Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: A patient presents with a thick nasal discharge and headache. Examination reveals hypertrophy of the inferior turbinate with a mulberry appearance. Which of the following is the most likely diagnosis?

Hypertrophic rhinitis. ***Hypertrophic rhinitis***- This is a form of **chronic rhinitis** where persistent inflammation leads to irreversible changes, including mucosal and sub-mucosal fibrosis and hypertrophy.- The inferior turbinate hypertrophy becomes nodular, leading to the characteristic irreversible **"mulberry appearance"** on examination, correlating with thick discharge and obstruction.*Atrophic rhinitis*- This condition involves **atrophy** (shrinking) of the nasal mucosa and associated turbinates, leading to wide nasal passages, crusting, and often a foul smell (**ozena**).- The examination would show diminished turbinate size and a patent nasal cavity, which contradicts the finding of turbinate hypertrophy.*Common cold*- While causing discharge and headache, the discharge is typically watery (**rhinorrhea**) initially, progressing to mucoid, and the illness is acute and self-limiting.- It does not cause permanent or marked **fibrotic hypertrophy** of the inferior turbinates with a mulberry appearance, which is a sign of chronic inflammation.*Nasal polyp*- Nasal polyps are pale, glistening, freely mobile, non-tender masses that typically resemble **peeled grapes** and usually arise from the middle meatus.- Polyps represent edematous mucosa and are distinct from the fixed, hyperplastic tissue constituting the hypertrophied inferior turbinate itself.

Q: A 40-year-old patient presents with recurrent and severe nosebleeds from the anterior nasal septum. The bleeding has been refractory to nasal packing and chemical cautery. A decision is made to proceed with surgical ligation to control the bleeding. Which of the following arteries is the primary target for ligation in the management of this patient's anterior epistaxis?

Sphenopalatine artery. ***Sphenopalatine artery*** - The **Sphenopalatine artery** (terminal branch of the internal maxillary artery) is the **dominant blood supply** to the nasal cavity, including the anterior nasal septum via its **septal branches**. - It is the **major contributor** to **Kiesselbach's plexus** (Little's area), which is located in the anteroinferior nasal septum and is the source of 90% of anterior epistaxis. - **Endoscopic sphenopalatine artery ligation (ESPAL)** is the **first-line surgical intervention** for refractory anterior epistaxis that has failed conservative management (packing, cautery). - This procedure has high success rates (85-95%) and is now the gold standard for surgical management of severe anterior and posterior epistaxis. *Anterior ethmoidal artery* - Branch of the **ophthalmic artery** (internal carotid system) that supplies the **superior anterior** nasal cavity and anterior ethmoid cells. - It contributes **minimally** to Kiesselbach's plexus; its main territory is the **roof and upper anterior nasal cavity**. - Anterior ethmoidal artery ligation (via external or endoscopic approach) is indicated for **superior anterior** or **roof bleeding**, NOT typical anteroinferior septal bleeding. *Facial artery* - The **superior labial artery** (branch of facial artery) contributes to the inferior aspect of Kiesselbach's plexus but is a **minor contributor**. - Facial artery ligation is **ineffective** for controlling severe nasal bleeding as it is too distal and doesn't address the main vascular supply. *Internal maxillary artery* - Parent vessel of the sphenopalatine artery; ligation is performed when **sphenopalatine artery ligation is technically difficult or has failed**. - Historically performed via **transantral (Caldwell-Luc) approach**, now rarely needed due to success of endoscopic sphenopalatine artery ligation. - Reserved for severe refractory cases or when endoscopic access is not feasible.

Q: A patient presents to the emergency department with significant nasal trauma after a fall. Examination reveals a deviated nasal pyramid and palpation confirms crepitus and mobility of the nasal bones. A lateral nasal bone X-ray confirms a displaced nasal bone fracture. Which of the following instruments is specifically designed for the closed reduction of a displaced nasal bone fracture?

Walsham forceps. ***Walsham forceps*** - The **Walsham forceps** is specifically designed for the **closed reduction** of displaced nasal bone fractures, utilizing an internal blade and an external padded blade for controlled lifting and manipulation. - They allow the surgeon to gain purchase on the fractured segments to safely elevate **depressed nasal bones** and restore the nasal pyramid's shape. *Tilley's forceps* - **Tilley's nasal dressing forceps** are primarily used for general purposes, such as removing foreign bodies, packing the nose, or removing **small polyps** from the nasal cavity. - They lack the necessary structure, leverage, and specialized curve required to successfully engage and **reduce** a bony nasal fracture. *Luc's forceps* - **Luc's forceps** are generally used for applying **anterior nasal packing** or removing dressings, serving primarily as a dressing forceps. - Although used in the nose, they do not have the specialized geometry needed to grasp and elevate the bony cartilage for **fracture reduction**. *Bayonet forceps* - **Bayonet forceps** are commonly used in microscopic or endoscopic procedures (e.g., ear or fine nasal surgery) because their offset handle prevents the surgeon's hand from obstructing the line of sight. - They are used for fine grasping, packing, or dissection, but are entirely unsuitable for the heavy task of **reducing** a **displaced nasal bone fracture**.

