Complications of Sinusitis — MCQs
A 1-year-old child was brought to the outpatient department with a soft and compressible swelling on the nose that increases on coughing. Which of the following is most likely the diagnosis?
Complications of tubercular meningitis include all except
Most common sinus to be involved in acute sinusitis?
A man presents 6 hrs after head injury complaining of mild proptosis and scleral hyperemia:
Mucormycosis of the paranasal sinus is most common in?
A 19-year-old young girl with a previous history of repeated pain over the medial canthus and chronic use of nasal decongestants presented with an abrupt onset of fever, chills, and rigor, diplopia on lateral gaze, moderate proptosis, and chemosis. On examination, the optic disc is congested. What is the most likely diagnosis?
Frontal headache is due to inflammation of which sinus?
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
What is the treatment of choice for ethmoidal polyps?
Which sinus drainage is impaired in the following image?
Complications of Sinusitis Indian Medical PG Practice Questions and MCQs
Question 1: A 1-year-old child was brought to the outpatient department with a soft and compressible swelling on the nose that increases on coughing. Which of the following is most likely the diagnosis?
- A. Meningoencephalocele (Correct Answer)
- B. Arteriovenous malformation
- C. Lacrimal sac cyst
- D. Ethmoid cyst
Explanation: ***Meningoencephalocele*** - A soft, compressible nasal swelling that increases with **coughing** or **straining** is highly suggestive of a meningoencephalocele due to increased intracranial pressure. - This condition involves a **herniation of brain tissue** (encephalocele) and meninges through a bony defect, often in the nasal region. *Lacrimal sac cyst* - A lacrimal sac cyst would typically present as a swelling in the **medial canthal region** and is usually associated with **tear duct obstruction**, not directly on the nose increasing with coughing. - While soft, it is not usually **compressible** or affected by changes in intracranial pressure in the same way. *Arteriovenous malformation* - An arteriovenous malformation (AVM) would typically present as a **pulsatile** mass with a **bruit**, and might cause warmth or discoloration. - It would not characteristically increase in size with **coughing** as a result of intracranial pressure changes. *Ethmoid cyst* - An ethmoid cyst is a fluid-filled sac originating from the **ethmoid sinuses**. While it can cause nasal obstruction or swelling, it usually presents as a firm, non-pulsatile mass. - It would not typically exhibit **compressibility** with an increase in size when coughing, differentiating it from an intracranial connection.
Question 2: Complications of tubercular meningitis include all except
- A. Hydrocephalus
- B. Cerebral Artery Thrombosis
- C. Cortical venous thrombosis (Correct Answer)
- D. Cranial Nerve Palsy
Explanation: ***Cortical venous thrombosis*** - While TB meningitis can cause vascular complications, **isolated cortical venous thrombosis** is a rare and atypical complication. - The inflammatory exudate in TB meningitis typically affects arteries and basal cisterns, leading to problems like arteritis and communicating or obstructive hydrocephalus [1]. *Hydrocephalus* - This is a common complication due to the inflammatory exudate in the **basal cisterns**, which obstructs the flow of cerebrospinal fluid (CSF) [2]. - It can be either **communicating** (impaired absorption) or **non-communicating** (obstructive due to blockage) [2]. *Cerebral Artery Thrombosis* - The **inflammatory exudate** surrounding basal cisterns in TB meningitis can lead to vasculitis and thrombosis of nearby arteries, especially the large cerebral arteries. - This can result in **ischemic strokes** and focal neurological deficits [3]. *Cranial Nerve Palsy* - The inflamed meninges and exudate can directly compress or damage **cranial nerves** as they exit the brainstem and travel through the basal cisterns. - Cranial nerves III, IV, VI, VII, and VIII are particularly susceptible to this complication.
Question 3: Most common sinus to be involved in acute sinusitis?
- A. Ethmoid
- B. Maxillary (Correct Answer)
- C. Sphenoid
- D. Frontal
Explanation: ***Maxillary*** - The **maxillary sinuses** are the largest paranasal sinuses and are the most commonly involved in acute sinusitis due to their anatomical position and drainage characteristics. - Their ostia (drainage openings) are located on the superior aspect of the sinus, which can make drainage difficult when the patient is upright, leading to stasis of secretions and increased susceptibility to infection. *Ethmoid* - The ethmoid sinuses are a group of small air cells located between the eyes and are the second most commonly infected in sinusitis. - While frequently involved, especially in children, they are not as commonly affected as the maxillary sinuses in the general adult population with acute sinusitis. *Sphenoid* - The sphenoid sinuses are located deep within the skull, behind the eyes, and are the least commonly involved in acute sinusitis. - Inflammation here can be serious due to proximity to important structures like the optic nerves and carotid arteries, but it's not the most frequent site of infection. *Frontal* - The frontal sinuses are located in the forehead and are less commonly involved in acute sinusitis compared to the maxillary and ethmoid sinuses. - Their development is not complete until adolescence, and they are typically drained via the frontonasal duct, which can become easily obstructed.
