Esthesioneuroblastoma — MCQs
Which of the following is an indication for Functional Endoscopic Sinus Surgery (FESS)?
True about neuroblastoma:
Which brain tumor has the worst prognosis in children?
A 1-year-old child presented with a swelling in the left flank with episodes of flushing, diarrhea, sweating and bone pain. The diagnosis is -
A 19-year-old young girl with a previous history of repeated pain over the medial canthus and chronic use of nasal decongestants presented with an abrupt onset of fever, chills, and rigor, diplopia on lateral gaze, moderate proptosis, and chemosis. On examination, the optic disc is congested. What is the most likely diagnosis?
Young's operation is done for:
Which of the following is NOT typically associated with acute bacterial sinusitis?
The following test is done for the evaluation of:
A 72-year-old man presents to his primary care physician with progressively worsening hearing loss. He states that his trouble with hearing began approximately 7-8 years ago. He is able to hear when someone is speaking to him; however, he has difficulty with understanding what is being said, especially when there is background noise. In addition to his current symptoms, he reports a steady ringing in both ears, and at times experiences dizziness. Medical history is significant for three prior episodes of acute otitis media. Family history is notable for his father being diagnosed with cholesteatoma. His temperature is 98.6°F (37°C), blood pressure is 138/88 mmHg, pulse is 74/min, and respirations are 13/min. On physical exam, when a tuning fork is placed in the middle of the patient's forehead, sound is appreciated equally on both ears. When a tuning fork is placed by the external auditory canal and subsequently on the mastoid process, air conduction is greater than bone conduction. Which of the following is most likely the cause of this patient's symptoms?
A boy has developed epistaxis. What is the treatment of choice?
Esthesioneuroblastoma Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is an indication for Functional Endoscopic Sinus Surgery (FESS)?
- A. inverted papilloma
- B. Optic nerve decompression
- C. Orbital abscess
- D. Nasal polyposis (Correct Answer)
Explanation: ***Nasal polyposis*** - **Nasal polyposis refractory to medical management** is one of the most common and primary indications for **FESS**, as it allows for direct removal of polyps and restoration of sinus drainage and ventilation. - **FESS** aims to improve ventilation and mucociliary clearance within the paranasal sinuses, addressing the underlying chronic rhinosinusitis that leads to polyp formation. *Inverted papilloma* - **Inverted papilloma** is a benign but locally aggressive **epithelial tumor** that does require surgical excision, and FESS techniques are used for its removal. - However, it often requires **extended endoscopic approaches** (such as medial maxillectomy or modified endoscopic medial maxillectomy) rather than standard FESS to ensure complete removal and prevent recurrence due to its invasive growth pattern. - In the context of this question, **nasal polyposis** is the more straightforward and common indication for standard FESS. *Orbital abscess* - An **orbital abscess** is a surgical emergency requiring prompt drainage. While endoscopic sinus surgery may be used as part of the surgical approach to drain the abscess and address contributing sinusitis, the primary goal is abscess drainage rather than the sinus disease itself. - The indication here is the orbital complication, not chronic sinus disease per se. *Optic nerve decompression* - **Endoscopic optic nerve decompression** can be performed using FESS techniques for conditions like traumatic optic neuropathy or compressive lesions. - However, this is a specialized, advanced procedure for specific optic nerve pathology, not a routine indication for FESS in the management of chronic rhinosinusitis and its direct complications.
Question 2: True about neuroblastoma:
- A. Metastasis rarely present
- B. Tumor of autonomic nervous system (Correct Answer)
- C. Earliest detected in late childhood
- D. All of the options
Explanation: ***Tumor of autonomic nervous system*** - **Neuroblastoma** is a malignancy that arises from **neuroblasts**, which are immature nerve cells of the **sympathetic nervous system** (part of the autonomic nervous system). - It most commonly originates in the **adrenal medulla** (50% of cases) or other areas along the sympathetic chain in the abdomen, chest, or neck. - This statement is **correct** and represents the fundamental pathophysiology of neuroblastoma. *Metastasis rarely present* - This statement is **incorrect** because neuroblastoma is known for its **high rate of metastasis** at diagnosis. - Approximately **50-60%** of patients present with **metastatic disease** at the time of diagnosis. - Common sites of metastasis include **bone marrow** (most common), bone, liver, and lymph nodes. - Stage 4 disease is more common than localized disease in children over 18 months. *Earliest detected in late childhood* - This statement is **incorrect** as neuroblastoma typically presents in **early childhood**, with a median age of diagnosis around **17-22 months**. - It is one of the most common **solid tumors in infants** and young children, with **90% of cases diagnosed before age 5 years**. - Rarely seen in late childhood or adolescence, making this the opposite of the truth. *All of the options* - This option is **incorrect** because only **one statement** (tumor of autonomic nervous system) is true, rendering "All of the options" false.
