Diseases of the Nose and Paranasal Sinuses — MCQs

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

Question 371: Which of the following is NOT an indication for immediate referral to an ENT specialist in a case of epistaxis?

A. Uncontrolled bleeding
B. Suspected nasal tumor
C. Bleeding despite nasal packing
D. Mild bleeding resolved with pressure (Correct Answer)

Explanation: ***Mild bleeding resolved with pressure*** - This scenario suggests a **self-limiting epistaxis** episode that responds to standard first-aid measures. - No indication for **ENT specialist intervention**, as the problem has already been successfully managed. *Uncontrolled bleeding* - **Persistent bleeding** despite initial management attempts (e.g., direct pressure, vasoconstrictive sprays) warrants immediate ENT referral. - This indicates a potentially **larger vessel involvement** or an underlying coagulopathy requiring specialized intervention. *Suspected nasal tumor* - **Recurrent or persistent epistaxis**, especially when unilateral or accompanied by other nasal symptoms (e.g., obstruction, pain, anosmia), raises suspicion for a **nasal or sinonasal malignancy**. - An ENT specialist is crucial for thorough evaluation, including **endoscopy and biopsy**, to rule out or diagnose a tumor. *Bleeding despite nasal packing* - If **bleeding persists** or recurs after appropriate nasal packing (anterior or posterior), it signifies a failure of initial specialized management. - This situation requires urgent **ENT assessment** to identify the source and consider more advanced interventions like **cautery or surgical ligation**.

Question 372: A 30-year-old woman presents with chronic nasal obstruction, headaches, and a foul-smelling discharge. A CT scan of the sinuses reveals a mass in the left maxillary sinus. Most likely diagnosis?

A. Chronic sinusitis due to bacterial infection (Correct Answer)
B. Nasal septal deviation
C. Allergic fungal sinusitis
D. Nasal obstruction due to polyp

Explanation: ***Chronic sinusitis due to bacterial infection*** - The combination of **chronic nasal obstruction**, **headaches**, **foul-smelling discharge**, and a **mass in the maxillary sinus** is most consistent with chronic bacterial sinusitis. - The **foul-smelling discharge** is pathognomonic for **anaerobic bacterial infection**, which is characteristic of chronic sinusitis with stagnant secretions. - The mass seen on CT likely represents inflammatory tissue such as **granulation tissue**, **organized mucopus**, or an **inflammatory polyp** secondary to chronic infection. - Chronic bacterial sinusitis can lead to mucosal thickening and polypoid changes that appear as mass-like lesions on imaging. *Allergic fungal sinusitis* - While allergic fungal sinusitis (AFRS) can present with a mass-like lesion due to allergic mucin accumulation, it typically does **NOT** produce foul-smelling discharge. - AFRS discharge is typically thick, inspissated, and described as "peanut butter-like" but not foul-smelling unless there is secondary bacterial superinfection. - AFRS usually affects multiple sinuses bilaterally and is associated with nasal polyposis, asthma, and allergic history. *Nasal septal deviation* - **Nasal septal deviation** is an anatomical abnormality that can contribute to sinus obstruction and predispose to sinusitis, but it does not directly cause an intrasinus mass or foul-smelling discharge. - CT would show deviation of the nasal septum but would not explain the mass within the maxillary sinus itself. *Nasal obstruction due to polyp* - While **nasal polyps** can cause obstruction and are often associated with chronic sinusitis, they typically arise from the middle meatus or ethmoid region rather than presenting as a discrete mass within the maxillary sinus. - Polyps themselves are bland inflammatory tissue and do not typically produce foul-smelling discharge unless secondarily infected with anaerobic bacteria, in which case the underlying diagnosis would be chronic bacterial sinusitis.

Question 373: A child presents with unilateral foul-smelling nasal discharge. What is the most likely cause?

