Page 19 of 21
EN4.{27,31-34} | Sinonasal Inflammation and Tumours — Graded Quiz
Click any question card to reveal the correct answer.
Nasal biopsy in a young male with suspected juvenile nasopharyngeal angiofibroma (JNA) is contraindicated primarily because it may cause:
Correct. JNA is fed by the internal maxillary artery (branch of external carotid artery) and is one of the most vascular tumours encountered in ENT practice. Biopsy causes severe, potentially fatal haemorrhage that cannot be controlled locally. This is the cardinal rule: NEVER biopsy a suspected JNA.
JNA is an extremely vascular benign fibrovascular tumour of adolescent males. Biopsy causes catastrophic haemorrhage because the tumour is fed by the internal maxillary artery. Diagnosis must be made on clinical grounds + contrast CT/MRI + angiography — never by biopsy.
Biopsy does not cause tumour spread (A) — JNA is benign with no metastatic potential. Intracranial extension (C) is a feature of advanced untreated tumour, not caused by biopsy. Anosmia (D) is not a consequence of nasopharyngeal biopsy. The sole contraindication is catastrophic haemorrhage.
Click to reveal answer
Ethmoidal nasal polyps typically differ from antrochoanal (Killian's) polyps in that ethmoidal polyps are:
Correct. Ethmoidal polyps are bilateral, multiple, arise from the middle meatus and ethmoid sinuses, and occur in adults with allergy, CRS, or Samter's triad. Antrochoanal polyp (Killian's polyp) is single, unilateral, and originates from the maxillary antrum — more common in young adults and children.
Ethmoidal polyps = bilateral, multiple, allergic, in adults; arise from ethmoidal sinuses/middle meatus. Antrochoanal polyp = unilateral, single, arises from the maxillary antrum, common in young adults/children. This laterality distinction is a classic ENT known-trap.
Option A describes antrochoanal polyp, not ethmoidal polyp. Option C describes JNA. Option D describes features suggesting sinonasal malignancy (unilateral + bony erosion).
Click to reveal answer
Which investigation is the most important FIRST step in the management of a suspected sinonasal malignancy in a 55-year-old male presenting with unilateral nasal obstruction, epistaxis, and facial swelling?
Correct. In suspected sinonasal malignancy, histopathological confirmation via endoscopic biopsy is the essential first step. CT and MRI are critical for staging and surgical planning, but treatment cannot begin without tissue diagnosis. Unlike JNA, biopsy is not contraindicated in sinonasal tumours.
Definitive diagnosis of sinonasal malignancy requires tissue histopathology. CT/MRI delineate extent for staging but cannot replace tissue diagnosis. Biopsy under nasal endoscopy is the investigation that confirms the diagnosis. Unlike JNA, sinonasal tumours (e.g., SCC, adenocarcinoma) must be biopsied — biopsy is not contraindicated.
CT (A) defines anatomy and extent but cannot provide histological diagnosis. MRI (C) is essential for soft-tissue and intracranial extent but is used after or alongside biopsy, not before. PET-CT (D) is for staging after diagnosis — it is not a first-line diagnostic tool.
Click to reveal answer
A 22-year-old male presents with recurrent episodes of unilateral profuse epistaxis for 6 months and progressive right nasal obstruction. On examination there is a pink vascular mass in the right nasal cavity. The SINGLE MOST IMPORTANT step before any surgical management is:
Correct. Pre-operative embolisation of JNA's feeding vessels (primarily branches of the internal maxillary artery from the external carotid system) is performed 24–48 hours before surgical resection. This reduces intraoperative blood loss to manageable levels. Without embolisation, blood loss can be massive and fatal. Biopsy and FNAC are contraindicated.
In JNA, pre-operative embolisation (24–48 hours before surgery) of the feeding internal maxillary artery branches is the mandatory step before surgical excision. It reduces intraoperative haemorrhage dramatically, making safe resection possible. Biopsy and FNAC remain absolutely contraindicated.
Biopsy (A) and FNAC (D) are absolutely contraindicated in JNA — both risk catastrophic haemorrhage. Nasal packing (C) is a temporising measure for active epistaxis, not the pre-operative planning step that makes surgery safe.
Click to reveal answer
Granulomatosis with polyangiitis (Wegener's granulomatosis) affecting the nose is characterised on histopathology by:
Correct. GPA (Wegener's granulomatosis) is histopathologically characterised by necrotising granulomata associated with vasculitis — affecting small and medium vessels. This distinguishes it from TB (caseous, AFB) and sarcoidosis (non-caseating, no vasculitis). ANCA (usually c-ANCA/anti-PR3) is the serological marker.
GPA (Wegener's) = necrotising granulomata + vasculitis + c-ANCA (anti-PR3). Nasal TB = caseating granulomata + Langhans cells + AFB. Sarcoidosis = non-caseating granulomata, no vasculitis. Rhinoscleroma = Mikulicz cells (foamy macrophages with Klebsiella rhinoscleromatis) + Russell bodies.
Caseating granulomata with Langhans cells and AFB (A) = nasal tuberculosis. Non-caseating granulomata without vasculitis (B) = sarcoidosis. Foamy macrophages (Mikulicz cells) with Klebsiella rhinoscleromatis (D) = rhinoscleroma.