Question 3: Which brain tumor has the worst prognosis in children?
- A. Brainstem glioma (Correct Answer)
- B. Craniopharyngioma
- C. Cerebellar astrocytoma
- D. Pineal body tumor
Explanation: ***Brainstem glioma*** - **Diffuse intrinsic pontine gliomas (DIPG)** are particularly aggressive, typically unresponsive to conventional therapies, and have a median survival of less than one year. - Their critical location in the **brainstem** makes surgical resection extremely difficult and often impossible without causing severe neurological deficits [2]. *Craniopharyngioma* - While they can be challenging to treat due to their proximity to vital structures like the **optic chiasm** and **hypothalamus**, they are generally benign and have a good prognosis with complete surgical resection. - They tend to recur if not completely removed, but recurrence is often amenable to further treatment. *Cerebellar astrocytoma* - These are often **low-grade (pilocytic astrocytomas)** and have an excellent prognosis, especially if surgical gross total resection is achieved [2]. - They are usually cystic and well-demarcated, making them more amenable to curative surgical removal. *Pineal body tumor* - The prognosis of pineal region tumors varies greatly depending on the **histology** (e.g., germinoma, pineoblastoma, pineocytoma) [1]. - While some are aggressive (like pineoblastomas), a significant portion, such as germinomas, are highly sensitive to **radiation therapy** and have a relatively good prognosis [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1140-1141. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1319-1320.
Question 4: A 1-year-old child presented with a swelling in the left flank with episodes of flushing, diarrhea, sweating and bone pain. The diagnosis is -
- A. Wilms tumor
- B. Pheochromocytoma
- C. Neuroblastoma (Correct Answer)
- D. Medulloblastoma
Explanation: ***Neuroblastoma*** - The combination of a **flank mass** in a 1-year-old child, along with paraneoplastic symptoms like **flushing, diarrhea, and sweating** (due to catecholamine secretion), and **bone pain** (indicating metastatic disease), is highly characteristic of neuroblastoma. - Neuroblastoma is a common extracranial solid tumor of childhood arising from **neural crest cells**, often presenting with abdominal mass and systemic symptoms. *Wilms tumor* - While Wilms tumor also presents as a **flank mass** in young children, it typically does not cause the systemic symptoms of flushing, diarrhea, or sweating, nor significant bone pain from metastasis. - Patients with Wilms tumor often present with **asymptomatic abdominal mass** detected incidentally. *Pheochromocytoma* - **Pheochromocytoma** can cause symptoms like flushing, sweating, and episodic hypertension due to catecholamine release, but it is **rare in children** and typically presents as an adrenal mass, not a flank mass with bone pain. - It usually presents with **hypertension crises**, which are not mentioned here. *Medulloblastoma* - **Medulloblastoma** is a **brain tumor** and would present with neurological symptoms such as headache, vomiting, and ataxia, not a flank mass or systemic symptoms like flushing, diarrhea, and sweating. - It is a **malignant tumor** of the cerebellum and does not cause peripheral masses or bone metastases in this manner.
Question 5: A 19-year-old young girl with a previous history of repeated pain over the medial canthus and chronic use of nasal decongestants presented with an abrupt onset of fever, chills, and rigor, diplopia on lateral gaze, moderate proptosis, and chemosis. On examination, the optic disc is congested. What is the most likely diagnosis?
