusitis is -
A 30-year-old woman presents with chronic nasal obstruction, headaches, and a foul-smelling discharge. A CT scan of the sinuses reveals a mass in the left maxillary sinus. Most likely diagnosis?
During functional endoscopic sinus surgery the position of the patient is
Which of the following is a common topical use of the medicine shown in the image?
Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
A 35-year-old woman presents with facial pain, nasal congestion, and purulent nasal discharge for 10 days. What is the most likely diagnosis?
A 35-year-old female patient presents with complaints of nasal obstruction and post-nasal drip. There is a past history of FESS for failed conservative management 5 years ago. Uncinectomy and maxillary ostium dilation was done during the previous FESS. A DNE done now shows patent ostia and mucosal edema of the maxillary sinus lining. What is the next best step in management? FESS - Functional endoscopic sinus surgery
Which of the following is not a feature of ethmoidal polyp?
Allergic Fungal Sinusitis Indian Medical PG Practice Questions and MCQs
Question 1: Best diagnostic test for fungal skin infection –
- A. KOH test (Correct Answer)
- B. Diascopy
- C. Patch test
- D. Wood's lamp
Explanation: ***Correct: KOH test*** - The **potassium hydroxide (KOH) test** is the **most common and rapid method** for diagnosing dermatophyte infections. - It involves dissolving keratinous material to visualize **fungal hyphae** and **spores** under a microscope. - KOH test is **quick, inexpensive, and can be performed in any outpatient setting**, making it the best first-line diagnostic test. *Incorrect: Diascopy* - **Diascopy** is used to determine if a lesion is **vascular** (erythematous and blanches) or **non-vascular** (purpuric and does not blanch). - It involves pressing a glass slide against the lesion and observing color changes. - This test is not relevant for fungal identification. *Incorrect: Patch test* - A **patch test** is used to identify **allergic contact dermatitis** by applying specific allergens to the skin and observing for a delayed hypersensitivity reaction. - It is not designed to detect or diagnose fungal infections. *Incorrect: Wood's lamp* - A **Wood's lamp** emits ultraviolet light and is used to detect certain skin conditions that fluoresce. - While it can help diagnose some fungal infections like **Tinea capitis** caused by *Microsporum* species (which fluoresces green), it is **not a definitive diagnostic test** for all fungal infections. - Many common dermatophytes do not fluoresce, leading to false negatives.
Question 2: Which of the following is typically not associated with allergic pulmonary aspergillosis?
- A. High IgE level
- B. Pleural effusion
- C. Recurrent pneumonia
- D. Occurrence in patients with old cavitary lesions (Correct Answer)
Explanation: Occurrence in patients with old cavitary lesions - Allergic bronchopulmonary aspergillosis (ABPA) primarily affects patients with **asthma** or **cystic fibrosis**, causing an allergic response to *Aspergillus* spores within the airways. - The presence of old cavitary lesions is a hallmark of **aspergilloma**, a distinct form of aspergillus infection, rather than ABPA [1]. *High IgE level* - ABPA is characterized by an intense **T-helper 2 immune response** to *Aspergillus* antigens, leading to significantly elevated total and *Aspergillus*-specific **IgE levels**. - **Serological tests** showing high IgE are a key diagnostic criterion for ABPA. *Pleural effusion* - While less common, **pleural effusions** can occur in severe cases of ABPA, typically due to associated **pneumonitis** or bronchial obstruction. - It indicates significant inflammatory involvement beyond the airways. *Recurrent pneumonia* - Patients with ABPA often experience recurrent episodes of **pulmonary infiltrates**, which can clinically present as recurrent pneumonia. - These episodes are due to **bronchial obstruction** by mucus plugs and inflammatory reactions to the fungus, leading to localized inflammation and consolidation [1].
