Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: A 72-year-old man presents to the emergency department complaining of frequent nose-bleeds. What is the most likely site of acute epistaxis?

Septum. **Explanation:** The most common site for acute epistaxis is the **nasal septum**, specifically the anteroinferior portion known as **Kiesselbach’s plexus** (or Little’s area). This area is a highly vascular watershed zone where four to five arteries anastomose (Sphenopalatine, Greater palatine, Superior labial, and Anterior ethmoidal arteries). Because this region is located near the nares, it is highly susceptible to trauma, digital irritation, and drying of the mucosa, making it the source of approximately 90% of all nosebleeds. **Analysis of Options:** * **Turbinates (A):** While the turbinates are highly vascularized (especially the inferior turbinate), they are rarely the primary site of spontaneous acute epistaxis compared to the septum. * **Maxillary & Ethmoid Sinuses (C & D):** Bleeding from the sinuses is uncommon and usually associated with severe trauma, malignancy, or chronic inflammatory conditions. These represent "posterior" or "deep" sources, which are far less frequent than anterior septal bleeds. **NEET-PG High-Yield Pearls:** * **Little’s Area (Kiesselbach’s Plexus):** Most common site for **Anterior Epistaxis**. * **Woodruff’s Plexus:** Located over the posterior end of the middle turbinate; it is the most common site for **Posterior Epistaxis** (often seen in elderly or hypertensive patients). * **Artery of Epistaxis:** The **Sphenopalatine artery** is the most common vessel involved in posterior epistaxis. * **First-line Management:** Firm pressure on the nasal alae (Trott’s maneuver) for 10–15 minutes. If this fails, anterior nasal packing or chemical cautery (silver nitrate) is indicated.

Q: A 16-year-old girl presented with a history of nasal obstruction for the last 2 months. A CT scan was performed, revealing the following findings. What is the most likely diagnosis?

Antrochoanal polyp. ***Antrochoanal polyp*** - CT scan typically shows a **smooth, soft tissue mass** originating from the **maxillary sinus** extending through the **accessory ostium** with a characteristic **dumbbell appearance** into the choana and nasopharynx. - Common in **adolescent females** presenting with **unilateral nasal obstruction**, which matches this clinical presentation perfectly. *Juvenile Nasopharyngeal Angiofibroma* - This condition occurs **exclusively in adolescent males** due to hormonal influences, making it impossible in a 16-year-old girl. - CT shows a **highly vascular mass** in the nasopharynx with **epistaxis** as a prominent symptom, which is not mentioned here. *Nasopharyngeal carcinoma* - Typically occurs in **older adults** (40-60 years) and is rare in adolescents, especially without associated symptoms like **hearing loss** or **cranial nerve palsies**. - CT shows **irregular, infiltrative masses** with **cervical lymphadenopathy**, unlike the smooth appearance of antrochoanal polyps. *Adenoid hypertrophy* - More common in **younger children** (3-7 years) and typically causes **bilateral nasal obstruction** rather than unilateral symptoms. - CT shows **symmetric enlargement** of adenoid tissue in the nasopharynx without the characteristic **maxillary sinus origin** seen in antrochoanal polyps.

Q: What is the characteristic feature of an ethmoidal polyp?

It is recurrent.. **Explanation:** Ethmoidal polyps are non-neoplastic edematous projections of the ethmoidal sinus mucosa. The correct answer is **C (It is recurrent)** because these polyps are multifactorial in origin, often linked to chronic mucosal inflammation, allergy, or aspirin sensitivity (Sampter’s Triad). Even after surgical removal (FESS), the underlying mucosal tendency remains, leading to a high rate of recurrence unless the systemic cause is managed. **Analysis of Options:** * **A. It is due to infection:** While chronic rhinosinusitis can coexist, ethmoidal polyps are primarily **allergic or inflammatory** in nature. In contrast, Antrochoanal polyps are more frequently associated with infection. * **B. It is typically single:** Ethmoidal polyps are characteristically **multiple, bilateral, and grape-like** in appearance. A single, unilateral polyp is more likely to be an Antrochoanal polyp or a neoplasm. * **D. It occurs primarily in children:** These polyps are most common in **adults**. If multiple nasal polyps are found in a child, the clinician must immediately rule out **Cystic Fibrosis**. **High-Yield Clinical Pearls for NEET-PG:** * **Appearance:** Pale, translucent, mobile, and insensitive to touch (unlike the inferior turbinate). * **Sampter’s Triad:** Nasal polyposis, Bronchial asthma, and Aspirin intolerance. * **Kartagener’s Syndrome:** Often presents with nasal polyposis, bronchiectasis, and situs inversus. * **Treatment of Choice:** Medical management (steroids) initially; Functional Endoscopic Sinus Surgery (FESS) for refractory cases.