- A. Cavernous sinus thrombosis (Correct Answer)
- B. Orbital inflammation
- C. Acute sinusitis
- D. Optic nerve compression
Explanation: **Cavernous sinus thrombosis** - The abrupt onset of **fever, chills, rigor, diplopia on lateral gaze, moderate proptosis, and chemosis, along with a congested optic disc**, points towards inflammation and thrombosis within the cavernous sinus. - A history of recurrent pain over the **medial canthus** (suggesting infection near the nose/eyes) and chronic use of **nasal decongestants** (potentially obstructing venous drainage or causing mucosal changes) further increases the suspicion for cavernous sinus thrombosis originating from orbital or sinonasal infections. *Orbital inflammation* - While orbital inflammation can present with **proptosis, chemosis, and optic disc congestion**, the presence of **diplopia on lateral gaze (suggesting oculomotor nerve involvement)** and systemic symptoms like **fever, chills, and rigor** strongly indicates a more widespread and severe process beyond simple inflammation, such as thrombosis. - Orbital inflammation typically lacks the characteristic severe systemic toxicity and specific cranial nerve palsies associated with cavernous sinus thrombosis. *Acute sinusitis* - **Acute sinusitis** can present with fever and localized pain, but it does not typically cause **diplopia on lateral gaze, significant proptosis, chemosis, or optic disc congestion**. - The symptoms described are much more severe and involve structures beyond the paranasal sinuses. *Optic nerve compression* - **Optic nerve compression** would primarily cause visual disturbances, such as **vision loss or visual field defects**, and potentially optic disc edema. [1] - It would not explain the prominent **proptosis, chemosis, diplopia on lateral gaze**, or the significant systemic symptoms like **fever, chills, and rigor**.
Question 6: Young's operation is done for:
- A. Allergic rhinitis
- B. Vasomotor rhinitis
- C. Atrophic rhinitis (Correct Answer)
- D. Antrochoanal polyp
Explanation: ***Atrophic rhinitis*** - **Young's operation** is a surgical procedure specifically designed to treat **atrophic rhinitis**. - The goal of the surgery is to narrow the nasal passages by creating a **synechia** (adhesion) to reduce airflow and improve the humidification and temperature of inspired air. *Allergic rhinitis* - Allergic rhinitis is primarily managed with **medical therapy**, including antihistamines, nasal corticosteroids, and allergen avoidance. - Surgical intervention, if considered, typically involves procedures like turbinate reduction, not Young's operation, and is less common for this condition. *Vasomotor rhinitis* - Vasomotor rhinitis is a **non-allergic, non-infectious condition** characterized by fluctuating nasal congestion and rhinorrhea, often triggered by irritants or temperature changes. - Treatment usually involves **medical management** with anticholinergics or nasal corticosteroids, and sometimes turbinate reduction, but not Young's operation. *Antrochoanal polyp* - An antrochoanal polyp is a benign growth originating in the **maxillary sinus** and extending into the choana. - The primary treatment is **surgical removal**, typically via endoscopic sinus surgery, which is distinct from Young's operation.
Question 7: Which of the following is NOT typically associated with acute bacterial sinusitis?
- A. Purulent nasal discharge
- B. Epistaxis (Correct Answer)
- C. Facial pain
- D. Fever
Explanation: ***Epistaxis*** - While possible due to **mucosal inflammation** or irritation from forceful blowing, **epistaxis (nosebleeds)** is not considered a typical or primary symptom of acute bacterial sinusitis. - The main symptoms revolve around pressure, discharge, and systemic signs of infection. *Purulent nasal discharge* - This is a hallmark symptom of acute bacterial sinusitis, indicating the presence of **bacterial infection** and inflammation in the sinuses. - The discharge is often thick, colored (yellow, green), and can be accompanied by a **foul odor**. *Facial pain* - **Facial pain** or pressure, especially around the cheeks, forehead, or eyes, is a characteristic symptom stemming from inflammation and fluid accumulation within the **sinus cavities**. - This pain often worsens when bending forward. *Fever* - **Fever** is a systemic sign of infection and is commonly present in acute bacterial sinusitis, especially in more severe cases. - It indicates the body's immune response to the bacterial invasion.
Question 8: The following test is done for the evaluation of:
- A. Cheek tenderness in maxillary sinusitis (Correct Answer)
- B. Abnormality of nasal valve
- C. Severity of proptosis
- D. Skin pinch for dehydration
Explanation: ***Cheek tenderness in maxillary sinusitis*** - The image shows a person palpating the area over the **maxillary sinus** with their fingers. This examination technique is used to elicit tenderness, a common sign of **maxillary sinusitis**. - **Tenderness on palpation** over the maxillary sinus is a key clinical finding indicating inflammation or infection within the sinus cavity. *Abnormality of nasal valve* - Evaluation of the nasal valve typically involves external observation, internal examination with a speculum, or specialized maneuvers like the **Cottle test**, which involves pulling the cheek laterally to open the valve; it does not involve pressing on the cheek as depicted. - The nasal valve is an internal structure, and its palpation for abnormality would not be performed by pressing on the outer cheekbone as shown. *Severity of proptosis* - Proptosis (exophthalmos) refers to the **abnormal protrusion of the eyeball**. It is typically measured using an **exophthalmometer**. - The action shown in the image, pressing on the cheek, is not a method used to assess or quantify the severity of proptosis. *Skin pinch for dehydration* - The **skin pinch test** (turgor test) for dehydration is usually performed by pinching the skin on the back of the hand, lower arm, or abdomen, not the cheek. - Delayed return of the pinched skin to its normal state, known as **poor skin turgor**, indicates dehydration. The image does not show this technique.
