Diseases of the Nose and Paranasal Sinuses — MCQs

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

Question 141: What is the treatment of Rhinitis Medicamentosa?

A. Withdrawal of nasal drops with a short course of steroids (Correct Answer)
B. Antibiotics
C. Polypectomy
D. Increasing the dose of the nasal drops

Explanation: **Explanation:** **Rhinitis Medicamentosa** is a condition of rebound nasal congestion caused by the prolonged use (typically >5–7 days) of topical nasal decongestants (e.g., Oxymetazoline, Xylometazoline). These drugs cause vasoconstriction; however, chronic use leads to tachyphylaxis, interstitial edema, and secondary vasodilation, resulting in a "rebound" phenomenon where the patient feels more congested than before. **Why Option A is Correct:** The primary goal of treatment is to break the cycle of dependency. 1. **Withdrawal:** Immediate cessation of the offending topical decongestant is mandatory to allow the nasal mucosa to recover. 2. **Steroids:** Systemic or topical corticosteroids are used to reduce the underlying mucosal inflammation and edema, making the withdrawal process tolerable for the patient. **Why Other Options are Incorrect:** * **Option B (Antibiotics):** Rhinitis Medicamentosa is a drug-induced physiological change, not a bacterial infection. Antibiotics have no role unless there is a secondary bacterial sinusitis. * **Option C (Polypectomy):** This is a surgical procedure for nasal polyps. While chronic rhinitis can lead to mucosal hypertrophy, the initial management is medical withdrawal, not surgery. * **Option D (Increasing the dose):** This would exacerbate the condition, leading to further mucosal damage and worsening the rebound congestion. **High-Yield NEET-PG Pearls:** * **Pathophysiology:** Chronic use leads to the loss of vascular tone and permanent damage to the ciliary epithelium. * **Clinical Presentation:** The patient often describes a "red, beefy" nasal mucosa on examination. * **Management Tip:** To ease withdrawal, some clinicians suggest stopping the drops in one nostril at a time (the "one-nostril-at-a-time" method) while starting intranasal steroid sprays.

Question 142: Regarding nasal syphilis, which of the following statements is true, except?

A. Perforation can occur in the nasal septum.
B. Saddle nose deformity may develop.
C. In newborns, the condition presents as snuffles.
D. Secondary syphilis is the common association. (Correct Answer)

Explanation: ### Explanation The correct answer is **D**, as secondary syphilis is actually the **least common** stage to manifest in the nose. Nasal syphilis primarily presents in two forms: **Congenital** and **Acquired (Tertiary)**. **1. Why Option D is the correct answer (The "Except" statement):** Secondary syphilis typically presents with systemic symptoms like skin rashes and lymphadenopathy. While it can cause simple rhinitis with mucous patches, it is rare and clinically insignificant compared to the destructive nature of the Tertiary stage. Tertiary syphilis is the classic association for chronic granulomatous nasal lesions (gummata). **2. Analysis of other options:** * **Option A (Septal Perforation):** In Tertiary syphilis, gummata (painless granulomas) involve the **bony** part of the nasal septum (vomer). This leads to necrosis and perforation. *Contrast this with Tuberculosis/Lupus, which affects the cartilaginous part.* * **Option B (Saddle Nose Deformity):** The destruction of the bony support (bridge of the nose) due to gummatous osteitis leads to the collapse of the nasal bridge, resulting in a "Saddle Nose" deformity. * **Option C (Snuffles):** This is the hallmark of **Early Congenital Syphilis** (appearing at 3–6 weeks of age). It presents as severe rhinitis with purulent, blood-stained discharge and nasal obstruction, often causing difficulty in feeding. ### High-Yield Clinical Pearls for NEET-PG: * **Site of Perforation:** Syphilis affects the **bone**; Tuberculosis/Leprosy/Trauma affects the **cartilage**. * **Late Congenital Syphilis:** Presents at puberty with **Hutchinson’s Triad** (Interstitial keratitis, Sensorineural hearing loss, and Hutchinson’s teeth). * **Treatment of Choice:** Systemic Penicillin remains the gold standard. * **Key Differential:** If a patient has a "woody hard" granuloma that is painless, think Syphilis; if it is painful and bleeds, think Malignancy or Rhinoscleroma.

