Diseases of the Nose and Paranasal Sinuses — MCQs

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

Question 111: Foul-smelling nasal discharge is seen in all the following conditions except?

A. Nasal myiasis
B. Choanal atresia (Correct Answer)
C. Foreign body in the nose
D. Rhinolith

Explanation: ### Explanation The correct answer is **B. Choanal atresia**. **1. Why Choanal Atresia is the correct answer:** Choanal atresia is a congenital failure of the posterior nasal aperture to canalize. It presents with **mucoid, non-foul-smelling nasal discharge** because the obstruction is anatomical and sterile. In bilateral cases, the neonate presents with cyclic cyanosis (relieved by crying), while unilateral cases may remain undiagnosed until later in life, presenting only with persistent, thick, odorless mucoid discharge and nasal obstruction. **2. Analysis of Incorrect Options (Conditions with foul-smelling discharge):** * **Nasal Myiasis (A):** Caused by infestation of maggots (*Chrysomyia bezziana*). The tissue destruction and secondary bacterial infection lead to an extremely foul, putrid odor. * **Foreign Body in the Nose (C):** A long-standing, neglected foreign body (usually in children) leads to localized inflammation, pressure necrosis, and secondary infection, resulting in **unilateral, purulent, and foul-smelling** discharge. * **Rhinolith (D):** A "nose stone" formed by the deposition of calcium and magnesium salts around a central nidus (foreign body or blood clot). Like a foreign body, it causes chronic irritation and infection, leading to a characteristic malodorous discharge. **3. Clinical Pearls for NEET-PG:** * **Unilateral foul-smelling discharge in a child:** Always rule out a **Foreign Body** first. * **Unilateral foul-smelling discharge in an adult:** Rule out **Malignancy** or **Rhinolith**. * **Atrophic Rhinitis:** Another high-yield cause of foul-smelling discharge (Mercaptan production), often described as "social death" due to *mercitism* (patient cannot smell their own stench due to atrophy of olfactory epithelium). * **Magnesium sulfate** or **Turpentine oil** is used in Myiasis to suffocate maggots before manual removal.

Question 112: Pott's puffy tumor is related to which of the following conditions?

A. Infected cell in middle turbinate
B. Tuberculous sinusitis
C. Pyogenic infection of frontal sinus (Correct Answer)
D. Cavernous sinus thrombosis

Explanation: **Explanation:** **Pott’s Puffy Tumor** is a clinical entity characterized by a **subperiosteal abscess** of the frontal bone associated with underlying **osteomyelitis**. 1. **Why Option C is Correct:** The condition most commonly arises as a complication of an acute **pyogenic infection of the frontal sinus**. The infection spreads from the sinus to the frontal bone via direct extension or through the **valveless diploic veins** (Breschet’s veins). This leads to osteomyelitis and the formation of a fluctuant, "puffy" swelling on the forehead. Despite the name, it is not a neoplastic "tumor" but an inflammatory mass. 2. **Why Other Options are Incorrect:** * **Option A:** An infected cell in the middle turbinate is known as an infected **Concha Bullosa**, which typically causes nasal obstruction or localized pain but does not lead to frontal bone abscesses. * **Option B:** While Sir Percivall Pott (who first described the condition) is also associated with Pott’s disease (spinal TB), Pott’s Puffy Tumor is strictly a **pyogenic** (usually *Staphylococcus* or *Streptococcus*) complication, not tuberculous. * **Option C:** Cavernous sinus thrombosis is a dreaded intracranial complication of facial or sinus infections, but it involves the venous sinuses of the brain, not a subperiosteal forehead swelling. **Clinical Pearls for NEET-PG:** * **Etiology:** Most common in adolescents due to increased diploic vein vascularity. * **Diagnosis:** **Contrast-enhanced CT (CECT)** is the gold standard to visualize the bone erosion and abscess. * **Complications:** High risk of intracranial spread, leading to **epidural abscess** or meningitis. * **Management:** Requires urgent IV antibiotics and surgical drainage (often via Trephination or FESS).

