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RGUHS ENT - NOSE: Important Questions & Answers (Supplementary Exam Pattern)

RGUHS Exam Format Reminder:

• Long Essay (LE): 10 marks - Write etiology, clinical features, investigations, treatment + diagram
• Short Essay (SE): 5 marks - Brief note with key points + diagram if relevant
• Short Answer (SA): 3 marks - 5-6 lines, crisp points

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LONG ESSAY QUESTIONS (10 Marks Each)

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Q1. Describe the etiology, clinical features, investigations and treatment of Atrophic Rhinitis.

• Primary - Common in developing countries (subtropical/temperate zones); organisms - Klebsiella ozaenae, Staph. aureus, Proteus mirabilis, E. coli
• Secondary - Developed countries; follows trauma, sinonasal surgery, irradiation, or granulomatous disease

• Exact cause unknown; chronic bacterial infection is implicated
• Hormonal influence (more common in young females)
• Racial and nutritional factors
• Autonomic dysfunction

• Squamous metaplasia of columnar ciliated epithelium
• Glandular atrophy
• Diffuse endarteritis obliterans
• Loss of mucociliary function

• Foul-smelling yellow/green nasal crusts (ozena)
• Anosmia (paradoxically, patient does not smell own odour - merciful anosmia)
• Wide nasal cavity (atrophied turbinates)
• Nasal obstruction (paradoxical - wide cavity feels blocked due to lack of air sensation)
• Epistaxis on removing crusts
• Headache, nasal dryness

• Nasal endoscopy
• CT scan - shows widened nasal cavity, atrophied turbinates
• Culture and sensitivity of nasal swab
• Biopsy (histopathology as above)

• Nasal saline irrigation / alkaline douches to remove crusts
• Topical/systemic antibiotics (ciprofloxacin, rifampicin based on C&S)
• Glucose-glycerin nasal drops
• Oestrogen sprays
• Vitamin A, D supplementation

• Young's operation - Complete closure of both nostrils for 6 months → moist atmosphere → mucosa regenerates (classical operation)
• Modified Young's operation - Submucosal injection of paraffin or teflon to narrow nasal cavity
• Submucosal implants (autologous fat, cartilage) to narrow cavity
• Lautenschlager operation - Displacing lateral nasal wall medially

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Q2. Describe the etiology, clinical features, investigations and management of Nasal Polyposis.

1. Ethmoidal polyps - Bilateral, multiple, arise from ethmoid sinuses; associated with allergy
2. Antrochoanal polyp (Killian's polyp) - Unilateral, arises from maxillary antrum, passes through middle meatus to choana

• Chronic allergic rhinitis
• Chronic sinusitis
• Asthma (samter's triad - asthma + aspirin sensitivity + nasal polyps)
• Cystic fibrosis (bilateral polyps in children - always think of this)
• Non-allergic rhinitis with eosinophilia (NARES)

• Bilateral nasal obstruction (progressive)
• Watery nasal discharge
• Anosmia / hyposmia
• Nasal twang to voice
• Pale, grey, glistening smooth masses in nasal cavity (insensitive to touch)
• "Frog face" deformity (in longstanding massive polyposis)

• Nasal endoscopy (gold standard)
• CT sinuses - shows extent; ethmoidal opacification
• Allergy testing (skin prick test, serum IgE)
• Biopsy to rule out malignancy
• Sweat chloride test in children (to rule out cystic fibrosis)

• Intranasal corticosteroids - first line (budesonide, mometasone) - shrinks polyps
• Oral steroids (short course) for large polyps
• Antihistamines (if allergic component)
• Aspirin desensitization (in Samter's triad)

• Functional Endoscopic Sinus Surgery (FESS) - preferred; removes polyps and opens sinus drainage pathways
• Classical polypectomy with Luc's forceps (older method; high recurrence)
• Caldwell-Luc operation (for antrochoanal polyp)

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Q3. Describe the etiology, clinical features and management of Deviated Nasal Septum (DNS).

• Birth trauma - forceps delivery, passage through narrow pelvis
• Postnatal trauma - nasal injuries, sports injuries
• Growth factors - asymmetric growth of nasal septum and floor of nose
• Racial predisposition

• Type I: Unilateral vertical ridge, not touching lateral wall
• Type II: Unilateral ridge touching lateral wall
• Type III: Caudal dislocation of septal cartilage
• Type IV: S-shaped deviation (bilateral)
• Type V: Spur with contralateral flat septum
• Type VI: Type III + V
• Type VII: All of the above combined

• Nasal obstruction (unilateral or bilateral)
• Paradoxical nasal obstruction - patient feels obstruction on patent side due to compensatory hypertrophy of opposite turbinate
• Headache (pressure on turbinate - Sluder's neuralgia)
• Epistaxis (from spur area - exposed mucosa)
• Nasal discharge, sinusitis (blocked sinus drainage)
• Snoring, sleep disturbance
• External deviation of nasal pyramid

• Anterior rhinoscopy - visualize deviation
• Nasal endoscopy
• CT scan nose and sinuses (if surgery planned)

• Conservative - decongestants, steam inhalation (symptomatic relief only)
• Surgical - Septoplasty (Submucous resection of deviated part with preservation of mucosa and L-strut of cartilage) - surgery of choice
  • SMR (Killian's operation) - older, removes more cartilage; risk of saddle nose
  • Septoplasty + FESS done together if sinusitis co-exists

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Q4. Describe the etiology, clinical features, investigations and treatment of Allergic Rhinitis.

