Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: What is the name of the incision used for the maxillary sinus?

Weber Ferguson incision. The **Weber-Ferguson incision** is the classic surgical approach used for **Total Maxillectomy**. It provides extensive exposure to the maxillary sinus and the midface by reflecting a large cheek flap. The incision typically starts at the infraorbital margin (or subciliary), runs down the lateral aspect of the nose (paranasal), curves around the alar flare, and extends vertically through the midline of the upper lip (philtrum). ### Explanation of Options: * **Weber-Ferguson Incision (Correct):** The gold standard for accessing the maxillary antrum in cases of malignancy (e.g., Squamous Cell Carcinoma of the Maxilla). It allows the surgeon to visualize the entire maxilla while preserving the facial nerve. * **Lynch-Howarth Incision:** This is a curvilinear incision made between the inner canthus of the eye and the nasal bridge. It is primarily used for **External Ethmoidectomy** and accessing the frontal sinus. * **Crile’s Y Incision:** A traditional incision used for **Radical Neck Dissection (RND)**. It consists of a vertical limb and two horizontal limbs forming a 'Y' shape to expose the cervical lymph nodes. * **Schobinger’s Incision:** Another incision used in **Neck Dissection**, particularly for protecting the carotid artery. It involves a large superiorly based flap. ### High-Yield Clinical Pearls for NEET-PG: * **Caldwell-Luc Operation:** This uses a **sublabial (gingivobuccal)** incision to enter the maxillary sinus through the canine fossa. It is used for benign conditions (e.g., chronic sinusitis, removal of foreign bodies). * **Dieffenbach Extension:** A modification of the Weber-Ferguson incision where an extension is made along the lower eyelid to provide better access to the orbital floor. * **Moure’s Lateral Rhinotomy:** Used for accessing the ethmoid sinuses and nasal cavity; it is essentially the upper portion of the Weber-Ferguson incision without the lip-split.

Q: A unilateral mass causing nasal obstruction is seen in the nose of a patient. What is the most probable diagnosis?

Antrochoanal polyp. **Explanation:** The presentation of a **unilateral nasal mass** causing obstruction is a classic clinical scenario in ENT. **Why Antrochoanal (AC) Polyp is the correct answer:** An Antrochoanal polyp originates from the mucosa of the maxillary sinus, passes through the accessory ostium, and extends into the choana and nasopharynx. It is characteristically **unilateral** and solitary. It is most commonly seen in children and young adults. Clinically, it presents as a smooth, grayish-white mass that is insensitive to touch and does not bleed on probing. **Analysis of Incorrect Options:** * **Rhinophyma (Option A):** This is a benign skin condition characterized by hypertrophy of the sebaceous glands of the nose, resulting in a bulbous, "potato-like" appearance. It is an external deformity, not an internal nasal mass. * **Furuncle (Option B):** This is an acute infection (usually Staphylococcal) of a hair follicle in the nasal vestibule. While it causes swelling and obstruction, it is primarily characterized by intense pain, redness, and tenderness, rather than a chronic mass. * **Atrophic Rhinitis (Option D):** This is a chronic inflammatory condition characterized by atrophy of the nasal mucosa and turbinates. It presents with a roomy nasal cavity filled with foul-smelling crusts (ozena), rather than a space-occupying mass. **High-Yield Clinical Pearls for NEET-PG:** * **Ethmoidal Polyps:** Usually bilateral, multiple, and associated with allergies or asthma (e.g., Samter’s triad). * **AC Polyp Management:** The treatment of choice is surgical removal via **FESS (Functional Endoscopic Sinus Surgery)**. * **Differential Diagnosis:** In an adolescent male with a unilateral nasal mass and profuse epistaxis, always consider **Juvenile Nasopharyngeal Angiofibroma (JNA)**. * **Inverted Papilloma:** Another unilateral mass, but typically seen in older age groups and has a high risk of malignant transformation.

Q: What is the diagnosis of a child presenting with a pulsatile swelling on the medial side of the nose?

Meningocele. ### Explanation The correct diagnosis is **Meningocele**. **Why Meningocele is the Correct Answer:** A meningocele is a type of neural tube defect where the meninges herniate through a bony defect in the skull (cranium bifidum). When located at the base of the skull, it can present as a mass on the **medial side of the nose** (nasoethmoidal or nasofrontal). The hallmark clinical feature is that the swelling is **pulsatile** and exhibits an **expansile impulse on coughing or crying** (Furstenberg test). This occurs because the sac is in direct communication with the subarachnoid space, allowing cerebrospinal fluid (CSF) pressure changes to be transmitted to the swelling. **Analysis of Incorrect Options:** * **A. Teratoma:** These are germ cell tumors containing elements from all three germ layers. While they can occur in the head and neck (epignathus), they are typically solid, heterogeneous, and non-pulsatile. * **C. Dermoid Cyst:** This is the most common midline nasal mass. However, dermoid cysts are **non-pulsatile** and do not increase in size with crying because they do not communicate with the intracranial space. They often present with a small pit or sinus tract. * **D. Carcinoma of the ethmoid bone:** This is extremely rare in children. It presents as a destructive, solid, rapidly growing mass, often associated with epistaxis and nasal obstruction, rather than a soft, pulsatile swelling. **High-Yield Clinical Pearls for NEET-PG:** * **Furstenberg Test:** Positive in encephaloceles/meningoceles (compression of internal jugular veins leads to enlargement of the mass). * **Imaging:** MRI is the gold standard to evaluate intracranial extension before any surgical intervention or biopsy. * **Contraindication:** **Never aspirate or biopsy** a midline nasal mass until a meningocele has been ruled out, as this can lead to a CSF leak and meningitis.