Question 3: The type of allergic reaction seen in allergic fungal sinusitis is -
- A. Type 2 and Type 3
- B. Type 1 and Type 2
- C. Type 4 and Type 1
- D. Type 1 and Type 3 (Correct Answer)
Explanation: ***Type 1 and Type 3*** - **Allergic fungal sinusitis (AFS)** is primarily characterized by **IgE-mediated hypersensitivity (Type I)** against fungal antigens, manifesting as immediate allergic responses [1]. - **Immune complex formation and deposition (Type III hypersensitivity)** also plays a significant role, contributing to chronic inflammation and tissue damage in the sinuses [2]. - These are considered the **predominant mechanisms** in AFS pathogenesis for clinical and examination purposes. *Type 1 and Type 2* - While **Type I hypersensitivity** (IgE-mediated) is a key component of AFS, **Type II hypersensitivity** (cytotoxic, antibody-dependent) is not involved [1]. - Type II reactions involve antibodies binding to cell surface antigens causing direct cell destruction, which is not a mechanism in AFS [1]. *Type 2 and Type 3* - **Type II hypersensitivity** is not a mechanism in AFS, as the disease does not involve antibody-mediated cellular cytotoxicity [1]. - Although **Type III hypersensitivity** is involved, the absence of Type I (the primary mechanism) makes this option incorrect [2]. *Type 4 and Type 1* - **Type I hypersensitivity** is the primary mechanism in AFS [1]. **Type IV hypersensitivity** (delayed-type, T-cell mediated) may play a contributory role in chronic inflammation. - However, the **classic teaching emphasizes Types I and III** as the predominant hypersensitivity reactions in AFS, with Type I (IgE-mediated) and Type III (immune complex) being the primary drivers of the clinical presentation and pathology [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 208-211. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 214-215.
Question 4: A 30-year-old woman presents with chronic nasal obstruction, headaches, and a foul-smelling discharge. A CT scan of the sinuses reveals a mass in the left maxillary sinus. Most likely diagnosis?
- A. Chronic sinusitis due to bacterial infection (Correct Answer)
- B. Nasal septal deviation
- C. Allergic fungal sinusitis
- D. Nasal obstruction due to polyp
Explanation: ***Chronic sinusitis due to bacterial infection*** - The combination of **chronic nasal obstruction**, **headaches**, **foul-smelling discharge**, and a **mass in the maxillary sinus** is most consistent with chronic bacterial sinusitis. - The **foul-smelling discharge** is pathognomonic for **anaerobic bacterial infection**, which is characteristic of chronic sinusitis with stagnant secretions. - The mass seen on CT likely represents inflammatory tissue such as **granulation tissue**, **organized mucopus**, or an **inflammatory polyp** secondary to chronic infection. - Chronic bacterial sinusitis can lead to mucosal thickening and polypoid changes that appear as mass-like lesions on imaging. *Allergic fungal sinusitis* - While allergic fungal sinusitis (AFRS) can present with a mass-like lesion due to allergic mucin accumulation, it typically does **NOT** produce foul-smelling discharge. - AFRS discharge is typically thick, inspissated, and described as "peanut butter-like" but not foul-smelling unless there is secondary bacterial superinfection. - AFRS usually affects multiple sinuses bilaterally and is associated with nasal polyposis, asthma, and allergic history. *Nasal septal deviation* - **Nasal septal deviation** is an anatomical abnormality that can contribute to sinus obstruction and predispose to sinusitis, but it does not directly cause an intrasinus mass or foul-smelling discharge. - CT would show deviation of the nasal septum but would not explain the mass within the maxillary sinus itself. *Nasal obstruction due to polyp* - While **nasal polyps** can cause obstruction and are often associated with chronic sinusitis, they typically arise from the middle meatus or ethmoid region rather than presenting as a discrete mass within the maxillary sinus. - Polyps themselves are bland inflammatory tissue and do not typically produce foul-smelling discharge unless secondarily infected with anaerobic bacteria, in which case the underlying diagnosis would be chronic bacterial sinusitis.
Question 5: During functional endoscopic sinus surgery the position of the patient is
- A. Lateral
- B. Lithotomy
- C. Reverse Trendelenburg (Correct Answer)
- D. Trendelenburg
Explanation: ***Reverse Trendelenburg*** - This position helps to reduce **venous congestion** in the surgical field, which is crucial for maintaining clear visibility during **functional endoscopic sinus surgery (FESS)**. - It minimizes **bleeding** by allowing gravity to drain blood away from the head and neck, improving surgical precision and safety. *Trendelenburg* - This position involves tilting the patient with the head lower than the feet, which would increase **venous pressure** in the head and neck. - Increased venous congestion would lead to significant **bleeding**, severely impairing visibility during FESS. *Lateral* - The lateral position is generally used for procedures involving the **side of the body**, such as kidney surgery or lung procedures. - It does not provide the optimal ergonomic access or venous drainage benefits required for **endoscopic sinus surgery**. *Lithotomy* - The lithotomy position is characterized by the patient lying on their back with hips and knees flexed and supported, primarily used for **pelvic or perineal procedures**. - This position is entirely inappropriate for **head and neck surgery** as it does not allow proper access to the sinus area.
