Diseases of the Nose and Paranasal Sinuses — MCQs

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

Question 81: Nasal allergy is most often due to which of the following?

A. Pollen grains (Correct Answer)
B. Animal dander
C. House dust
D. Automobile exhaust

Explanation: **Explanation:** **Nasal allergy (Allergic Rhinitis)** is a Type I IgE-mediated hypersensitivity reaction of the nasal mucosa to inhaled allergens. **Why Pollen grains is the correct answer:** Pollen grains are the **most common cause of seasonal allergic rhinitis** (also known as Hay Fever). These are wind-borne (anemophilous) microspores from grasses, weeds, and trees. Because they are produced in massive quantities during specific seasons and are light enough to remain airborne for long periods, they represent the most frequent trigger for acute, episodic nasal allergy globally. **Analysis of Incorrect Options:** * **House dust:** While a very common cause of *perennial* (year-round) allergic rhinitis, the primary allergen within house dust is actually the **House Dust Mite (*Dermatophagoides pteronyssinus*)** and its fecal matter, rather than the dust itself. * **Animal dander:** This is a significant trigger for sensitized individuals (especially those with pets like cats and dogs), but it is considered an indoor allergen and is statistically less common as a primary cause compared to pollen in the general population. * **Automobile exhaust:** This acts as an **irritant or pollutant** rather than a true allergen. It can exacerbate existing rhinitis (Non-allergic rhinitis with eosinophilia or vasomotor rhinitis) but does not typically induce the specific IgE-mediated response characteristic of true nasal allergy. **High-Yield Clinical Pearls for NEET-PG:** * **Cardinal Symptoms:** Paroxysmal sneezing, nasal obstruction, watery rhinorrhea, and itching of the eyes/nose. * **Physical Findings:** Pale, boggy, or bluish nasal mucosa with hypertrophied turbinates. * **Cytology:** Nasal smear typically shows an abundance of **eosinophils**. * **Treatment of Choice:** **Intranasal corticosteroids** (e.g., Fluticasone, Mometasone) are the most effective maintenance therapy. * **Samter’s Triad:** Aspirin sensitivity, Bronchial Asthma, and Nasal Polyps (often associated with chronic rhinosinusitis).

Question 82: What is the largest paranasal sinus?

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

Explanation: **Explanation:** The **Maxillary sinus** (Antrum of Highmore) is the largest of all the paranasal sinuses. It is a pyramidal-shaped cavity located within the body of the maxilla. In an adult, its average capacity is approximately **15 ml**. **Why the other options are incorrect:** * **Frontal sinus:** These are located within the frontal bone. While they vary significantly in size and are often asymmetrical, they are considerably smaller than the maxillary sinus. * **Ethmoidal sinus:** These consist of multiple small air cells (anterior, middle, and posterior) rather than a single large cavity. Even collectively, their volume is less than that of the maxillary sinus. * **Sphenoid sinus:** Located within the body of the sphenoid bone, these are smaller and more deeply situated than the maxillary sinuses. **Clinical Pearls for NEET-PG:** * **First to develop:** The Maxillary sinus is the first sinus to develop (at the 3rd month of fetal life). * **First to appear radiologically:** The Maxillary sinus is visible on X-ray at birth (though the Ethmoids are also present). * **Drainage:** It drains into the **middle meatus** via the hiatus semilunaris. Because its ostium is located high on its medial wall, it drains poorly in the upright position, making it the most common sinus involved in sinusitis. * **Relationship to Teeth:** The floor of the sinus is closely related to the roots of the **1st and 2nd molar teeth**; dental infections can frequently lead to secondary maxillary sinusitis.

Question 83: All of the following are part of Samter's triad except?

