Diseases of the Nose and Paranasal Sinuses — MCQs

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

Question 191: Furstenberg's test is positive in which of the following conditions?

A. Nasal Glioma
B. Nasal Labial Cyst
C. Encephalocele (Correct Answer)
D. Nasal Bone Fracture

Explanation: **Explanation:** **Furstenberg’s Test** is a clinical maneuver used to differentiate congenital midline nasal masses. It is based on the principle of **intracranial communication**. ### Why Encephalocele is Correct: An **Encephalocele** is a herniation of cranial contents (brain tissue and meninges) through a defect in the skull base. Because there is a direct connection with the subarachnoid space, any maneuver that increases intracranial pressure (ICP)—such as crying, straining, or bilateral compression of the internal jugular veins (Furstenberg’s test)—will cause the nasal mass to **pulsate and expand** in size. A positive test confirms this intracranial connection. ### Why Other Options are Incorrect: * **Nasal Glioma:** These are ectopic rests of glial tissue. While they share a similar embryological origin with encephaloceles, they have **lost their intracranial connection** (sequestered). Therefore, Furstenberg’s test is **negative**. * **Nasal Labial Cyst:** This is a soft tissue cyst located in the nasolabial fold (extraosseous). It has no relation to the cranial cavity or the nasal roof. * **Nasal Bone Fracture:** This is a traumatic bony injury. While it causes swelling and epistaxis, it does not involve herniation of intracranial contents. ### High-Yield Clinical Pearls for NEET-PG: * **Transillumination Test:** Encephaloceles often transilluminate (due to CSF content), whereas Nasal Gliomas do not. * **Biopsy Warning:** Never biopsy a midline nasal mass until an encephalocele has been ruled out via imaging (CT/MRI) to avoid a **CSF leak and meningitis**. * **Pulsation:** Encephaloceles may demonstrate expansile pulsations synchronous with the arterial pulse.

Question 192: Premaxilla-premaxillary cyst is also known as which of the following?

A. Nasoalveolar cyst
B. Nasopalatine cyst
C. Incisive canal cyst
D. Globulomaxillary cyst (Correct Answer)

Explanation: **Explanation:** The **Globulomaxillary cyst** is a non-odontogenic fissure cyst that occurs at the junction of the **premaxilla** (formed by the primary palate) and the **maxilla** (formed by the secondary palate). It is classically located between the roots of the maxillary lateral incisor and the canine. Radiographically, it presents as a characteristic **inverted pear-shaped radiolucency** that causes the roots of these teeth to diverge. **Analysis of Options:** * **A. Nasoalveolar cyst (Klestadt’s cyst):** This is a soft tissue cyst located in the nasolabial fold, outside the bone. It does not typically present as an intraosseous premaxillary radiolucency. * **B & C. Nasopalatine / Incisive canal cyst:** These are the same entity. They are the most common non-odontogenic cysts of the maxilla, located in the midline of the anterior palate (incisive canal). They present as a **heart-shaped radiolucency** between the central incisors, not at the premaxilla-maxilla junction. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Between the maxillary lateral incisor and canine. * **Radiology:** "Inverted pear-shaped" radiolucency. * **Vitality:** Unlike radicular cysts, the teeth associated with a globulomaxillary cyst are **vital**. * **Current Concept:** Many modern pathologists consider the "Globulomaxillary cyst" a clinical term rather than a distinct pathological entity, as most cases are actually odontogenic (like lateral periodontal cysts or keratocysts) or inflammatory in origin. However, for exam purposes, the association with the premaxillary junction remains high-yield.

Question 193: An 18-year-old boy presented with repeated epistaxis and a mass arising from the lateral wall of his nose extending into the nasopharynx. Surgical intervention is planned. All of the following statements regarding his management are true, except which one?

A. Adequate blood transfusion should be arranged.
B. A lateral rhinotomy approach may be utilized.
C. A transpalatal approach is typically employed. (Correct Answer)
D. A transmaxillary approach can be considered.