Question 143: All of the following are true of antrochoanal polyp except?

A. Common in young
B. Single and unilateral
C. Bleeds on touch (Correct Answer)
D. Treatment involves FESS

Explanation: **Explanation:** Antrochoanal polyps (Killian's polyp) are benign, non-neoplastic growths that arise from the mucosa of the maxillary sinus, exit through the accessory ostium, and extend into the choana and nasopharynx. **Why "Bleeds on touch" is the correct answer (False statement):** Antrochoanal polyps are typically **translucent, pearly white, or grayish-pink** in appearance. They are relatively avascular and smooth. Unlike malignant tumors (like inverted papilloma or squamous cell carcinoma) or vascular tumors (like Juvenile Nasopharyngeal Angiofibroma), they **do not bleed on touch**. If a nasal mass bleeds easily, a clinician should suspect malignancy or a vascular lesion rather than a simple polyp. **Analysis of other options:** * **A. Common in young:** True. These polyps are most frequently seen in children and young adults, unlike ethmoidal polyps which are more common in older adults. * **B. Single and unilateral:** True. Antrochoanal polyps are characteristically solitary and affect only one side. Bilateral presentation is extremely rare. * **D. Treatment involves FESS:** True. Functional Endoscopic Sinus Surgery (FESS) is the gold standard. The goal is to remove the polyp and its stalk from the maxillary sinus to prevent recurrence. **High-Yield Clinical Pearls for NEET-PG:** * **Components:** It has three parts—Antral, Nasal, and Choanal. * **Radiology:** On X-ray/CT, it shows opacification of the maxillary sinus with a soft tissue mass extending into the nasopharynx. * **Differential Diagnosis:** Must be differentiated from **Angiofibroma** (which occurs in adolescent males and bleeds profusely). * **Historical Note:** The Caldwell-Luc operation was previously used but has been largely replaced by FESS.

Question 144: Which of the following arteries does NOT participate in the anastomosis in Little's area?

A. Anterior ethmoid artery
B. Sphenopalatine artery
C. Posterior ethmoid artery (Correct Answer)
D. Greater palatine artery

Explanation: **Explanation:** **Little’s Area** (also known as Kiesselbach’s plexus) is a highly vascularized region located in the anteroinferior part of the nasal septum. It is the most common site for epistaxis (nosebleeds). **1. Why the Correct Answer is Right:** The **Posterior Ethmoid Artery** is the correct answer because it does **not** contribute to the plexus. It supplies the superior turbinate and the posterior part of the nasal septum. Anatomically, it enters the nasal cavity further back and higher up than Little's area. **2. Analysis of Incorrect Options (The Contributors):** Little’s area is formed by the anastomosis of four main arteries derived from both the Internal Carotid Artery (ICA) and External Carotid Artery (ECA) systems: * **Anterior Ethmoid Artery (Option A):** A branch of the Ophthalmic artery (ICA system). It supplies the anterosuperior part of the septum. * **Sphenopalatine Artery (Option B):** Known as the "Artery of Epistaxis," it is a terminal branch of the Maxillary artery (ECA system). * **Greater Palatine Artery (Option D):** A branch of the Maxillary artery (ECA system) that reaches the septum via the incisive canal. * **Superior Labial Artery (Septal branch):** A branch of the Facial artery (ECA system). **3. Clinical Pearls for NEET-PG:** * **Woodruff’s Plexus:** Located posteriorly (venous plexus) over the middle and inferior turbinates; it is the common site for **posterior epistaxis**. * **Artery of Epistaxis:** Sphenopalatine artery. * **Trotter’s Triad:** Associated with Nasopharyngeal Carcinoma (Conductive deafness, Palatal palsy, and Temporofacial neuralgia). * **Management:** Anterior epistaxis from Little's area is typically managed with chemical cautery (Silver Nitrate) or anterior nasal packing.

