Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: Which paranasal sinus is most commonly involved in a patient presenting with symptoms of a toothache and sinusitis?

Maxillary sinus. **Explanation:** The **Maxillary sinus** is the correct answer due to its unique anatomical relationship with the oral cavity. The floor of the maxillary sinus is formed by the alveolar process of the maxilla, which lies in close proximity to the roots of the maxillary teeth (specifically the **2nd premolar and 1st and 2nd molars**). 1. **Referred Pain:** Because the maxillary sinus and the upper teeth share a common nerve supply via the **Superior Alveolar Nerve** (a branch of the Maxillary nerve, V2), inflammation within the sinus (sinusitis) can be perceived as a toothache. 2. **Odontogenic Sinusitis:** Approximately 10–12% of maxillary sinusitis cases are "odontogenic," meaning they are caused by dental infections, periapical abscesses, or complications from dental extractions. **Analysis of Incorrect Options:** * **Ethmoid Sinus:** Primarily presents with pain at the bridge of the nose or medial canthus of the eye. * **Frontal Sinus:** Typically presents with a "frontal headache" or pain above the eyebrows, often showing a characteristic "office headache" pattern (worse in the morning, better in the evening). * **Sphenoid Sinus:** Pain is usually referred to the vertex (top of the head), occiput, or retro-orbital region. **High-Yield Clinical Pearls for NEET-PG:** * **First sinus to develop:** Ethmoid (present at birth). * **Largest paranasal sinus:** Maxillary (Antrum of Highmore). * **Most common sinus involved in adult sinusitis:** Maxillary sinus. * **Most common sinus involved in childhood sinusitis:** Ethmoid sinus. * **Drainage:** The maxillary sinus drains into the **middle meatus** via the hiatus semilunaris. Its drainage is physiologically disadvantaged because the ostium is located superiorly on its medial wall.

Q: A 7-year-old child presents with unilateral nasal obstruction and foul-smelling nasal discharge. What is the most likely diagnosis?

Foreign body. **Explanation:** The clinical presentation of **unilateral nasal obstruction** accompanied by **foul-smelling, purulent, or blood-stained nasal discharge** in a child is a classic "spotter" for a **Nasal Foreign Body (FB)** until proven otherwise. Children often insert small objects (beads, seeds, button batteries) into the nose, which leads to local inflammation, secondary bacterial infection, and the characteristic malodorous discharge. **Analysis of Options:** * **Foreign Body (Correct):** The hallmark triad is a pediatric patient, unilateral symptoms, and foul odor. * **Rhinophyma:** This is a hypertrophy of the sebaceous glands of the nose, typically seen in elderly males as a complication of acne rosacea. It presents as a bulbous, "potato-like" nose, not with discharge. * **Rhinosporidiosis:** Caused by *Rhinosporidium seeberi*, it presents as a friable, leafy, strawberry-like polypoid mass that bleeds on touch. It is usually associated with history of bathing in stagnant water and is not typically characterized by a foul odor unless heavily infected. * **Angiofibroma (JNA):** This is a benign but aggressive tumor seen almost exclusively in **adolescent males**. It presents with painless, profuse, recurrent epistaxis and progressive nasal obstruction, rather than foul-smelling discharge. **Clinical Pearls for NEET-PG:** * **Button Batteries:** These are surgical emergencies due to the risk of liquefactive necrosis and septal perforation within hours. **Do not** use saline drops as they increase conductivity. * **Living Foreign Bodies (Magots):** Caused by *Lucilia sericata* (Green bottle fly). Treatment involves instilling 25% chloroform to stun the larvae before manual removal. * **Radiology:** Most nasal FBs are radiolucent; X-rays are primarily useful for metallic objects or batteries.

Q: Regarding nasal syphilis, which of the following statements is true?

Secondary syphilis is the common association.. **Explanation:** Nasal syphilis is a manifestation of infection by *Treponema pallidum*. Understanding its presentation across different stages is crucial for NEET-PG. **Why Option D is Correct:** In the context of clinical practice and epidemiological prevalence, **Secondary Syphilis** is the most common stage associated with nasal involvement. It typically presents as persistent rhinitis with mucous patches and generalized lymphadenopathy. While primary syphilis (chancre) is rare in the nose, secondary and tertiary stages are more frequently documented in ENT clinics. **Analysis of Incorrect Options:** * **Option A & B:** These are characteristic of **Tertiary Syphilis**. In this stage, a "gumma" (granulomatous lesion) forms, which predilects the **bony part** of the nasal septum. This leads to necrosis, resulting in a large septal perforation and the classic **Saddle Nose Deformity** due to the collapse of the nasal bridge. * **Option C:** While "snuffles" (purulent, blood-stained nasal discharge) is indeed a hallmark of **Congenital Syphilis** in newborns, it is a specific pediatric manifestation rather than a general rule for nasal syphilis across all age groups. **High-Yield Clinical Pearls for NEET-PG:** * **Septal Perforation:** Syphilis typically involves the **bony septum**, whereas Tuberculosis (Lupus Vulgaris) involves the **cartilaginous septum**. * **Congenital Syphilis Triad (Hutchinson’s):** Interstitial keratitis, sensorineural hearing loss (8th nerve deafness), and notched incisors. * **Diagnosis:** VDRL/RPR for screening; FTA-ABS (Treponemal test) for confirmation. * **Treatment:** Penicillin G remains the drug of choice.