Q: A 15-year-old female presents with nasal obstruction and occasional profuse epistaxis for last 8 weeks. Nasal speculum view and histopathology of resected lesion is given. All are correct about the diagnosis except:

Best cultured on nasal inoculation in hamster. *Best cultured on nasal inoculation in hamster* - This statement is **incorrect** because *Rhinosporidium seeberi*, the causative agent of rhinosporidiosis (which is indicated by the images and clinical presentation), is an **uncultivable organism** in artificial media or animal models. - Its complex life cycle and specific host requirements make *in vitro* or *in vivo* culture challenging and largely unsuccessful. *Multiple fungal spherules embedded in stroma of connective tissue* - The histopathology image clearly shows characteristic **spherules** of varying sizes, containing numerous endospores, embedded within the connective tissue stroma, which is typical for rhinosporidiosis. - These spherules represent different stages of the organism's life cycle. *Infection originates from stagnant water* - *Rhinosporidium seeberi* is commonly found in **stagnant water** (rivers, ponds) and is often associated with swimming, bathing, or working in such environments. - Exposure to contaminated water is the primary mode of transmission for this rare chronic granulomatous disease. *Surgical excision is best treatment* - **Surgical excision** of the mass with electrocoagulation of the base is considered the most effective treatment for rhinosporidiosis to prevent recurrence. - Anti-fungal medications like dapsone may be used as an adjunct to reduce recurrence rates.

Q: Identify the surgical procedure being performed in the image shown below.

Caldwell Luc operation. ***Caldwell Luc operation*** - The image shows an **incision in the gingivobuccal sulcus** above the upper incisor/canine teeth, reflecting the periosteum to access the anterior wall of the maxillary sinus, which is characteristic of the Caldwell-Luc operation. - This procedure involves creating an opening into the **maxillary antrum** to remove diseased tissue, often visualized through the anterior sinus wall as depicted in the right panel. *Inferior meatal antrostomy* - An inferior meatal antrostomy involves creating an opening in the **lateral nasal wall**, specifically beneath the inferior turbinate, to drain the maxillary sinus. - The approach in the image, through the oral cavity, is inconsistent with an inferior meatal antrostomy. *Proof puncture* - **Proof puncture** (also known as antral washout) is a diagnostic and therapeutic procedure where a needle is inserted into the maxillary sinus, typically through the inferior meatus, to aspirate contents and irrigate. - It does not involve a large surgical incision in the gingiva or removal of bone as shown in the image. *Superior meatal antrostomy* - The superior meatus is an anatomical space in the nasal cavity positioned **above the superior turbinate**. - A superior meatal antrostomy would access the posterior ethmoid cells or sphenoid sinus, not the maxillary sinus through an oral approach, and is not a standard procedure for maxillary sinus issues.

Q: An 8-year-old boy presents with recurrent episodes of epistaxis. Histopathological specimen of the excised lesion is shown below. All are correct about this condition except:

Holman-Miller sign is always present in all cases. ***Holman-Miller sign*** - The **Holman-Miller sign** (anterior bowing of the posterior wall of the maxillary antrum) is a helpful **radiological finding** in JNA but is **NOT always present** in all cases. - This sign is **supportive** when present but is not **pathognomonic** or universally found, making any claim of universal presence incorrect. *Frog face deformity* - **Frog face deformity** is indeed a characteristic physical finding in advanced **juvenile nasopharyngeal angiofibroma (JNA)** cases. - Results from significant **tumor extension** and **facial bone remodeling** due to mass effect, pushing facial structures forward and outward. *Management of emergency bleeding with adrenaline soaked gauze* - **Adrenaline-soaked gauze** is a valid emergency management approach for **epistaxis** in JNA due to its **vasoconstrictor** properties. - Provides temporary **hemostasis** while definitive treatment is planned, though systemic effects like **hypertension** must be monitored. *Radowski stage IIIB involves cavernous sinus extension* - The **Radkowski staging system** for JNA correctly classifies **Stage IIIB** as involving **cavernous sinus** extension. - This advanced staging is clinically significant for **surgical planning** and prognosis due to involvement of critical neurovascular structures.

Q: A 10-year-old child is brought with complaints of daily headache and nasal stuffiness. He also has paroxysms of sneezing daily. Nasal examination shows a lesion as shown in the image. All are true about the condition shown except?

Antrochoanal polyp grows towards anterior choana. ***Antrochoanal polyp grows towards anterior choana*** - An **antrochoanal polyp** originates from the maxillary sinus and typically grows towards the **posterior choana** and into the nasopharynx, not the anterior choana. - Polyps usually grow unilaterally and do not spread to the anterior choana. *Nasal polyp in right nostril* - The image clearly shows a **pinkish, edematous mass** protruding from the patient's right nostril, consistent with a nasal polyp. - The child's symptoms of **nasal stuffiness, headache, and sneezing** are also characteristic of nasal polyps. *Stage IV polyp goes up to floor of nose* - The **Lund-Mackay staging system** or similar classification systems for nasal polyps categorize Stage IV polyps as those that **obstruct the entire nasal cavity** or protrude outside the nostril, which matches the visual presentation in the image. - While not specifically mentioning the "floor of the nose" as a distinct stage element, a Stage IV polyp signifies extensive growth throughout the nasal cavity. *Krause nasal snare is used for removal of polyps* - A **Krause nasal snare** is a common surgical instrument used in polypectomy for the removal of larger nasal polyps. - It works by looping around the base of the polyp and excising it, often under local anesthesia.

