Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses Indian Medical PG Practice Questions and MCQs

Question 101: 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?

A. Caldwell-Luc procedure
B. Creation of a nasal antrostomy window for proper aeration and drainage.
C. Smoothening the bone margins of the socket and placement of sutures across the socket. (Correct Answer)
D. Insertion of iodoform gauze packing into the socket to allow healing by second intention.

Explanation: ### Explanation The question describes an **Oro-antral Communication (OAC)**, a common complication of maxillary molar extraction due to the close proximity of the tooth roots to the floor of the maxillary sinus. #### 1. Why Option C is Correct Management of an OAC depends primarily on the **size of the perforation** and the **presence of infection**: * **Small defects (<2 mm):** Usually heal spontaneously with a firm blood clot. * **Moderate defects (2–6 mm):** This case (0.5 cm) falls into this category. The standard management involves promoting a stable clot. This is achieved by **smoothening sharp bony margins** (to prevent mucosal irritation) and achieving **primary closure** by suturing the gingival margins across the socket. This prevents food and saliva from entering the sinus, allowing natural healing. #### 2. Why Other Options are Incorrect * **Option A (Caldwell-Luc):** This is an invasive procedure used to remove diseased sinus mucosa or foreign bodies (e.g., a root tip pushed into the sinus). It is not indicated for a fresh, simple perforation. * **Option B (Nasal Antrostomy):** While drainage is important in chronic sinusitis, it is not the primary treatment for a fresh OAC. The priority is closing the oral communication. * **Option D (Iodoform Gauze):** Packing the socket is **contraindicated**. It prevents the formation of a natural blood clot and can lead to the formation of a permanent **Oro-antral Fistula (OAF)** by epithelializing the tract. #### 3. Clinical Pearls for NEET-PG * **Most common site:** Maxillary first molar, followed by the second molar and second premolar. * **Diagnosis:** Positive **"Nose-blowing test"** (air or bubbles escaping through the socket when the patient exhales against pinched nostrils). * **Large defects (>6 mm):** These rarely heal spontaneously and require surgical flaps (e.g., Buccal advancement flap or Palatal rotation flap). * **Post-op Advice:** Patients must be instructed **not to blow their nose** for 2 weeks to avoid pressure changes that could dislodge the healing clot.

Question 102: The nasal mucosa is supplied by which artery?

A. Only the external carotid artery
B. Only the internal carotid artery
C. Mainly the external carotid artery (Correct Answer)
D. Mainly the internal carotid artery

Explanation: 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 103: Which of the following statements is NOT true regarding inverted papilloma?

A. It is always unilateral.
B. It is more common in females. (Correct Answer)
C. 10-15% of the cases may be associated with squamous cell carcinoma.
D. It is also called Ringertz tumor.

Explanation: **Explanation:** Inverted papilloma (Schneiderian papilloma) is a benign but locally aggressive sinonasal tumor. The correct answer is **Option B** because inverted papilloma is significantly **more common in males**, with a male-to-female ratio of approximately **3:1 to 5:1**. It typically presents in the 5th to 7th decades of life. **Analysis of other options:** * **Option A (Always unilateral):** This is a characteristic feature. It almost always presents as a unilateral nasal mass, typically arising from the lateral wall of the nose (middle meatus). Bilateral involvement is extremely rare. * **Option C (Association with SCC):** Inverted papilloma is notorious for its potential for malignant transformation. Approximately **10-15%** of cases are associated with synchronous or metachronous **Squamous Cell Carcinoma (SCC)**. * **Option D (Ringertz tumor):** This is the eponymous name for inverted papilloma, named after Nils Ringertz who described its histopathology. **Clinical Pearls for NEET-PG:** * **Histopathology:** The hallmark is the **endophytic growth pattern**, where the surface epithelium proliferates and invaginates into the underlying stroma (hence "inverted"). * **Site of Origin:** Most commonly the **lateral nasal wall** (near the middle turbinate or ethmoid sinus). * **Clinical Presentation:** Unilateral nasal obstruction and epistaxis. * **Management:** Requires wide surgical excision (usually **Endoscopic Medial Maxillectomy**) due to a high recurrence rate and risk of malignancy. * **Imaging:** CT shows a unilateral soft tissue mass with characteristic **bony remodeling** or focal hyperostosis at the site of origin.

Question 104: What is the most common cause of unilateral epistaxis in a 5-year-old child?

