Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: A 35-year-old female patient presents with complaints of nasal obstruction and post-nasal drip. There is a past history of FESS for failed conservative management 5 years ago. Uncinectomy and maxillary ostium dilation was done during the previous FESS. A DNE done now shows patent ostia and mucosal edema of the maxillary sinus lining. What is the next best step in management? FESS - Functional endoscopic sinus surgery

Tissue biopsy for histopathological examination. ***Tissue biopsy for histopathological examination*** - The patient has persistent **mucosal edema** despite previous FESS and patent ostia, raising suspicion for less common etiologies such as **eosinophilic mucin rhinosinusitis** or even a **neoplastic process**, which require histological confirmation. - A biopsy is essential to differentiate between inflammatory conditions not responsive to standard medical therapy and other distinct pathologies, guiding further specific treatment. *Immediate revision FESS* - Revision FESS is usually considered when there is evidence of **recurrent obstruction** or **sinus scarring**, neither of which is indicated by the "patent ostia" observed during DNE. - Performing FESS without addressing the underlying cause of persistent mucosal edema is unlikely to be curative and risks repeat failure. *High-dose systemic steroids* - While systemic steroids can reduce inflammation, persistent symptoms despite prior surgical intervention and observed mucosal edema warrant investigating the underlying cause before resorting to high-dose systemic therapy. - Prolonged use of high-dose systemic steroids carries significant side effects and should be reserved for cases where the etiology is well-defined and responsive, such as severe asthma or certain inflammatory conditions. *Topical antifungal therapy* - While fungal elements can contribute to rhinosinusitis, the broad application of topical antifungals without specific evidence of fungal infection (e.g., fungal balls, invasive fungal sinusitis) is not standard initial management. - The description of "mucosal edema" and absence of specific fungal features (like thick, inspissated mucin or fungal hyphae) makes empirical antifungal therapy less appropriate as the primary next step.

Q: A South Indian male farmer presents to the ENT OPD with complaints of reddish mass coming out from the nose as shown in the image below and the histopathology examination is also given below. What is the likely diagnosis?

Rhinosporidiosis. **Rhinosporidiosis** - The image shows a **reddish, friable mass** in the nose, and the histopathology reveals **large sporangia** containing endospores, which are characteristic findings of *Rhinosporidium seeberi*, the causative agent of rhinosporidiosis. - The patient's demographic (South Indian male farmer) is also consistent, as rhinosporidiosis is **endemic in India and Sri Lanka** and is often associated with exposure to **stagnant water**. *Nasal polyp* - Nasal polyps are typically **pale, yellowish-grey, glistening, and translucent** masses, contrasting with the reddish appearance in the image. - Histologically, they show **edematous stroma** with inflammatory cells but lack the distinct sporangia seen in the provided image. *Inverted papilloma* - Inverted papillomas are characterized by **endophytic growth** of squamous or transitional epithelium into the underlying stroma. - Although they can be reddish, their histopathology shows **inverted papillary projections**, not fragmented sporangia. *Antrochoanal polyp* - An antrochoanal polyp typically originates from the **maxillary sinus** and extends into the choana and nasopharynx, which may not be overtly visible as a mass presenting anteriorly in the nostril without further examination. - Like other nasal polyps, its histological appearance would be **edematous inflammatory tissue** without the parasitic structures seen here.

Q: Young's operation is done for:

Atrophic rhinitis. ***Atrophic rhinitis*** - **Young's operation** is a surgical procedure specifically designed to treat **atrophic rhinitis**. - The goal of the surgery is to narrow the nasal passages by creating a **synechia** (adhesion) to reduce airflow and improve the humidification and temperature of inspired air. *Allergic rhinitis* - Allergic rhinitis is primarily managed with **medical therapy**, including antihistamines, nasal corticosteroids, and allergen avoidance. - Surgical intervention, if considered, typically involves procedures like turbinate reduction, not Young's operation, and is less common for this condition. *Vasomotor rhinitis* - Vasomotor rhinitis is a **non-allergic, non-infectious condition** characterized by fluctuating nasal congestion and rhinorrhea, often triggered by irritants or temperature changes. - Treatment usually involves **medical management** with anticholinergics or nasal corticosteroids, and sometimes turbinate reduction, but not Young's operation. *Antrochoanal polyp* - An antrochoanal polyp is a benign growth originating in the **maxillary sinus** and extending into the choana. - The primary treatment is **surgical removal**, typically via endoscopic sinus surgery, which is distinct from Young's operation.

Q: Frontal headache is due to inflammation of which sinus?