Q: The following test is done for the evaluation of:

Abnormality of nasal valve. ***Abnormality of nasal valve*** - The image demonstrates the **Cottle test**, where fingers are placed on the cheek lateral to the nose and gently pulled laterally to open the **internal nasal valve**. - If breathing improves with this maneuver, it indicates **nasal valve dysfunction** or collapse, helping diagnose nasal obstruction. *Cheek tenderness in maxillary sinusitis* - Assessment of **maxillary sinusitis** involves direct palpation over the maxillary sinus area below the eye, not lateral traction on the cheek. - **Tenderness on palpation** would be elicited by pressing directly over the sinus, not by pulling the cheek laterally as shown. *Severity of proptosis* - **Proptosis** (exophthalmos) is measured using an **exophthalmometer** to quantify eyeball protrusion. - The lateral traction maneuver shown has no relevance to assessing **ocular protrusion** or orbital pathology. *Skin pinch for dehydration* - The **skin turgor test** for dehydration involves pinching skin on the back of the hand, forearm, or abdomen, not the cheek area. - **Poor skin turgor** is assessed by delayed return of pinched skin to normal position, which is not the technique demonstrated.

Question 1

A patient presents with a thick nasal discharge and headache. Examination reveals hypertrophy of the inferior turbinate with a mulberry appearance. Which of the following is the most likely diagnosis?

Accepted Answer

Hypertrophic rhinitis

Answer

Common cold

Answer

Nasal polyp

Answer

Atrophic rhinitis

Question 2

A 40-year-old patient presents with recurrent and severe nosebleeds from the anterior nasal septum. The bleeding has been refractory to nasal packing and chemical cautery. A decision is made to proceed with surgical ligation to control the bleeding. Which of the following arteries is the primary target for ligation in the management of this patient's anterior epistaxis?

Accepted Answer

Sphenopalatine artery

Answer

Internal maxillary artery

Answer

Anterior ethmoidal artery

Answer

Facial artery

Question 3

A patient presents to the emergency department with significant nasal trauma after a fall. Examination reveals a deviated nasal pyramid and palpation confirms crepitus and mobility of the nasal bones. A lateral nasal bone X-ray confirms a displaced nasal bone fracture. Which of the following instruments is specifically designed for the closed reduction of a displaced nasal bone fracture?

Accepted Answer

Walsham forceps

Answer

Luc's forceps

Answer

Bayonet forceps

Answer

Tilley's forceps

Question 4

A 15-year-old female presents with nasal obstruction and occasional profuse epistaxis for last 8 weeks. Nasal speculum view and histopathology of resected lesion is given. All are correct about the diagnosis except:

Accepted Answer

Best cultured on nasal inoculation in hamster

Answer

Multiple fungal spherules embedded in stroma of connective tissue

Answer

Infection originates from stagnant water

Answer

Surgical excision is best treatment

Question 5

Identify the surgical procedure being performed in the image shown below.

Accepted Answer

Caldwell Luc operation

Answer

Inferior meatal antrostomy

Answer

Proof puncture

Answer

Superior meatal antrostomy

Question 6

All are contraindications to the procedure shown below except:

Accepted Answer

Antral cyst

Answer

Acute maxillary sinusitis

Answer

Fractured maxilla

Answer

Children less than 3 years

Question 7

An 8-year-old boy presents with recurrent episodes of epistaxis. Histopathological specimen of the excised lesion is shown below. All are correct about this condition except:

Accepted Answer

Holman-Miller sign is always present in all cases

Answer

Frog face deformity can occur in advanced cases

Answer

Emergency bleeding can be managed with adrenaline-soaked gauze

Answer

Radkowski stage IIIB involves cavernous sinus extension

Question 8

A 10-year-old child is brought with complaints of daily headache and nasal stuffiness. He also has paroxysms of sneezing daily. Nasal examination shows a lesion as shown in the image. All are true about the condition shown except?

Accepted Answer

Antrochoanal polyp grows towards anterior choana

Answer

Nasal polyp in right nostril

Answer

Stage IV polyp goes up to floor of nose

Answer

Krause nasal snare is used for removal of polyps

Question 9

The volume of the balloons shown in epistaxis balloon is: (Recent NEET Pattern 2016-17)

Accepted Answer

72. (d)

Answer

73. (b)

Answer

74. (b)

Answer

75. (c)

Question 10

The following test is done for the evaluation of:

Accepted Answer

Abnormality of nasal valve

Answer

Cheek tenderness in maxillary sinusitis

Answer

Severity of proptosis

Answer

Skin pinch for dehydration

Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses — MCQs

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