Diseases of the Nose and Paranasal Sinuses — MCQs

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

Question 211: In which stage of syphilis is the nose commonly involved?

A. Primary
B. Secondary
C. Tertiary (Correct Answer)
D. Equally involved in all stages

Explanation: **Explanation:** The nose is most commonly and severely involved in the **Tertiary stage** of syphilis. In this stage, the characteristic lesion is the **Gumma**, a chronic granulomatous reaction. * **Why Tertiary is correct:** Tertiary syphilis involves the nasal bones (specifically the bony septum) and the bridge of the nose. The gummatous process leads to extensive necrosis and destruction of the osteochondral framework. This results in the classic **"Saddle Nose" deformity** due to the collapse of the nasal bridge. Perforation of the bony septum is a hallmark of tertiary syphilis (unlike tuberculosis, which typically affects the cartilaginous septum). * **Why Primary is incorrect:** Primary syphilis involves a painless chancre. While it can occur on the external nose or vestibule via direct inoculation, it is extremely rare. * **Why Secondary is incorrect:** Secondary syphilis typically presents with systemic symptoms like skin rashes and lymphadenopathy. Nasal involvement is rare but may manifest as persistent rhinitis (snuffles) or mucous patches. * **Why "Equally involved" is incorrect:** The pathological impact on the nose is disproportionately higher and more clinically significant in the tertiary stage. **High-Yield Clinical Pearls for NEET-PG:** 1. **Congenital Syphilis:** Presents with **"Snuffles"** (purulent/bloody nasal discharge) in the early stage and **Saddle Nose** in the late stage. 2. **Bony vs. Cartilaginous:** Syphilis attacks the **bony septum**; Lupus/Tuberculosis attacks the **cartilaginous septum**. 3. **Diagnosis:** Screening is done via VDRL/RPR; confirmation via FTA-ABS (Treponemal test). 4. **Treatment:** Long-acting Penicillin (Benzathine Penicillin G) remains the drug of choice.

Question 212: What is the best surgical treatment for chronic maxillary sinusitis?

A. Repeated antral washout
B. Fiberoptic endoscopic sinus surgery (Correct Answer)
C. Caldwell-Luc's operation
D. Horgan's operation

Explanation: **Explanation:** The management of chronic maxillary sinusitis has evolved significantly with the understanding of the **Osteomeatal Complex (OMC)**. **1. Why Fiberoptic Endoscopic Sinus Surgery (FESS) is the Correct Answer:** FESS is currently the **gold standard** and treatment of choice. The underlying medical concept is the restoration of **mucociliary clearance**. In health, the maxillary sinus drains superiorly through its natural ostium into the middle meatus. FESS is a physiological surgery that focuses on widening the natural ostium and clearing obstructions in the OMC, allowing the sinus to drain and ventilate naturally while preserving the sinus mucosa. **2. Why the other options are incorrect:** * **Repeated Antral Washout:** This is a conservative, temporary procedure. It provides symptomatic relief by removing pus but does not address the underlying anatomical obstruction or the diseased OMC. * **Caldwell-Luc’s Operation:** Once the standard, it is now reserved for specific cases (e.g., fungal balls, orbital floor fractures, or failed FESS). It is a non-physiological approach that involves creating a permanent window in the inferior meatus and removing the sinus lining, which often leads to complications like facial numbness or cheek swelling. * **Horgan’s Operation:** This is a transantral approach to the ethmoid sinuses via a Caldwell-Luc incision. It is largely obsolete in the era of endoscopy. **Clinical Pearls for NEET-PG:** * **Primary goal of FESS:** To restore the natural ventilation and drainage of the sinuses. * **Messerklinger Technique:** The specific endoscopic technique used to address the OMC. * **First-line treatment:** Always medical management (antibiotics, steroids, saline rinses) for 3–4 weeks before considering surgery. * **CT Scan (PNS):** The investigation of choice before performing FESS to map the anatomy and extent of disease.

Question 213: Complications of paranasal sinusitis include all except?

