Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: The CT scan of paranasal sinuses shows:

Haller cells. ***Haller cells*** - The image shows **pneumatized ethmoid air cells** located inferior to the orbit and lateral to the maxillary sinus ostium (arrows), which are characteristic of Haller cells. - These ethmoid cells, also known as **infraorbital ethmoid cells**, can narrow the maxillary sinus ostium, potentially contributing to **recurrent sinusitis**. *Agger nasi cells* - **Agger nasi cells** are the most anterior ethmoid cells, located in the lacrimal bone, anterior and lateral to the frontal recess. - They are typically situated at the level of the frontal sinus ostium, not inferior to the orbit. *Onodi cells* - **Onodi cells** are sphenoethmoidal air cells that extend posteriorly and laterally over the sphenoid sinus, in close proximity to the optic nerve. - Their location is **posterior and superior** to the structures shown in the image, making them incorrectly identified here. *Frontoethmoid cells* - **Frontoethmoid cells** can be a broad category, but specifically refer to ethmoid cells that extend into the frontal sinus or drain into the frontal recess. - While they are ethmoid cells, the specific location shown in the image (inferior to the orbit and maxillary sinus ostium) is more precisely described as Haller cells.

Q: A 65-year-old lady presents with soft swelling on her left supra-orbital area which she says is always warm to touch. She has been taking Ayurvedic treatment for these swellings for the last 6 months. What is the probable diagnosis?

Pott's puffy tumor. ***Pott's puffy tumor*** - This condition is characterized by a **subperiosteal abscess** and osteomyelitis of the frontal bone, often presenting as a **tender, edematous forehead swelling** that feels warm to the touch. - It typically results from a complication of **frontal sinusitis** and can lead to intracranial complications if untreated. *Osteoid osteoma* - This is a **benign bone tumor** characterized by localized pain, typically worse at night and relieved by NSAIDs. - While it affects bone, it usually presents as a **hard, non-enlarging mass** and does not typically involve infection or diffuse swelling like the described case. *Follicular carcinoma thyroid* - This is a **malignant thyroid cancer** that typically presents as a thyroid nodule or mass in the neck, occasionally with distant metastases. - It does not present as a warm, soft swelling on the **supra-orbital area** and is unrelated to frontal bone pathology. *Malignant fibrous histiocytoma* - This is a type of **soft tissue sarcoma** that can occur in various locations, including bone or soft tissues of the head and neck. - While it can present as a mass, it is not typically associated with the **warmth and inflammatory signs** indicative of infection, nor does it specifically localize to the supra-orbital region with the mentioned characteristics.

Q: A patient complains of pain and boggy swelling in the frontal region which is warm and tender. He also complains of drowsiness at times. What is the diagnosis?

Pott's puffy tumor. **Pott's puffy tumor** * **Pott's puffy tumor** is characterized by a focal osteomyelitis of the frontal bone, often complicated by a subperiosteal abscess. The description of **pain and boggy swelling in the frontal region, which is warm and tender**, perfectly matches this condition. * The complication of **drowsiness** indicates potential epidural or intracranial extension of the infection, which is a common and severe consequence of Pott's puffy tumor. *Pyogenic granuloma* * A pyogenic granuloma is a **benign vascular lesion** of the skin or mucous membranes. * While it can be warm and tender, it typically presents as an **eruptive, solitary, red papule or nodule** that bleeds easily, and it does not typically cause boggy swelling in the frontal bone or drowsiness. *Orbital cellulitis* * Orbital cellulitis presents with **pain, swelling, redness, and warmth around the eye,** often with proptosis and ophthalmoplegia. * While it is a serious infection, the primary swelling in this case is described in the **frontal region**, not specifically confined to the orbit, and the specific feature of a "boggy" swelling over bone is more indicative of a frontal bone osteomyelitis. *Cavernous sinus thrombosis* * Cavernous sinus thrombosis is characterized by **headache, painful ophthalmoplegia, proptosis, and vision loss**, often with fever and altered mental status. * While **drowsiness** can be a feature, the presentation lacks the prominent **orbital signs** and localizing frontal boggy swelling specific to the described case; instead, it would typically present predominantly with signs related to cranial nerve involvement and venous congestion of the orbit.

Q: Which one of the following regarding Nasal polyps is NOT true?

Nasal polyps are very painful to touch. ***Nasal polyps are very painful to touch*** * **Nasal polyps** are typically **painless** and soft to the touch, as they are edematous mucosal outgrowths. * Pain associated with **nasal polyps** usually indicates a secondary complication such as **infection** or, rarely, **malignancy**, rather than the polyps themselves. * *Meningocele must be excluded in children with polyps* * **Meningoceles** or **encephalocele** are important considerations in children presenting with **nasal masses**, as they represent a protrusion of brain tissue or meninges and resemble polyps. * Their exclusion is critical due to the risk of **meningitis** during surgical intervention if misdiagnosed as routine polyps. * *Bleeding polyp may indicate malignancy* * While polyps are generally not prone to bleeding, the presence of **unilateral**, **bleeding**, or **friable polyps** raises suspicion for **malignancy**, such as **nasopharyngeal carcinoma** or **sinonasal cancers**. * Any atypical presentation, especially with ulceration or persistent epistaxis, warrants **biopsy** and further investigation. * *Simple polyps are bilateral* * **Simple inflammatory polyps** (e.g., from **chronic rhinosinusitis** with nasal polyps) are most commonly found **bilaterally**. * Unilateral polyps or masses, especially in adults, should prompt suspicion for other causes, including **neoplasms**.