Question 6: Which of the following is a common topical use of the medicine shown in the image?
- A. Rhino cerebral mucormycosis
- B. Inlay type I myringoplasty
- C. Post-adenoidectomy to control bleeding (Correct Answer)
- D. Subglottic stenosis
Explanation: ***Post-adenoidectomy to control bleeding*** - The image shows **Neo-Synephrine (phenylephrine)**, a potent **alpha-adrenergic agonist** that causes **vasoconstriction**. - Its vasoconstrictive properties make it useful topically to reduce **bleeding** during and after surgical procedures like **adenoidectomy**. *Rhino cerebral mucormycosis* - This is a serious fungal infection requiring systemic antifungal therapy, often **amphotericin B**. Topical phenylephrine has no role in treating the infection itself. - While bleeding might be a symptom of mucormycosis, phenylephrine would only offer temporary symptomatic relief, not address the underlying fungal pathology. *Inlay type I myringoplasty* - Myringoplasty is a surgical procedure to repair a perforated eardrum. Topical phenylephrine is not indicated for this procedure. - The primary goal of this surgery is to reconstruct the **tympanic membrane**, and phenylephrine would not contribute to tissue healing or graft integration. *Subglottic stenosis* - This condition involves narrowing of the airway below the vocal cords, often requiring surgical intervention or corticosteroids. - Phenylephrine is a decongestant and vasoconstrictor, and as such, it does not have a therapeutic role in resolving the **fibrotic narrowing** characteristic of subglottic stenosis.
Question 7: Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
- A. Statements 1 & 2 are correct, 2 is not explaining 1 (Correct Answer)
- B. Statements 1 and 2 are correct and 2 is the correct explanation for 1
- C. Statements 1 and 2 are incorrect
- D. Statement 1 is incorrect
Explanation: ***Correct: Statements 1 & 2 are correct, 2 is not explaining 1*** **Analysis of Statement 1:** - A 59-year-old patient with **flaccid bullae** and **suprabasal acantholytic split** on histopathology is the classic presentation of **Pemphigus vulgaris** - The flaccid (easily ruptured) nature of bullae distinguishes it from tense bullae seen in bullous pemphigoid - The suprabasal location of the split (just above the basal layer) with acantholysis (loss of cell-to-cell adhesion) is pathognomonic - **Statement 1 is CORRECT** ✓ **Analysis of Statement 2:** - The **"row of tombstones" or "tombstone appearance"** is indeed a diagnostic histopathological feature of Pemphigus vulgaris - This appearance results from basal keratinocytes remaining attached to the basement membrane while suprabasal cells separate due to acantholysis - The intact basal cells standing upright resemble a row of tombstones - **Statement 2 is CORRECT** ✓ **Does Statement 2 explain Statement 1?** - Statement 2 describes a **histopathological appearance** (tombstone pattern) that is a **consequence** of the suprabasal split - However, it does NOT explain the **underlying cause** of the flaccid bullae or the suprabasal split - The true explanation involves **IgG autoantibodies against desmoglein 3 (and desmoglein 1)**, which attack intercellular adhesion structures (desmosomes), causing **acantholysis** - Therefore, **Statement 2 does NOT explain Statement 1** ✗ *Incorrect: Statement 2 is the correct explanation for Statement 1* - While both statements describe features of Pemphigus vulgaris, the tombstone appearance is a descriptive finding, not an explanatory mechanism *Incorrect: Statements 1 and 2 are incorrect* - Both statements are medically accurate descriptions of Pemphigus vulgaris features *Incorrect: Statement 1 is incorrect* - Statement 1 correctly describes the cardinal clinical and histopathological features of Pemphigus vulgaris
Question 8: A 35-year-old woman presents with facial pain, nasal congestion, and purulent nasal discharge for 10 days. What is the most likely diagnosis?