A. Orbital cellulitis
B. Seizure
C. Nasal furuncles (Correct Answer)
D. Cavernous sinus thrombosis

Explanation: **Explanation:** The correct answer is **Nasal furuncles**. **1. Why Nasal Furuncles is the correct answer:** A nasal furuncle is an acute localized infection (usually staphylococcal) of a hair follicle in the **nasal vestibule**. The nasal vestibule is lined by skin, not respiratory mucosa. Therefore, a furuncle is a primary infection of the external nose/skin and **not a complication** arising from the paranasal sinuses. In fact, a nasal furuncle can lead to complications like cavernous sinus thrombosis, but it is never caused by sinusitis. **2. Analysis of Incorrect Options (Actual Complications):** * **Orbital Cellulitis:** This is the **most common** complication of acute sinusitis (especially ethmoiditis) due to the thinness of the *lamina papyracea*, which allows infection to spread easily from the sinuses to the orbit. * **Seizure:** This occurs as a result of **intracranial complications** such as meningitis, brain abscess (most common in the frontal lobe from frontal sinusitis), or subdural empyema. These conditions irritate the cerebral cortex, triggering seizures. * **Cavernous Sinus Thrombosis (CST):** This is a life-threatening inflammatory thrombosis of the cavernous sinus, usually resulting from the retrograde spread of infection from the ethmoid or sphenoid sinuses via the ophthalmic veins. **Clinical Pearls for NEET-PG:** * **Most common complication of sinusitis:** Orbital complications (specifically Preseptal/Orbital cellulitis). * **Most common sinus involved in orbital complications:** Ethmoid sinus (in children) and Frontal sinus (in adults). * **Pott’s Puffy Tumor:** A high-yield term referring to osteomyelitis of the frontal bone with overlying soft tissue edema, seen as a complication of frontal sinusitis. * **Chandler’s Classification:** Used to grade the severity of orbital complications of sinusitis.

Question 214: DNS may be associated with all the following except?

A. Recurrent sphenoiditis (Correct Answer)
B. Acute otitis media
C. Hypertrophy of the inferior turbinate
D. Recurrent maxillary sinusitis

Explanation: ### Explanation **Deviated Nasal Septum (DNS)** is a common clinical condition where the nasal septum is displaced from the midline, leading to mechanical obstruction and secondary changes in the sinonasal physiology. #### Why "Recurrent Sphenoiditis" is the Correct Answer The sphenoid sinus drains into the **sphenoethmoidal recess**, located high and posterior in the nasal cavity. Unlike the anterior group of sinuses (frontal, maxillary, and anterior ethmoid), the sphenoid sinus drainage is rarely affected by typical septal deviations. DNS primarily impacts the **osteomeatal complex (OMC)** in the middle meatus. Therefore, isolated recurrent sphenoiditis is not a standard complication of DNS. #### Analysis of Other Options * **Acute Otitis Media (AOM):** DNS can cause stasis of secretions and predispose the patient to infections. Furthermore, it can lead to **Eustachian tube dysfunction** due to altered airflow dynamics or associated mucosal edema, which increases the risk of middle ear infections like AOM. * **Hypertrophy of the Inferior Turbinate:** This is a classic compensatory mechanism. To protect the patent airway from drying out on the side opposite the deviation (the concave side), the inferior turbinate undergoes **compensatory hypertrophy**. * **Recurrent Maxillary Sinusitis:** A deviated septum often impinges on the middle meatus, obstructing the OMC. This impairs the ventilation and drainage of the maxillary sinus, leading to stasis of secretions and recurrent infections. #### High-Yield Clinical Pearls for NEET-PG * **Cottle’s Test:** Used to evaluate nasal valve patency in patients with DNS. * **Sluder’s Neuralgia:** Facial pain caused by a septal spur impinging on the lateral nasal wall (contact point headache). * **Treatment of Choice:** SMR (Submucous Resection) is generally avoided in children; **Septoplasty** is the preferred conservative surgical approach. * **Most common type of DNS:** Anterior dislocation.

Question 215: Which cyst is located at the junction of the median nasal process, lateral nasal process, and maxillary process?