Q: What is the presenting symptom of nasal myiasis?

Severe irritation with sneezing. **Explanation:** **Nasal Myiasis** (Peenash) is a condition caused by the infestation of the nasal cavity by the larvae of flies, most commonly *Chrysomyia bezziana*. It is frequently seen in patients with poor hygiene, atrophic rhinitis, or leprosy. **1. Why "Severe irritation with sneezing" is correct:** The **earliest** presenting symptom of nasal myiasis is intense irritation in the nose accompanied by persistent sneezing and lacrimation. This occurs because the fly deposits eggs (or larvae) in the nasal vestibule; as the larvae begin to move and crawl over the sensitive nasal mucosa, they trigger a profound foreign body reaction and mechanical irritation, leading to the characteristic sneezing. **2. Analysis of Incorrect Options:** * **B. Maggots:** While the presence of maggots is the hallmark of the disease, it is a **clinical finding** rather than the initial presenting symptom. Maggots are usually visualized or expelled later as the infestation progresses. * **C. Nasal pain:** Pain occurs in the later stages once the larvae begin to burrow into the tissues and cause secondary infection or necrosis. * **D. Impaired olfaction:** While destruction of the olfactory mucosa can occur in chronic or severe cases, it is not a primary presenting symptom. **Clinical Pearls for NEET-PG:** * **Predisposing factor:** Atrophic rhinitis (due to the wide nasal room and lack of sensation, allowing flies to enter unnoticed). * **Complications:** Palatal perforation, septal destruction, and orbital/intracranial extension (meningitis). * **Management:** The primary treatment is the manual removal of maggots using forceps. To facilitate this, **Turpentine oil** is instilled into the nasal cavity to irritate the maggots, forcing them to come out of the crevices. * **Definitive Treatment:** Once maggots are removed, the underlying condition (like Atrophic Rhinitis) must be treated.

Q: Epistaxis in an elderly person is most commonly due to:

Hypertension. **Explanation:** **1. Why Hypertension is the Correct Answer:** In elderly patients, epistaxis is most frequently **posterior** in origin. The primary underlying cause is **Hypertension**, which leads to arteriosclerosis (hardening) of the blood vessels. These brittle vessels lose their ability to contract effectively when injured, leading to profuse bleeding. The most common site for posterior epistaxis is **Woodruff’s Plexus**, located over the posterior end of the middle turbinate, where the sphenopalatine artery is the chief vessel involved. **2. Why Other Options are Incorrect:** * **A. Foreign Body:** This is a common cause of epistaxis and unilateral foul-smelling nasal discharge in **children**, not the elderly. * **B. Bleeding Disorder:** While systemic conditions like hemophilia or anticoagulant use can cause bleeding, they are statistically less common than hypertension as a primary cause in this age group. * **C. Nasopharyngeal Carcinoma:** While this can present with epistaxis (often blood-stained nasal discharge or "morning spit"), it is a neoplastic cause and is far less frequent than the vascular complications of hypertension. **3. Clinical Pearls for NEET-PG:** * **Little’s Area (Kiesselbach’s Plexus):** The most common site for **anterior** epistaxis (90% of cases), usually seen in children and young adults due to finger picking or trauma. * **Woodruff’s Plexus:** The most common site for **posterior** epistaxis, typically seen in the elderly. * **First-line Management:** For anterior epistaxis, Trotter’s method (pinching the nose and leaning forward). For refractory posterior epistaxis, posterior nasal packing or arterial ligation (Sphenopalatine artery) may be required. * **Most common artery involved in Epistaxis:** Sphenopalatine artery (a branch of the Maxillary artery).