A. Foreign body (Correct Answer)
B. Polyp
C. Atrophic rhinitis
D. Maggot infestation

Explanation: **Explanation:** The correct answer is **Foreign body (Option A)**. In the pediatric population, especially between the ages of 2 and 5 years, the most common cause of **unilateral, foul-smelling, purulent nasal discharge**—often associated with blood-stained secretions (epistaxis)—is an impacted nasal foreign body. Children in this age group frequently insert small objects (beads, seeds, button batteries) into their nostrils. The foreign body causes local mucosal irritation, pressure necrosis, and secondary infection, leading to localized bleeding. **Analysis of Incorrect Options:** * **Polyp (Option B):** While nasal polyps can cause obstruction, they are relatively rare in young children (except in cases of Cystic Fibrosis). When present, they typically cause bilateral symptoms and are more likely to cause watery discharge rather than frank epistaxis. * **Atrophic rhinitis (Option C):** This is a chronic inflammatory condition characterized by mucosal atrophy and foul-smelling crusts (ozaena). It is typically seen in young adults (more common in females) and presents with bilateral roomy nasal cavities, not as acute unilateral epistaxis in a toddler. * **Maggot infestation (Option D):** Also known as Nasal Myiasis, this occurs due to the laying of eggs by the *Chrysomya bezziana* fly. While it causes foul discharge and bleeding, it is usually associated with poor hygiene, atrophic rhinitis, or debilitated states, and is less common than simple foreign bodies in healthy children. **Clinical Pearls for NEET-PG:** * **Triad of Nasal Foreign Body:** Unilateral nasal discharge + Foul odor + Blood-staining. * **Button Batteries:** These are surgical emergencies due to the risk of liquefactive necrosis and septal perforation within hours. * **Management:** Most foreign bodies can be removed using a "Hook" (e.g., Day’s hook) by passing it behind the object and pulling it forward. Avoid using forceps for smooth, round objects as they may slip and be aspirated.

Question 105: Inverted papilloma of the nose arises from which anatomical location?

A. Lateral wall of the nose (Correct Answer)
B. Roof of the nose
C. Tip of the nose
D. Septum

Explanation: **Explanation:** **Inverted Papilloma (Ringertz Tumor)** is a benign but locally aggressive epithelial tumor of the nasal cavity. The correct answer is the **lateral wall of the nose**, specifically the region of the middle meatus or the ethmoid sinus complex. 1. **Why the Lateral Wall is Correct:** Inverted papilloma characteristically arises from the Schneiderian membrane (ectoderm-derived Schneiderian mucosa) that lines the lateral nasal wall and paranasal sinuses. The most common site of origin is the **lateral wall of the nose**, often near the middle turbinate or the ostiomeatal complex, from where it frequently extends secondarily into the maxillary and ethmoid sinuses. 2. **Why Other Options are Incorrect:** * **Roof of the nose:** This area is primarily associated with olfactory epithelium and is a common site for Esthesioneuroblastoma, not inverted papilloma. * **Tip of the nose:** This is a cutaneous site. Common pathologies here include vestibulitis, furuncles, or squamous cell carcinoma of the skin. * **Septum:** While "fungiform" papillomas (another subtype of Schneiderian papilloma) typically arise from the nasal septum, **inverted** papillomas specifically favor the lateral wall. **High-Yield Clinical Pearls for NEET-PG:** * **Histology:** It is called "inverted" because the surface epithelium proliferates and invaginates *downward* into the underlying stroma (endophytic growth), rather than outward. * **Malignant Potential:** It is associated with **Squamous Cell Carcinoma** in about 5-15% of cases. * **Clinical Feature:** Usually presents as **unilateral** nasal obstruction and epistaxis. On examination, it appears as a pale, bulky, "mulberry-like" mass. * **Management:** Requires wide surgical excision (usually **Medial Maxillectomy** via endoscopic or open approach) due to a high rate of local recurrence.

Question 106: In a 60-year-old adult, which of the following diseases causes expansile maxillary lesions?

A. Paget's disease (Correct Answer)
B. Acromegaly
C. Fibrous Dysplasia
D. Rickets

Explanation: **Explanation:** The correct answer is **Paget’s Disease (Osteitis Deformans)**. In Paget’s disease, there is a localized disorder of bone remodeling characterized by excessive bone resorption followed by disorganized and excessive bone formation. In the head and neck, it commonly affects the skull and the maxilla. In an **elderly patient (typically >50-60 years)**, Paget’s disease is a classic cause of progressive, painless, bilateral **expansile enlargement of the maxilla**. This often leads to a "lion-like" facial appearance (leontiasis ossea) and causes widening of the alveolar ridges, resulting in ill-fitting dentures—a classic clinical sign in NEET-PG questions. **Why other options are incorrect:** * **Acromegaly:** While it causes bony overgrowth due to excess Growth Hormone, it primarily affects the **mandible** (prognathism) and the frontal bone (frontal bossing), rather than causing isolated expansile maxillary lesions. * **Fibrous Dysplasia:** This also causes expansile bone lesions where normal bone is replaced by fibrous tissue. However, it is primarily a disease of the **young (children and adolescents)**. In a 60-year-old, Paget’s is statistically and clinically more probable. * **Rickets:** This is a disease of vitamin D deficiency in **children** leading to soft bones and skeletal deformities; it does not cause expansile maxillary masses in adults. **High-Yield Clinical Pearls for NEET-PG:** * **Paget’s Disease:** Look for "Cotton wool" appearance on X-ray, elevated Serum Alkaline Phosphatase (with normal Calcium/Phosphate), and a risk of malignant transformation to Osteosarcoma (1%). * **Fibrous Dysplasia:** Look for "Ground glass" appearance on CT and "Chinese letter" patterns on histology. * **Maxillary Expansion:** If unilateral and in a younger patient, consider an Antrochoanal polyp or Benign tumors; if bilateral and elderly, think Paget’s.