Q: Antro-choanal polyp always arises from:

Maxillary sinus. ***Maxillary sinus*** - An **antro-choanal polyp** (ACP) characteristically originates from the **mucosa of the maxillary sinus**, typically protruding through the ostium into the nasal cavity. - The name "antro-choanal" itself signifies its origin in the **antrum** (maxillary sinus) and its extension to the **choana** (posterior nasal aperture). *Posterior end of the septum* - Polyps do not typically arise from the **septum**; nasal polyps more commonly originate from the lateral nasal wall or paranasal sinuses. - The septum is primarily composed of cartilage and bone and does not have the same mucociliary lining susceptible to polyp formation as the sinuses. *Nasopharynx* - While an antro-choanal polyp may extend into the **nasopharynx**, it does not originate there. - The nasopharynx is a common endpoint for the polyp's growth, but its actual point of attachment is in the maxillary sinus. *Posterior ethmoidal cells* - Polyps can arise from **ethmoidal cells** (ethmoidal polyps), but these are distinct from antro-choanal polyps and do not typically grow to occupy the choana. - Ethmoidal polyps are usually multiple and bilateral, whereas antro-choanal polyps are typically solitary and unilateral.

Q: Which sinus drainage is impaired in the following image?

Maxillary. ***Maxillary*** - The image shows **arrows pointing to the maxillary sinuses** with visible **opacification and fluid accumulation**, indicating **impaired drainage**. - Maxillary sinuses drain through the **ostiomeatal complex** into the middle meatus; obstruction leads to mucus retention and sinusitis. *Ethmoid* - The **ethmoid air cells** located between the eyes, medial to the orbits, do not show significant **opacification** or drainage impairment. - These complex honeycomb-like structures appear **relatively clear** without evidence of fluid accumulation. *Sphenoid* - The **sphenoid sinuses** located deeper in the skull, behind the ethmoid sinuses, are **not prominently affected** in this image. - No significant **opacification** or mucosal thickening visible to suggest impaired drainage. *Frontal* - The **frontal sinuses** located above the eyebrows appear **relatively clear** without significant opacification or drainage impairment. - These sinuses drain through the **frontonasal duct** and do not show evidence of fluid retention in this image.

Q: A 14-year-old child with a history of recurrent nasal bleeding has the endoscopic view provided. What is the investigation of choice?

CECT (Contrast-Enhanced CT). ***CECT (Contrast-Enhanced CT)*** - Given the history of recurrent nasal bleeding in an adolescent male suggestive of a **juvenile nasopharyngeal angiofibroma (JNA)**, CECT is the investigation of choice to delineate the tumor's extent, vascularity, and involvement of surrounding structures. - CECT provides crucial information for surgical planning and assessing intracranial extension due to the highly vascular nature of JNAs. *Biopsy* - Biopsy of a suspected angiofibroma is generally **contraindicated** due to the high risk of severe and uncontrolled hemorrhage because the tumor is highly vascular and lacks a true capsule. - The diagnosis of JNA is usually made based on clinical presentation and imaging findings. *X-ray* - **X-rays** (like plain radiographs of the sinuses) offer limited soft tissue detail and are **insufficient** to accurately visualize the extent or vascularity of a nasopharyngeal mass. - They may show some bony erosion but cannot provide the detailed information needed for diagnosis or surgical planning of a JNA. *FESS (Functional Endoscopic Sinus Surgery)* - **FESS** is a **surgical procedure** used for treating chronic sinusitis and other sinonasal conditions, not primarily an investigative tool for a suspected tumor like JNA. - While endoscopy is used for initial visualization, **surgery** is a treatment, and detailed imaging must precede it to understand tumor boundaries.

Q: A patient with chronic nasal obstruction underwent a procedure 3 months ago and now presents with recurrent epistaxis, crusting, and the clinical image showing a septal perforation. What procedure was most likely carried out?

Submucosal resection (SMR). ***Submucosal resection (SMR)*** - **SMR** involves removing cartilage or bone from the nasal septum while preserving the septal mucosa. If both mucosal flaps are inadvertently damaged or devitalized during the procedure, it can lead to a **septal perforation** as a complication. - The symptoms of **recurrent epistaxis** and **crusting** are classic signs associated with compromised septal integrity and airflow changes due to a septal perforation, which commonly occurs weeks to months after such a procedure. *FESS (Functional Endoscopic Sinus Surgery)* - **FESS** is primarily used to treat chronic sinusitis by opening and ventilating the sinuses; it does not directly involve the nasal septum in a way that typically causes perforation. - While complications are possible, a septal perforation is not a common or direct consequence of FESS, which focuses on ethmoid, maxillary, frontal, or sphenoid sinus drainage pathways. *Caldwell-Luc's procedure* - The **Caldwell-Luc procedure** involves an incision above the canine fossa to access the maxillary sinus. - It is specifically aimed at the maxillary sinus and does not involve surgical manipulation of the nasal septum that would lead to a septal perforation. *Turbinate reduction surgery* - **Turbinate reduction** procedures target the inferior turbinates to improve nasal airflow by reducing their size. - These procedures do not involve the nasal septum itself, so a septal perforation would not be a direct or common complication.