Q: Following Caldwell-Luc operation, a patient develops hypoesthesia. Which nerve is likely damaged?

Infraorbital nerve. ### Explanation **1. Why the Correct Answer is Right:** The **Caldwell-Luc operation** involves creating a window in the anterior wall of the maxilla through the canine fossa to access the maxillary sinus. The **infraorbital nerve** (a branch of the maxillary division of the trigeminal nerve) exits through the infraorbital foramen, which is located just superior to the canine fossa. During the surgical incision or retraction of the soft tissues of the cheek, this nerve is highly vulnerable to traction, compression, or direct injury. Damage to this nerve leads to **hypoesthesia** (numbness) of the cheek, upper lip, and upper gingiva. **2. Why the Other Options are Wrong:** * **Supraorbital nerve:** This is a branch of the frontal nerve (Ophthalmic division, V1). It exits through the supraorbital notch/foramen above the eye and supplies the forehead and scalp; it is not involved in maxillary sinus surgery. * **Maxillary nerve (V2):** While the infraorbital nerve is a branch of V2, the main trunk of the maxillary nerve lies deeper in the pterygopalatine fossa. A standard Caldwell-Luc procedure affects the peripheral branch (infraorbital) rather than the main trunk. * **Mandibular nerve (V3):** This nerve supplies the lower jaw, teeth, and tongue. It is anatomically distant from the surgical site of the maxillary sinus. **3. Clinical Pearls for NEET-PG:** * **Indications for Caldwell-Luc:** Removal of foreign bodies (e.g., root of a tooth) from the sinus, management of Oro-antral fistula, and as an approach to the pterygopalatine fossa (Lynch’s procedure). * **Most common complication:** Cheek swelling and numbness (infraorbital nerve injury). * **Anatomical Landmark:** The incision is made in the gingivolabial sulcus above the roots of the premolar teeth, avoiding the canine tooth to prevent dental denervation.

Q: Which of the following statements about nasal glioma is FALSE?

It is transilluminating.. **Explanation:** Nasal glioma is a rare, benign congenital anomaly consisting of ectopic glial tissue that has lost its intracranial connection. Understanding its clinical features is crucial for differentiating it from other midline nasal masses like encephaloceles. **Why Option D is the Correct (False) Statement:** Unlike an **encephalocele**, which contains a patent connection to the subarachnoid space and is filled with cerebrospinal fluid (CSF), a nasal glioma is a solid mass of glial tissue and fibrous stroma. Because it lacks a fluid-filled sac, it **does not transilluminate**. Transillumination is a classic feature of encephaloceles. **Analysis of Other Options:** * **Option A (MRI):** MRI is the gold standard investigation. It is essential to rule out any intracranial extension or "stalk" before surgical intervention to prevent CSF leaks or meningitis. * **Option B (Surgical Excision):** The definitive treatment is complete surgical excision, usually via an external approach (like a lateral rhinotomy) or endoscopic approach, depending on the location. * **Option C (Non-pulsatile):** Since nasal gliomas are isolated from the intracranial space, they do not exhibit pulsations or expansion upon crying/straining (negative Furstenberg’s test), unlike encephaloceles. **High-Yield Clinical Pearls for NEET-PG:** 1. **Furstenberg’s Test:** Positive in Encephalocele (mass expands on compression of internal jugular vein); Negative in Nasal Glioma. 2. **Location:** 60% are extranasal (on the bridge of the nose), 30% are intranasal, and 10% are both. 3. **Origin:** They are essentially "sequestered" encephaloceles that failed to recede during development. 4. **Biopsy Warning:** Never biopsy a midline nasal mass in a child until an intracranial connection has been ruled out by imaging.

Q: A female who underwent laparoscopic appendectomy for acute appendicitis developed difficulty in breathing and a swelling in the anterior part of the nasal septum after bumping her nose on a table on post-operative day 2. What is the next line of management?