Question 107: A patient presents with a nasal polypoidal mass and subcutaneous nodules on the skin. What is the most likely diagnosis?

A. Zygomycosis
B. Rhinosporidiosis (Correct Answer)
C. Sporotrichosis
D. Aspergillosis

Explanation: **Explanation:** The correct diagnosis is **Rhinosporidiosis**, a chronic granulomatous infection caused by *Rhinosporidium seeberi*. While primarily known for causing friable, strawberry-like nasal polyps, it can spread hematogenously to involve the skin, presenting as **subcutaneous nodules** or verrucous lesions. This systemic dissemination is a high-yield clinical feature often tested in NEET-PG. **Why the other options are incorrect:** * **Zygomycosis (Mucormycosis):** This is an aggressive, angioinvasive fungal infection typically seen in uncontrolled diabetics. It presents with black eschar, rapid tissue necrosis, and orbital involvement, rather than chronic subcutaneous nodules. * **Sporotrichosis:** Known as "Rose gardener’s disease," it typically presents with a primary skin ulcer and linear lymphocutaneous nodules. While it involves the skin, it rarely presents as a primary nasal polypoidal mass. * **Aspergillosis:** In the nose, this usually presents as a non-invasive fungal ball (mycetoma) or allergic fungal rhinosinusitis (AFRS). It does not typically manifest with subcutaneous skin nodules. **Clinical Pearls for NEET-PG:** * **Causative Agent:** *Rhinosporidium seeberi* (now classified as a Mesomycetozoea, not a true fungus). * **Classic Appearance:** Leaf-like, vascular, "strawberry" polyp with white dots (sporangia) on the surface. * **Histology:** Large, thick-walled **sporangia** containing thousands of **endospores** (diagnostic). * **Epidemiology:** Common in South India (Tamil Nadu, Kerala) and Sri Lanka; associated with bathing in stagnant pond water. * **Treatment:** Wide surgical excision with cautery of the base; **Dapsone** is used to prevent recurrence.

Question 108: All of the following are true of septoplasty for deviated nasal septum (DNS) except?

A. Indicated in septal deviation
B. Mucoperichondrium is stripped off (Correct Answer)
C. Preferably done after 16 years of age
D. May be indicated in some cases of epistaxis

Explanation: ### Explanation **Septoplasty** is a conservative surgical procedure aimed at correcting a deviated nasal septum (DNS) while preserving as much septal framework as possible. **Why Option B is the Correct Answer (The False Statement):** In Septoplasty, the mucoperichondrium/mucoperiosteum is **elevated on only one side** (unilateral flap). The flap on the opposite side is kept intact to maintain the blood supply to the septal cartilage. In contrast, **Submucous Resection (SMR)** involves stripping the mucoperichondrium from **both sides** (bilateral flaps), which increases the risk of septal perforation and "saddle nose" deformity. **Analysis of Other Options:** * **Option A:** DNS causing nasal obstruction, headache (Sluder’s neuralgia), or sinusitis is the primary indication for septoplasty. * **Option C:** It is preferably done after **17–18 years** of age (once mid-facial growth is complete). However, in modern practice, "conservative septoplasty" can be performed in children if the obstruction is severe, though the general rule for exams remains 16–18 years. * **Option D:** Septoplasty is indicated in epistaxis if a septal spur is causing localized drying/crusting or if the deviation prevents access to a bleeding vessel for cauterization. **High-Yield Clinical Pearls for NEET-PG:** * **Killian’s Incision:** Used in SMR (placed 5mm behind the caudal border). * **Freer’s Incision:** Used in Septoplasty (placed at the caudal border/hemitransfixion). * **Cottle’s Operation:** A sophisticated version of septoplasty addressing all four areas of the septum. * **Complication:** The most common complication of septal surgery is a **septal hematoma**, which, if untreated, leads to a septal abscess and subsequent saddle nose deformity.