Q: A diabetic male presents with facial pain and blackish discoloration in the nose. The CT image shows bone erosion and sinus involvement. What is the most likely diagnosis?

Rhino-orbital-cerebral mucormycosis. ***Rhino-orbital-cerebral mucormycosis*** - This diagnosis is strongly suggested by the clinical triad of an **immunocompromised state (diabetes)**, the presence of a **black necrotic eschar** in the nose, and imaging evidence of **bone erosion**. - Mucormycosis is an **angioinvasive** fungal infection that causes tissue infarction and necrosis, leading to the characteristic black discoloration and rapid spread through tissues. *Acute bacterial sinusitis* - While it causes facial pain and sinus inflammation, it typically presents with purulent discharge and does not cause a **black necrotic eschar**. - **Bone erosion** is a very rare complication and not a characteristic feature, unlike in invasive fungal disease. *Allergic fungal sinusitis* - This is a **non-invasive** hypersensitivity reaction to fungi and does not cause tissue destruction, necrosis, or bone erosion. - It is characterized by the presence of thick **allergic mucin** containing eosinophils and fungal hyphae within the sinuses, often in atopic individuals. *Nasal polyposis* - This condition involves benign mucosal growths that cause chronic nasal obstruction and anosmia, not acute facial pain or tissue necrosis. - Nasal polyps may remodel bone over time due to pressure, but they do not cause the rapid and destructive **bone erosion** seen in this invasive process.

Q: Which of the following is shown in the image below (circled)?

Osteomeatal complex. ***Osteomeatal complex*** - The circled area highlights the **osteomeatal complex (OMC)**, a functional unit of the lateral nasal wall located in the middle meatus. - The OMC is the final common drainage pathway for the **frontal**, **maxillary**, and **anterior ethmoid sinuses**, and its obstruction is a primary cause of chronic rhinosinusitis. *Columella* - The **columella** is the external, soft tissue structure that separates the nostrils at the base of the nose. - It is an external feature and is not an internal bony or mucosal structure visible in this coronal CT view of the paranasal sinuses. *Nasal valve* - The **nasal valve** is the narrowest segment of the nasal airway, located much more anteriorly in the nasal cavity, near the nostril opening. - It is a functional area defined by the junction of the nasal septum and the upper lateral cartilage, not the region shown in the middle meatus. *Crest of maxilla* - The **crest of the maxilla**, or nasal crest, is a bony ridge on the floor of the nasal cavity where the inferior edge of the nasal septum articulates. - The circled structure is located superiorly and laterally within the middle meatus, not on the inferior floor of the nasal cavity.

Q: A patient presented to the OPD with complaints of greenish black matter in the nose with foul-smelling discharge. What is the diagnosis?

Atrophic rhinitis. ***Atrophic rhinitis***- This condition is characterized by progressive atrophy of the nasal mucosa and underlying turbinate bones, leading to excessively wide nasal cavities.- The presence of large, dry, **greenish-black crusts** that produce a very offensive, sickening smell (**ozena**) is the classic defining feature, matching the patient's presentation.*Allergic rhinitis*- This condition presents with symptoms like watery rhinorrhea, sneezing, nasal itching, and **conjunctivitis**, often triggered by specific allergens.- It is an inflammatory condition and does not result in the mucosal atrophy or the formation of large, fetid, **greenish-black crusts** (ozena).*Rhinitis caseosa*- This rare form is characterized by the accumulation of a firm, malodorous, **cheese-like** (caseous) material that acts as a foreign body within the nasal cavity, differentiating it from the general crusting of atrophic rhinitis.- While it causes a very foul smell, the material retrieved is typically described as caseous or putty-like, not the widespread greenish-black crusts typical of ozena.*Rhinitis sicca*- This condition involves localized **dryness** and minor crusting, often restricted to the anterior nasal septum, typically seen in dry climates or specific occupations.- It is characterized by persistent dryness and discomfort but generally lacks the severe **mucosal atrophy** or the intense, offensive odor (**ozena**) associated with generalized greenish-black crusts found in atrophic rhinitis.

Q: A 45-year-old male was admitted with respiratory distress. CT showed a nasal polyp with fluid collection in the sinus. Drainage of which of the following is obstructed?