Question 145: A patient, post-laparoscopic appendicectomy, experienced a fall from bed resulting in nasal swelling and difficulty breathing. What is the next step in management?

A. Administer antibiotics for 7-10 days
B. Observation in hospital
C. Surgical drainage (Correct Answer)
D. Discharge after 2 days with follow-up in 8 weeks

Explanation: **Explanation:** The clinical presentation of nasal swelling and airway obstruction following trauma (the fall) is highly suggestive of a **Nasal Septal Hematoma**. This occurs when blood collects between the septal cartilage and its overlying mucoperichondrium. **Why Surgical Drainage is the Correct Answer:** A septal hematoma is a surgical emergency. The septal cartilage relies on the perichondrium for its blood supply through diffusion. The collection of blood separates these layers, leading to **ischemic necrosis** of the cartilage. If not drained immediately via incision and drainage (I&D), it can lead to a septal abscess, septal perforation, or a permanent cosmetic deformity known as **Saddle Nose Deformity**. **Analysis of Incorrect Options:** * **Option A (Antibiotics):** While antibiotics are given post-drainage to prevent secondary infection (abscess), they cannot evacuate the hematoma or restore blood supply to the cartilage. * **Option B (Observation):** Observation is contraindicated as the pressure from the hematoma will continue to compromise the cartilage's viability. * **Option D (Discharge/Delayed Follow-up):** Delaying treatment for 8 weeks would guarantee permanent structural damage and potential intracranial complications if an abscess forms. **NEET-PG High-Yield Pearls:** * **Clinical Sign:** On examination, look for a bilateral, soft, fluctuant, reddish/purplish bulge on the septum that does not shrink with topical vasoconstrictors. * **Management:** Wide horizontal incision (to prevent premature closure) followed by nasal packing to prevent re-accumulation. * **Most Common Complication:** If untreated, the most common late complication is **Saddle Nose Deformity** due to cartilage destruction. * **Pediatric Note:** In children, even minor trauma can cause a hematoma; always check the septum in pediatric nasal injuries.

Question 146: Which of the following is NOT a component of Kiesselbach's plexus?

A. Superior labial artery
B. Posterior ethmoidal artery (Correct Answer)
C. Sphenopalatine artery
D. Greater palatine artery

Explanation: **Explanation:** **Kiesselbach’s Plexus** (also known as Little’s area) is a highly vascularized region located on the anteroinferior part of the nasal septum. It is the most common site for epistaxis (90% of cases). **1. Why Posterior Ethmoidal Artery is the Correct Answer:** The **Posterior ethmoidal artery** does not contribute to Kiesselbach's plexus. It supplies the superior turbinate and the posterior part of the nasal septum. In contrast, the **Anterior ethmoidal artery** is a key component of the plexus. Remembering this distinction is a frequent "trap" in NEET-PG questions. **2. Analysis of Incorrect Options (Components of the Plexus):** The plexus is formed by the anastomosis of four main arteries derived from both the Internal Carotid Artery (ICA) and External Carotid Artery (ECA) systems: * **Superior Labial Artery (Option A):** A branch of the Facial artery (ECA), supplying the anteroinferior septum. * **Sphenopalatine Artery (Option C):** Known as the "Artery of Epistaxis," it is the terminal branch of the Maxillary artery (ECA). * **Greater Palatine Artery (Option D):** A branch of the Maxillary artery (ECA) that enters the nose through the incisive canal. * *(Not listed in options but essential)*: **Anterior Ethmoidal Artery**, a branch of the Ophthalmic artery (ICA). **Clinical Pearls for NEET-PG:** * **Woodruff’s Plexus:** Located posteriorly (venous plexus), it is the most common site for **posterior epistaxis**, involving the sphenopalatine artery. * **Little’s Area:** The clinical name for the site where Kiesselbach’s plexus is located. * **Management:** Anterior epistaxis is typically managed by local pressure (Trotter’s method) or chemical cautery (Silver Nitrate), whereas posterior epistaxis often requires packing or arterial ligation.