A. Aspirin sensitivity
B. Asthma
C. Ethmoidal polyposis
D. Anosmia (Correct Answer)

Explanation: **Explanation:** **Samter’s Triad** (also known as Aspirin-Exacerbated Respiratory Disease or AERD) is a clinical condition characterized by a specific combination of three findings. 1. **Aspirin Sensitivity:** Patients experience bronchospasm or rhinitis after ingesting Aspirin or other NSAIDs (due to the inhibition of the COX-1 pathway, leading to an overproduction of pro-inflammatory leukotrienes). 2. **Asthma:** Typically adult-onset and often severe. 3. **Nasal Polyposis:** Characteristically bilateral and ethmoidal in origin. **Why Anosmia is the correct answer:** While **Anosmia** (loss of smell) is a very common *symptom* resulting from extensive nasal polyposis, it is not a formal component of the triad itself. In the context of NEET-PG, examiners frequently use "Anosmia" or "Atopy" as distractors for this classic triad. **Analysis of Incorrect Options:** * **Aspirin sensitivity:** A core component; these patients must avoid NSAIDs to prevent life-threatening bronchoconstriction. * **Asthma:** A core component; usually develops after the onset of rhinitis. * **Ethmoidal polyposis:** A core component; these polyps are typically eosinophilic and have a high recurrence rate after surgery. **Clinical Pearls for NEET-PG:** * **Pathophysiology:** It is not an IgE-mediated allergy but a metabolic abnormality of the arachidonic acid cascade (Leukotriene shift). * **Widal’s Triad:** Another name for Samter’s Triad. * **Treatment:** Management involves topical/systemic steroids, leukotriene receptor antagonists (e.g., Montelukast), endoscopic sinus surgery (FESS), and sometimes aspirin desensitization. * **Aspirin Burn:** A related term referring to the worsening of respiratory symptoms upon NSAID ingestion.

Question 84: A 4-year-old child presents with bleeding from the right side of the nose. He also has purulent discharge from the same side. What is the most likely diagnosis?

A. Septal deviation with right maxillary sinusitis
B. Unilateral choanal atresia
C. Antrochoanal polyp
D. Foreign body (Correct Answer)

Explanation: **Explanation:** The clinical presentation of **unilateral, foul-smelling, purulent nasal discharge** associated with **epistaxis** (bleeding) in a child is a classic "spotter" for a **Nasal Foreign Body (FB)**. 1. **Why Foreign Body is correct:** Children often insert small objects (beads, seeds, button batteries) into the nasal cavity. Over time, the object causes local mucosal irritation, pressure necrosis, and secondary infection. This leads to the characteristic triad: unilateral involvement, purulent/fetid discharge, and occasional bleeding from mucosal erosion. 2. **Why other options are incorrect:** * **Septal deviation/Sinusitis:** While sinusitis causes purulent discharge, it is rarely strictly unilateral in children without an underlying anatomical or obstructive cause. Isolated deviation is uncommon at age 4 and rarely causes foul discharge. * **Unilateral Choanal Atresia:** This typically presents with thick, mucoid discharge (inability to blow the nose) and nasal obstruction present since birth, rather than acute purulent/bloody discharge. * **Antrochoanal Polyp:** These are more common in older children/adolescents. While they cause unilateral obstruction, they typically present with mucoid discharge and a visible mass in the oropharynx or posterior choana, rather than acute blood-stained pus. **Clinical Pearls for NEET-PG:** * **Most common site:** Anterior to the middle turbinate or on the floor of the nose. * **Button Batteries:** These are surgical emergencies due to the risk of liquefactive necrosis and septal perforation within hours. **Do not** use saline drops as they accelerate electrolysis. * **Rhinolith:** A neglected foreign body can act as a nidus for calcium salt deposition, forming a "nasal stone." * **Management:** Use the "Parent’s Kiss" technique or removal via a Jobson-Horne probe/hook. Avoid forceps for smooth, round objects as they may push the FB into the airway.

Question 85: The most common site of leak in CSF rhinorrhoea is?