Click to reveal answer
Acute bacterial rhinosinusitis (ABRS) must be distinguished from viral URTI because ABRS may require antibiotics. The MOST reliable clinical criterion to diagnose ABRS is:
Correct. Most viral URTIs resolve within 7–10 days. Symptoms persisting beyond 10 days without improvement, or a biphasic illness with worsening after initial improvement (double-sickening), are the EPOS criteria that indicate ABRS and justify antibiotic treatment. Purulent discharge alone is insufficient as it occurs in viral URTI.
The EPOS diagnostic criterion for ABRS: persistence of symptoms >10 days without improvement OR worsening after initial improvement ('double-sickening'). Purulent discharge and fever alone do not differentiate ABRS from viral URTI. Bilateral nasal obstruction and anosmia are features of CRS/polyps, not ABRS.
Purulent discharge with facial pain (A) occurs in viral URTI — not specific for ABRS. Fever >38°C (B) is also non-specific. Bilateral nasal obstruction with anosmia (D) are features of CRS with nasal polyps, not acute bacterial sinusitis.
Click to reveal answer
Which of the following sinonasal malignancies is most strongly associated with occupational exposure to hardwood dust?
Correct. Ethmoid sinus adenocarcinoma has a well-established association with hardwood dust exposure (furniture makers, carpenters, joiners). It is an occupational cancer for which surveillance is recommended for at-risk workers. The risk is so consistent that it is listed in occupational disease schedules in many countries.
Ethmoid sinus adenocarcinoma is classically and strongly associated with hardwood (furniture-making) and softwood dust exposure, as well as leather dust. SCC of the maxillary sinus is associated with nickel refining and chromate exposure. NPC is associated with EBV + nitrosamines in salted fish (Cantonese diet). Olfactory neuroblastoma has no established occupational association.
Maxillary SCC (A) is linked to nickel refining and chromate exposure, not hardwood dust. NPC (C) is associated with EBV and dietary nitrosamines (salted fish) — not wood dust. Olfactory neuroblastoma (D) has no well-established occupational association.
Click to reveal answer
A patient with maxillary sinusitis develops periorbital oedema, proptosis, and restricted eye movement with systemic fever. The most dangerous immediate complication that must be excluded urgently is:
Correct. Proptosis + restricted eye movements + fever in sinusitis indicates orbital complication beyond preseptal cellulitis. Subperiosteal abscess (Chandler Stage III) or orbital abscess (Stage IV) must be excluded urgently by contrast CT. Delayed drainage risks optic nerve damage (permanent blindness) and cavernous sinus thrombosis (Stage V).
Proptosis + restricted eye movement + fever in the context of sinusitis = orbital complication (Chandler stage II–IV). This is an ophthalmic and ENT emergency. The most dangerous immediate concern requiring urgent imaging (CT orbit) and ENT/ophthalmic assessment is subperiosteal or orbital abscess — which needs surgical drainage to prevent vision loss and intracranial spread. Preseptal cellulitis lacks proptosis and restricted EOM.
Preseptal cellulitis (A) causes eyelid swelling without proptosis or restricted EOM — it is a less serious complication managed with IV antibiotics. Dacryocystitis (C) is lacrimal sac infection causing medial canthal swelling — not related to sinusitis orbital spread. Allergic shiners (D) are dark circles from venous stasis — a benign finding.
Click to reveal answer
Samter's triad (Aspirin-Exacerbated Respiratory Disease, AERD) consists of which three findings?
Correct. Samter's triad (AERD) = (1) nasal polyps, (2) asthma, (3) aspirin/NSAID hypersensitivity. The underlying mechanism is inhibition of COX-1 by aspirin/NSAIDs causing excess cysteinyl leukotriene production, triggering bronchospasm and nasal inflammation. Montelukast is a targeted treatment.
Samter's triad = nasal polyps + asthma + aspirin/NSAID sensitivity (AERD). Mechanism = COX-1 inhibition diverts arachidonic acid to cysteinyl leukotriene overproduction. Kartagener's = polyps + bronchiectasis + situs inversus. Churg-Strauss = polyps + eosinophilia + vasculitis. Young's = sinusitis/bronchiectasis + azoospermia.
Nasal polyps + bronchiectasis + situs inversus = Kartagener's syndrome (primary ciliary dyskinesia). Nasal polyps + eosinophilia + vasculitis = Churg-Strauss syndrome (EGPA). Nasal polyps + sinusitis + azoospermia = Young's syndrome.
Click to reveal answer
Nasopharyngeal carcinoma (NPC) is strongly associated with which viral agent, particularly the undifferentiated (WHO Type III) subtype?
Correct. NPC — especially the undifferentiated WHO Type III (lymphoepithelioma) subtype — is strongly and consistently associated with EBV infection. EBV viral capsid antigen (VCA-IgA) and early antigen (EA-IgA) are used as serological markers. The endemic form in Southern China and South-East Asia is particularly EBV-associated.
NPC is strongly associated with EBV infection — particularly the undifferentiated (lymphoepithelioma) WHO Type III subtype endemic in Southern China and South-East Asia. EBV serology (VCA-IgA, EA-IgA) is used as a tumour marker. HPV is associated with oropharyngeal SCC. HHV-8 causes Kaposi's sarcoma.
HPV (A) is strongly associated with oropharyngeal squamous cell carcinoma (base of tongue, soft palate, tonsils) but not NPC. HSV-1 (C) causes herpetic infections but not NPC. HHV-8 (D) causes Kaposi's sarcoma and primary effusion lymphoma — not NPC.
Click to reveal answer