Question 113: What is the most effective medical treatment for nasal polyps?

A. Topical decongestant nasal drops
B. Antihistamines
C. Topical steroids (Correct Answer)
D. Non-steroid anti-inflammatory drugs (NSAIDs)

Explanation: **Explanation:** Nasal polyps are non-neoplastic, edematous masses of the sinonasal mucosa, typically resulting from chronic inflammation (often associated with Th2-mediated eosinophilic infiltration). **Why Topical Steroids are the Correct Answer:** Topical corticosteroids (e.g., Fluticasone, Mometasone) are the **first-line medical treatment** for nasal polyps. They work by reducing mucosal inflammation, decreasing the size of the polyps, and improving symptoms like nasal obstruction and anosmia. They act by inhibiting cytokine release and reducing eosinophil survival within the polypoid tissue. **Analysis of Incorrect Options:** * **A. Topical decongestants:** These provide temporary relief by vasoconstriction but do not treat the underlying inflammatory pathology. Prolonged use ( >5-7 days) leads to **rhinitis medicamentosa**. * **B. Antihistamines:** These are only beneficial if the patient has concurrent allergic rhinitis. They have no direct effect on shrinking established polypoid tissue. * **D. NSAIDs:** These are generally avoided, especially in patients with **Samter’s Triad** (Aspirin sensitivity, Asthma, and Nasal Polyposis), as they can exacerbate symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **Medical Management:** If topical steroids fail, a short course of **systemic steroids** (e.g., Prednisolone) is the most effective "medical polypectomy." * **Surgical Management:** The procedure of choice for refractory cases is **FESS (Functional Endoscopic Sinus Surgery)**. * **Samter’s Triad (Aspirin-Exacerbated Respiratory Disease):** A classic exam favorite consisting of Nasal Polyps + Bronchial Asthma + Aspirin Sensitivity. * **Unilateral Polyp:** Always rule out malignancy or Inverted Papilloma; in children, consider an Encephalocele or Antrochoanal polyp.

Question 114: The transillumination test was commonly performed to diagnose infection of which paranasal sinus?

A. Maxillary sinus
B. Frontal sinus
C. Sphenoid sinus
D. Both maxillary and frontal sinuses (Correct Answer)

Explanation: **Explanation:** The **Transillumination Test** is a traditional clinical bedside procedure used to assess the aeration of the paranasal sinuses. It relies on the principle that a healthy, air-filled sinus allows light to pass through its walls, whereas a sinus filled with fluid, pus, or a thickened mucosal lining (as seen in sinusitis) will appear opaque. **Why the correct answer is D:** The test is specifically applicable to the **Maxillary** and **Frontal** sinuses because they are located superficially, allowing light to be transmitted through the overlying skin or oral cavity. * **Maxillary Sinus:** A light source is placed inside the mouth (over the hard palate) with the lips closed. A normal sinus shows a crescent of light below the eye and a pupillary glow. * **Frontal Sinus:** The light source is placed against the medial floor of the supraorbital ridge. A normal sinus shows a glow on the forehead. **Why other options are incorrect:** * **Sphenoid and Ethmoid Sinuses:** These are deep-seated sinuses located centrally in the skull base. They are surrounded by thick bone and other anatomical structures, making them inaccessible for transillumination. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** While transillumination was common in the past, **Non-Contrast CT (NCCT) of the Paranasal Sinuses** is now the gold standard for diagnosing sinusitis. * **Limitations:** The test has high false-positive rates due to variations in bony thickness (e.g., sinus hypoplasia). * **Dark Room Requirement:** The test must be performed in a completely darkened room to be effective. * **Clinical Sign:** Absence of light transmission is termed "opacity," suggesting pathology like acute sinusitis or a tumor.

Question 115: Cottle's test is used to diagnose which of the following conditions?

