Diseases of the Nose and Paranasal Sinuses Practice Questions

Q: Miculicz and Russel bodies upon biopsy are seen in which condition?

Rhinoscleroma. **Explanation:** **Rhinoscleroma** is a chronic granulomatous disease caused by **Klebsiella rhinoscleromatis** (Frisch Bacillus). It typically progresses through three stages: Catarrhal, Proliferative (Granulomatous), and Cicatricial. The diagnosis is confirmed via biopsy during the proliferative stage, which reveals two pathognomonic histological features: 1. **Mikulicz Cells:** Large, foamy histiocytes (macrophages) with a vacuolated cytoplasm containing the causative bacilli. 2. **Russell Bodies:** Eosinophilic, hyaline-like inclusion bodies found within plasma cells, representing accumulated immunoglobulins. **Analysis of Incorrect Options:** * **Rhinophyma:** A benign hypertrophy of the sebaceous glands of the nose, often associated with long-standing acne rosacea. Histology shows sebaceous hyperplasia and fibrosis, not Mikulicz cells. * **Rhinosporidiosis:** Caused by *Rhinosporidium seeberi*. Histology typically shows large, thick-walled **sporangia** containing numerous endospores. * **Rhinolith:** A "nasal stone" formed by the deposition of mineral salts (calcium and magnesium) around a foreign body nidus. It is a physical entity, not a cellular pathology. **High-Yield Clinical Pearls for NEET-PG:** * **Organism:** *Klebsiella rhinoscleromatis* (Gram-negative, diplobacillus). * **Site:** Most commonly starts in the **subepithelial layer of the nasal septum** (at the junction of the vestibule and the nasal cavity). * **Clinical Sign:** "Hebra Nose" (woody hard deformity of the nose). * **Drug of Choice:** Streptomycin and Tetracycline are traditional; Ciprofloxacin is also highly effective. * **Biopsy:** Mikulicz cells are the hallmark of the **Proliferative stage**.

Q: In Chevallet fracture of the nasal septum, what is the mechanism of trauma?

Blow from below. **Explanation:** Nasal septal fractures are classified based on the direction of the force applied. The correct answer is **Blow from below** because of the specific anatomical displacement it causes. * **Mechanism of Chevallet Fracture (Blow from below):** When a force is applied to the nose from an inferior direction (e.g., a blow to the tip of the nose), it results in a **vertical fracture** of the nasal septum. This force typically involves the cartilaginous septum (quadrangular cartilage) and can lead to its displacement or buckling. * **Jarjavay Fracture (Blow from the front):** In contrast, a blow directly from the front (Option C) results in a **horizontal fracture** of the septum. The force travels along the vomero-ethmoid suture, often causing the septal cartilage to be dislocated from the vomerine groove. * **Blow from above (Option A):** A force from above usually results in a depressed fracture of the nasal bones or a comminuted fracture of the ethmoid bone, rather than the specific vertical septal pattern seen in Chevallet fractures. **High-Yield Clinical Pearls for NEET-PG:** 1. **Chevallet = Vertical fracture** (Mnemonic: "V" in Chevallet for Vertical; force from below). 2. **Jarjavay = Horizontal fracture** (Force from the front). 3. **Septal Hematoma:** Always rule this out in nasal trauma. If present, it requires immediate incision and drainage to prevent septal necrosis (Saddle nose deformity) or abscess formation. 4. **Management:** Most septal fractures are managed via closed reduction under local or general anesthesia within 7–10 days before the bones fixate.

Q: A biopsy taken from a granulomatous lesion of the nose revealed Mikulicz's cells and eosinophilic structures in the cytoplasm of the plasma cells. What is the likely diagnosis?

