Juvenile Nasopharyngeal Angiofibroma — MCQs
Treatment of choice for angiofibroma -
A 14-year-old child with a history of recurrent nasal bleeding has the endoscopic view provided. What is the investigation of choice?
A 13-year-old boy presents with right-sided nasal obstruction and recurrent epistaxis for the past 6 months. What is the most likely diagnosis?
A person presents with neck node and B type tympanogram. What is the most likely diagnosis?
Juvenile nasopharyngeal angiofibroma spreading to pterygomaxillary fossa is which stage?
A boy has developed epistaxis. What is the treatment of choice?
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?
Identify the surgical procedure being performed in the image shown below.
What is the most common space-occupying lesion in the cerebellopontine angle?
CSF rhinorrhea is most commonly seen in fracture of which of the following bones?
Juvenile Nasopharyngeal Angiofibroma Indian Medical PG Practice Questions and MCQs
Question 1: Treatment of choice for angiofibroma -
- A. Radiotherapy
- B. Combination of treatments (Surgery and Radiotherapy)
- C. Chemotherapy
- D. Surgery (Correct Answer)
Explanation: ***Surgery*** - **Surgical excision** is considered the **gold standard** and primary treatment for **nasopharyngeal angiofibroma**, especially for localized and resectable tumors. - Complete removal aims to prevent tumor recurrence and alleviate symptoms like **epistaxis** and **nasal obstruction**. *Radiotherapy* - **Radiotherapy** is generally reserved for **recurrent** or **unresectable tumors**, or cases with **intracranial extension**. - It carries risks of side effects such as **growth retardation** and **secondary malignancies**, making it less favorable as a first-line treatment. *Combination of treatments (Surgery and Radiotherapy)* - A **combination** approach is typically utilized for **advanced-stage tumors** where complete surgical resection is challenging, or in cases of recurrence. - It is not the initial treatment for most angiofibromas, which often respond well to surgery alone. *Chemotherapy* - **Chemotherapy** has **limited efficacy** in the treatment of angiofibroma due to the tumor's benign nature and its primary vascular composition. - It is rarely used, even in recurrent or advanced cases, as other modalities like surgery or radiotherapy are more effective.
Question 2: A 14-year-old child with a history of recurrent nasal bleeding has the endoscopic view provided. What is the investigation of choice?
- A. Biopsy
- B. X-ray
- C. FESS (Functional Endoscopic Sinus Surgery)
- D. CECT (Contrast-Enhanced CT) (Correct Answer)
Explanation: ***CECT (Contrast-Enhanced CT)*** - Given the history of recurrent nasal bleeding in an adolescent male suggestive of a **juvenile nasopharyngeal angiofibroma (JNA)**, CECT is the investigation of choice to delineate the tumor's extent, vascularity, and involvement of surrounding structures. - CECT provides crucial information for surgical planning and assessing intracranial extension due to the highly vascular nature of JNAs. *Biopsy* - Biopsy of a suspected angiofibroma is generally **contraindicated** due to the high risk of severe and uncontrolled hemorrhage because the tumor is highly vascular and lacks a true capsule. - The diagnosis of JNA is usually made based on clinical presentation and imaging findings. *X-ray* - **X-rays** (like plain radiographs of the sinuses) offer limited soft tissue detail and are **insufficient** to accurately visualize the extent or vascularity of a nasopharyngeal mass. - They may show some bony erosion but cannot provide the detailed information needed for diagnosis or surgical planning of a JNA. *FESS (Functional Endoscopic Sinus Surgery)* - **FESS** is a **surgical procedure** used for treating chronic sinusitis and other sinonasal conditions, not primarily an investigative tool for a suspected tumor like JNA. - While endoscopy is used for initial visualization, **surgery** is a treatment, and detailed imaging must precede it to understand tumor boundaries.
Question 3: A 13-year-old boy presents with right-sided nasal obstruction and recurrent epistaxis for the past 6 months. What is the most likely diagnosis?
