Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: Large nasal cavity with thick crust formation internally and a 'woody' feel of the external nose is characteristic of which condition?

Rhinoscleroma. **Explanation:** **Rhinoscleroma** is a chronic granulomatous disease caused by *Klebsiella rhinoscleromatis* (Frisch bacillus). It typically progresses through three stages: Catarrhal (atrophic), Proliferative (granulomatous), and Cicatricial (fibrotic). * **Why it is correct:** In the **atrophic stage**, patients present with a large nasal cavity and foul-smelling crusts (mimicking atrophic rhinitis). However, as it progresses to the **proliferative stage**, painless, non-ulcerating granulomas form. These granulomas eventually undergo fibrosis in the **cicatricial stage**, leading to the characteristic **"woody" or "hard" feel** of the external nose and potential stenosis of the nares. **Why other options are incorrect:** * **Rhinosporidiosis:** Caused by *Rhinosporidium seeberi*, it presents as a leafy, strawberry-like, friable vascular polyp, usually following exposure to stagnant water. It does not cause a "woody" external nose. * **Atrophic Rhinitis:** While it features a large nasal cavity and thick green crusts (roomy nose), it is characterized by atrophy of the mucosa and turbinates, not the "woody" induration seen in Rhinoscleroma. * **Vasomotor Rhinitis:** A non-allergic condition characterized by nasal congestion and watery rhinorrhea triggered by autonomic instability; it lacks crusting or structural changes. **High-Yield Clinical Pearls for NEET-PG:** * **Biopsy findings:** Look for **Mikulicz cells** (foamy macrophages containing the bacilli) and **Russell bodies** (eosinophilic hyaline inclusions in plasma cells). * **Drug of Choice:** Streptomycin and Tetracycline are traditionally used; Ciprofloxacin is also effective. * **Involvement:** It typically starts in the nose but can involve the nasopharynx, larynx (subglottis), and trachea.

Q: The lamina papyracea is anatomically situated between which structures?

Ethmoid sinus and orbit. ### Explanation **1. Why the Correct Answer is Right:** The **lamina papyracea** (also known as the orbital plate of the ethmoid bone) is a paper-thin, smooth bone that forms the **lateral wall of the ethmoid sinus** and the **medial wall of the orbit**. Anatomically, it serves as the delicate partition separating these two structures. Its extreme thinness makes it the most common site for the spread of infection from the ethmoid air cells into the orbit, leading to orbital cellulitis. **2. Why the Incorrect Options are Wrong:** * **Option A (Optic nerve and orbit):** The optic nerve is located within the orbit (posteriorly) and enters via the optic canal. The lamina papyracea is a bony wall, not a divider between a nerve and its cavity. * **Option B (Maxillary sinus and orbit):** The structure separating the maxillary sinus from the orbit is the **orbital floor** (maxillary bone), which is the site of "blow-out" fractures. * **Option C (Cranial cavity and orbit):** The **roof of the orbit** (frontal bone) and the **cribriform plate** (ethmoid bone) separate the orbit and nasal cavity from the anterior cranial fossa. **3. Clinical Pearls & High-Yield Facts for NEET-PG:** * **Orbital Cellulitis:** The lamina papyracea is the most common route for the spread of ethmoiditis into the orbit (Chandler’s Classification). * **FESS Landmark:** During Functional Endoscopic Sinus Surgery (FESS), accidental penetration of the lamina papyracea can lead to orbital hematoma or injury to the medial rectus muscle. * **Haller Cells:** These are infraorbital ethmoid air cells that grow into the floor of the orbit/roof of the maxillary sinus. * **Thickness:** It is one of the thinnest bones in the human body, hence the name "papyracea" (Latin for paper-like).

Q: Foul-smelling nasal discharge is seen in all except?

Choanal atresia. **Explanation:** The hallmark of **foul-smelling (cacosmia), unilateral nasal discharge** in clinical practice is usually the presence of necrotic tissue, decaying organic matter, or specific bacterial putrefaction. **Why Choanal Atresia is the correct answer:** Choanal atresia is a congenital narrowing or occlusion of the posterior nasal aperture. It presents with a **thick, gelatinous, and odorless** discharge (due to accumulated goblet cell secretions that cannot drain into the nasopharynx). It does not involve tissue necrosis or foreign material decay, thus it lacks the characteristic foul smell. **Analysis of Incorrect Options:** * **Nasal Myiasis:** Caused by infestation with maggots (usually *Chrysomyia bezziana*). The larvae cause extensive tissue destruction and necrosis, leading to a classic, repulsive putrid odor. * **Foreign Body in Nose:** A long-standing foreign body (especially organic) triggers a local inflammatory response, secondary bacterial infection, and suppuration, resulting in unilateral, foul-smelling, purulent discharge. * **Rhinolith:** These are "nasal stones" formed by the deposition of mineral salts around a neglected foreign body nidus. They cause pressure necrosis of the mucosa and trap secretions, leading to a characteristic malodor. **High-Yield Clinical Pearls for NEET-PG:** * **Unilateral foul-smelling discharge in a child:** Always rule out a **Foreign Body** first. * **Unilateral foul-smelling discharge in an elderly patient:** Always rule out **Malignancy**. * **Bilateral Choanal Atresia:** A neonatal emergency because newborns are obligatory nasal breathers. It presents with cyclic cyanosis (relieved by crying). * **Other causes of foul discharge:** Atrophic rhinitis (Merciful anosmia), Chronic Sinusitis (especially fungal or dental origin), and Midline Lethal Granuloma.