Rhinoscleroma. **Explanation:** The clinical presentation and histopathological findings described are classic for **Rhinoscleroma**, a chronic granulomatous disease caused by the Gram-negative coccobacillus *Klebsiella pneumoniae subsp. rhinoscleromatis* (Frisch bacillus). **Why Rhinoscleroma is correct:** The diagnosis is confirmed by two pathognomonic histological features: 1. **Mikulicz’s Cells:** Large, foamy histiocytes (macrophages) with vacuolated cytoplasm containing the causative organism. 2. **Russell Bodies:** Eosinophilic, hyaline-like inclusions found in the cytoplasm of plasma cells, representing accumulated immunoglobulin. **Why other options are incorrect:** * **Mucormycosis:** A fungal infection characterized by broad, non-septate hyphae with right-angle branching and extensive angioinvasion leading to necrosis. It does not show Mikulicz’s cells. * **Rhinosporidiosis:** Caused by *Rhinosporidium seeberi*, it presents with friable, strawberry-like nasal masses. Histology shows large, thick-walled **sporangia** containing numerous endospores. * **Nasal Leprosy:** Caused by *Mycobacterium leprae*. While it is a granulomatous disease, it is characterized by acid-fast bacilli (AFB) and, in the lepromatous form, "foamy" Lepra cells, but lacks Russell bodies and the specific Frisch bacillus. **High-Yield Pearls for NEET-PG:** * **Stages of Rhinoscleroma:** Atrophic stage (resembles atrophic rhinitis) → Granulomatous/Proliferative stage (painless nodules) → Cicatricial stage (stenosis and scarring). * **Hebra Nose:** The characteristic external deformity caused by expansion of the nasal framework in the proliferative stage. * **Treatment:** Long-term antibiotics (Streptomycin and Tetracycline are traditional; Ciprofloxacin is now preferred). * **Site:** It most commonly involves the nasal septum and floor but can spread to the nasopharynx and larynx.

Q: What is the ideal treatment for rhinosporidiosis?

Excision with cautery at base. **Explanation:** **Rhinosporidiosis** is a chronic granulomatous infection caused by *Rhinosporidium seeberi* (now classified as a fish parasite/Mesomycetozoea). It typically presents as a leafy, strawberry-like, friable polypoid mass in the nose. **Why Option B is Correct:** The definitive treatment for rhinosporidiosis is **wide surgical excision** of the mass. The "gold standard" technique involves using **diathermy (cautery) at the base** of the lesion. This is crucial because the organism is highly vascular and tends to recur if any spores remain. Cauterization serves two purposes: it ensures hemostasis and destroys the deep-seated sporangia in the surrounding mucosa, significantly reducing the high recurrence rate associated with this disease. **Why Other Options are Incorrect:** * **A & C (Rifampicin & Tetracycline):** These are antibacterial agents. *R. seeberi* is not a bacterium and does not respond to standard antibiotics. While **Dapsone** is sometimes used as an adjuvant to inhibit the maturation of sporangia, it is not the primary treatment. * **D (Laser):** While lasers can be used for excision, conventional wide excision with electrocautery remains the standard and most cost-effective recommendation in textbooks for complete eradication of the base. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** *Rhinosporidium seeberi* (Mesomycetozoea). * **Classic Appearance:** "Strawberry-like" mass with white dots (sporangia) on the surface. * **Epidemiology:** Most common in South India (Tamil Nadu, Kerala) and Sri Lanka; associated with bathing in stagnant pond water. * **Diagnosis:** Histopathology shows large, thick-walled **sporangia** containing thousands of **endospores**. * **Adjuvant Therapy:** Oral Dapsone (administered for 6–12 months) is the medical treatment of choice to prevent recurrence after surgery.

Q: Which sinus is least involved in children?

Sphenoid. **Explanation:** The development of paranasal sinuses follows a specific chronological order, which is a high-yield topic for NEET-PG. The correct answer is **Sphenoid** because it is the last sinus to pneumatize and become clinically significant. **1. Why Sphenoid is the Correct Answer:** The sphenoid sinus is absent at birth. It starts to pneumatize around the age of 3–5 years but remains very small throughout early childhood. It only reaches its full size and clinical relevance after puberty (around 12–15 years). Therefore, it is the least involved in pediatric sinusitis. **2. Analysis of Incorrect Options:** * **Ethmoid (A):** This is the **most developed** sinus at birth and is the most common site for sinusitis in infants and young children. * **Maxillary (B):** Present at birth (though small) and rapidly expands during the eruption of deciduous teeth. It is frequently involved in childhood respiratory infections. * **Frontal (C):** Not present at birth. It starts developing from the anterior ethmoid cells around age 2 and is radiologically visible by age 6–7. While it develops late, the sphenoid remains less frequently involved in the early pediatric age group. **Clinical Pearls for NEET-PG:** * **Order of Development:** Ethmoid → Maxillary → Sphenoid → Frontal. * **First to develop (Embryologically):** Maxillary (at 10 weeks gestation). * **Present at birth:** Ethmoid and Maxillary. * **Radiologically visible at birth:** Only Ethmoid. * **Most common sinus involved in children:** Ethmoid. * **Most common sinus involved in adults:** Maxillary.

