Diseases of the Nose and Paranasal Sinuses — MCQs

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?

Q329

A 12-year-old male with a history of recurrent epistaxis presents with nasal obstruction for the past 1 year. On examination the presence of nasal mass and investigation shows bowing of the posterior wall of maxillary sinus. What is the probable diagnosis?

Q330

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:

Diseases of the Nose and Paranasal Sinuses Indian Medical PG Practice Questions and MCQs

Question 321: What is the presenting symptom of nasal myiasis?

A. Severe irritation with sneezing (Correct Answer)
B. Maggots
C. Nasal pain
D. Impaired olfaction

Explanation: **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.

Question 322: Which of the following is NOT a cause of epistaxis?

A. Allergic rhinitis (Correct Answer)
B. Foreign body
C. Tumor
D. Hypertension

Explanation: **Explanation:** The correct answer is **A. Allergic rhinitis**. While allergic rhinitis causes nasal congestion, sneezing, and itching, it is not a direct cause of epistaxis. However, it is important to note that *trauma* secondary to nose picking (due to itching) or the side effects of topical steroid sprays can cause bleeding, but the disease process itself does not erode blood vessels or cause spontaneous hemorrhage. **Analysis of other options:** * **Foreign body:** A common cause of unilateral, foul-smelling, blood-stained nasal discharge, especially in children. The local inflammation and pressure necrosis caused by the object lead to epistaxis. * **Tumor:** Both benign (e.g., Juvenile Nasopharyngeal Angiofibroma) and malignant (e.g., Squamous cell carcinoma) tumors are highly vascular or cause tissue destruction, leading to profuse or recurrent epistaxis. * **Hypertension:** A classic systemic cause of epistaxis, particularly in the elderly. It often results in **posterior epistaxis** from Woodruff’s plexus due to the rupture of sclerotic vessels under high pressure. **High-Yield Clinical Pearls for NEET-PG:** * **Little’s Area (Kiesselbach’s Plexus):** The most common site for anterior epistaxis (90%). It is formed by the anastomosis of five arteries: Sphenopalatine, Greater palatine, Superior labial, and Anterior/Posterior ethmoidal arteries. * **Woodruff’s Plexus:** The most common site for posterior epistaxis, located over the posterior end of the middle turbinate. * **First-line management:** Pinching the nose (Trotter’s method) for 10–15 minutes. * **Drug of choice:** For hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), a common systemic cause, Bevacizumab is often discussed.

Question 323: Pain sensations from the ethmoidal sinus are carried by which nerve?

A. Frontal Nerve
B. Lacrimal Nerve
C. Nasociliary Nerve (Correct Answer)
D. Infraorbital Nerve

Explanation: **Explanation:** The sensory innervation of the paranasal sinuses is primarily derived from the branches of the **Trigeminal Nerve (CN V)**. Specifically, the ethmoidal sinuses are supplied by the **Nasociliary nerve**, which is a major branch of the Ophthalmic division (V1). **Why Nasociliary Nerve is Correct:** The Nasociliary nerve gives off two critical branches: the **Anterior and Posterior Ethmoidal nerves**. These nerves pass through their respective foramina in the medial wall of the orbit to enter the cranial cavity and then descend into the nasal cavity. They provide sensory innervation (pain, touch, temperature) to the mucosal lining of the anterior and posterior ethmoidal air cells. **Analysis of Incorrect Options:** * **Frontal Nerve (A):** A branch of V1 that divides into the supraorbital and supratrochlear nerves. It primarily supplies the skin of the forehead, scalp, and the **frontal sinus**, not the ethmoidal sinus. * **Lacrimal Nerve (B):** The smallest branch of V1, it provides sensory supply to the lacrimal gland, conjunctiva, and the lateral aspect of the upper eyelid. * **Infraorbital Nerve (D):** A continuation of the Maxillary nerve (V2). While it supplies the **maxillary sinus**, it does not contribute to the innervation of the ethmoidal cells. **Clinical Pearls for NEET-PG:** * **Hilger’s Rule:** Remember that the anterior ethmoidal nerve is a common site for local anesthetic blocks during nasal surgeries. * **Referred Pain:** Due to the shared innervation via the Nasociliary nerve, ethmoidal sinusitis often presents as pain referred to the **medial canthus** of the eye or the bridge of the nose. * **Sphenoid Sinus:** Innervated by the posterior ethmoidal nerve and branches from the pterygopalatine ganglion.

Question 324: A 22-year-old male with recurrent bleeding, presents with bowing of posterior maxillary wall on CECT. All are false except?