Question 9: A 72-year-old man presents to his primary care physician with progressively worsening hearing loss. He states that his trouble with hearing began approximately 7-8 years ago. He is able to hear when someone is speaking to him; however, he has difficulty with understanding what is being said, especially when there is background noise. In addition to his current symptoms, he reports a steady ringing in both ears, and at times experiences dizziness. Medical history is significant for three prior episodes of acute otitis media. Family history is notable for his father being diagnosed with cholesteatoma. His temperature is 98.6°F (37°C), blood pressure is 138/88 mmHg, pulse is 74/min, and respirations are 13/min. On physical exam, when a tuning fork is placed in the middle of the patient's forehead, sound is appreciated equally on both ears. When a tuning fork is placed by the external auditory canal and subsequently on the mastoid process, air conduction is greater than bone conduction. Which of the following is most likely the cause of this patient's symptoms?
- A. Stapedial abnormal bone growth
- B. Endolymphatic hydrops
- C. Cochlear hair cell degeneration (Correct Answer)
- D. Accumulation of desquamated keratin debris
Explanation: ***Cochlear hair cell degeneration*** - The patient's **progressive, bilateral hearing loss** over several years, difficulty understanding speech in noise, and **tinnitus** are classic symptoms of **presbycusis**, which results from age-related **degeneration of cochlear hair cells**. - The **normal Weber test** (no lateralization) and **Rinne test** (air conduction > bone conduction) indicate a **sensorineural hearing loss**, consistent with cochlear pathology rather than conductive issues. *Stapedial abnormal bone growth* - This condition (**otosclerosis**) causes **conductive hearing loss** due to fixation of the stapes, which would present with an **abnormal Rinne test** (bone conduction > air conduction) in the affected ear. - While it can cause progressive hearing loss and tinnitus, the normal Rinne test contradicts this diagnosis. *Endolymphatic hydrops* - This is the underlying pathology of **Ménière's disease**, which typically presents with episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness. - The patient's dizziness is non-episodic, and the absence of fluctuating hearing loss and aural fullness makes Ménière's less likely. *Accumulation of desquamated keratin debris* - This describes a **cholesteatoma**, which typically causes **conductive hearing loss** and often presents with otorrhea, earache, and possibly vestibular symptoms. - The normal Rinne test (indicating sensorineural loss) and lack of otorrhea or earache make cholesteatoma unlikely, despite a family history.
Question 10: A boy has developed epistaxis. What is the treatment of choice?
- A. Cauterization of vessels
- B. Surgical ligation
- C. Digital pressure (Correct Answer)
- D. Nasal packing
Explanation: ***Digital pressure*** - This is the **initial and most common first-line treatment** for acute epistaxis, especially in children, as most nosebleeds originate from Kiesselbach's plexus in the anterior septum. - Applying firm, continuous pressure to the soft part of the nose for 10-15 minutes can effectively compress the bleeding vessels and promote clot formation. *Cauterization of vessels* - This method is used when **digital pressure fails** to control the bleeding and the bleeding site can be identified, often in the anterior septum. - It involves using chemical (e.g., silver nitrate) or electrical methods to seal the bleeding vessel. *Surgical ligation* - **Surgical ligation** is reserved for severe, posterior epistaxis that is refractory to other methods like nasal packing or embolization. - It involves surgically tying off the major arteries supplying the nose (e.g., internal maxillary, external carotid) and carries greater risks. *Nasal packing* - **Nasal packing** is typically used when direct pressure has failed, and the bleeding site is not easily amenable to cauterization, or in cases of posterior epistaxis. - It involves inserting material into the nasal cavity to apply direct pressure to the bleeding vessel, but it is more invasive and uncomfortable than digital pressure.
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