Q: An 85-year-old hypertensive man is evaluated in the emergency department for recent onset epistaxis. His blood pressure is 150/80 mm Hg, and hematocrit is 39%. What is the most likely source of bleeding?

Posterior nasal septum. **Explanation:** The correct answer is **Posterior nasal septum**. In elderly patients, especially those with comorbidities like hypertension or atherosclerosis, epistaxis often originates from the **posterior part of the nasal cavity**. The specific site is usually the posterior part of the nasal septum or the lateral wall, supplied by the **Sphenopalatine artery** (a branch of the maxillary artery). This area is known as **Woodruff’s Plexus**, located over the posterior end of the middle turbinate on the lateral wall and the corresponding septal area. Unlike anterior bleeds, posterior epistaxis is more profuse, often flows into the pharynx, and usually requires packing or endoscopic cauterization. **Why other options are incorrect:** * **Anterior nasal septum:** This is the site of **Little’s Area (Kiesselbach’s Plexus)**. While it is the most common site for epistaxis in children and young adults (90% of cases), it is less likely to be the primary source in an elderly, hypertensive patient presenting with a significant recent-onset bleed. * **Inferior/Middle turbinate:** While these structures are highly vascular, they are rarely the primary source of spontaneous epistaxis compared to the septal plexuses. **NEET-PG High-Yield Pearls:** * **Little’s Area (Anterior):** Formed by the anastomosis of the Sphenopalatine, Greater palatine, Superior labial, and Anterior ethmoidal arteries. * **Woodruff’s Plexus (Posterior):** Formed by the Sphenopalatine, Ascending pharyngeal, and Posterior nasal arteries. * **Management:** Anterior bleeds are managed with chemical cautery (Silver nitrate) or anterior packing; posterior bleeds often require **Post-nasal packing** or **Sphenopalatine Artery Ligation (SPAL)**. * **Trotter’s Method:** The first-aid maneuver for epistaxis (sitting up and pinching the nose).

Q: Which of the following is true regarding ethmoidal polyps?

Associated with bronchial asthma. **Explanation:** Ethmoidal polyps are non-neoplastic, edematous hypertrophies of the ethmoidal sinus mucosa. They are typically associated with chronic inflammation and allergies. **Why Option D is Correct:** Ethmoidal polyps are frequently associated with **bronchial asthma** and aspirin sensitivity. This clinical triad (Asthma, Aspirin sensitivity, and Nasal Polyposis) is known as **Samter’s Triad** (or Widal’s Triad). The underlying pathophysiology involves a shift in the arachidonic acid metabolism toward the leukotriene pathway, leading to chronic mucosal inflammation in both the upper and lower airways. **Why Other Options are Incorrect:** * **A. Epistaxis:** Ethmoidal polyps are typically painless and do not bleed. If a "polyp" presents with epistaxis, one must rule out malignancy (like Squamous Cell Carcinoma) or an Inverted Papilloma. * **B. Unilateral presentation:** Ethmoidal polyps are almost always **bilateral** and multiple (resembling a "bunch of grapes"). A unilateral polyp in an adult should be viewed with suspicion for malignancy; in a child, it may be an Antrochoanal polyp or an Encephalocele. * **C. Common in patients under 10 years:** These polyps are most common in adults. If nasal polyps are found in a child under 10, it is a high-yield clinical indicator to screen for **Cystic Fibrosis**. **High-Yield Clinical Pearls for NEET-PG:** * **Appearance:** Pale, translucent, mobile, and insensitive to touch (unlike the turbinates). * **Kartagener’s Syndrome:** Often associated with nasal polyposis, bronchiectasis, and situs inversus. * **Treatment of Choice:** Functional Endoscopic Sinus Surgery (FESS) is the surgical mainstay, but medical management with topical/systemic steroids is essential to prevent the high recurrence rate.