Maxillary sinus. ***Maxillary sinus*** - The coronal CT scan clearly shows opacification (fluid collection) in the right **maxillary sinus**, the large air-filled space located inferior to the orbit and lateral to the nasal cavity. - Nasal polyps commonly arise in the **middle meatus**, which is the primary drainage site for the maxillary sinus via the **maxillary ostium**. Obstruction here leads to fluid retention and sinusitis. *Ethmoidal sinus* - The **ethmoidal sinuses** are a complex of small air cells located between the orbits. While some mild mucosal thickening may be present, they are not the site of the large, complete fluid collection seen in the image. - These sinuses also drain into the **middle meatus** (anterior and middle ethmoidal cells) and **superior meatus** (posterior ethmoidal cells), but the primary pathology shown is not within the ethmoid air cells themselves. *Sphenoidal sinus* - The **sphenoidal sinus** is located more posteriorly within the sphenoid bone, behind the ethmoid sinuses, and is not the sinus shown to be opacified in this anterior coronal view. - It drains into the **sphenoethmoidal recess**, a location superior and posterior to the superior turbinate, anatomically distinct from the area affected by the polyp. *Frontal sinus* - The **frontal sinuses** are situated superior to the orbits within the frontal bone. The image shows these sinuses are well-aerated and free of significant fluid. - Drainage of the frontal sinus occurs via the **frontonasal duct** into the **middle meatus**. Obstruction would cause fluid buildup superior to the eye, which is not seen here.

Question 1

A 72-year-old man presents to the emergency department complaining of frequent nose-bleeds. What is the most likely site of acute epistaxis?

Accepted Answer

Septum

Answer

Turbinate

Answer

Maxillary sinus

Answer

Ethmoid sinus

Question 2

A patient presented to ENT OPD with complaints of headache and nasal stuffiness. On CT scan, heterogeneous opacification involving multiple sinuses along with bone erosion was noticed. What would be the most likely diagnosis?

Accepted Answer

Allergic Fungal rhinosinusitis

Answer

Acute bacterial rhinosinusitis

Answer

Chronic Bacterial rhinosinusitis

Answer

Invasive Fungal Rhinosinusitis

Question 3

A 16-year-old girl presented with a history of nasal obstruction for the last 2 months. A CT scan was performed, revealing the following findings. What is the most likely diagnosis?

Accepted Answer

Antrochoanal polyp

Answer

Juvenile Nasopharyngeal Angiofibroma

Answer

Nasopharyngeal carcinoma

Answer

Adenoid hypertrophy

Question 4

What is the characteristic feature of an ethmoidal polyp?

Accepted Answer

It is recurrent.

Answer

It is due to infection.

Answer

It is typically single.

Answer

It occurs primarily in children.

Question 5

What is the presenting symptom of nasal myiasis?

Accepted Answer

Severe irritation with sneezing

Answer

Maggots

Answer

Nasal pain

Answer

Impaired olfaction

Question 6

Epistaxis in an elderly person is most commonly due to:

Accepted Answer

Hypertension

Answer

Foreign body

Answer

Bleeding disorder

Answer

Nasopharyngeal carcinoma

Question 7

A diabetic male presents with facial pain and blackish discoloration in the nose. The CT image shows bone erosion and sinus involvement. What is the most likely diagnosis?

Accepted Answer

Rhino-orbital-cerebral mucormycosis

Answer

Acute bacterial sinusitis

Answer

Allergic fungal sinusitis

Answer

Nasal polyposis

Question 8

Which of the following is shown in the image below (circled)?

Accepted Answer

Osteomeatal complex

Answer

Nasal valve

Answer

Columella

Answer

Crest of maxilla

Question 9

A patient presented to the OPD with complaints of greenish black matter in the nose with foul-smelling discharge. What is the diagnosis?

Accepted Answer

Atrophic rhinitis

Answer

Rhinitis caseosa

Answer

Allergic rhinitis

Answer

Rhinitis sicca

Question 10

A 45-year-old male was admitted with respiratory distress. CT showed a nasal polyp with fluid collection in the sinus. Drainage of which of the following is obstructed?

Accepted Answer

Maxillary sinus

Answer

Ethmoidal sinus

Answer

Frontal sinus

Answer

Sphenoidal sinus

Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses — MCQs

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