Question 4: A man presents 6 hrs after head injury complaining of mild proptosis and scleral hyperemia:
- A. Caroticocavernous fistula
- B. Retro-orbital hematoma (Correct Answer)
- C. Pneumo-orbit
- D. Orbital cellulitis
Explanation: ***Retro-orbital hematoma*** - The sudden onset of **proptosis** and **scleral hyperemia** within hours of a head injury is highly suggestive of bleeding behind the eye. - A **retro-orbital hematoma** causes increased orbital pressure, leading to the forward displacement of the eyeball (proptosis) and conjunctival injection (scleral hyperemia). *Caroticocavernous fistula* - This condition involves an abnormal communication between the carotid artery and the cavernous sinus, typically presenting with a **pulsatile proptosis** and a **bruit** over the eye. - While it can cause proptosis and hyperemia, its onset is usually not as acute as 6 hours post-trauma without being a direct major vessel injury in a recent trauma. *Pneumo-orbit* - A pneumo-orbit involves **air entering the orbit**, often following trauma that fractures an orbital wall communicating with a paranasal sinus. - Symptoms include **periorbital crepitus** and exophthalmos, but scleral hyperemia is not a primary or dominant feature. *Orbital cellulitis* - Orbital cellulitis is an **infection of the orbital tissues**, usually presenting with proptosis, ophthalmoplegia, pain, and fever. - This is an infectious process and would typically take longer than 6 hours to develop to such an extent after an acute trauma without an open wound or obvious contamination.
Question 5: Mucormycosis of the paranasal sinus is most common in?
- A. Diabetes (Correct Answer)
- B. Individuals with HIV
- C. Individuals on immunosuppressive therapy
- D. Patients who have undergone surgery
Explanation: Diabetes - **Diabetic ketoacidosis** significantly impairs neutrophil function, reducing the body's ability to resist fungal infections like mucormycosis. [1] - The **hyperglycemic** and **acidotic** environment in uncontrolled diabetes promotes the growth and invasiveness of Mucorales fungi. [1] *Individuals with HIV* - While HIV can lead to **immunocompromise**, mucormycosis is less common in this population than in those with diabetes; other opportunistic infections are more prevalent with HIV. - HIV primarily affects **CD4+ T-lymphocytes**, whereas mucormycosis is more often associated with defects in phagocytic function. *Individuals on immunosuppressive therapy* - **Immunosuppressive therapy**, such as corticosteroids or chemotherapy, can increase the risk of fungal infections, but **uncontrolled diabetes** is the most significant risk factor for rhinocerebral mucormycosis. [1] - The type of immunosuppression and underlying condition are critical; while relevant, it is not as uniquely predisposing as diabetic ketoacidosis. [1] *Patients who have undergone surgery* - Surgical patients, especially those with prolonged hospital stays or extensive wounds, can be susceptible to various infections, but mucormycosis is not specifically or most commonly linked to surgery as an isolated risk factor. - **Nosocomial infections** after surgery are often bacterial; fungal infections, when they occur, are typically associated with profound immunosuppression or specific device-related issues, not surgery alone.
Question 6: A 19-year-old young girl with a previous history of repeated pain over the medial canthus and chronic use of nasal decongestants presented with an abrupt onset of fever, chills, and rigor, diplopia on lateral gaze, moderate proptosis, and chemosis. On examination, the optic disc is congested. What is the most likely diagnosis?