Explanation: **Explanation:** The clinical presentation of an 18-year-old male with recurrent epistaxis and a nasopharyngeal mass is classic for **Juvenile Nasopharyngeal Angiofibroma (JNA)**. JNA is a benign but locally aggressive, highly vascular tumor. **Why Option C is the Correct Answer (The False Statement):** While the **transpalatal approach** provides access to the nasopharynx, it is **not typically employed** for JNA today. It offers limited exposure to the lateral extensions of the tumor (like the pterygopalatine fossa), carries a high risk of palatal fistula, and can interfere with maxillofacial growth in young patients. Modern management favors endoscopic or more extensive external approaches. **Analysis of Other Options:** * **Option A (True):** JNA is extremely vascular. Significant intraoperative blood loss is expected; therefore, arranging adequate blood transfusion and performing **pre-operative embolization** (24–48 hours prior) are standard protocols. * **Option B & D (True):** These are recognized surgical routes. A **lateral rhinotomy** or a **transmaxillary approach** (like the Weber-Fergusson incision or Medial Maxillectomy) provides the necessary wide exposure to reach the tumor's origin at the sphenopalatine foramen and its lateral extensions. **High-Yield Clinical Pearls for NEET-PG:** * **Origin:** Specifically from the superior margin of the **sphenopalatine foramen**. * **Diagnosis:** Primarily clinical and radiological (Contrast CT/MRI). **Biopsy is contraindicated** due to the risk of torrential hemorrhage. * **Holman-Miller Sign:** Anterior bowing of the posterior wall of the maxillary sinus seen on CT (pathognomonic). * **Gold Standard Treatment:** Surgical excision. Endoscopic endonasal resection is now preferred for early-stage tumors (Fisch I & II).

Question 194: Which of the following is a known complication of acute sinusitis?

A. Orbital cellulitis
B. Potts puffy tumor (Correct Answer)
C. Conjunctival chemosis
D. Subdural abscess

Explanation: **Explanation:** **Potts Puffy Tumor** is a classic, high-yield complication of **acute frontal sinusitis**. It is characterized by subperiosteal abscess and overlying soft tissue edema of the forehead. The underlying mechanism is **osteomyelitis of the frontal bone**, which occurs due to the spread of infection through the diploic veins (veins of Breschet) or by direct extension. It presents as a fluctuant, tender swelling on the forehead. **Analysis of Options:** * **Orbital Cellulitis (Option A):** While this is a common complication of ethmoid sinusitis, Potts Puffy Tumor is specifically associated with frontal bone osteomyelitis, making it a more distinct "named" complication often tested in exams. * **Conjunctival Chemosis (Option C):** This is a clinical sign (swelling of the conjunctiva) seen in orbital complications or cavernous sinus thrombosis, but it is not a primary diagnosis or a specific "tumor-like" complication. * **Subdural Abscess (Option D):** This is an intracranial complication. While acute sinusitis can lead to intracranial spread, Potts Puffy Tumor is the specific extracranial complication involving the bone and soft tissue. **NEET-PG High-Yield Pearls:** * **Most common sinus involved in orbital complications:** Ethmoid sinus (due to the thin *lamina papyracea*). * **Most common sinus involved in intracranial complications:** Frontal sinus. * **Chandler’s Classification:** Used to stage orbital complications of sinusitis (Stage I: Preseptal cellulitis to Stage V: Cavernous sinus thrombosis). * **Management of Potts Puffy Tumor:** Requires IV antibiotics and surgical drainage (often via a trephination or endoscopic approach).

Question 195: Which of the following statements is true regarding ethmoidal polyps?

A. Epistaxis
B. Unilateral
C. Common in individuals less than 10 years of age
D. Associated with bronchial asthma (Correct Answer)

Explanation: **Explanation:** Ethmoidal polyps are multiple, pedunculated, grape-like masses arising from the ethmoidal air cells. They are primarily inflammatory in nature and are strongly associated with **Type I hypersensitivity and chronic inflammation.** **Why the correct answer is right:** * **Associated with Bronchial Asthma:** Ethmoidal polyposis is frequently part of a systemic respiratory mucosal disorder. A classic association is **Samter’s Triad (Aspirin-Exacerbated Respiratory Disease)**, which consists of: 1. Nasal Polyposis, 2. Bronchial Asthma, and 3. Aspirin Intolerance. Approximately 20-30% of patients with ethmoidal polyps have coexisting asthma. **Why the incorrect options are wrong:** * **A. Epistaxis:** Ethmoidal polyps are typically painless and do not bleed on touch. If a "polyp" presents with epistaxis, one must rule out malignancy or an **Angiofibroma**. * **B. Unilateral:** Ethmoidal polyps are almost always **bilateral**. A strictly unilateral polyp in an adult should raise suspicion of an **Inverted Papilloma** or malignancy; in a child, it may be an Encephalocele. (Note: Antrochoanal polyps are typically unilateral). * **C. Common in individuals < 10 years:** These polyps are most common in **adults**. If multiple nasal polyps are seen in a child under 10, the clinician must investigate for **Cystic Fibrosis**. **High-Yield Clinical Pearls for NEET-PG:** * **Appearance:** "Peeled grape" appearance; pale, translucent, and insensitive to touch. * **Origin:** Most commonly from the **middle meatus** (lateral wall of the nose). * **Kartagener’s Syndrome:** Associated with bronchiectasis, sinusitis, situs inversus, and nasal polyps. * **Investigation of Choice:** Non-contrast CT (NCCT) of the Paranasal Sinuses (PNS). * **Treatment of Choice:** Functional Endoscopic Sinus Surgery (FESS) if medical management (steroids) fails.