Q: What is Pott's puffy tumor?

Osteomyelitis of the frontal bone. **Explanation:** **Pott’s Puffy Tumor** is a clinical entity characterized by **subperiosteal abscess** associated with **osteomyelitis of the frontal bone**. It typically occurs as a complication of acute or chronic frontal sinusitis or, less commonly, due to direct head trauma. 1. **Why Option C is correct:** The infection from the frontal sinus spreads to the marrow of the frontal bone (osteomyelitis), leading to bone necrosis. This results in a collection of pus between the bone and the periosteum, manifesting clinically as a soft, fluctuant, "puffy" swelling on the forehead. 2. **Why other options are incorrect:** * **Option A:** Osteosarcoma is a primary malignant bone tumor, not an infectious process. * **Option B:** Adamantinoma (Ameloblastoma) is a benign but locally aggressive odontogenic tumor typically involving the mandible, unrelated to the frontal bone or sinusitis. * **Option D:** While aspergillosis can affect the sinuses, Pott’s Puffy Tumor is specifically defined by bacterial osteomyelitis (often polymicrobial, including anaerobes and Streptococci). **High-Yield Clinical Pearls for NEET-PG:** * **Eponym:** Named after Sir Percivall Pott (1760). * **Clinical Presentation:** Forehead swelling, fever, and headache. * **Complications:** It is a surgical emergency because it can lead to intracranial complications like **epidural abscess**, subdural empyema, or meningitis. * **Diagnosis:** Contrast-enhanced CT (CECT) is the gold standard to visualize bone destruction and intracranial extension. * **Management:** Requires intravenous antibiotics and surgical drainage (often via endoscopic sinus surgery or trephination).

Q: What is the most appropriate management for antrochoanal polyp in children?

Intranasal polypectomy. **Explanation:** An **Antrochoanal Polyp (Killian’s Polyp)** is a solitary, pedunculated mass that arises from the mucosa of the maxillary sinus, exits through the accessory ostium, and extends into the choana. **Why Intranasal Polypectomy is correct:** In the pediatric population, the primary goal of surgery is to remove the polyp while preserving the developing permanent tooth buds and the growth centers of the maxilla. **Intranasal polypectomy** (often performed via Functional Endoscopic Sinus Surgery - FESS) is the treatment of choice. It allows for the removal of the polyp and its stalk through the natural or accessory ostium with minimal morbidity. **Why other options are incorrect:** * **Caldwell-Luc Operation:** This involves entering the maxillary sinus through the canine fossa. It is **contraindicated in children** (usually until age 17) because it can damage developing secondary dentition and interfere with mid-facial growth. * **Corticosteroids:** While useful for ethmoidal (allergic) polyps, antrochoanal polyps are typically non-allergic and do not respond significantly to medical management. Surgery is definitive. * **Wait and Watch:** Antrochoanal polyps cause progressive nasal obstruction, sinusitis, and can lead to sleep apnea or craniofacial changes; therefore, active surgical intervention is required. **High-Yield Clinical Pearls for NEET-PG:** * **Origin:** Most commonly from the **maxillary sinus antrum** (near the accessory ostium). * **Radiology:** Shows a soft tissue mass filling the maxillary sinus and extending into the nasopharynx; the "Haller cell" is a common anatomical variant associated with it. * **Components:** It has three parts—antral, nasal, and choanal. * **Recurrence:** The most common cause of recurrence is the failure to remove the **antral attachment** (stalk) of the polyp.

Q: Apple-jelly nodules on the nasal septum are found in which of the following conditions?