A. Acute sinusitis
B. Allergic rhinitis
C. Choanal atresia
D. Nasal foreign body (Correct Answer)

Explanation: ***Nasal foreign body*** - A **unilateral, foul-smelling nasal discharge** in a child is highly suggestive of a nasal foreign body, as it irritates the mucosa causing inflammation and bacterial growth. - Children often insert small objects into their nostrils, leading to these characteristic symptoms. *Acute sinusitis* - Acute sinusitis typically presents with **bilateral nasal discharge**, facial pain/pressure, and fever. - While discharge can be purulent and foul-smelling, it is usually **not unilateral** unless there's an underlying anatomical abnormality. *Allergic rhinitis* - Allergic rhinitis is characterized by **clear, watery bilateral nasal discharge**, sneezing, itching, and nasal congestion, often with seasonal triggers. - The discharge is **not typically unilateral or foul-smelling**. *Choanal atresia* - Choanal atresia is a congenital blockage of the nasal passage, usually causing **bilateral nasal obstruction and difficulty breathing**, particularly in neonates. - It would present from birth with **respiratory distress**, and discharge would likely be clear and mucous, not foul-smelling and unilateral.

Question 374: A 30-year-old woman presents with a two-month history of nasal congestion and greenish nasal discharge. What is the most likely diagnosis?

A. Acute sinusitis
B. Allergic rhinitis
C. Chronic sinusitis (Correct Answer)
D. Nasal polyps

Explanation: ***Chronic sinusitis*** - The patient's **2-month history** of nasal congestion and **greenish (purulent) discharge** indicates persistent rhinosinusitis lasting beyond the acute phase. - While some classifications define chronic sinusitis as symptoms >12 weeks, many clinical guidelines and exam contexts use **>4 weeks** as the threshold to distinguish from acute sinusitis. - The **purulent (greenish) discharge** indicates ongoing bacterial inflammation rather than a simple viral upper respiratory infection. - **Symptom duration** is the key diagnostic criterion differentiating chronic from acute sinusitis. *Acute sinusitis* - Acute sinusitis typically presents with symptoms lasting **less than 4 weeks**. - While symptoms like nasal congestion and purulent discharge are similar, the **2-month duration** exceeds the acute timeframe. - Acute viral sinusitis usually resolves within 7-10 days. *Allergic rhinitis* - Allergic rhinitis typically involves **clear, watery (not purulent) nasal discharge**, sneezing, nasal itching, and conjunctival symptoms. - The **greenish discharge** indicates bacterial infection rather than allergic inflammation. - Usually presents with seasonal pattern or clear allergen triggers, which are not mentioned here. *Nasal polyps* - Nasal polyps cause nasal obstruction and may present with **reduced sense of smell (hyposmia/anosmia)** and facial pressure. - While they can be associated with chronic rhinosinusitis, the primary complaint of **2 months of purulent discharge** points more directly to chronic sinusitis as the underlying diagnosis. - Polyps themselves don't produce purulent discharge unless complicated by secondary infection.

Question 375: A patient presents with severe epistaxis that does not respond to anterior nasal packing. What is the next step in management?

A. Posterior nasal packing (Correct Answer)
B. Antibiotic therapy
C. Observation
D. CT scan of the sinuses

Explanation: ***Posterior nasal packing*** - When **anterior nasal packing** fails to control severe epistaxis, it suggests a **posterior nasal bleed**, necessitating posterior packing to apply pressure to the posterior nasal cavity. - **Posterior packing** effectively compresses the vessels originating from the **sphenopalatine artery** or **internal carotid artery** system, which are common sources of severe posterior bleeds. *Antibiotic therapy* - **Antibiotics** are not a primary treatment for active epistaxis itself, but rather used to prevent complications such as **rhinosinusitis** or **toxic shock syndrome** if packing remains in place for an extended period. - Administering antibiotics alone would not stop the active bleeding and could delay definitive treatment. *Observation* - **Observation** is inappropriate for severe epistaxis that has failed anterior packing, as it risks severe **blood loss**, **hemodynamic instability**, and potentially **airway compromise**. - Persistent, uncontrolled bleeding requires immediate intervention, not just monitoring. *CT scan of the sinuses* - A **CT scan** of the sinuses is useful for identifying underlying structural abnormalities, **tumors**, or **sinusitis** that might contribute to recurrent epistaxis, but it is not an acute management step for active, severe bleeding. - Performing a CT scan would delay crucial interventions needed to control the hemorrhage in an unstable patient.