- A. JNA (Correct Answer)
- B. Coagulation disorder
- C. Antrochoanal polyp
- D. Allergic rhinitis
Explanation: ***JNA (Juvenile Nasopharyngeal Angiofibroma)*** - **Classic presentation**: Adolescent male with **unilateral nasal obstruction** and **recurrent, often profuse epistaxis** - JNA is a **highly vascular benign tumor** that predominantly affects males aged 10-18 years - Though benign, it is **locally aggressive** and can extend into adjacent structures (orbit, skull base) - The combination of age, gender, unilateral symptoms, and recurrent epistaxis makes this the most likely diagnosis *Coagulation disorder* - Would cause **generalized bleeding tendencies**, not localized unilateral nasal obstruction - Epistaxis would typically be **bilateral** and associated with other bleeding manifestations (easy bruising, gum bleeding, prolonged bleeding from cuts) - No mass effect or persistent obstruction would be expected - Other systemic bleeding signs are absent in this presentation *Antrochoanal polyp* - **Benign inflammatory lesion** originating from maxillary sinus, extending through ostium into choana - Can cause nasal obstruction but epistaxis is **much less common and less severe** than in JNA - More commonly associated with **chronic sinusitis symptoms** (rhinorrhea, postnasal drip, facial pressure) - Less vascular than JNA, so recurrent profuse epistaxis would be unusual *Allergic rhinitis* - Characterized by **bilateral symptoms**: nasal obstruction, sneezing, rhinorrhea, and nasal itching - Often has **seasonal pattern** or clear allergen triggers - May cause minor epistaxis from mucosal irritation, but not the **severe recurrent epistaxis** seen here - **Unilateral** persistent obstruction would be atypical for allergic rhinitis
Question 4: A person presents with neck node and B type tympanogram. What is the most likely diagnosis?
- A. Acoustic neuroma
- B. Nasopharyngeal CA (Correct Answer)
- C. None of the options
- D. Angiofibroma
Explanation: ***Nasopharyngeal CA*** - A **neck node** can be a presenting symptom of **nasopharyngeal carcinoma (NPC)** due to metastatic spread to cervical lymph nodes, often as the first presenting feature in ~75% of cases. - A **Type B tympanogram** indicates reduced compliance of the tympanic membrane, often due to **otitis media with effusion (OME)**, which can be caused by Eustachian tube obstruction from a nasopharyngeal mass like NPC. - This is the **classic presentation** combining lymphadenopathy with conductive hearing loss/middle ear effusion. *Acoustic neuroma* - An **acoustic neuroma** (vestibular schwannoma) typically presents with **unilateral sensorineural hearing loss**, tinnitus, and balance issues. - It does not directly cause an obstructive process leading to a Type B tympanogram or cervical lymphadenopathy. - Metastasis from acoustic neuroma is extremely rare. *Angiofibroma* - **Angiofibroma** is a benign, highly vascular tumor typically found in the **nasopharynx**, primarily affecting adolescent males. - While it can cause **nasal obstruction** and epistaxis, leading to Eustachian tube dysfunction and a Type B tympanogram, it is **benign and does not metastasize** to neck nodes. - This is a key differentiating feature from nasopharyngeal carcinoma.
Question 5: Juvenile nasopharyngeal angiofibroma spreading to pterygomaxillary fossa is which stage?
- A. Stage IV
- B. Stage III
- C. Stage II (Correct Answer)
- D. Stage I
Explanation: ***Stage II*** - This stage describes **tumor extension** to the **pterygomaxillary fossa** or maxillary, ethmoid, or sphenoid sinuses with bone destruction. - According to the **Fisch staging system** (most widely used), pterygomaxillary fossa involvement specifically defines Stage II disease. - This represents locally advanced disease beyond the nasopharynx but without infratemporal fossa or intracranial extension. *Stage III* - This stage signifies extension to the **infratemporal fossa**, **orbit**, or **parasellar region** (remaining lateral to cavernous sinus). - It represents more extensive local spread than pterygomaxillary fossa involvement alone. - Requires more complex surgical approaches and has greater morbidity. *Stage IV* - This stage indicates **intracranial extension** with involvement of the **cavernous sinus**, **optic chiasm**, or **pituitary fossa**. - It represents the most advanced disease with the highest surgical complexity and potential for complications. - Often requires combined neurosurgical approaches. *Stage I* - Stage I describes a tumor strictly confined to the **nasopharynx** and **nasal cavity** without extension to adjacent structures. - This is the earliest stage with the best prognosis and typically amenable to endoscopic resection. - No bone destruction or extension to sinuses or fossae.
Question 6: 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.
Question 7: 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 8: Identify the surgical procedure being performed in the image shown below.
