Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: Identify the device shown in the image below:

Cochlear implant. ***Cochlear implant*** - The image displays the external components of a **cochlear implant**: a **speech processor** worn behind the ear connected to an external transmitter that sends signals to an implanted receiver. - This device is designed to provide a sense of sound to individuals with **severe-to-profound hearing loss** by directly stimulating the auditory nerve. *Transcranial magnetic stimulation* - This therapy involves a **coil placed on the scalp** that delivers magnetic pulses to stimulate nerve cells in the brain, typically for depression or migraines. - It does not involve ear-worn components or internal surgical implants of the type seen in the image. *Vagus nerve stimulation* - This involves a device surgically implanted under the skin in the chest, with wires connected to the **vagus nerve** in the neck. - It is used to treat epilepsy and depression and does not have external components positioned around the ear or on the head as depicted. *Deep brain stimulation* - This neurosurgical procedure involves implanting electrodes into specific areas of the brain, connected to a pulse generator (similar to a pacemaker) implanted in the chest. - It is primarily used for movement disorders like Parkinson's disease and does not feature external ear-worn components visible in the image.

Q: The image shows presence of the following:

Cryptotic ear. ***Cryptotic ear*** - This image clearly depicts a **cryptotic ear**, where the superior helix is abnormally buried beneath the skin of the temporal region. - This deformity is characterized by the **lack of a normal superior auricular fold**, making the ear appear compressed or partially hidden. *Macrotia* - **Macrotia** refers to abnormally large ears, a characteristic not evident in the provided image. - The size of the ears in the image appears to be within a normal range, despite the abnormal folding. *Stahl's ear deformity* - **Stahl's ear deformity** is characterized by an extra fold of cartilage, often creating a pointed or "Spock ear" appearance, which is not what is shown. - The distinctive feature of Stahl's ear is a **third crus** in the antihelix, leading to a prominent, pointed upper helix. *Cauliflower ear* - **Cauliflower ear** results from trauma to the ear cartilage, leading to a lumpy, scarred appearance due to hematoma and subsequent fibrosis. - This condition is typically seen in boxers or wrestlers and presents with a **deformed, irregular ear surface**, unlike the smooth appearance in the image.

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.

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.

Question 1

Identify the device shown in the image below:

Accepted Answer

Cochlear implant

Answer

Transcranial magnetic stimulation

Answer

Vagus nerve stimulation

Answer

Deep brain stimulation

Question 2

The image shows presence of the following:

Accepted Answer

Cryptotic ear

Answer

Macrotia

Answer

Stahl's ear deformity

Answer

Cauliflower ear

Question 3

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 4

Antro-choanal polyp always arises from:

Accepted Answer

Maxillary sinus

Answer

Posterior end of the septum

Answer

Nasopharynx

Answer

Posterior ethmoidal cells

Question 5

Which sinus drainage is impaired in the following image?

Accepted Answer

Maxillary

Answer

Ethmoid

Answer

Sphenoid

Answer

Frontal

Question 6

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 7

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 8

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

Question 9

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 10

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

Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses — MCQs

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