Q: Which of the following is true about an antrochoanal polyp?

Usually singular. **Explanation:** **Antrochoanal (AC) Polyps** (also known as Killian’s polyp) are benign growths that arise from the mucosa of the maxillary antrum, exit through the natural or accessory ostium, and extend into the choana and nasopharynx. * **Why Option B is Correct:** AC polyps are **characteristically solitary and unilateral**. Unlike ethmoidal polyps, which grow in clusters, an AC polyp consists of a single mass with three parts: antral, nasal, and choanal. * **Why Options A & C are Incorrect:** AC polyps are primarily seen in **children and young adults**, whereas ethmoidal polyps are more common in older adults. Because they arise from a single maxillary sinus, they are almost always **unilateral**. Bilateral presentation is extremely rare and should prompt a search for alternative diagnoses. * **Why Option D is Incorrect:** The etiology of AC polyps is generally attributed to **chronic infection** (sinusitis) rather than allergy. In contrast, ethmoidal polyps are strongly associated with Type 1 hypersensitivity (allergy), asthma, and aspirin sensitivity. **High-Yield Clinical Pearls for NEET-PG:** * **Radiology:** On CT scan, they appear as a homogenous mass filling the maxillary sinus and extending into the nasopharynx through an enlarged ostium. * **Clinical Feature:** They cause **expiratory** nasal obstruction (the polyp acts as a ball-valve, moving into the choana during expiration). * **Treatment of Choice:** Functional Endoscopic Sinus Surgery (FESS) to remove the polyp and its base to prevent recurrence. * **Differential Diagnosis:** In a young male with a nasopharyngeal mass, always rule out Juvenile Nasopharyngeal Angiofibroma (JNA).

Q: A young diabetic patient presents with blackish nasal discharge. What is the most likely diagnosis?

Mucormycosis. **Explanation:** The clinical presentation of a **diabetic patient** with **blackish nasal discharge** is a classic "spotter" for **Mucormycosis** (specifically Rhinocerebral Mucormycosis). **Why Mucormycosis is correct:** Mucormycosis is an opportunistic angioinvasive fungal infection caused by fungi of the order Mucorales. It thrives in acidic environments (Diabetic Ketoacidosis) and high glucose levels. The hallmark of this disease is **angioinvasion**, where the fungi invade blood vessels, leading to thrombosis and subsequent **tissue necrosis**. This necrosis manifests clinically as a characteristic **black eschar** on the turbinates or palate and blackish nasal discharge. **Why other options are incorrect:** * **Aspergillosis:** While it can cause fungal balls (Maxillary sinus) or invasive disease in immunocompromised patients, it typically presents with greenish-brown "peanut butter" discharge rather than acute black necrosis. * **Rhinosporidiosis:** Caused by *Rhinosporidium seeberi*, it presents as a friable, leafy, strawberry-like vascular polyp in the nose, usually following bathing in stagnant water. It does not cause black necrosis. * **Moniliasis (Candidiasis):** Typically presents as white, curd-like patches (thrush) on mucosal surfaces; it is not associated with black necrotic discharge. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Uncontrolled Diabetes (DKA), Neutropenia, and Iron overload (Deferoxamine use). * **Diagnosis:** KOH mount shows **broad, ribbon-like, aseptate hyphae** branching at **right angles (90°)**. * **Management:** Surgical debridement + Intravenous **Liposomal Amphotericin B** (Drug of choice). * **Imaging:** "Black Turbinate Sign" on MRI (indicates necrosis).

Q: All are true about maxillary sinusitis except?

No variation of pain with jaw movement. In **Acute Maxillary Sinusitis**, the pain is typically localized over the malar region (upper jaw) and may radiate to the teeth or forehead. A characteristic clinical feature of maxillary sinusitis is that the **pain is aggravated by movements of the jaw**, such as chewing or talking, and by bending forward. This occurs because the roots of the upper molar and premolar teeth are in close proximity to the floor of the maxillary sinus. Therefore, the statement that there is "no variation of pain with jaw movement" is **incorrect**, making it the right choice for this "except" question. **Analysis of other options:** * **Option A:** Pain over the upper jaw is the hallmark symptom due to the location of the sinus and the distribution of the infraorbital nerve. * **Option C:** The maxillary sinus is the **most common** sinus to be involved in both acute and chronic infections in adults, followed by the ethmoid, frontal, and sphenoid sinuses. * **Option D:** The maxillary and ethmoid sinuses are **present at birth** (though small). The frontal sinus appears at age 2 and is radiologically visible by age 6, while the sphenoid sinus appears around age 3. **Clinical Pearls for NEET-PG:** * **Pritchard’s Sign:** Tenderness over the anterior wall of the maxillary sinus. * **Postural Variation:** Maxillary sinus pain often worsens in the evening (as the sinus fills up during the day). * **Drainage:** The maxillary sinus drains into the **middle meatus** via the hiatus semilunaris. Its drainage is anatomically disadvantaged because the ostium is located high on its medial wall.