Frontal. ***Frontal*** - Inflammation of the **frontal sinuses** typically causes pain and pressure over the forehead, known as a **frontal headache**. - The pain is often worse in the morning, when bending over, or with changes in **barometric pressure**. *Sphenoid* - **Sphenoid sinusitis** usually causes a headache behind the eyes, at the **vertex of the head**, or in the occipital region. - It is less common than other forms of sinusitis and often presents with more diffuse, deep-seated pain. *Ethmoidal* - **Ethmoidal sinusitis** typically results in pain and pressure between the eyes or over the **bridge of the nose**. - It can also cause eye pain and is sometimes mistaken for a **tension headache**. *Maxillary* - **Maxillary sinusitis** commonly causes pain and pressure in the cheeks, under the eyes, and in the upper teeth, often exacerbated by **chewing or biting**. - This pain can radiate to the temples or ears, but it typically does not manifest as a **frontal headache**.

Q: Most common malignancy of maxillary antrum:

Squamous cell Carcinoma. ***Squamous cell Carcinoma*** - **Squamous cell carcinoma (SCC)** accounts for approximately **80% of all malignant tumors** of the maxillary antrum. - This prevalence is due to the **squamous metaplasia** of the respiratory epithelium lining the sinus, especially in response to chronic irritation or inflammation. *Mucoepidermoid Carcinoma* - While it can occur in the maxillary sinus, **mucoepidermoid carcinoma** is a rare tumor, typically arising from **minor salivary glands**. - It is far **less common** than squamous cell carcinoma in the maxillary antrum. *Adenoid cystic Carcinoma* - **Adenoid cystic carcinoma** is a relatively rare tumor that more commonly affects the **major and minor salivary glands** and is known for its **perineural invasion** and slow growth, but it is not the most common in the maxillary antrum. - Its presence in the maxillary sinus is usually an **extension from adjacent structures** or a primary tumor of minor salivary glands within the sinus. *Adenocarcinoma* - **Adenocarcinoma** of the maxillary antrum is less common than SCC, often associated with exposure to **wood dust** or **leather processing**. - It typically arises from **seromucinous glands** within the sinus lining, but its incidence is significantly lower than that of squamous cell carcinoma.

Q: A young boy came to OPD with complaints of difficulty in breathing. On examination, bilateral polyps were found. On aspiration, bleeding was seen. What will be the initial management?

Topical corticosteroids. ***Topical corticosteroids*** - **Topical corticosteroids** are the **first-line medical management** for **nasal polyps**, helping to reduce inflammation and shrink polyp size. - They work by reducing local inflammation and edema, improving nasal airway patency and breathing. - **Important note**: The presence of **bleeding on aspiration** suggests a **vascular lesion** (such as juvenile nasopharyngeal angiofibroma in young males), which would require **imaging (CT/MRI) before any intervention** and **no biopsy** due to hemorrhage risk. However, if these are inflammatory polyps, topical steroids remain the initial medical management. *Antihistaminic* - **Antihistamines** are not first-line treatment for nasal polyps, as polyps are primarily an **eosinophilic inflammatory condition** rather than a simple IgE-mediated allergic reaction. - While antihistamines may help with associated allergic rhinitis symptoms, they do **not shrink polyps** or address the underlying inflammatory pathology. *Septoplasty* - **Septoplasty** is a surgical procedure to correct a **deviated nasal septum**, not for treating nasal polyps. - This would not address the bilateral polyps causing difficulty in breathing. *I and D* - **Incision and drainage (I&D)** is performed for abscesses or pus collections, which is not the presentation here. - Nasal polyps are benign inflammatory masses, not infectious collections requiring drainage.

Q: Most prominent and largest air cell of ethmoidal sinus?

Bulla ethmoidalis. ***Bulla ethmoidalis*** - The **bulla ethmoidalis** is universally present and is consistently described as the **largest and most prominent** of the anterior ethmoid air cells. - It forms an anatomical landmark that is consistently superior and posterior to the **hiatus semilunaris**. *Onodi cell* - The **Onodi cell** is a posterior ethmoid air cell that pneumatizes laterally and superiorly into the sphenoid bone, in close proximity to the optic nerve. - While clinically significant due to its relationship with the optic nerve, it is not the largest or most prominent ethmoidal air cell. *Haller cell* - A **Haller cell** is an infraorbital ethmoid cell located along the floor of the orbit, extending into the maxillary sinus. - These cells can contribute to **ostial obstruction** of the maxillary sinus but are typically small compared to the bulla ethmoidalis. *Agger nasi cell* - The **agger nasi cell** is the most anterior ethmoid air cell, located in the lacrimal bone anterior to the frontal recess. - It is often one of the first ethmoid cells to pneumatize but is generally small and not considered the most prominent.

Q: Failure of rupture of buccopharyngeal membrane leads to?