Question 196: Which of the following is NOT a paranasal sinus?

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

Explanation: ### Explanation **Correct Answer: D. Pyriform** **1. Why Pyriform is the Correct Answer:** The **Pyriform sinus** (or pyriform fossa) is not a paranasal sinus; it is a part of the **hypopharynx** (laryngopharynx). It consists of two pear-shaped mucosal recesses located on either side of the laryngeal inlet, bounded laterally by the thyroid cartilage and medially by the aryepiglottic fold. Clinically, it is a common site for the lodgment of foreign bodies and the development of hypopharyngeal malignancies. **2. Why the other options are incorrect:** The Paranasal Sinuses (PNS) are air-filled cavities within the cranial and facial bones that communicate with the nasal cavity. They are divided into two groups: * **A. Frontal Sinus:** Located in the frontal bone; drains into the middle meatus via the frontonasal duct. * **B. Ethmoid Sinus:** A complex of air cells within the ethmoid bone (divided into anterior, middle, and posterior groups). * **C. Sphenoid Sinus:** Located deep within the body of the sphenoid bone; drains into the sphenoethmoidal recess. *(Note: The **Maxillary sinus** is the fourth paranasal sinus, not listed here.)* **3. NEET-PG High-Yield Pearls:** * **Development:** The **Ethmoid** sinus is the first to develop (present at birth). The **Maxillary** sinus is the first to be seen radiologically (at 4–5 months). The **Frontal** sinus is the last to develop. * **Drainage:** All sinuses drain into the **Middle Meatus**, EXCEPT the Posterior Ethmoid (Superior Meatus) and the Sphenoid (Sphenoethmoidal Recess). * **Clinical Significance of Pyriform Fossa:** It is known as the **"Smuggler’s Fossa"** (used to hide small items) and is a "silent area" for tumors, often presenting late with referred otalgia via the internal laryngeal nerve.

Question 197: Nasal septum perforation occurs in all the following except?

A. Tuberculosis
B. Nasal surgery
C. Syphilis
D. Allergic rhinitis (Correct Answer)

Explanation: **Explanation:** Nasal septal perforation occurs when there is a full-thickness defect in the cartilaginous or bony septum, leading to communication between the two nasal cavities. **Why Allergic Rhinitis is the Correct Answer:** Allergic rhinitis is an IgE-mediated inflammatory response of the nasal mucosa. While it causes symptoms like sneezing, rhinorrhea, and mucosal edema, it **does not** cause tissue necrosis or destruction of the underlying septal cartilage or bone. Therefore, it is not a cause of septal perforation. **Why the other options are incorrect (Causes of Perforation):** * **Nasal Surgery:** This is the **most common cause** of septal perforation (iatrogenic). It typically occurs during Submucous Resection (SMR) or Septoplasty when bilateral, opposing tears are made in the mucoperichondrial flaps. * **Tuberculosis:** Chronic granulomatous infections like TB cause "cold" necrosis. TB typically affects the **cartilaginous** part of the septum. * **Syphilis:** Tertiary syphilis (gumma formation) is a classic cause of perforation. Unlike TB, syphilis characteristically involves the **bony septum** (vomer). **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common site:** The anterior cartilaginous septum (Kiesselbach’s plexus area) due to its tenuous blood supply. 2. **Infectious causes:** Leprosy (affects the anterior cartilaginous part), Syphilis (affects the bony part), and Rhinoscleroma. 3. **Traumatic causes:** Nose picking (epistaxis digitarum), septal hematoma, and bilateral cauterization for epistaxis. 4. **Drug-induced:** Chronic cocaine snorting (due to intense vasoconstriction and ischemia) and prolonged use of topical steroid sprays if directed incorrectly at the septum. 5. **Wegener’s Granulomatosis:** A common systemic cause involving necrotizing granulomas.

Question 198: Which of the following statements about antrochoanal polyps is false?

A. They are typically unilateral and single.
B. They arise from the maxillary sinus and grow backwards towards the choana.
C. Avulsion is considered the treatment of choice. (Correct Answer)
D. They are commonly found in children and young adults.