Question 147: Kiesselbach's area is formed by the anastomosis of which arteries?

A. Sphenopalatine artery and superior labial artery (Correct Answer)
B. Sphenopalatine artery and anterior ethmoidal artery
C. Anterior ethmoidal artery and posterior ethmoidal artery
D. Anterior ethmoidal artery and superior labial artery

Explanation: **Explanation:** Kiesselbach’s plexus (also known as **Little’s area**) is a highly vascularized region located in the anteroinferior part of the nasal septum. It is the most common site for epistaxis (90% of cases). **1. Why the Correct Answer is Right:** The plexus is formed by the anastomosis of four (sometimes five) major arteries. According to the options provided, the **Sphenopalatine artery** (a branch of the Maxillary artery) and the **Superior Labial artery** (a branch of the Facial artery) are two primary contributors. The complete list of contributing arteries includes: * **Anterior Ethmoidal artery** (from Ophthalmic artery) * **Sphenopalatine artery** (Terminal branch of Maxillary artery) * **Greater Palatine artery** (from Maxillary artery) * **Superior Labial artery** (Septal branch from Facial artery) **2. Analysis of Incorrect Options:** * **Option B & D:** While the Anterior Ethmoidal artery and Superior Labial artery are part of the plexus, these options are incomplete compared to the standard definition of the anastomosis involving both Internal and External Carotid systems. * **Option C:** The Posterior Ethmoidal artery typically supplies the superior turbinate and upper septum but does **not** contribute to Kiesselbach’s plexus. **3. Clinical Pearls for NEET-PG:** * **Woodruff’s Plexus:** Located in the posterior part of the nasal cavity (inferior to the posterior end of the middle turbinate); it is the most common site for **posterior epistaxis**, primarily involving the Sphenopalatine artery. * **Little’s Area:** This is the clinical "danger zone" for nose picking. * **Management:** Anterior epistaxis from this area is typically managed with direct pressure (Trotter’s method) or chemical cautery (Silver Nitrate). * **Arterial Origin:** It represents a site of anastomosis between the **Internal Carotid Artery** (via Ethmoidal branches) and the **External Carotid Artery** (via Sphenopalatine, Greater Palatine, and Facial branches).

Question 148: A 10-year-old child presents with unilateral nasal obstruction, epistaxis, and swelling over the cheek. What is the most likely diagnosis?

A. Nasal polyp
B. Nasopharyngeal carcinoma
C. Angiofibroma (Correct Answer)
D. Foreign bodies

Explanation: **Explanation:** The clinical triad of **unilateral nasal obstruction, recurrent epistaxis, and facial swelling** in a young male child is a classic presentation of **Juvenile Nasopharyngeal Angiofibroma (JNA)**. **1. Why Angiofibroma is Correct:** JNA is a benign but locally aggressive, highly vascular tumor that almost exclusively affects adolescent males (typically 10–20 years old). It originates near the sphenopalatine foramen. As the tumor grows, it expands into the pterygopalatine fossa, leading to the characteristic **cheek swelling** (Frog-face deformity in advanced stages). The vascular nature of the tumor explains the profuse, spontaneous epistaxis. **2. Why Other Options are Incorrect:** * **Nasal Polyp:** Usually presents with bilateral obstruction and watery discharge. While they can cause swelling (e.g., Ethmoidal polyps), they rarely cause significant epistaxis. * **Nasopharyngeal Carcinoma:** More common in older adults (bimodal peak) or associated with EBV. It typically presents with cervical lymphadenopathy and serous otitis media rather than acute cheek swelling in a child. * **Foreign Bodies:** Common in children and cause unilateral obstruction and malodorous/purulent discharge, but they do not cause facial swelling or massive epistaxis. **3. NEET-PG High-Yield Pearls:** * **Holman-Miller Sign (Antral Sign):** Forward bowing of the posterior wall of the maxillary sinus seen on lateral X-ray or CT. * **Diagnosis:** Contrast-enhanced CT (CECT) is the investigation of choice. **Biopsy is contraindicated** due to the risk of life-threatening hemorrhage. * **Treatment:** Surgical excision (usually preceded by preoperative embolization to reduce blood loss). * **Origin:** Sphenopalatine foramen/Pterygopalatine fossa.