Q: What is the treatment of choice for nasal synechiae?

Surgical removal of adhesions. **Explanation:** **Nasal synechiae** (adhesions) are abnormal bridges of tissue connecting the nasal septum to the turbinates. They most commonly occur as a complication of nasal surgery (e.g., septoplasty or turbinate reduction) or trauma, where opposing raw mucosal surfaces heal together. **1. Why Surgical Removal is the Correct Answer:** The definitive treatment for established nasal synechiae is **surgical excision (adhesiolysis)**. The adhesions must be physically divided, usually with cold instruments or lasers, to restore the patency of the nasal airway. However, simple excision alone has a high recurrence rate because the raw surfaces tend to fuse again during healing. Therefore, surgery is almost always followed by the placement of a physical barrier (like a silastic splint or medicated sponge) to keep the surfaces apart. **2. Analysis of Incorrect Options:** * **Topical Mitomycin C (Option B):** While Mitomycin C (an anti-fibrotic agent) is often used **adjunctively** after surgery to prevent fibroblast proliferation and recurrence, it cannot "dissolve" or treat an existing fibrous adhesion on its own. * **Nasal Stent (Option C):** Similar to Mitomycin, a stent or splint is a **preventative measure** used post-operatively. A stent cannot treat synechiae unless the adhesions are first surgically removed. * **None of the above (Option D):** Incorrect, as surgical intervention is the standard of care. **Clinical Pearls for NEET-PG:** * **Most common site:** Between the inferior turbinate and the nasal septum. * **Prevention:** The most effective way to prevent synechiae is meticulous surgical technique and the use of **silastic nasal splints** post-operatively. * **Symptoms:** Patients typically present with nasal obstruction and occasionally crusting or sinusitis due to impaired mucociliary clearance.

Q: Kiesselbach's plexus is situated on which part of the nasal cavity?

Medial wall of the nasal cavity. **Explanation:** **Kiesselbach’s Plexus** (also known as Little’s area) is a highly vascularized region located on the **anteroinferior part of the nasal septum**, which forms the **medial wall of the nasal cavity**. This area is the most common site for epistaxis (nosebleeds), accounting for approximately 90% of cases. The plexus is formed by the anastomosis of four (sometimes five) major arteries: 1. **Anterior Ethmoidal Artery** (from Internal Carotid) 2. **Sphenopalatine Artery** (from External Carotid) 3. **Greater Palatine Artery** (from External Carotid) 4. **Superior Labial Artery** (from External Carotid) **Analysis of Incorrect Options:** * **Option A:** The medial wall of the middle ear contains structures like the promontory and the oval window, not a vascular plexus related to the nose. * **Option B:** The lateral wall of the nasopharynx contains the opening of the Eustachian tube and the Fossa of Rosenmüller (common site for Nasopharyngeal Carcinoma). * **Option D:** The laryngeal aspect of the epiglottis is part of the upper airway and is not involved in nasal vascularity. **Clinical Pearls for NEET-PG:** * **Woodruff’s Plexus:** Located on the lateral wall of the nasal cavity posteriorly (near the sphenopalatine foramen); it is the most common site for **posterior epistaxis** in elderly patients. * **First-line treatment** for bleeding from Kiesselbach’s plexus is Trotter’s method (pinching the nose and leaning forward) or chemical cautery with Silver Nitrate. * **Artery of Epistaxis:** The Sphenopalatine artery is clinically referred to as the "Artery of Epistaxis."

Q: What is the treatment of choice for antrochoanal polyp?

Endoscopic removal. **Explanation:** An **Antrochoanal Polyp (Killian’s Polyp)** is a solitary polyp that arises from the mucosa of the maxillary sinus (usually near the accessory ostium), passes through the natural or accessory ostium into the middle meatus, and extends posteriorly into the choana and nasopharynx. **Why Endoscopic Removal is the Treatment of Choice:** Functional Endoscopic Sinus Surgery (FESS) is the gold standard. It allows for the precise identification of the polyp’s stalk and its point of origin within the maxillary sinus. By widening the natural ostium (middle meatal antrostomy), the surgeon can ensure complete removal of the antral portion, which is crucial to **prevent recurrence**. It is minimally invasive, preserves sinus physiology, and has lower morbidity compared to open procedures. **Analysis of Incorrect Options:** * **Caldwell-Luc Operation:** Historically used to remove the antral part of the polyp via the canine fossa. While effective for preventing recurrence, it is now reserved for recurrent cases or when endoscopic access is impossible, as it carries risks of infraorbital nerve injury and dental damage. * **Intranasal Polypectomy:** This involves simple avulsion of the nasal part of the polyp. It is considered inadequate because it fails to remove the antral base, leading to a very high recurrence rate. **High-Yield Clinical Pearls for NEET-PG:** * **Origin:** Most commonly from the posterior/lateral wall or floor of the **maxillary sinus**. * **Components:** It has three parts—Antral, Nasal, and Choanal. * **Radiology:** On X-ray (Water’s view) or CT, it appears as a hazy maxillary sinus with a soft tissue mass extending into the nasopharynx. * **Differential Diagnosis:** Must be differentiated from a juvenile nasopharyngeal angiofibroma (JNA) in adolescent males; however, AC polyps are typically avascular and do not bleed on touch.