A. Globulomaxillary cyst
B. Median palatine cyst
C. Nasopalatine cyst
D. Nasoalveolar cyst (Correct Answer)

Explanation: ### Explanation **Correct Option: D. Nasoalveolar cyst (also known as Nasolabial cyst)** The **Nasoalveolar cyst** is a non-odontogenic, soft-tissue cyst. It originates from the entrapment of epithelial remnants at the site of fusion between three processes: the **median nasal process**, the **lateral nasal process**, and the **maxillary process**. * **Clinical Presentation:** It typically presents as a slowly enlarging, painless swelling in the nasolabial fold, often causing ala flare or bulging into the nasal vestibule and labio-gingival sulcus. Unlike other cysts in this region, it is primarily a **soft-tissue cyst** and does not usually show radiolucency on X-rays unless it causes pressure erosion of the underlying bone. **Why other options are incorrect:** * **A. Globulomaxillary cyst:** Historically described as occurring at the junction of the globular and maxillary processes (between the lateral incisor and canine). It is an intraosseous cyst, appearing as an inverted "pear-shaped" radiolucency. * **B. Median palatine cyst:** Located in the midline of the hard palate, posterior to the incisive canal. It results from epithelial entrapment during the fusion of the lateral palatine shelves. * **C. Nasopalatine cyst (Incisive canal cyst):** The most common non-odontogenic cyst of the maxilla. It is located in the midline of the anterior palate within the incisive canal and presents as a "heart-shaped" radiolucency. **High-Yield Clinical Pearls for NEET-PG:** * **Klestsadt’s Cyst:** Another name for the Nasoalveolar cyst. * **Bimanual Palpation:** This cyst can be felt with one finger in the nasal vestibule and another in the gingivolabial sulcus (fluctuant swelling). * **Treatment:** Surgical excision via a sublabial (Caldwell-Luc) approach is the treatment of choice. * **Key Differentiator:** Nasoalveolar cyst is **extra-osseous** (soft tissue), whereas the others listed are **intra-osseous** (bony).

Question 216: What is the most common cause of recurrent epistaxis in a 15-year-old female?

A. Juvenile nasopharyngeal fibroma
B. Rhinosporidiosis
C. Foreign body
D. Hematological disorder (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Hematological disorder** In a **15-year-old female** presenting with recurrent epistaxis, the most common systemic cause is a **hematological disorder**, specifically **von Willebrand Disease (vWD)** or **Immune Thrombocytopenic Purpura (ITP)**. At this age, the onset of menstruation (menarche) often brings these underlying coagulopathies to light, manifesting as both menorrhagia and recurrent epistaxis. While Little’s area trauma is the most common cause of epistaxis in children generally, among the provided clinical options for this specific demographic, systemic bleeding disorders take precedence. **Analysis of Incorrect Options:** * **A. Juvenile Nasopharyngeal Angiofibroma (JNA):** This is a highly vascular, benign tumor that causes profuse epistaxis and nasal obstruction. However, it is **almost exclusively seen in adolescent males**. It is a "rule-out" diagnosis for males; it is extremely rare in females. * **B. Rhinosporidiosis:** Caused by *Rhinosporidium seeberi*, it presents as a leafy, strawberry-like friable mass in the nose. While it causes bleeding on touch, it is geographically restricted (endemic to South India/Sri Lanka) and is not the "most common" cause. * **C. Foreign Body:** This typically presents in younger children (2–5 years) with **unilateral, foul-smelling, purulent nasal discharge** and occasional blood-staining, rather than recurrent frank epistaxis in an adolescent. **Clinical Pearls for NEET-PG:** * **Most common site of Epistaxis:** Little’s area (Kiesselbach's plexus) on the anterior nasal septum. * **Most common cause of Epistaxis (Overall):** Trauma (Finger picking). * **Woodruff’s Plexus:** Located over the posterior end of the middle turbinate; the most common site for **posterior epistaxis** (usually in elderly, hypertensive patients). * **JNA Triad:** Adolescent male + Recurrent profuse epistaxis + Nasal mass (Check for **Holman-Miller sign** on CT).