- A. Inferior meatal antrostomy
- B. Caldwell Luc operation (Correct Answer)
- C. Proof puncture
- D. Superior meatal antrostomy
Explanation: ***Caldwell Luc operation*** - The image shows an **incision in the gingivobuccal sulcus** above the upper incisor/canine teeth, reflecting the periosteum to access the anterior wall of the maxillary sinus, which is characteristic of the Caldwell-Luc operation. - This procedure involves creating an opening into the **maxillary antrum** to remove diseased tissue, often visualized through the anterior sinus wall as depicted in the right panel. *Inferior meatal antrostomy* - An inferior meatal antrostomy involves creating an opening in the **lateral nasal wall**, specifically beneath the inferior turbinate, to drain the maxillary sinus. - The approach in the image, through the oral cavity, is inconsistent with an inferior meatal antrostomy. *Proof puncture* - **Proof puncture** (also known as antral washout) is a diagnostic and therapeutic procedure where a needle is inserted into the maxillary sinus, typically through the inferior meatus, to aspirate contents and irrigate. - It does not involve a large surgical incision in the gingiva or removal of bone as shown in the image. *Superior meatal antrostomy* - The superior meatus is an anatomical space in the nasal cavity positioned **above the superior turbinate**. - A superior meatal antrostomy would access the posterior ethmoid cells or sphenoid sinus, not the maxillary sinus through an oral approach, and is not a standard procedure for maxillary sinus issues.
Question 9: What is the most common space-occupying lesion in the cerebellopontine angle?
- A. Meningioma
- B. Glioma
- C. Neurofibroma
- D. Acoustic neuroma (Correct Answer)
Explanation: **Explanation:** The **Cerebellopontine Angle (CPA)** is a potential space in the posterior cranial fossa. The correct answer is **Acoustic Neuroma** (also known as Vestibular Schwannoma), which accounts for approximately **80–85%** of all CPA tumors. 1. **Acoustic Neuroma (Correct):** These are benign, slow-growing tumors arising from the Schwann cells of the vestibular nerve (most commonly the inferior vestibular nerve). They typically present with unilateral sensorineural hearing loss, tinnitus, and dysequilibrium. 2. **Meningioma (Incorrect):** This is the **second most common** CPA lesion, accounting for about 10–15% of cases. Unlike acoustic neuromas, they often do not widen the internal auditory canal (IAC) and may show calcification or a "dural tail" on MRI. 3. **Epidermoid Cyst (Incorrect):** These are the third most common CPA lesions (approx. 5%). They are congenital and characterized by a "pearly" appearance and restricted diffusion on MRI. 4. **Neurofibroma (Incorrect):** While associated with Neurofibromatosis Type 1, the tumors in the CPA (specifically in NF-2) are actually **Schwannomas**, not neurofibromas. 5. **Glioma (Incorrect):** These are primary brain parenchyma tumors (e.g., brainstem gliomas) and are rarely primary occupants of the CPA space. **NEET-PG High-Yield Pearls:** * **Gold Standard Investigation:** Contrast-enhanced MRI (Gadolinium) is the investigation of choice. * **Bilateral Acoustic Neuromas:** Pathognomonic for **Neurofibromatosis Type 2 (NF-2)**. * **Audiometry Finding:** Characterized by "Retrocochlear" pathology (Poor speech discrimination score out of proportion to pure tone loss and absence of recruitment). * **Order of Frequency in CPA:** Acoustic Neuroma > Meningioma > Epidermoid > Facial Nerve Schwannoma.
Question 10: CSF rhinorrhea is most commonly seen in fracture of which of the following bones?
- A. Cribriform plate (Correct Answer)
- B. Temporal bone
- C. Nasal bone
- D. Occipital bone
Explanation: **Explanation:** **Cribriform plate (Option A)** is the correct answer because it is the thinnest part of the anterior skull base and is intimately fused with the underlying dura mater. Due to this anatomical fragility, even minor head trauma can result in a dural tear. Since the cribriform plate forms the roof of the nasal cavity, any breach allows Cerebrospinal Fluid (CSF) to leak directly into the nose, manifesting as **CSF rhinorrhea**. **Analysis of Incorrect Options:** * **Temporal bone (Option B):** Fractures here (especially longitudinal) more commonly lead to **CSF otorrhea** (leakage through the ear). While CSF rhinorrhea can occur if the tympanic membrane is intact and fluid drains via the Eustachian tube, it is statistically less common than leaks from the anterior cranial fossa. * **Nasal bone (Option C):** These are the most common facial fractures, but they are extracranial. Unless the fracture extends superiorly into the frontal or ethmoid bones, it does not involve the dural sac. * **Occipital bone (Option D):** Fractures here involve the posterior cranial fossa. These are more likely to cause cranial nerve palsies or cerebellar injury rather than rhinorrhea. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of spontaneous CSF leak:** Tegmen tympani or Ethmoid roof. * **Most common site of traumatic CSF leak:** Cribriform plate/Ethmoid bone. * **Confirmatory Test:** **Beta-2 Transferrin** (most specific) or Beta-trace protein. * **Target Sign/Halo Sign:** Seen when CSF is mixed with blood on a paper/linen (CSF migrates further, forming a clear outer ring). * **Management:** Initial conservative management (bed rest, head elevation, avoiding straining). If persistent, endoscopic endonasal repair is the gold standard.
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