A. Sphenoid sinus
B. Frontal sinus
C. Cribriform plate (Correct Answer)
D. Tegmen tympani

Explanation: **Explanation:** **1. Why Cribriform Plate is Correct:** The **cribriform plate of the ethmoid bone** is the most common site for spontaneous and traumatic CSF rhinorrhoea. This is due to its unique anatomy: it is the thinnest part of the skull base (often only 0.05 mm thick) and is perforated by numerous olfactory nerve filaments. These perforations create natural points of weakness. Furthermore, the dura mater is tightly adherent to the bone in this region, making it prone to tearing even with minor trauma or fluctuations in intracranial pressure. **2. Analysis of Incorrect Options:** * **Sphenoid Sinus:** While a common site for leaks following transsphenoidal surgeries or in cases of "Sternberg’s canal" defects, it is less frequent than the ethmoid region. * **Frontal Sinus:** Leaks here usually occur due to significant anterior skull base trauma (e.g., RTA). While clinically important, the thick posterior wall of the frontal sinus makes it less common than the cribriform plate. * **Tegmen Tympani:** This is the most common site for **CSF Otorrhoea**. If the tympanic membrane is intact, CSF may flow down the Eustachian tube and present as "paradoxical rhinorrhoea," but it is not the primary site for rhinorrhoea. **3. Clinical Pearls for NEET-PG:** * **Most common cause overall:** Accidental Trauma (80%). * **Most common site of traumatic leak:** Cribriform plate/Ethmoid roof. * **Investigation of choice (Site localization):** HRCT of the paranasal sinuses (Bone window). * **Confirmatory test (Gold Standard):** Beta-2 Transferrin assay (most specific marker in the fluid). * **Target Sign/Halo Sign:** Seen when CSF is mixed with blood on a paper/linen. * **Management:** Most traumatic leaks settle with conservative management (bed rest, head elevation). If surgery is needed, the **Endoscopic Endonasal approach** is the preferred modality.

Question 86: All these structures are found in the lateral nasal wall except?

A. Superior Turbinate
B. Vomer (Correct Answer)
C. Agger nasi
D. Hasner's valve

Explanation: ### Explanation The lateral nasal wall is a complex anatomical structure composed of several bones and landmarks. Understanding its composition is crucial for endoscopic sinus surgery (FESS). **Why Vomer is the Correct Answer:** The **Vomer** is a thin, flat bone that forms the posteroinferior part of the **nasal septum** (the medial wall of the nasal cavity). It does not contribute to the lateral nasal wall. The lateral wall is primarily formed by the ethmoid bone, maxilla, lacrimal bone, inferior concha, palatine bone, and the medial pterygoid plate. **Analysis of Incorrect Options:** * **Superior Turbinate:** This is a part of the ethmoid bone located on the posterosuperior aspect of the lateral nasal wall. * **Agger Nasi:** This is the most anterior ethmoidal air cell, found on the lateral wall just anterior to the attachment of the middle turbinate. It serves as a key landmark in FESS. * **Hasner’s Valve (Plica Lacrimalis):** This is a mucosal fold located at the distal end of the nasolacrimal duct, which opens into the **inferior meatus** on the lateral nasal wall. **High-Yield Clinical Pearls for NEET-PG:** * **Bones of the Lateral Wall:** Remember the mnemonic **"M-E-L-I-P"** (Maxilla, Ethmoid, Lacrimal, Inferior concha, Palatine). * **Turbinates:** The Superior and Middle turbinates are parts of the **Ethmoid bone**, whereas the **Inferior turbinate** is an independent bone. * **Osteomeatal Complex (OMC):** This is the functional unit of the lateral wall where the frontal, maxillary, and anterior ethmoid sinuses drain. * **Sphenopalatine Foramen:** Located behind the posterior end of the middle turbinate; it is the "gateway" for the main arterial supply to the nasal cavity.

Question 87: Improvement in nasal patency by retracting the lateral part of the cheek and thus testing the vestibular component of the nose is called what?