Question 217: Septal hematoma of the nose is best treated with which of the following?

A. Incision and drainage (Correct Answer)
B. Nasal packing
C. Antibiotics
D. Nasal decongestants

Explanation: **Explanation:** **1. Why Incision and Drainage (I&D) is the Correct Answer:** A septal hematoma is a collection of blood between the septal cartilage and its overlying mucoperichondrium. Because the cartilage depends entirely on the perichondrium for its blood supply (via diffusion), the pressure from a hematoma causes **ischemic necrosis** of the cartilage. Immediate **Incision and Drainage** is the gold standard treatment to evacuate the clot, restore blood supply, and prevent complications. Following drainage, a small corrugated rubber drain is often placed, and bilateral nasal packing is applied to prevent re-accumulation. **2. Why the Other Options are Incorrect:** * **B. Nasal Packing:** While nasal packing is used *after* drainage to prevent recurrence, it is not a primary treatment. Packing alone without drainage will not remove the existing clot. * **C. Antibiotics:** These are used as an adjunct to prevent secondary infection (which leads to a septal abscess), but they cannot evacuate the hematoma. * **D. Nasal Decongestants:** These act on the nasal mucosa to reduce congestion but have no effect on a subperichondrial collection of blood. **Clinical Pearls for NEET-PG:** * **Most common cause:** Trauma (accidental or surgical). * **Clinical Sign:** A soft, fluctuant, reddish/purplish bulge on the septum; it does not shrink with topical vasoconstrictors. * **Complications of untreated hematoma:** 1. **Septal Abscess:** Secondary infection (most common organism: *S. aureus*). 2. **Saddle Nose Deformity:** Due to necrosis and collapse of the cartilaginous vault. 3. **Septal Perforation.** * **Management Tip:** Always aspirate or incise if a hematoma is suspected following nasal trauma to avoid permanent cosmetic deformity.

Question 218: Maggots in the nose are best treated by:

A. Chloroform diluted with water (Correct Answer)
B. Liquid paraffin
C. Systemic antibiotics
D. Lignocaine spray

Explanation: **Explanation:** **Nasal Myiasis** (maggots in the nose) is caused by the infestation of larvae from the fly *Chrysomyia bezziana*. It is commonly seen in patients with atrophic rhinitis, leprosy, or poor hygiene, where the foul smell attracts flies. **1. Why Chloroform is the treatment of choice:** The primary goal in treating nasal myiasis is the complete removal of larvae. Maggots are highly resilient and tend to retreat deep into the paranasal sinuses or osteomeatal complex when touched. **Chloroform (diluted with water or oil in a 1:4 ratio)** acts as a volatile anesthetic that paralyzes or kills the maggots, making them lose their grip on the nasal mucosa. Once immobilized, they can be easily removed with forceps. **2. Analysis of Incorrect Options:** * **Liquid Paraffin:** While it can suffocate some organisms by blocking their respiratory spiracles, it is far less effective than chloroform at inducing the rapid paralysis required to prevent maggots from migrating deeper into the skull base. * **Systemic Antibiotics:** These are used as an adjunct to treat secondary bacterial infections resulting from tissue destruction, but they do not address the primary problem (the living larvae). * **Lignocaine Spray:** This provides local anesthesia to the mucosa but does not effectively kill or immobilize the maggots. **High-Yield Clinical Pearls for NEET-PG:** * **Commonest cause:** Atrophic rhinitis (due to the characteristic *foetor*). * **Treatment Protocol:** Instill Chloroform + Water (1:4) $\rightarrow$ Wait for paralysis $\rightarrow$ Manual removal with Tilley’s forceps. * **Complications:** Maggots can cause extensive tissue destruction, leading to septal perforation, palatal destruction, or even meningitis if they penetrate the cribriform plate. * **Alternative:** Turpentine oil is sometimes used, but chloroform remains the classic textbook answer.

Question 219: A 68-year-old male with a history of diabetes presents with black, foul-smelling nasal discharge. Examination reveals blackish discoloration of the inferior turbinates. What is the most likely diagnosis?