Question 109: Which of the following is common about tumors of the Peripheral Nervous System (PNS) and Nasal Cavity?

A. Squamous cell carcinoma is the most common type.
B. Adenoid cystic carcinoma is the most common type.
C. Melanoma can occur. (Correct Answer)
D. Adenoid cystic carcinoma.

Explanation: ### Explanation **1. Why the Correct Answer is Right:** Mucosal Melanoma is a rare but aggressive malignancy that can arise from both the **nasal cavity** and the **paranasal sinuses (PNS)**. These tumors originate from melanocytes located in the respiratory mucosa of the sinonasal tract. While they represent only about 1% of all melanomas, they are a significant diagnostic consideration in these regions because they often present at an advanced stage with a poor prognosis. **2. Why the Other Options are Incorrect:** * **Option A (Squamous Cell Carcinoma - SCC):** While SCC is the most common malignancy of the **maxillary sinus**, it is not the most common tumor of the **nasal cavity** (where inverted papilloma is the most common benign tumor and SCC is common but not the "unifying" commonality in the context of this specific comparative question). * **Options B & D (Adenoid Cystic Carcinoma):** This is the most common **minor salivary gland tumor** of the sinonasal tract. While it occurs in both the PNS and nasal cavity, it is less frequent overall than SCC. It is characterized by perineural invasion and a "Swiss-cheese" pattern on histology, but it is not the defining commonality intended by this question. **3. Clinical Pearls for NEET-PG:** * **Most common site for Sinonasal SCC:** Maxillary Sinus (80%), followed by the Ethmoid Sinus. * **Occupational Risk:** Woodworkers (hardwood dust) have a significantly increased risk of **Adenocarcinoma** (specifically the ethmoid sinus). * **Inverted Papilloma:** Arises from the lateral wall of the nose; it is locally aggressive and has a 10% risk of malignant transformation into SCC. * **Esthesioneuroblastoma:** A neurogenic tumor arising from the olfactory epithelium in the roof of the nasal cavity (Kallmann’s area). * **Melanoma Presentation:** Often presents with epistaxis and nasal obstruction; look for "pigmented mass" on endoscopy, though 10-20% can be amelanotic.

Question 110: All of the following are causes of saddle nose deformity except?

A. Trauma
B. Hematoma
C. Leprosy
D. Sarcoidosis (Correct Answer)

Explanation: **Explanation:** **Saddle nose deformity** is characterized by a depression of the nasal bridge due to the destruction or collapse of the nasal septum (specifically the cartilaginous or bony framework). **Why Sarcoidosis is the correct answer:** While sarcoidosis is a granulomatous disease that affects the nose, it primarily involves the **nasal mucosa** rather than the septum. It typically presents with mucosal crusting, "strawberry" spots, or polyps. Unlike other granulomatous diseases (like Wegener’s), it rarely causes extensive septal perforation or structural collapse, making it an unlikely cause of saddle nose deformity. **Analysis of incorrect options:** * **Trauma (Option A):** This is the most common cause. Direct injury can fracture the nasal bones or the septal cartilage, leading to immediate or delayed structural collapse. * **Hematoma (Option B):** A septal hematoma strips the perichondrium from the cartilage, depriving it of its blood supply. This leads to **avascular necrosis** of the cartilage, resulting in a saddle nose if not drained promptly. * **Leprosy (Option C):** Lepromatous leprosy specifically targets the cartilaginous part of the nasal septum. Destruction of the septal support leads to a characteristic "low-bridge" saddle nose. **High-Yield Clinical Pearls for NEET-PG:** * **Syphilis:** Congenital syphilis causes destruction of the **bony** septum (leading to a saddle nose), whereas Leprosy affects the **cartilaginous** septum. * **Wegener’s Granulomatosis:** A classic cause of saddle nose due to necrotizing granulomas and vasculitis of the septum. * **Relapsing Polychondritis:** An autoimmune condition that can lead to the destruction of nasal and auricular cartilage. * **Management:** Minor deformities are treated with **augmentation rhinoplasty** (using cartilage or bone grafts).

Practice by Chapter

Rhinitis

Practice Questions

Acute Rhinosinusitis

Practice Questions

Chronic Rhinosinusitis

Practice Questions

Nasal Polyposis

Practice Questions

Allergic Fungal Sinusitis

Practice Questions

Deviated Nasal Septum

Practice Questions

Epistaxis

Practice Questions

Nasal Trauma

Practice Questions

Choanal Atresia

Practice Questions

CSF Rhinorrhea

Practice Questions

Tumors of the Nose and Paranasal Sinuses

Practice Questions

Complications of Sinusitis

Practice Questions

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