Question 376: A patient with chronic nasal polyps presents with anosmia and recurrent infections. Nasal endoscopy reveals extensive polypoid changes. What is the most appropriate treatment plan?

A. Oral corticosteroids and observation
B. Endoscopic sinus surgery and postop corticosteroids (Correct Answer)
C. Topical antihistamines and decongestants
D. Referral for immunotherapy

Explanation: ***Endoscopic sinus surgery and postop corticosteroids*** - For **extensive chronic nasal polyps** with symptoms like anosmia and recurrent infections, **Endoscopic Sinus Surgery (ESS)** is the definitive treatment to remove polyps and improve drainage. - **Postoperative corticosteroids** are crucial to reduce inflammation and recurrence rates after surgery. *Oral corticosteroids and observation* - While **oral corticosteroids** can temporarily shrink polyps, they are not a long-term solution for extensive, chronic cases and carry systemic side effects. - **Observation** alone is insufficient when significant symptoms like anosmia and recurrent infections are present due to extensive polyps. *Topical antihistamines and decongestants* - **Antihistamines** are used for allergic rhinitis symptoms, not for the structural obstruction caused by extensive nasal polyps. - **Decongestants** provide temporary relief of congestion but have no effect on polyp size and can lead to rhinitis medicamentosa with prolonged use. *Referral for immunotherapy* - **Immunotherapy** is primarily used for managing allergic rhinitis and some forms of asthma, targeting specific allergens. - It is not a direct treatment for **nasal polyps** or their associated complications like anosmia and recurrent infections.

Question 377: What is the primary treatment for nasal polyps?

A. Antibiotics
B. Antihistamines
C. Steroids (Correct Answer)
D. Surgery

Explanation: ***Steroids*** - **Topical nasal corticosteroids** are the primary treatment for nasal polyps, as they reduce inflammation and can shrink polyps. - Oral corticosteroids may be used for a short course to achieve rapid reduction in polyp size, especially for severe cases. *Antibiotics* - Antibiotics are used to treat **bacterial infections**, not nasal polyps, which are non-cancerous growths of inflamed tissue. - They would only be prescribed if there's a co-existing **bacterial sinusitis**. *Antihistamines* - Antihistamines are used to treat **allergic reactions** by blocking histamine, which causes symptoms like sneezing and runny nose. - They do not directly treat the **inflammation or growth** of nasal polyps. *Surgery* - Surgery is typically considered for nasal polyps only if **medical treatments like steroids are ineffective**, or if the polyps are very large and causing significant obstruction. - While effective at removing polyps, recurrence is common if underlying inflammation is not managed, often with **post-operative steroids**.

Question 378: A patient with chronic sinusitis presents with proptosis and diplopia. A CT scan shows a mass in the ethmoid sinus extending into the orbit. What is the most likely diagnosis?

