"Rhinology" — Practice

Question 1

The nasolacrimal duct drains into the

Accepted Answer

C

Question 2

A 45-year-old has a single polypoid mass in the right nasal cavity with unilateral obstruction and occasional bleeding. The most appropriate next step is

Accepted Answer

B

Question 3

A 7-year-old with sinusitis has left eyelid swelling with full eye movements, normal vision and no proptosis. Two days later he has proptosis with painful restricted movement. What has changed and what is required?

Accepted Answer

He has progressed from preseptal cellulitis, Chandler stage I, to postseptal orbital involvement of at least stage II. The orbital septum is the anatomical divide: preseptal disease spares vision, movement and globe position, while postseptal disease produces proptosis, restricted painful movement and threatens sight.

He now needs urgent contrast CT of sinuses and orbits to look for a subperiosteal abscess, intravenous antibiotics, and joint ENT and ophthalmology assessment with formal acuity and colour vision testing. Loss of colour vision or a relative afferent pupillary defect indicates optic nerve compromise and mandates urgent surgical decompression.

Question 4

A patient has used xylometazoline several times daily for three months and reports his nose is more blocked than ever. Explain and treat.

Accepted Answer

Rhinitis medicamentosa. Topical alpha-agonist decongestants vasoconstrict initially, but after a few days the vessels rebound with vasodilatation as each dose wears off, so obstruction returns worse than baseline.

The patient then increases the dose, which shortens the interval further and produces a self-reinforcing cycle with tachyphylaxis. Treatment is withdrawal of the decongestant under cover of an intranasal corticosteroid, with explicit counselling that symptoms will worsen transiently before improving. The general rule is that topical decongestants should not be used beyond about five days.

Question 5

A patient develops clear watery discharge from one nostril after endoscopic sinus surgery, worse on leaning forward. Which test settles it, and why not the alternatives?

Accepted Answer

Beta-2 transferrin. It is a variant of transferrin produced by neuraminidase activity in the central nervous system and is present in cerebrospinal fluid, perilymph and aqueous humour but not in nasal secretions, tears or serum, so detecting it in the fluid confirms a leak.

The traditional glucose test is unreliable because nasal secretions themselves contain glucose and blood contamination confounds the result, and the halo or double ring sign on filter paper is suggestive rather than diagnostic. Confirmation matters because a leak means a skull base breach with continuing risk of meningitis, requiring imaging to localise the defect and definitive repair.

Question 6

A 58-year-old with poorly controlled diabetes has three days of left facial pain and cheek numbness. The nasal cavity looks almost normal apart from a dusky area on the middle turbinate. What must be excluded, and how is it managed?

Accepted Answer

Acute invasive fungal rhinosinusitis, most likely mucormycosis. The combination of an unimpressive nasal appearance with pain and numbness out of proportion is characteristic, and numbness specifically indicates angioinvasion with nerve infarction, so a dusky or insensate turbinate represents dead tissue rather than inflammation.

He needs urgent nasal endoscopy with biopsy for KOH mount and histopathology showing broad aseptate hyphae with right-angle branching, contrast imaging of sinuses, orbit and brain, and immediate correction of glycaemia and any ketoacidosis.

Treatment is combined surgical debridement of all necrotic tissue and systemic liposomal amphotericin B. The combination matters: reported survival was around 57 per cent with surgery alone and about 61 per cent with amphotericin alone, against roughly 70 per cent with both, because angioinvasion thromboses the vessels that would otherwise deliver the drug.

Question 7

Explain why endoscopic sinus surgery targets a small area in the middle meatus rather than opening each diseased sinus.

Accepted Answer

Because the maxillary, anterior ethmoid and frontal sinuses all drain through the osteomeatal complex, a narrow region in the middle meatus. Disease confined to that small area therefore obstructs three sinuses simultaneously, which is why multi-sinus disease so often has a single anatomical cause.

Clearing the complex restores the physiological drainage pathway and allows normal mucociliary transport to resume, and mucosa that was inflamed only because of stasis recovers without being removed. Stripping the sinus linings, by contrast, destroys the ciliated epithelium on which clearance depends and produces a sinus that cannot clear itself even when widely opened. The principle is to restore function rather than to remove tissue, and it also explains why topical steroid and irrigation, which reach the complex, remain the backbone of medical treatment.

Question 8

A 34-year-old lost her sense of smell after a viral illness eight months ago and says food has no taste, though her tongue feels normal. Classify the problem and advise.

Accepted Answer

This is post-viral sensorineural olfactory loss, from damage to the olfactory epithelium and its neurons rather than from obstruction of airflow.

Her complaint of lost taste is expected and does not indicate a gustatory problem. Flavour is largely retronasal olfaction, so patients with anosmia describe food as tasteless while basic taste modalities of sweet, salt, sour, bitter and umami remain intact, which matches her normal tongue sensation.

Advice has two parts. Recovery from post-viral loss is slow and often incomplete but continues over many months, so eight months is not the endpoint. Olfactory training, deliberate repeated sniffing of a fixed set of distinct odours twice daily over months, has the best evidence for improving recovery. Safety counselling matters too, since she cannot detect gas leaks, smoke or spoiled food and needs alarms and date-based food discarding.

Question 9

A 16-year-old is struck on the nose playing cricket. Two days later he has complete bilateral nasal obstruction and a bilateral bulging of the septum. What is the diagnosis and why can it not wait?

Accepted Answer

Septal haematoma, blood collecting between the perichondrium and the septal cartilage on both sides.

It cannot wait because septal cartilage is avascular and derives its entire nutrition by diffusion from the overlying perichondrium. Stripping that layer away starves the cartilage, and necrosis begins within days. Once the cartilage dies the septum perforates, and loss of dorsal support produces a saddle nose deformity that requires major reconstructive surgery to correct. A haematoma is also an excellent culture medium, so secondary abscess formation with the risk of intracranial spread through valveless veins is a further reason for urgency.

Management is prompt incision and drainage with a small dependent incision, evacuation of clot, quilting sutures or packing to prevent reaccumulation, and antibiotic cover.

Practice — "Rhinology"

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