Explanation: ### Explanation **Why Option C is the correct (False) statement:** While **avulsion** (simple removal) was historically practiced, it is **not** the treatment of choice because it carries a high recurrence rate (approx. 25%). The polyp originates from the lining of the maxillary sinus; if the stalk (pedicle) is not completely removed from its site of origin, the polyp will regrow. The current **gold standard treatment is Functional Endoscopic Sinus Surgery (FESS)**, which allows for the complete removal of the polyp along with its base at the maxillary antrum, often by widening the natural ostium or performing a mega-antrostomy. **Analysis of other options:** * **Option A (True):** Antrochoanal polyps (Killian’s polyp) are almost always **unilateral and solitary**, unlike ethmoidal polyps which are typically bilateral and multiple. * **Option B (True):** They originate from the mucosa of the **maxillary antrum**, exit through the accessory (or natural) ostium, and extend posteriorly into the **choana** and nasopharynx due to the direction of ciliary flow and inspiratory air currents. * **Option D (True):** These polyps are most frequently diagnosed in **children and young adults**, whereas ethmoidal polyps are more common in adults. **Clinical Pearls for NEET-PG:** * **Components:** An antrochoanal polyp has three parts: Antral, Nasal, and Choanal. * **Radiology:** On X-ray (Water’s view), it shows opacification of the involved maxillary sinus. On CT, it appears as a homogenous mass extending from the maxillary sinus to the choana. * **Differential Diagnosis:** In a young male with a mass in the nasopharynx, always rule out Juvenile Nasopharyngeal Angiofibroma (JNA). * **Historical Procedure:** The Caldwell-Luc operation was previously used for recurrent cases but has largely been replaced by FESS.

Question 199: Inverted papilloma of the nose is also known as which of the following?

A. Schneiderian papilloma (Correct Answer)
B. Klatskin's tumour
C. Bowen's disease
D. Pyoderma gangrenosum

Explanation: **Explanation:** **1. Why Schneiderian Papilloma is correct:** The nasal cavity and paranasal sinuses are lined by a unique ectoderm-derived mucosa known as the **Schneiderian membrane**. Inverted papilloma is a benign but locally aggressive epithelial tumor arising from this membrane; hence, it is collectively referred to as a **Schneiderian papilloma**. The term "inverted" refers to the characteristic histological growth pattern where the surface epithelium proliferates downward into the underlying stroma rather than outward. **2. Why the other options are incorrect:** * **Klatskin’s tumour:** This is a hilar cholangiocarcinoma occurring at the junction of the right and left hepatic ducts. It is a gastrointestinal/hepatobiliary pathology. * **Bowen’s disease:** This represents squamous cell carcinoma in situ of the skin. It is a dermatological condition and not specific to the nasal mucosa. * **Pyoderma gangrenosum:** This is a rare, non-infectious inflammatory dermatosis characterized by painful skin ulcers, often associated with systemic diseases like Inflammatory Bowel Disease (IBD). **3. High-Yield Clinical Pearls for NEET-PG:** * **Site of Origin:** Most commonly arises from the **lateral wall of the nose** (middle meatus/ethmoid sinus region). * **Clinical Presentation:** Unilateral nasal obstruction and epistaxis. * **Key Characteristic:** It has a high rate of recurrence and a **10% risk of malignant transformation** into Squamous Cell Carcinoma. * **Management:** Complete surgical excision, typically via **Endoscopic Sinus Surgery (ESS)** or Medial Maxillectomy. * **HPV Association:** Subtypes 6 and 11 are often implicated in the etiology.

Question 200: A young patient presents with headache, epiphora, and bilateral nasal obstruction, without fever. What is the most likely diagnosis?

A. Nasal polyp
B. Juvenile angiofibroma (Correct Answer)
C. Nasal carcinoma
D. Rhinoscleroma

Explanation: **Explanation:** The clinical presentation of a young patient with **bilateral nasal obstruction**, **headache**, and **epiphora** (excessive tearing) strongly suggests a space-occupying lesion in the nasopharynx. **Juvenile Nasopharyngeal Angiofibroma (JNA)** is a benign but locally aggressive, highly vascular tumor typically seen in adolescent males. While it originates in the sphenopalatine foramen (unilateral), it frequently grows to fill the nasopharynx, causing **bilateral obstruction**. Epiphora occurs due to the tumor's pressure on the nasolacrimal duct, and headaches result from sinus blockage or pressure on the skull base. The absence of fever helps rule out acute inflammatory conditions. **Why other options are incorrect:** * **Nasal Polyp:** While they cause bilateral obstruction and headache, they are usually associated with anosmia and watery rhinorrhea rather than the significant pressure symptoms (like epiphora) seen in JNA. * **Nasal Carcinoma:** This is rare in young patients and typically presents with unilateral symptoms, foul-smelling discharge, and cervical lymphadenopathy. * **Rhinoscleroma:** A chronic granulomatous disease that causes obstruction and a "woody hard" nose, but it usually presents with characteristic stages (atrophic, granulomatous, cicatricial) and is less likely to cause epiphora compared to a bulky nasopharyngeal mass. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Adolescent male + Profuse recurrent epistaxis + Nasal obstruction. * **Holman-Miller Sign:** Anterior bowing of the posterior wall of the maxilla seen on CT/MRI. * **Diagnosis:** Biopsy is **contraindicated** due to the risk of torrential hemorrhage; diagnosis is clinical and radiological. * **Treatment of Choice:** Surgical excision (usually preceded by embolization to reduce blood loss).

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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