Question 149: Features associated with Deviated Nasal Septum (DNS) include all of the following except?

A. Epistaxis
B. Atrophy of turbinate (Correct Answer)
C. Hypertrophy of turbinate
D. Recurrent sinusitis

Explanation: ### Explanation **Deviated Nasal Septum (DNS)** refers to a physical shift of the nasal septum from the midline, which leads to structural and functional changes within the nasal cavity. **Why "Atrophy of turbinate" is the correct answer:** In DNS, the nasal cavity is divided into a **narrow side** (convexity) and a **wider side** (concavity). To compensate for the excess room on the wider side and to regulate airflow/humidification, the body undergoes **Compensatory Hypertrophy** of the inferior turbinate. Therefore, DNS is associated with *hypertrophy*, not *atrophy*. Atrophy of turbinates is typically seen in conditions like Atrophic Rhinitis (Ozaena). **Analysis of Incorrect Options:** * **Epistaxis:** The sharp angulation at the site of a septal spur or deviation stretches the overlying mucosa, making it thin and prone to drying and crusting. This leads to the rupture of small vessels, causing nosebleeds. * **Hypertrophy of turbinate:** As mentioned, this is a compensatory mechanism on the side opposite the deviation to prevent excessive drying of the mucosa. * **Recurrent Sinusitis:** DNS can obstruct the **osteomeatal complex**, impairing the drainage and ventilation of the paranasal sinuses, which leads to stasis of secretions and infection. **High-Yield Clinical Pearls for NEET-PG:** * **Cottle’s Test:** Used to evaluate nasal valve patency in DNS. * **Sluder’s Neuralgia:** Facial pain caused by a septal spur pressing against the lateral nasal wall (contact point headache). * **Treatment of Choice:** Septoplasty is preferred over SMR (Submucous Resection) in younger patients to preserve septal support.

Question 150: Pain in the vertex is typically seen in which condition?

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

Explanation: **Explanation:** The correct answer is **Sphenoid Sinusitis**. **1. Why Sphenoid Sinusitis is correct:** The sphenoid sinus is located deep within the skull, close to the center of the cranial base. Pain originating from the sphenoid sinus is typically referred to the **vertex** (the top of the head), the occiput, or behind the eyes (retro-orbital). This referred pain pattern occurs because the sinus is innervated by the ophthalmic division of the trigeminal nerve (CN V1) and the sphenopalatine ganglion. Sphenoid sinusitis is often called the "forgotten sinus" because its symptoms are vague and do not present with typical facial pressure. **2. Why the other options are incorrect:** * **Ethmoid Sinusitis:** Pain is typically localized to the **bridge of the nose**, the medial canthus of the eye, or the retro-orbital area. * **Frontal Sinusitis:** Characterized by pain in the **forehead** (supraorbital region). It often follows a "periodic" or "office headache" pattern, where pain starts in the morning and subsides by late afternoon as the sinus drains. * **Maxillary Sinusitis:** Pain is felt over the **cheek** (infraorbital region) and may be referred to the upper teeth (dental pain), as the superior alveolar nerves supply both the sinus and the teeth. **3. Clinical Pearls for NEET-PG:** * **Office Headache:** Classic sign of Frontal Sinusitis. * **Mnemonic for Pain Sites:** * Frontal → Forehead * Maxillary → Cheek/Teeth * Ethmoid → Bridge of nose * Sphenoid → Vertex/Occiput * **Complications:** Sphenoid sinusitis is high-risk due to its proximity to the optic nerve, cavernous sinus, and internal carotid artery. Always rule it out in cases of isolated vertex headache.

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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