A. Epley's maneuver
B. Cottle's test (Correct Answer)
C. Schwartz maneuver
D. Helmich maneuver

Explanation: ### Explanation **Correct Answer: B. Cottle’s test** **1. Why Cottle’s Test is Correct:** Cottle’s test is a clinical maneuver used to evaluate **nasal valve stenosis**. The nasal valve (specifically the internal nasal valve) is the narrowest part of the nasal airway, bounded by the caudal edge of the upper lateral cartilage, the septum, and the inferior turbinate. * **Mechanism:** The clinician uses one or two fingers to pull the patient's cheek laterally, away from the midline. * **Interpretation:** If this action opens the valve and the patient reports a significant improvement in nasal patency (easier breathing), the test is **positive**, indicating that the nasal valve is the primary site of obstruction. **2. Why the Other Options are Incorrect:** * **A. Epley’s maneuver:** This is a repositioning maneuver used to treat **Benign Paroxysmal Positional Vertigo (BPPV)** by moving canaliths from the posterior semicircular canal back into the utricle. * **C. Schwartz maneuver:** This is not a standard ENT clinical test. (Note: *Schwartz sign* refers to the "flamingo flush" seen on the promontory in active Otosclerosis). * **D. Helmich (Heimlich) maneuver:** This is an emergency procedure used to treat **upper airway obstruction** caused by a foreign body (choking). **3. High-Yield Clinical Pearls for NEET-PG:** * **Internal Nasal Valve:** The narrowest part of the entire respiratory tract. The normal angle is **10–15 degrees**. * **Components of the Nasal Valve:** Septum, Upper Lateral Cartilage (ULC), and the anterior end of the Inferior Turbinate. * **Modified Cottle’s Test:** Performed using a small ear speculum or a cotton-tipped applicator to support the ULC internally; it is considered more specific than the standard cheek retraction. * **Surgical Management:** If Cottle's test is positive, the patient may require a **functional rhinoplasty** (e.g., spreader grafts) rather than a simple septoplasty.

Question 88: What are the pathognomic features of Maxillary sinusitis?

A. Mucopus in the middle meatus (Correct Answer)
B. Inferior turbinate hypertrophy
C. Purulent nasal discharge
D. Atrophic sinusitis

Explanation: ### Explanation **Correct Option: A. Mucopus in the middle meatus** The maxillary sinus, along with the frontal and anterior ethmoidal sinuses, drains into the **middle meatus** via the osteomeatal complex. In acute or chronic maxillary sinusitis, the presence of a "pus streak" or mucopus specifically localized in the middle meatus is considered a pathognomonic clinical finding during anterior rhinoscopy or nasal endoscopy. A classic diagnostic maneuver is the **Postural Test (Fraenkel’s Test)**: the patient’s nose is cleared of pus, and the head is tilted forward and toward the unaffected side. If fresh pus reappears in the middle meatus, it confirms the maxillary sinus as the source. **Why other options are incorrect:** * **B. Inferior turbinate hypertrophy:** This is a non-specific finding usually associated with allergic rhinitis, vasomotor rhinitis, or compensatory hypertrophy due to a deviated nasal septum (DNS). * **C. Purulent nasal discharge:** While a common symptom of sinusitis, it is not pathognomonic for the *maxillary* sinus specifically. It can occur in vestibulitis, foreign bodies, or any other paranasal sinus infection. * **D. Atrophic sinusitis:** This is a chronic degenerative condition (often called Ozaena) characterized by mucosal atrophy and crusting, rather than the acute suppurative process seen in maxillary sinusitis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common sinus involved** in adults is the Maxillary sinus; in children, it is the Ethmoid sinus. * **First-line investigation:** X-ray PNS (Water’s View) showing opacity or an air-fluid level. * **Gold standard investigation:** Non-Contrast CT (NCCT) of the Paranasal Sinuses. * **Antral Puncture (Lichwitz Puncture):** The needle is passed through the **inferior meatus** (the thinnest part of the lateral wall). * **Dental Origin:** Approximately 10% of maxillary sinusitis cases are odontogenic (usually related to the 1st molar).