Q: What is the best X-ray view to visualize the maxillary sinus?

Water's view. **Explanation:** The **Water’s view (Occipitomental view)** is the gold standard radiographic projection for visualizing the **maxillary sinuses**. In this position, the patient’s chin is tilted up against the film, which displaces the dense petrous part of the temporal bone downwards, preventing it from overlapping and obscuring the maxillary antrum. This provides a clear, unobstructed view of the sinus floor and walls, making it ideal for detecting sinusitis, air-fluid levels, or fractures of the orbital floor (blow-out fractures). **Analysis of Incorrect Options:** * **Caldwell’s view (Occipitofrontal view):** This is the best view for the **frontal and ethmoid sinuses**. In this view, the petrous bone lies over the lower part of the orbit and the maxillary sinus, making the latter difficult to evaluate. * **Lateral view:** This is primarily used to visualize the **sphenoid sinus**, the nasopharynx (for adenoids), and the anterior/posterior walls of the frontal sinuses. * **Occlusal anterior view:** This is a dental radiograph used to visualize the floor of the mouth or the palate; it is not used for paranasal sinus evaluation. **High-Yield Clinical Pearls for NEET-PG:** * **Best view for Sphenoid Sinus:** Lateral view or Open-mouth Water’s view. * **Best view for Ethmoid Sinus:** Caldwell’s view. * **Best view for Frontal Sinus:** Caldwell’s view. * **Gold Standard Investigation:** While X-rays are common screening tools, **Non-Contrast CT (NCCT) of the Paranasal Sinuses** is the investigation of choice for chronic sinusitis and preoperative planning (FESS).

Question 1

Which paranasal sinus is most commonly involved in a patient presenting with symptoms of a toothache and sinusitis?

Accepted Answer

Maxillary sinus

Answer

Ethmoid sinus

Answer

Frontal sinus

Answer

Sphenoid sinus

Question 2

A 7-year-old child presents with unilateral nasal obstruction and foul-smelling nasal discharge. What is the most likely diagnosis?

Accepted Answer

Foreign body

Answer

Rhinophyma

Answer

Rhinosporidiosis

Answer

Angiofibroma

Question 3

Regarding nasal syphilis, which of the following statements is true?

Accepted Answer

Secondary syphilis is the common association.

Answer

Perforation of the septum occurs.

Answer

Saddle nose deformity may occur.

Answer

In newborns, it presents as snuffles.

Question 4

What is the treatment of choice for nasal synechiae?

Accepted Answer

Surgical removal of adhesions

Answer

Topical mitomycin

Answer

Nasal stent

Answer

None of the above

Question 5

Which of the following statements regarding paranasal sinuses is true?

Accepted Answer

The mucous membrane of the maxillary sinus and the upper premolar teeth have the same nerve supply.

Answer

The maxillary sinus of the newborn is relatively large compared to that of the adult.

Answer

The frontal, sphenoidal, maxillary, and anterior ethmoidal sinuses drain into the middle meatus.

Answer

The sphenoidal sinuses are supplied by anterior ethmoidal nerves.

Question 6

Kiesselbach's plexus is situated on which part of the nasal cavity?

Accepted Answer

Medial wall of the nasal cavity

Answer

Medial wall of the middle ear

Answer

Lateral wall of the nasopharynx

Answer

Laryngeal aspect of the epiglottis

Question 7

What is the treatment of choice for antrochoanal polyp?

Accepted Answer

Endoscopic removal

Answer

Caldwell-Luc operation

Answer

Intranasal polypectomy

Answer

None of the above

Question 8

An 18-year-old girl presented with multiple nasal polypi in both nostrils, nasal obstruction, and sinusitis. CT scan shows dense shadows in the sinuses. Histopathology did not show fungal invasion of tissues. Which of the following treatments is NOT indicated?

Accepted Answer

Amphotericin B

Answer

Intranasal corticosteroids

Answer

Surgical removal

Answer

Anti-histamines

Question 9

What is the commonest cause of unilateral mucopurulent rhinorrhea in a child?

Accepted Answer

Foreign body

Answer

Adenoids blocking the airways

Answer

Deviated nasal septum

Answer

Inadequately treated acute frontal sinusitis

Question 10

What is the best X-ray view to visualize the maxillary sinus?

Accepted Answer

Water's view

Answer

Caldwell's view

Answer

Lateral view

Answer

Occlusal anterior view

Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses — MCQs

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