A. Deviated nasal septum (Correct Answer)
B. Rhinosporidiosis
C. Antrochoanal polyp
D. Allergic rhinitis

Explanation: **Explanation:** **Cottle’s Test** is a clinical maneuver used to evaluate **nasal valve stenosis**, which is often a functional consequence of a **Deviated Nasal Septum (DNS)**. 1. **Why Option A is Correct:** The nasal valve is the narrowest part of the nasal airway. In patients with DNS or caudal septal deviation, this area becomes further compromised. During the test, the cheek is pulled laterally away from the midline while the patient breathes quietly. If this action opens the nasal valve and the patient reports a **significant improvement in the ease of breathing**, the test is considered **positive**. This indicates that the obstruction is at the level of the nasal valve, frequently due to septal deviation. 2. **Why Other Options are Incorrect:** * **Rhinosporidiosis:** This is a granulomatous infection caused by *Rhinosporidium seeberi*, typically presenting as a friable, strawberry-like polypoid mass. Diagnosis is clinical and confirmed by biopsy (sporangia). * **Antrochoanal Polyp:** This is a solitary mass arising from the maxillary sinus. Diagnosis is made via anterior rhinoscopy, posterior rhinoscopy, and CT imaging showing a dumbbell-shaped mass. * **Allergic Rhinitis:** This is an inflammatory condition characterized by sneezing, itching, and watery rhinorrhea. Diagnosis is based on history, physical exam (pale/boggy turbinates), and IgE/skin prick tests. **High-Yield Clinical Pearls for NEET-PG:** * **Nasal Valve:** Formed by the lower edge of the upper lateral cartilage, the septum, and the anterior end of the inferior turbinate. * **Modified Cottle’s Test:** Uses a cotton-tipped applicator or ear speculum to push the lateral wall of the valve internally; it is more specific for identifying the exact site of collapse. * **False Positives:** Can occur in patients with alar collapse or facial nerve paralysis.

Question 116: What is true about Angiofibroma?

A. Radiotherapy is the main treatment
B. Recurrence rate is high (Correct Answer)
C. Exclusively in females
D. Biopsy is must before initiating treatment

Explanation: **Juvenile Nasopharyngeal Angiofibroma (JNA)** is a benign but locally aggressive, highly vascular tumor. ### **Explanation of Options** * **Correct Answer (B): Recurrence rate is high.** Despite being histologically benign, JNA has a high recurrence rate (ranging from 6% to 40%). This is primarily due to its tendency to invade difficult-to-reach anatomical areas like the **pterygopalatine fossa**, infratemporal fossa, and sphenoid sinus, making complete surgical clearance challenging. * **Incorrect (A): Radiotherapy is the main treatment.** **Surgery** is the primary treatment of choice. Radiotherapy is reserved for cases with intracranial extension, residual disease, or recurrences where surgery is risky, due to the long-term risk of secondary malignancies and growth retardation in young patients. * **Incorrect (C): Exclusively in females.** JNA is seen **exclusively in adolescent males** (typically 10–20 years old). It is thought to be testosterone-dependent. If a similar lesion is found in a female, a karyotype should be performed to rule out genetic anomalies or the diagnosis should be reconsidered. * **Incorrect (D): Biopsy is must before initiating treatment.** Biopsy is **strictly contraindicated** because the tumor is extremely vascular and lacks a true capsule; a biopsy can lead to torrential, life-threatening hemorrhage. Diagnosis is made clinically and via imaging (CT/MRI). ### **High-Yield Clinical Pearls for NEET-PG** * **Classic Triad:** Adolescent male + Profuse recurrent epistaxis + Nasal obstruction. * **Holman-Miller Sign (Antral Sign):** Forward bowing of the posterior wall of the maxilla seen on CT. * **Diagnostic Sign:** "Frog-face" deformity (in advanced cases with facial swelling). * **Gold Standard Investigation:** Contrast-enhanced CT (CECT) and MRI. * **Pre-operative Step:** Digital Subtraction Angiography (DSA) with **embolization** 24–48 hours before surgery to reduce intraoperative blood loss. * **Blood Supply:** Most commonly the **Internal Maxillary Artery**.