- A. Cavernous sinus thrombosis (Correct Answer)
- B. Orbital inflammation
- C. Acute sinusitis
- D. Optic nerve compression
Explanation: **Cavernous sinus thrombosis** - The abrupt onset of **fever, chills, rigor, diplopia on lateral gaze, moderate proptosis, and chemosis, along with a congested optic disc**, points towards inflammation and thrombosis within the cavernous sinus. - A history of recurrent pain over the **medial canthus** (suggesting infection near the nose/eyes) and chronic use of **nasal decongestants** (potentially obstructing venous drainage or causing mucosal changes) further increases the suspicion for cavernous sinus thrombosis originating from orbital or sinonasal infections. *Orbital inflammation* - While orbital inflammation can present with **proptosis, chemosis, and optic disc congestion**, the presence of **diplopia on lateral gaze (suggesting oculomotor nerve involvement)** and systemic symptoms like **fever, chills, and rigor** strongly indicates a more widespread and severe process beyond simple inflammation, such as thrombosis. - Orbital inflammation typically lacks the characteristic severe systemic toxicity and specific cranial nerve palsies associated with cavernous sinus thrombosis. *Acute sinusitis* - **Acute sinusitis** can present with fever and localized pain, but it does not typically cause **diplopia on lateral gaze, significant proptosis, chemosis, or optic disc congestion**. - The symptoms described are much more severe and involve structures beyond the paranasal sinuses. *Optic nerve compression* - **Optic nerve compression** would primarily cause visual disturbances, such as **vision loss or visual field defects**, and potentially optic disc edema. [1] - It would not explain the prominent **proptosis, chemosis, diplopia on lateral gaze**, or the significant systemic symptoms like **fever, chills, and rigor**.
Question 7: Frontal headache is due to inflammation of which sinus?
- A. Sphenoid
- B. Ethmoidal
- C. Frontal (Correct Answer)
- D. Maxillary
Explanation: ***Frontal*** - Inflammation of the **frontal sinuses** typically causes pain and pressure over the forehead, known as a **frontal headache**. - The pain is often worse in the morning, when bending over, or with changes in **barometric pressure**. *Sphenoid* - **Sphenoid sinusitis** usually causes a headache behind the eyes, at the **vertex of the head**, or in the occipital region. - It is less common than other forms of sinusitis and often presents with more diffuse, deep-seated pain. *Ethmoidal* - **Ethmoidal sinusitis** typically results in pain and pressure between the eyes or over the **bridge of the nose**. - It can also cause eye pain and is sometimes mistaken for a **tension headache**. *Maxillary* - **Maxillary sinusitis** commonly causes pain and pressure in the cheeks, under the eyes, and in the upper teeth, often exacerbated by **chewing or biting**. - This pain can radiate to the temples or ears, but it typically does not manifest as a **frontal headache**.
Question 8: 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 9: What is the treatment of choice for ethmoidal polyps?
- A. Functional Endoscopic sinus surgery with polypectomy (Correct Answer)
- B. Intranasal ethmoidectomy
- C. Transantral ethmoidectomy
- D. Extranasal ethmoidectomy
Explanation: ***Functional Endoscopic sinus surgery with polypectomy*** - This is the **gold standard treatment** for ethmoidal polyps, as it allows for **direct visualization** and complete removal of polyps while preserving healthy mucosa. - It also enables restoration of normal sinus ventilation and drainage, which helps prevent recurrence. *Intranasal ethmoidectomy* - This is an **older technique** that is performed blindly and carries a higher risk of complications, such as **orbital or intracranial injury**, compared to endoscopic approaches. - It often results in incomplete polyp removal, leading to a higher rate of recurrence. *Transantral ethmoidectomy* - This approach, also known as the **Caldwell-Luc procedure**, is primarily used for diseases of the **maxillary sinus** and is not the preferred method for isolated ethmoidal polyps. - It is a more invasive external approach with risks including facial swelling, pain, and damage to dental nerves. *Extranasal ethmoidectomy* - This is a more invasive **external approach** involving an incision on the face and is generally reserved for extensive or complicated cases, such as **tumors or severe trauma**, not for routine polyp removal. - It carries risks of visible scarring and longer recovery times, making it less favorable than endoscopic techniques.
Question 10: Which sinus drainage is impaired in the following image?
- A. Ethmoid
- B. Sphenoid
- C. Frontal
- D. Maxillary (Correct Answer)
Explanation: ***Maxillary*** - The image shows **arrows pointing to the maxillary sinuses** with visible **opacification and fluid accumulation**, indicating **impaired drainage**. - Maxillary sinuses drain through the **ostiomeatal complex** into the middle meatus; obstruction leads to mucus retention and sinusitis. *Ethmoid* - The **ethmoid air cells** located between the eyes, medial to the orbits, do not show significant **opacification** or drainage impairment. - These complex honeycomb-like structures appear **relatively clear** without evidence of fluid accumulation. *Sphenoid* - The **sphenoid sinuses** located deeper in the skull, behind the ethmoid sinuses, are **not prominently affected** in this image. - No significant **opacification** or mucosal thickening visible to suggest impaired drainage. *Frontal* - The **frontal sinuses** located above the eyebrows appear **relatively clear** without significant opacification or drainage impairment. - These sinuses drain through the **frontonasal duct** and do not show evidence of fluid retention in this image.
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