Q: Mikulicz cells are characteristically seen in which condition?

Rhinoscleroma. **Explanation:** **Rhinoscleroma** is a chronic granulomatous disease caused by **Klebsiella rhinoscleromatis** (Frisch bacillus). The hallmark histological feature of this condition is the **Mikulicz cell**. These are large, pale, foamy macrophages with a vacuolated cytoplasm that contain the causative Gram-negative bacilli. Their presence, along with **Russell bodies** (eosinophilic inclusion bodies representing degenerated plasma cells), is pathognomonic for the proliferative stage of Rhinoscleroma. **Analysis of Incorrect Options:** * **Rhinosporidiosis:** Caused by *Rhinosporidium seeberi*. Histology characteristically shows large **sporangia** containing numerous endospores, not Mikulicz cells. * **Otomycosis:** A fungal infection of the external auditory canal (commonly *Aspergillus* or *Candida*). It presents with fungal hyphae and spores, not granulomatous foam cells. * **Ozaena (Atrophic Rhinitis):** Characterized by atrophy of the nasal mucosa and turbinates with foul-smelling crusts. While it involves squamous metaplasia, it does not feature Mikulicz cells. **High-Yield Clinical Pearls for NEET-PG:** * **Stages of Rhinoscleroma:** 1. Atrophic stage (mimics Ozaena), 2. Proliferative/Granulomatous stage (Mikulicz cells found here), 3. Cicatricial stage (leads to stenosis). * **Site of Origin:** Usually starts in the **subepithelial layer of the nose**, specifically the anterior nares or nasopharynx. * **Treatment:** Long-term antibiotics (Streptomycin and Tetracycline are traditional; Ciprofloxacin is also effective). * **Biopsy Findings:** Remember the "M & R" rule: **M**ikulicz cells and **R**ussell bodies.

Question 1

Large nasal cavity with thick crust formation internally and a 'woody' feel of the external nose is characteristic of which condition?

Accepted Answer

Rhinoscleroma

Answer

Rhinosporidiosis

Answer

Atrophic rhinitis

Answer

Vasomotor rhinitis

Question 2

The lamina papyracea is anatomically situated between which structures?

Accepted Answer

Ethmoid sinus and orbit

Answer

Optic nerve and orbit

Answer

Maxillary sinus and orbit

Answer

Cranial cavity and orbit

Question 3

Foul-smelling nasal discharge is seen in all except?

Accepted Answer

Choanal atresia

Answer

Nasal myiasis

Answer

Foreign body in nose

Answer

Rhinolith

Question 4

An 85-year-old hypertensive man is evaluated in the emergency department for recent onset epistaxis. His blood pressure is 150/80 mm Hg, and hematocrit is 39%. What is the most likely source of bleeding?

Accepted Answer

Posterior nasal septum

Answer

Anterior nasal septum

Answer

Inferior turbinate

Answer

Middle turbinate

Question 5

Which of the following is true regarding ethmoidal polyps?

Accepted Answer

Associated with bronchial asthma

Answer

Epistaxis

Answer

Unilateral presentation

Answer

Common in patients under 10 years of age

Question 6

Which of the following is true about an antrochoanal polyp?

Accepted Answer

Usually singular

Answer

Common in adults

Answer

Usually bilateral

Answer

Associated with allergy

Question 7

A young diabetic patient presents with blackish nasal discharge. What is the most likely diagnosis?

Accepted Answer

Mucormycosis

Answer

Aspergillosis

Answer

Rhinosporidiosis

Answer

Moniliasis

Question 8

All are true about maxillary sinusitis except?

Accepted Answer

No variation of pain with jaw movement

Answer

Pain over the upper jaw

Answer

Most common sinusitis in adults

Answer

Maxillary sinus present at birth

Question 9

Mikulicz cells are characteristically seen in which condition?

Accepted Answer

Rhinoscleroma

Answer

Rhinosporidiosis

Answer

Otomycosis

Answer

Ozaena

Question 10

A 32-year-old male patient presents with swelling in the left maxillary region and a feeling of heaviness in the maxillary sinus, following the extraction of his maxillary first molar one week prior. The extraction was performed via the transalveolar approach. What is the most common microbial population found in an infected maxillary sinus?

Accepted Answer

Polymicrobial with anaerobic organisms

Answer

Aerobic organisms

Answer

Fungal

Answer

Viral

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?