Question 117: A patient uses nasal drops continuously for a prolonged period. What is a possible adverse effect?

A. Mulberry turbinate
B. Allergic rhinitis
C. Vasomotor rhinitis
D. Rhinitis medicamentosa (Correct Answer)

Explanation: ### Explanation **Rhinitis Medicamentosa** is a condition of rebound nasal congestion caused by the prolonged use of topical nasal decongestants (typically **oxymetazoline** or **xylometazoline**). These drugs are sympathomimetic amines that cause vasoconstriction. When used for more than 3–5 days, they lead to a "rebound" phenomenon where the nasal mucosa becomes chronically congested and hypertrophied due to the downregulation of alpha-receptors and interstitial edema. This creates a vicious cycle where the patient uses more drops to relieve the worsening obstruction. **Analysis of Incorrect Options:** * **A. Mulberry turbinate:** This refers to the characteristic appearance of the posterior end of the inferior turbinate in **Chronic Hypertrophic Rhinitis**. It is caused by permanent thickening of the mucosa and submucosa, often due to chronic infection or allergy, rather than acute medication rebound. * **B. Allergic rhinitis:** This is an IgE-mediated hypersensitivity reaction to inhaled allergens (pollen, dust). While it presents with congestion, it is characterized by sneezing, itching, and watery rhinorrhea, not drug overuse. * **C. Vasomotor rhinitis:** This is a non-allergic, non-infectious condition caused by autonomic instability (parasympathetic overactivity). It is triggered by environmental changes like temperature, humidity, or strong odors, rather than topical medications. **High-Yield Clinical Pearls for NEET-PG:** * **Treatment:** The first step is immediate withdrawal of the nasal drops. Topical or systemic steroids are often prescribed to manage the withdrawal congestion. * **Duration:** Advise patients never to use topical decongestants for more than **5 consecutive days**. * **Pathology:** Look for keywords like "rebound congestion" and "tachyphylaxis" (diminishing response to successive doses).

Question 118: Which sinus opens into the middle meatus?

A. Posterior ethmoid sinus
B. Sphenoid sinus
C. Frontal sinus (Correct Answer)
D. Nasolacrimal duct

Explanation: **Explanation:** The drainage of the paranasal sinuses is a high-yield topic for NEET-PG, centered on the anatomy of the lateral wall of the nose. The **Middle Meatus** is the most clinically significant area as it receives the drainage of the "Anterior Group" of sinuses. **Why the Frontal Sinus is Correct:** The frontal sinus drains into the middle meatus via the **frontonasal duct**, which opens into the anterior part of the **hiatus semilunaris** (or the ethmoidal infundibulum). Along with the frontal sinus, the **maxillary sinus** and the **anterior ethmoid sinuses** also drain into the middle meatus. **Analysis of Incorrect Options:** * **A. Posterior ethmoid sinus:** This belongs to the "Posterior Group" and drains into the **Superior Meatus**. * **B. Sphenoid sinus:** This sinus drains into the **Sphenoethmoidal recess**, located above the superior turbinate. * **D. Nasolacrimal duct:** This structure is not a sinus; it opens into the **Inferior Meatus** (guarded by Hasner’s valve). **NEET-PG Clinical Pearls:** 1. **Ostiomeatal Complex (OMC):** This is the functional unit of the middle meatus. Obstruction here leads to sinusitis of the frontal, maxillary, and anterior ethmoid sinuses (the "Anterior Group"). 2. **Maxillary Sinus:** Its ostium is located superiorly on its medial wall, making natural drainage difficult; it opens into the posterior part of the hiatus semilunaris. 3. **Agger Nasi:** The most anterior ethmoidal air cell, often used as a landmark in FESS (Functional Endoscopic Sinus Surgery). 4. **Bulla Ethmoidalis:** The largest anterior ethmoid cell, which forms the upper boundary of the hiatus semilunaris.

Question 119: Which of the following is NOT true about rhinoscleroma?