A. Ethmoid sinus mucocele (Correct Answer)
B. Orbital cellulitis
C. Frontal sinusitis
D. Nasal polyps

Explanation: ***Ethmoid sinus mucocele*** - A **mucocele** is a slowly expanding, benign, cystic lesion filled with mucus, typically occurring due to obstruction of a sinus ostium. - Its expansion can erode bone and extend into adjacent structures like the **orbit**, causing **proptosis** and **diplopia** due to pressure on the ocular muscles or optic nerve. *Orbital cellulitis* - **Orbital cellulitis** presents with acute symptoms, including pain, swelling, fever, and rapid vision changes, and often follows an acute infection. - While it can cause proptosis and diplopia, it is typically an **acute inflammatory process** without the chronic mass effect seen on CT in this scenario. *Frontal sinusitis* - **Frontal sinusitis** typically causes headache, pain and tenderness over the forehead, and sometimes periorbital edema. - While it is a type of sinusitis, it is not described as a discrete mass extending into the orbit and usually does not cause proptosis and diplopia unless complicated by an abscess. *Nasal polyps* - **Nasal polyps** are benign growths of the nasal or sinus mucosa, often associated with chronic sinusitis, but they are typically confined to the nasal cavity and sinuses. - They cause nasal obstruction and discharge but rarely extend into the orbit to cause proptosis and diplopia unless they are large and cause significant bony remodeling or are associated with an underlying aggressive process.

Question 379: Angiofibroma is classified as what stage if it extends to one or more paranasal sinuses?

A. Stage I A
B. Stage II B (Correct Answer)
C. Stage III B
D. Stage IV B

Explanation: ***Stage II B*** - In the **Radkowski classification**, Stage IB (not IIB) specifically describes extension to **one or more paranasal sinuses** (maxillary, ethmoid, or sphenoid). - However, if using **Fisch classification**, Stage II encompasses extension into **pterygopalatine fossa** or paranasal sinuses (maxillary, ethmoid, sphenoid). - Note: The question appears to reference a hybrid staging system. In standard Radkowski classification, paranasal sinus extension alone is **Stage IB**, not IIB. - Patients present with **epistaxis, nasal obstruction**, and symptoms related to the affected sinus. *Stage I A* - In **Radkowski classification**, Stage IA indicates tumor confined to the **nasopharynx and nasal cavity** without extension to paranasal sinuses. - Symptoms include **recurrent epistaxis** and **nasal obstruction** in adolescent males. *Stage III B* - In **Radkowski classification**, Stage IIIB represents **extensive skull base erosion** with intracranial extension. - May involve **cavernous sinus, intracranial structures**, with risk of **cranial nerve palsies** and **intracranial complications**. *Stage IV B* - This stage is **not part of standard Radkowski or Fisch classifications**, which typically extend only to Stage III or IV without A/B subdivisions at advanced stages. - Most advanced classifications describe massive intracranial extension with involvement of critical neurovascular structures.

Question 380: A 40-year-old woman presents with nasal congestion and difficulty breathing. An X-ray reveals a deviation of the nasal septum. What is the most likely management?

A. Antibiotics
B. Septoplasty (Correct Answer)
C. Nasal corticosteroids
D. Observation

Explanation: ***Septoplasty*** - **Septoplasty** is the surgical correction of a **deviated nasal septum**, which is the direct cause of the patient's nasal congestion and difficulty breathing. - This procedure aims to straighten the septum, thereby improving airflow and resolving symptoms caused by the anatomical obstruction. - With X-ray confirmed deviation and significant symptoms, surgical correction is the **most likely definitive management**. *Antibiotics* - **Antibiotics** are used to treat bacterial infections, and there is no indication of an infection (e.g., fever, purulent discharge) in this patient's presentation. - A **deviated nasal septum** is an anatomical problem that cannot be resolved with medication. *Nasal corticosteroids* - **Nasal corticosteroids** are typically used to reduce inflammation in conditions like allergic rhinitis or chronic sinusitis. - While they may be tried as initial conservative management for mild DNS, they do not correct the underlying structural issue of a **deviated nasal septum**. - In this case with X-ray confirmed deviation and significant breathing difficulty, surgical correction is the most appropriate management. *Observation* - **Observation** is not appropriate when the patient is experiencing significant symptoms like difficulty breathing due to a clearly identified anatomical problem. - Delaying definitive treatment (septoplasty) would prolong the patient's discomfort and breathing difficulties.

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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