Incision and drainage. **Explanation:** The clinical presentation of post-traumatic nasal obstruction and a swelling in the anterior nasal septum is diagnostic of a **Septal Hematoma**. This occurs when trauma causes blood to collect between the septal cartilage and its overlying mucoperichondrium. **Why Incision and Drainage is correct:** A septal hematoma is a surgical emergency. The septal cartilage depends entirely on the overlying perichondrium for its blood supply (via diffusion). The pressure from the hematoma strips the perichondrium away, leading to **ischemic necrosis** of the cartilage. If not drained immediately via **Incision and Drainage (I&D)**, it can result in a septal abscess, septal perforation, or a "Saddle Nose" deformity due to loss of structural support. **Why other options are incorrect:** * **Oral/IV Antibiotics (B & D):** While antibiotics are given post-procedure to prevent secondary infection (abscess formation), they cannot evacuate the collected blood. Without drainage, the cartilage will necrose regardless of antibiotic use. * **Observation (C):** Waiting is contraindicated. A hematoma will not resolve spontaneously fast enough to save the underlying cartilage. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Sign:** On examination, a septal hematoma appears as a smooth, soft, fluctuant, cherry-red swelling. It does not shrink with topical vasoconstrictors (unlike turbinate hypertrophy). * **Site of Incision:** A small horizontal/hemitransfixion incision is made at the most dependent part. * **Post-Op Care:** After drainage, **bilateral nasal packing** is essential to prevent re-accumulation of blood. * **Complication:** If left untreated, it can progress to a **Septal Abscess**, which carries a risk of cavernous sinus thrombosis due to retrograde venous spread.

Q: A 60-year-old male complains of right-sided nasal obstruction and nasal discharge, which is sometimes blood-tinged. Biopsy findings are shown below. What is your diagnosis?

Rhinosporidiosis. ***Rhinosporidiosis*** - Characterized by **large sporangia** containing **endospores** on histopathology, which is pathognomonic for this fungal infection caused by *Rhinosporidium seeberi*. - Presents with **unilateral nasal obstruction** and **blood-tinged discharge** along with characteristic **polypoidal masses** in the nasal cavity. *Rhinoscleroma* - Histopathology shows **Mikulicz cells** (large foamy macrophages) containing **Donovan bodies** (*Klebsiella pneumoniae* subsp. *rhinoscleromatis*). - Typically presents with **progressive nasal deformity** and **nodular lesions** rather than polypoidal masses. *Wegener's granulomatosis* - Biopsy reveals **necrotizing granulomatous inflammation** with **multinucleated giant cells** and **vasculitis**. - Associated with **c-ANCA positivity** and systemic involvement including lungs and kidneys, not isolated nasal symptoms. *Stewart's granuloma* - Histopathology shows **lymphomatous infiltrate** with **atypical lymphoid cells** and **plasma cells**. - Represents a **midline destructive lesion** with aggressive tissue destruction, unlike the benign polypoidal growth pattern described.

Question 1

What is the name of the incision used for the maxillary sinus?

Accepted Answer

Weber Ferguson incision

Answer

Lynch Howarth incision

Answer

Crile's Y incision

Answer

Schobinger's incision

Question 2

A unilateral mass causing nasal obstruction is seen in the nose of a patient. What is the most probable diagnosis?

Accepted Answer

Antrochoanal polyp

Answer

Rhinophyma

Answer

Furuncle

Answer

Atrophic rhinitis

Question 3

What is the diagnosis of a child presenting with a pulsatile swelling on the medial side of the nose?

Accepted Answer

Meningocele

Answer

Teratoma

Answer

Dermoid cyst

Answer

Carcinoma of the ethmoid bone

Question 4

What is the treatment of choice in bilateral ethmoidal polyps?

Accepted Answer

Functional Endoscopic Sinus Surgery (FESS)

Answer

Ethmoidectomy

Answer

Endoscopic removal

Answer

Chemotherapy and Radiotherapy

Question 5

A child presents with unilateral, foul smelling nasal discharge. What is the most probable cause?

Accepted Answer

Foreign body

Answer

Acute sinusitis

Answer

Rhinolith

Answer

Nasal synechiae

Question 6

Following Caldwell-Luc operation, a patient develops hypoesthesia. Which nerve is likely damaged?

Accepted Answer

Infraorbital nerve

Answer

Supraorbital nerve

Answer

Maxillary nerve

Answer

Mandibular nerve

Question 7

Which of the following statements about nasal glioma is FALSE?

Accepted Answer

It is transilluminating.

Answer

Intracranial connection is best evaluated by MRI.

Answer

Treatment is primarily surgical excision.

Answer

It is non-pulsatile.

Question 8

A female who underwent laparoscopic appendectomy for acute appendicitis developed difficulty in breathing and a swelling in the anterior part of the nasal septum after bumping her nose on a table on post-operative day 2. What is the next line of management?

Accepted Answer

Incision and drainage

Answer

Oral antibiotics for 7-10 days

Answer

Observation

Answer

Intravenous antibiotics

Question 9

A 60-year-old male complains of right-sided nasal obstruction and nasal discharge, which is sometimes blood-tinged. Biopsy findings are shown below. What is your diagnosis?

Accepted Answer

Rhinosporidiosis

Answer

Rhinoscleroma

Answer

Wegener's granulomatosis

Answer

Stewart's granuloma

Question 10

A 20-year-old male presents with nasal obstruction and nasal discharge. Nasal endoscopy shows a large polyp in the right nostril extending into the nasopharynx. What is the most appropriate management for this patient?

Accepted Answer

Functional Endoscopic Sinus Surgery (FESS)

Answer

Intranasal polypectomy

Answer

Steroids

Answer

Caldwell-Luc procedure

Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses — MCQs

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