Question 89: What is true about nasal myiasis?

A. Commonly occurs in patients with ethmoidal polyps.
B. Results from the ova of the fly Chrysomia. (Correct Answer)
C. Treated by nasal saline instillation.
D. Cannot cause death of the patient.

Explanation: ### Explanation **Nasal Myiasis** (also known as Peenash) is a condition caused by the infestation of the nasal cavity by the larvae (maggots) of flies. **1. Why Option B is Correct:** The primary causative agent is the fly **Chrysomya bezziana**. The female fly deposits its **ova (eggs)** in the nasal cavity, usually attracted by the foul-smelling discharge associated with conditions like atrophic rhinitis or leprosy. These eggs hatch into larvae (maggots) within 8–24 hours, which then burrow into the mucous membrane and destroy surrounding tissues, including bone and cartilage. **2. Analysis of Incorrect Options:** * **Option A:** It is most commonly associated with **Atrophic Rhinitis** (due to the characteristic foul odor or *ozaena*) and leprosy, rather than ethmoidal polyps. * **Option C:** Treatment involves the instillation of **Chloroform and Turpentine oil** (in a 1:4 ratio) to stun or kill the maggots, followed by manual removal. Saline instillation is ineffective for killing larvae. * **Option D:** Nasal myiasis **can cause death**. If left untreated, the maggots can penetrate the skull base (cribriform plate), leading to meningitis, brain abscess, or massive hemorrhage from the erosion of major blood vessels. **3. High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** Foul-smelling nasal discharge, epistaxis, and the sensation of "something moving" inside the nose. * **Management:** Chloroform-turpentine mixture is the gold standard for immobilization. Systemic **Ivermectin** is now frequently used as an effective medical adjunct. * **Complications:** Palatal perforation, septal destruction, and orbital cellulitis. * **Prophylaxis:** Improving hygiene and treating the underlying atrophic rhinitis.

Question 90: What is the most definitive diagnostic method for sinusitis?

A. X-ray of paranasal sinuses
B. Proof puncture
C. Nasal endoscopy (Correct Answer)
D. Transillumination test

Explanation: **Explanation:** The diagnosis of sinusitis has evolved from traditional clinical methods to objective visualization. **Nasal Endoscopy (Diagnostic Nasal Endoscopy - DNE)** is currently considered the most definitive diagnostic tool because it allows for direct visualization of the middle meatus and the osteomeatal complex—the "final common pathway" for drainage of the frontal, maxillary, and anterior ethmoid sinuses. It can identify subtle signs like purulent discharge, edema, and polyps that are often missed on anterior rhinoscopy. **Analysis of Options:** * **X-ray Paranasal Sinuses (Option A):** Once common (e.g., Water’s view), it is now largely obsolete due to high false-negative rates and poor visualization of the ethmoid air cells. * **Proof Puncture (Option B):** Also known as antral lavage, it was historically the "gold standard" for maxillary sinusitis. However, it is invasive, carries risks (like air embolism), and is diagnostic only for the maxillary sinus, not the entire sinus complex. * **Transillumination Test (Option D):** A primitive bedside test with very low sensitivity and specificity; it is unreliable due to variations in bone thickness and soft tissue. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Imaging:** While endoscopy is the definitive clinical diagnostic tool, **Non-Contrast CT (NCCT) of the Paranasal Sinuses** is the "Gold Standard" for evaluating anatomy and extent of disease, especially before surgery (FESS). * **First-line Investigation:** Clinical diagnosis remains the first step, but DNE is the preferred objective method in a specialist setting. * **Middle Meatus:** This is the most critical area to examine during endoscopy, as it is the primary site for drainage of most major sinuses.

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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