Choanal atresia. ***Choanal atresia*** - The **buccopharyngeal membrane** (also called the oronasal or choanal membrane) normally ruptures to establish communication between the nasal cavity and the pharynx. - Failure of this rupture results in a bony or membranous obstruction of the posterior nasal opening (choana). - This presents as **bilateral nasal obstruction in neonates**, which is life-threatening as neonates are obligate nasal breathers. *Epistaxis* - This refers to a **nosebleed**, which is typically caused by trauma, dryness, or underlying blood dyscrasias. - It is not related to the developmental failure of the buccopharyngeal membrane. *Rhinophyma* - This is a feature of advanced **rosacea**, characterized by an enlarged, red, and bulbous nose due to sebaceous gland hypertrophy. - It is a dermatological condition unrelated to embryonic development. *Crooked nose* - A crooked nose usually results from **trauma** or developmental abnormalities of the nasal cartilages and bones. - It is a structural deformity of the external nose and not the internal nasal passages.

Q: CSF rhinorrhea is diagnosed by: MP 07

Beta-2 transferrin. ***Beta-2 transferrin*** - **Beta-2 transferrin** is the **gold standard** for diagnosing CSF rhinorrhea with **high specificity and sensitivity** - It is present **only in CSF, perilymph, and aqueous humor**, making it highly specific for CSF leak diagnosis - While it requires specialized laboratory analysis and may not be immediately available, it remains the **most reliable confirmatory test** - Modern alternatives include **Beta-trace protein**, which also has high specificity *Glucose estimation* - Historically used as a rapid screening test based on the presence of glucose in CSF - **Major limitation**: **Poor specificity** as nasal mucus, tears, and other secretions also contain glucose, leading to frequent false positives - A positive glucose test is suggestive but **not diagnostic** and requires confirmation with more specific tests - No longer considered the primary diagnostic method due to high false-positive rates *Halo sign* - The **halo sign** (or double ring sign) appears when nasal discharge mixed with blood is placed on filter paper, creating a central blood spot with a clear surrounding ring - **Not specific for CSF** - other watery fluids (tears, saline) mixed with blood can produce similar appearance - Useful as a **bedside screening test** but requires confirmation with biochemical analysis *All of the options* - While multiple tests can be used in the diagnostic workup, they have **different specificities and diagnostic values** - **Beta-2 transferrin** is the definitive diagnostic test, while others serve as screening or supportive tests - Therefore, "All of the options" is incorrect as the question asks for the diagnostic test, which specifically refers to the gold standard

Question 1

A 35-year-old female patient presents with complaints of nasal obstruction and post-nasal drip. There is a past history of FESS for failed conservative management 5 years ago.
Uncinectomy and maxillary ostium dilation was done during the previous FESS. A DNE done now shows patent ostia and mucosal edema of the maxillary sinus lining. What is the next best step in management?
FESS - Functional endoscopic sinus surgery

Accepted Answer

Tissue biopsy for histopathological examination

Answer

Immediate revision FESS

Answer

High-dose systemic steroids

Answer

Topical antifungal therapy

Question 2

A South Indian male farmer presents to the ENT OPD with complaints of reddish mass coming out from the nose as shown in the image below and the histopathology examination is also given below. What is the likely diagnosis?

Accepted Answer

Rhinosporidiosis

Answer

Nasal polyp

Answer

Inverted papilloma

Answer

Antrochoanal polyp

Question 3

Young's operation is done for:

Accepted Answer

Atrophic rhinitis

Answer

Allergic rhinitis

Answer

Vasomotor rhinitis

Answer

Antrochoanal polyp

Question 4

Frontal headache is due to inflammation of which sinus?

Accepted Answer

Frontal

Answer

Sphenoid

Answer

Ethmoidal

Answer

Maxillary

Question 5

Most common malignancy of maxillary antrum:

Accepted Answer

Squamous cell Carcinoma

Answer

Muco-epidermoid Carcinoma

Answer

Adenoid cystic Carcinoma

Answer

Adenocarcinoma

Question 6

A young boy came to OPD with complaints of difficulty in breathing. On examination, bilateral polyps were found. On aspiration, bleeding was seen. What will be the initial management?

Accepted Answer

Topical corticosteroids

Answer

Septoplasty

Answer

I and D

Answer

Antihistaminic

Question 7

Most prominent and largest air cell of ethmoidal sinus?

Accepted Answer

Bulla ethmoidalis

Answer

Onodi cell

Answer

Haller cell

Answer

Agger nasi cell

Question 8

Rhinoscleroma, true statement is:

Accepted Answer

Begins at the junction between the stratified squamous epithelium of the vestibule and the respiratory epithelium of the nose

Answer

Common in urban areas with high socioeconomic strata

Answer

Caused by Klebsiella ozonae

Answer

Histopathological picture with Mikulicz cell and the Russell body is not pathognomonic.

Question 9

Failure of rupture of buccopharyngeal membrane leads to?

Accepted Answer

Choanal atresia

Answer

Epistaxis

Answer

Rhinophyma

Answer

Crooked nose

Question 10

CSF rhinorrhea is diagnosed by: MP 07

Accepted Answer

Beta-2 transferrin

Answer

Halo sign

Answer

Glucose estimation

Answer

All of the options

Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses — MCQs

On this page

Practice by Chapter

Want unlimited practice?