A. Outgrown the blood supply
B. It lacks capsule
C. Tumor vessels lack contractility (Correct Answer)
D. Bleeding is from the adjacent invading blood vessels

Explanation: ***Tumor vessels lack contractility*** (CORRECT - Most relevant to bleeding) - **Juvenile Nasopharyngeal Angiofibroma** (JNA) consists of numerous thin-walled vessels that are **deficient in smooth muscle** (muscular coat). - This lack of normal vessel musculature prevents effective **vasoconstriction** and hemostasis after trauma or spontaneous rupture, leading to severe and recurrent **epistaxis**. - This is the **key pathological feature** explaining the recurrent bleeding in this patient. *Outgrown the blood supply* (FALSE) - JNA is highly **vascularized**, with profuse blood supply primarily from branches of the **external carotid artery** (maxillary artery, ascending pharyngeal artery). - The tumor has abundant, not inadequate, blood supply—hence the risk of massive hemorrhage during surgical excision. *Bleeding is from the adjacent invading blood vessels* (FALSE) - Bleeding is **intrinsic** to the tumor, emanating from the tumor's own abnormal, thin-walled sinusoidal vessels embedded within its fibrous stroma. - While JNA is locally invasive, the pathological hemorrhage originates from the **delicate tumor vasculature itself**, not from adjacent normal vessels. *It lacks capsule* (TRUE - But less relevant to bleeding) - JNA is indeed **non-encapsulated**, which contributes to its locally aggressive behavior, invasion of surrounding structures, and tendency to recur after incomplete excision. - However, this feature relates more to **local extension and recurrence** rather than the bleeding tendency, which is specifically due to the **non-contractile vessels**.

Question 325: A patient presented to the OPD with complaints of greenish black matter in the nose with foul-smelling discharge. What is the diagnosis?

A. Rhinitis caseosa
B. Allergic rhinitis
C. Atrophic rhinitis (Correct Answer)
D. Rhinitis sicca

Explanation: ***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.

Question 326: 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?

A. Ethmoidal sinus
B. Frontal sinus
C. Maxillary sinus (Correct Answer)
D. Sphenoidal sinus

Explanation: ***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 327: 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?

A. Common cold
B. Hypertrophic rhinitis (Correct Answer)
C. Nasal polyp
D. Atrophic rhinitis

Explanation: ***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.

Question 328: 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?

A. Internal maxillary artery
B. Sphenopalatine artery (Correct Answer)
C. Anterior ethmoidal artery
D. Facial artery

Explanation: ***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.

Question 329: A 12-year-old male with a history of recurrent epistaxis presents with nasal obstruction for the past 1 year. On examination the presence of nasal mass and investigation shows bowing of the posterior wall of maxillary sinus. What is the probable diagnosis?

A. Nasopharyngeal angiofibroma (Correct Answer)
B. Rhinosporidiosis
C. Antrochoanal polyp
D. Rhinoscleroma

Explanation: ***Nasopharyngeal angiofibroma*** - This diagnosis is strongly suggested by the classic triad of **adolescent male** (12 years old), **recurrent epistaxis**, and **nasal obstruction** - the typical presentation of this benign but locally aggressive tumor. - The **Holman-Miller sign** (bowing of the posterior wall of maxillary sinus) is pathognomonic for nasopharyngeal angiofibroma, indicating aggressive expansion and bony remodeling. *Rhinosporidiosis* - This condition presents as **friable, strawberry-like polyps** that may bleed, but doesn't cause the severe, recurrent epistaxis seen in this case. - It does not cause aggressive **bony remodeling** or the characteristic Holman-Miller sign seen on imaging. *Antrochoanal polyp* - While it can cause **unilateral nasal obstruction**, it rarely presents with severe, recurrent **epistaxis** as the predominant feature. - This benign polyp does not cause the aggressive **bony expansion** and Holman-Miller sign characteristic of angiofibroma. *Rhinoscleroma* - This chronic granulomatous infection caused by **Klebsiella rhinoscleromatis** typically presents with firm, sclerotic lesions and **crusting**. - It rarely causes the prominent, recurrent **epistaxis** or the destructive bony changes (Holman-Miller sign) seen in this patient.

Question 330: 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:

A. Multiple fungal spherules embedded in stroma of connective tissue
B. Best cultured on nasal inoculation in hamster (Correct Answer)
C. Infection originates from stagnant water
D. Surgical excision is best treatment

Explanation: *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.

Practice by Chapter

Rhinitis

Practice Questions

Acute Rhinosinusitis

Practice Questions

Chronic Rhinosinusitis

Practice Questions

Nasal Polyposis

Practice Questions

Allergic Fungal Sinusitis

Practice Questions

Deviated Nasal Septum

Practice Questions

Epistaxis

Practice Questions

Nasal Trauma

Practice Questions

Choanal Atresia

Practice Questions

CSF Rhinorrhea

Practice Questions

Tumors of the Nose and Paranasal Sinuses

Practice Questions

Complications of Sinusitis

Practice Questions

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