- A. Migraine
- B. Tension headache
- C. Trigeminal neuralgia
- D. Acute sinusitis (Correct Answer)
Explanation: ***Acute sinusitis*** - The combination of **facial pain**, **nasal congestion**, and **purulent nasal discharge** for 10 days is highly characteristic of acute sinusitis, indicating inflammation and infection of the paranasal sinuses. - The persistence of symptoms for over 7-10 days, or worsening symptoms after initial improvement, supports a bacterial etiology rather than a self-limiting viral infection. *Migraine* - Migraines typically present with **unilateral, throbbing headache**, often accompanied by **photophobia, phonophobia**, and nausea, without purulent nasal discharge [1]. - While facial pain can occur, it's usually not associated with nasal congestion or discharge [1]. *Tension headache* - Tension headaches are usually characterized by **bilateral, pressing or tightening pain**, often described as a band around the head, and are not associated with nasal symptoms or purulent discharge [1]. - They typically lack the other features of sinusitis or migraines. *Trigeminal neuralgia* - This condition involves **sudden, severe, brief, stabbing or shock-like pain** in the distribution of the trigeminal nerve, often triggered by light touch or movement. - It does not present with nasal congestion or purulent discharge.
Question 9: A 35-year-old female patient presents with complaints of nasal obstruction and post-nasal drip. There is a past history of FESS for failed conservative management 5 years ago. Uncinectomy and maxillary ostium dilation was done during the previous FESS. A DNE done now shows patent ostia and mucosal edema of the maxillary sinus lining. What is the next best step in management? FESS - Functional endoscopic sinus surgery
- A. Tissue biopsy for histopathological examination (Correct Answer)
- B. Immediate revision FESS
- C. High-dose systemic steroids
- D. Topical antifungal therapy
Explanation: ***Tissue biopsy for histopathological examination*** - The patient has persistent **mucosal edema** despite previous FESS and patent ostia, raising suspicion for less common etiologies such as **eosinophilic mucin rhinosinusitis** or even a **neoplastic process**, which require histological confirmation. - A biopsy is essential to differentiate between inflammatory conditions not responsive to standard medical therapy and other distinct pathologies, guiding further specific treatment. *Immediate revision FESS* - Revision FESS is usually considered when there is evidence of **recurrent obstruction** or **sinus scarring**, neither of which is indicated by the "patent ostia" observed during DNE. - Performing FESS without addressing the underlying cause of persistent mucosal edema is unlikely to be curative and risks repeat failure. *High-dose systemic steroids* - While systemic steroids can reduce inflammation, persistent symptoms despite prior surgical intervention and observed mucosal edema warrant investigating the underlying cause before resorting to high-dose systemic therapy. - Prolonged use of high-dose systemic steroids carries significant side effects and should be reserved for cases where the etiology is well-defined and responsive, such as severe asthma or certain inflammatory conditions. *Topical antifungal therapy* - While fungal elements can contribute to rhinosinusitis, the broad application of topical antifungals without specific evidence of fungal infection (e.g., fungal balls, invasive fungal sinusitis) is not standard initial management. - The description of "mucosal edema" and absence of specific fungal features (like thick, inspissated mucin or fungal hyphae) makes empirical antifungal therapy less appropriate as the primary next step.
Question 10: Which of the following is not a feature of ethmoidal polyp?
- A. Common in adults
- B. Commonly bilateral
- C. Associated with chronic rhinosinusitis
- D. Commonly found as a single polyp (Correct Answer)
Explanation: ***Commonly found as a single polyp*** - **Ethmoidal polyps** are typically **multiple** and bilateral, originating from the ethmoid sinuses. - They rarely present as a single, isolated polyp, which is more characteristic of antrochoanal polyps. - This is the key distinguishing feature that makes this statement INCORRECT. *Common in adults* - **Ethmoidal polyps** are indeed **more prevalent in adults** than in children. - Peak incidence occurs between 30-50 years of age. - Their incidence tends to increase with age, often associated with chronic rhinosinusitis. *Commonly bilateral* - **Ethmoidal polyps** almost invariably present as **bilateral polyps**, involving both sides of the nasal cavity. - This bilateral nature is a key differentiating feature from antrochoanal polyps, which are typically unilateral. - Bilateral presentation is one of the hallmark characteristics of ethmoidal polyps. *Associated with chronic rhinosinusitis* - **Ethmoidal polyps** are strongly associated with **chronic rhinosinusitis with nasal polyposis (CRSwNP)**. - They arise from chronic mucosal inflammation of the ethmoid sinuses. - Often associated with conditions like aspirin-exacerbated respiratory disease (AERD/Samter's triad) and non-allergic eosinophilic inflammation.
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