Lupus vulgaris. **Explanation:** **Lupus vulgaris** is the most common form of cutaneous tuberculosis, caused by *Mycobacterium tuberculosis*. When it involves the nose, it typically affects the **nasal vestibule and the cartilaginous part of the nasal septum**. The characteristic clinical finding is the presence of reddish-brown, translucent papules. When these nodules are viewed through a glass slide (diascopy), they blanch to reveal a yellowish-brown color, famously described as **"apple-jelly nodules."** If left untreated, it can lead to the destruction of the nasal alae and septal cartilage, though the bone is usually spared. **Why other options are incorrect:** * **Tuberculosis (Ulcerative type):** While Lupus vulgaris is a form of TB, the primary ulcerative form of nasal TB typically presents with painful, irregular ulcers and exuberant granulations rather than discrete apple-jelly nodules. * **Syphilis:** Nasal syphilis (Tertiary) is characterized by **gumma** formation. Unlike Lupus vulgaris, syphilis primarily attacks the **bony part** of the septum, leading to a characteristic "saddle nose" deformity. * **Rhinoscleroma:** Caused by *Klebsiella rhinoscleromatis*, it presents in three stages: catarrhal, proliferative (granulomatous), and cicatricial. It is characterized by woody-hard granulomas and **Mikulicz cells**, not apple-jelly nodules. **Clinical Pearls for NEET-PG:** * **Lupus Vulgaris:** Cartilage is destroyed, bone is spared. * **Syphilis:** Bone is destroyed, cartilage is spared. * **Rhinoscleroma:** Look for "Hebra nose" (tapir-like deformity) and "Frisch bacilli" on biopsy. * **Diascopy:** The specific clinical test used to elicit the apple-jelly appearance.

Question 1

Which one of the following is a cause of nasal obstruction in Atrophic Rhinitis?

Accepted Answer

Crusting

Answer

Secretions

Answer

Deviated nasal septum

Answer

Polyp

Question 2

Miculicz and Russel bodies upon biopsy are seen in which condition?

Accepted Answer

Rhinoscleroma

Answer

Rhinophyma

Answer

Rhinosporidiosis

Answer

Rhinolith

Question 3

In Chevallet fracture of the nasal septum, what is the mechanism of trauma?

Accepted Answer

Blow from below

Answer

Blow from above

Answer

Blow directly from the front

Answer

Any of the above

Question 4

A biopsy taken from a granulomatous lesion of the nose revealed Mikulicz's cells and eosinophilic structures in the cytoplasm of the plasma cells. What is the likely diagnosis?

Accepted Answer

Rhinoscleroma

Answer

Mucormycosis

Answer

Rhinosporidiosis

Answer

Nasal leprosy

Question 5

What is the ideal treatment for rhinosporidiosis?

Accepted Answer

Excision with cautery at base

Answer

Rifampicin

Answer

Tetracycline

Answer

Laser

Question 6

Which sinus is least involved in children?

Accepted Answer

Sphenoid

Answer

Ethmoid

Answer

Maxillary

Answer

Frontal

Question 7

A 9-year-old boy presents with nasal obstruction, proptosis, and recurrent epistaxis for 3-4 years. What is the appropriate management?

Accepted Answer

Embolisation followed by surgery

Answer

Routine radiological investigations

Answer

Embolisation alone should be done

Answer

Surgery is the treatment of choice

Question 8

What is Pott's puffy tumor?

Accepted Answer

Osteomyelitis of the frontal bone

Answer

Osteosarcoma of the frontal bone

Answer

Adamantinoma of the mandible

Answer

Proliferative aspergillosis of the maxillary sinus

Question 9

What is the most appropriate management for antrochoanal polyp in children?

Accepted Answer

Intranasal polypectomy

Answer

Caldwell-Luc operation

Answer

Corticosteroids

Answer

Wait and watch

Question 10

Apple-jelly nodules on the nasal septum are found in which of the following conditions?

Accepted Answer

Lupus vulgaris

Answer

Tuberculosis

Answer

Syphilis

Answer

Rhinoscleroma

Diseases of the Nose and Paranasal Sinuses — MCQs

Diseases of the Nose and Paranasal Sinuses — MCQs

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