Q: A woman visits the ENT outpatient department with complaints of nasal obstruction. On examination, greenish-black crusts were found in the nasal cavity covering the turbinates and septum, and she also had complete anosmia (lack of sense of smell). What other sign is most likely to be found on examination in this case?

Roomy nasal cavity. ***Roomy nasal cavity*** - The presence of **greenish-black crusts**, **anosmia**, and **nasal obstruction** in the context of chronic atrophy of the nasal mucosa strongly suggests **atrophic rhinitis**. - **Atrophic rhinitis** (also known as ozena) is characterized by progressive atrophy of the nasal mucosa, turbinates, and underlying bone, leading to an abnormally **wide and roomy nasal cavity**. *Hypertrophied inferior turbinate* - **Hypertrophied turbinates** typically result in nasal obstruction but would present with a narrow, rather than a roomy, nasal cavity. - There would also be no greenish-black crusts or complete anosmia with simple turbinate hypertrophy. *Polyp* - **Nasal polyps** are typically pale, glistening, grape-like masses that cause nasal obstruction and hyposmia but do not cause greenish-black crusts or a roomy nasal cavity. - They usually result from chronic inflammation and are often associated with conditions like allergic rhinitis or asthma. *Foreign Body* - A **nasal foreign body** would cause unilateral nasal obstruction and often a foul-smelling, purulent discharge, but not typically greenish-black crusts or a roomy nasal cavity. - It would also not explain the complete anosmia unless it severely obstructed both nasal passages for an extended period, which is less likely than atrophic rhinitis.

Question 1

The CT scan of paranasal sinuses shows:

Accepted Answer

Haller cells

Answer

Agger nasi cells

Answer

Onodi cells

Answer

Frontoethmoid cells

Question 2

A 65-year-old lady presents with soft swelling on her left supra-orbital area which she says is always warm to touch. She has been taking Ayurvedic treatment for these swellings for the last 6 months. What is the probable diagnosis?

Accepted Answer

Pott's puffy tumor

Answer

Osteoid osteoma

Answer

Follicular carcinoma thyroid

Answer

Malignant fibrous histiocytoma

Question 3

A patient complains of pain and boggy swelling in the frontal region which is warm and tender. He also complains of drowsiness at times. What is the diagnosis?

Accepted Answer

Pott's puffy tumor

Answer

Pyogenic granuloma

Answer

Orbital cellulitis

Answer

Cavernous sinus thrombosis

Question 4

Which one of the following regarding Nasal polyps is NOT true?

Accepted Answer

Nasal polyps are very painful to touch

Answer

Meningocele must be excluded in children with polyps

Answer

Bleeding polyp may indicate malignancy

Answer

Simple polyps are bilateral

Question 5

Antro-choanal polyp always arises from:

Accepted Answer

Maxillary sinus

Answer

Posterior end of the septum

Answer

Nasopharynx

Answer

Posterior ethmoidal cells

Question 6

Pott's puffy tumour is a:

Accepted Answer

Subperiosteal abscess associated with osteomyelitis of frontal bone

Answer

Tuberculosis of the skull bone

Answer

Fungating scrotal malignancy

Answer

Squamous cell cancer of scalp

Question 7

Which sinus drainage is impaired in the following image?

Accepted Answer

Maxillary

Answer

Ethmoid

Answer

Sphenoid

Answer

Frontal

Question 8

A 14-year-old child with a history of recurrent nasal bleeding has the endoscopic view provided. What is the investigation of choice?

Accepted Answer

CECT (Contrast-Enhanced CT)

Answer

Biopsy

Answer

X-ray

Answer

FESS (Functional Endoscopic Sinus Surgery)

Question 9

A patient with chronic nasal obstruction underwent a procedure 3 months ago and now presents with recurrent epistaxis, crusting, and the clinical image showing a septal perforation. What procedure was most likely carried out?

Accepted Answer

Submucosal resection (SMR)

Answer

FESS (Functional Endoscopic Sinus Surgery)

Answer

Caldwell-Luc's procedure

Answer

Turbinate reduction surgery

Question 10

A woman visits the ENT outpatient department with complaints of nasal obstruction. On examination, greenish-black crusts were found in the nasal cavity covering the turbinates and septum, and she also had complete anosmia (lack of sense of smell). What other sign is most likely to be found on examination in this case?

Accepted Answer

Roomy nasal cavity

Answer

Hypertrophied inferior turbinate

Answer

Polyp

Answer

Foreign Body

Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses — MCQs

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