A. It is caused by Klebsiella rhinoscleromatis. (Correct Answer)
B. It is a slowly progressing granulomatous disease.
C. It is most common in young adults aged 20-30 years.
D. Poor nutrition is a contributing factor to its spread.

Explanation: **Explanation** Rhinoscleroma is a chronic, progressive granulomatous disease of the upper respiratory tract. The question asks for the statement that is **NOT** true. 1. **Why Option A is the "Correct" Answer (The False Statement):** While *Klebsiella rhinoscleromatis* (Frisch Bacillus) is indeed the causative agent, in the context of this specific MCQ format, Option A is often used as a distractor or contains a subtle technicality in older textbooks. However, medically, *Klebsiella rhinoscleromatis* **is** the cause. If this option is marked as "Not True" in a specific key, it is usually due to a typographical error in the question source or a confusion with *Klebsiella ozaenae*. **Note:** In standard clinical teaching, Option A is factually correct, making this a "faulty" question where all options are actually true. In such cases, focus on the clinical features described in B, C, and D. 2. **Analysis of Other Options (True Statements):** * **Option B:** True. It is a chronic granulomatous infection that progresses through three stages: Atrophic, Granulomatous (proliferative), and Cicatricial (scarring). * **Option C:** True. It most commonly affects individuals in the 2nd and 3rd decades of life (20–30 years). * **Option D:** True. It is endemic in areas with poor hygiene, low socioeconomic status, and poor nutrition (e.g., parts of India, Central America, and Egypt). **High-Yield Clinical Pearls for NEET-PG:** * **Causative Organism:** *Klebsiella rhinoscleromatis* (Gram-negative, capsulated diplobacillus). * **Pathology (Gold Standard):** Presence of **Mikulicz cells** (foamy macrophages containing the bacilli) and **Russell bodies** (eosinophilic hyaline bodies representing degenerated plasma cells). * **Clinical Feature:** "Hebra Nose" (woody hard swelling of the nose). It typically starts in the nasopharynx or anterior nares. * **Treatment:** Long-term antibiotics (Streptomycin and Tetracycline) are the mainstay. Rifampicin is also effective. Surgery is reserved for cicatricial stenosis.

Question 120: In acute sinusitis, which paranasal sinus is most commonly involved in children?

A. Maxillary
B. Sphenoid
C. Ethmoid (Correct Answer)
D. Frontal

Explanation: **Explanation:** The correct answer is **Ethmoid (Option C)**. The primary reason lies in the embryological development and chronological appearance of the paranasal sinuses. 1. **Why Ethmoid is Correct:** The ethmoid sinuses are the only sinuses that are **well-developed and pneumatized at birth**. Because they are present and functional from infancy, they are the most frequent site of infection in young children. Furthermore, the ethmoid air cells have small ostia that easily become obstructed during viral upper respiratory infections, leading to secondary bacterial sinusitis. 2. **Why other options are incorrect:** * **Maxillary:** While the maxillary sinus is present at birth, it is merely a small slit and only becomes clinically significant and a common site of infection after the age of 3–4 years. In **adults**, the maxillary sinus is the most commonly involved. * **Sphenoid:** This sinus starts to pneumatize around age 3–5 and reaches adult size only by puberty. It is rarely involved in isolated acute sinusitis in children. * **Frontal:** This is the last sinus to develop. It is not radiologically visible until age 6–7 and does not fully develop until late adolescence. Therefore, frontal sinusitis is almost never seen in early childhood. **High-Yield Clinical Pearls for NEET-PG:** * **Order of development:** Ethmoid > Maxillary > Sphenoid > Frontal (Mnemonic: **E**very **M**edical **S**tudent **F**ails). * **Most common sinus involved in adults:** Maxillary Sinus. * **Most common complication of Ethmoiditis:** Orbital cellulitis (due to the thin *lamina papyracea*). * **First sinus to develop (embryologically):** Maxillary (around the 3rd month of fetal life), but Ethmoid is the most developed at birth.

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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