A. Mucormycosis (Correct Answer)
B. Aspergillosis
C. Infarct of the inferior turbinate
D. Foreign body

Explanation: ### **Explanation** **Correct Answer: A. Mucormycosis** The clinical presentation is classic for **Rhinocerebral Mucormycosis**, an opportunistic fungal infection caused by fungi of the order Mucorales. * **Pathophysiology:** The hallmark of Mucormycosis is **angioinvasion**. The fungus invades blood vessel walls, leading to thrombosis and subsequent tissue ischemia. This results in the characteristic **black necrotic eschar** (as seen on the inferior turbinate) and foul-smelling discharge. * **Risk Factors:** It predominantly affects immunocompromised individuals, most notably those with **uncontrolled Diabetes Mellitus** (especially during Ketoacidosis, as the fungus thrives in acidic, glucose-rich environments). --- ### **Why other options are incorrect:** * **B. Aspergillosis:** While it can cause fungal sinusitis, it typically presents as a "fungal ball" (non-invasive) or chronic invasive form. It rarely presents with the rapid, fulminant necrotic eschar seen in Mucormycosis. * **C. Infarct of the inferior turbinate:** While necrosis is an infarct, in the context of diabetes and foul discharge, the *cause* of the infarct is the angioinvasive fungus. "Infarct" is a pathological finding, not the primary diagnosis. * **D. Foreign body:** This usually presents in children with unilateral, foul-smelling discharge. While it can cause granulation tissue, it does not cause widespread black necrosis of the turbinates in an elderly diabetic patient. --- ### **High-Yield Clinical Pearls for NEET-PG:** 1. **Diagnosis:** Confirmed by **KOH mount** (showing broad, **non-septate hyphae** branching at **right angles/90°**) or biopsy. 2. **Radiology:** "Black Turbinate Sign" on MRI (lack of enhancement due to devitalization). 3. **Management:** * Aggressive surgical debridement. * Systemic **Liposomal Amphotericin B** (Drug of choice). * Control of underlying diabetes/ketoacidosis. 4. **Common Site:** Often starts in the middle turbinate or palate before spreading to the orbit and brain.

Question 220: Quadrilateral cartilage is attached to all except?

A. Ethmoid
B. Vomer
C. Sphenoid (Correct Answer)
D. Maxilla

Explanation: **Explanation:** The nasal septum is a composite structure consisting of both bony and cartilaginous components. The **quadrilateral cartilage** (also known as the septal cartilage) forms the anterior-inferior part of the septum. **Why Sphenoid is the correct answer:** The quadrilateral cartilage does not reach the sphenoid bone. It is separated from the sphenoid by the **vomer** and the **perpendicular plate of the ethmoid**. The sphenoid bone contributes to the posterior-most part of the nasal septum via the sphenoid rostrum, but it articulates with the vomer, not the cartilage. **Analysis of incorrect options:** * **Ethmoid (Perpendicular Plate):** The quadrilateral cartilage articulates **postero-superiorly** with the perpendicular plate of the ethmoid bone. * **Vomer:** The cartilage articulates **postero-inferiorly** with the vomer. * **Maxilla:** The cartilage articulates **inferiorly** with the nasal crest of the maxilla and the anterior nasal spine. **High-Yield Clinical Pearls for NEET-PG:** 1. **Composition of the Septum:** The major contributors are the Quadrilateral cartilage, Vomer, and Perpendicular plate of the Ethmoid. Minor contributors include the nasal bones, frontal spine, and the crests of the maxilla and palatine bones. 2. **Little’s Area (Kiesselbach's Plexus):** Located on the antero-inferior part of the quadrilateral cartilage; it is the most common site for epistaxis. 3. **Blood Supply:** The cartilage receives its nutrition via diffusion from the overlying mucoperichondrium. A **septal hematoma** can strip this layer away, leading to avascular necrosis and a "Saddle Nose" deformity. 4. **Septal Perforation:** Most commonly occurs in the cartilaginous part due to trauma or surgery (Submucous Resection).

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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