• Seasonal (hay fever) vs. Perennial
• ARIA classification: Intermittent (symptoms <4 days/week, <4 weeks) vs. Persistent (>4 days/week, >4 weeks)
• Mild / Moderate-Severe

• Pollens, house dust mite (Dermatophagoides pteronyssinus), animal dander, mould spores, cockroach, food allergens

• Type I (immediate) hypersensitivity reaction
• Sensitization phase: Allergen → IgE production → IgE binds mast cells
• Re-exposure: Allergen cross-links IgE → mast cell degranulation → histamine, leukotrienes, prostaglandins release
• Early phase: within minutes - sneezing, rhinorrhea
• Late phase: 4-8 hrs - nasal congestion, eosinophil infiltration

• Cardinal 4 symptoms: Sneezing (paroxysmal), Rhinorrhea (watery), Nasal itching, Nasal congestion
• Itchy, watery eyes (allergic conjunctivitis)
• "Allergic salute" (rubbing nose upward with palm) → supratip crease
• "Allergic shiners" (dark circles under eyes)
• Pale, bluish, boggy nasal mucosa
• Cobblestoning of posterior pharyngeal wall

• Skin prick test - gold standard for identifying allergens
• Serum total and specific IgE (RAST)
• Nasal smear - eosinophilia (>20%)
• Nasal provocation test

• Antihistamines - 1st line (cetirizine, loratadine, fexofenadine - 2nd gen preferred)
• Intranasal corticosteroids - most effective drug (fluticasone, mometasone)
• Leukotriene receptor antagonists (montelukast) - good for associated asthma
• Decongestants (oxymetazoline - not >5 days to avoid rhinitis medicamentosa)
• Nasal cromoglycate (prophylaxis)
• Anti-IgE therapy (omalizumab) - for severe cases

• Gradual desensitization with increasing doses of allergen
• Indicated in moderate-severe cases not responding to pharmacotherapy
• Gives long-lasting benefit

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SHORT ESSAY QUESTIONS (5 Marks Each)

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Q5. Epistaxis - Etiology and Management

• Anterior epistaxis (80%): Little's area (Kiesselbach's plexus) - anterior nasal septum; anastomosis of 4 arteries (anterior ethmoidal, sphenopalatine, greater palatine, superior labial)
• Posterior epistaxis (20%): Woodruff's plexus (posterolateral nasal wall) - from sphenopalatine artery

• Local: Trauma (nose picking - commonest), inflammation (rhinitis, sinusitis), tumors, foreign body, DNS (spur), post-operative
• Systemic: Hypertension, coagulopathies (haemophilia, thrombocytopenia), anticoagulants, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), blood dyscrasias, liver disease, uraemia
• Idiopathic (most common)

• Sit upright, lean forward (prevent blood swallowing)
• Pinch soft part of nose for 10-15 minutes
• Cold compress over nose

• Chemical cautery: Silver nitrate stick/TCA to Little's area
• Electrical cautery

• Anterior nasal packing - bismuth iodoform paraffin paste (BIPP) ribbon gauze; kept 24-48 hrs
• Posterior nasal packing - Brighton's balloon / Foley's catheter inflation; if packing fails

• Ligation of arteries: Maxillary artery (transantral), anterior ethmoidal artery, external carotid artery
• Endoscopic sphenopalatine artery ligation - now preferred over open surgery
• Embolization - for recurrent/refractory posterior epistaxis (91-97% success rate)

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Q6. Nasal Septal Hematoma

• History of nasal trauma
• Bilateral nasal obstruction (blood on both sides puffs up septum)
• Tender, boggy, fluctuant swelling on nasal septum (bilaterally)
• No transillumination (blood is opaque) - differentiates from polyp
• Fever if abscess has formed

• Prompt incision and drainage (I&D) - within 24-48 hours is essential
• Vertical incision on one side of septum
• Evacuate hematoma completely
• Quilting sutures / through-and-through sutures to prevent re-accumulation
• Bilateral nasal packing
• Systemic antibiotics to prevent abscess
• Follow up for saddle nose deformity (if late)

• Septal abscess
• Cartilage necrosis
• Saddle nose deformity
• Intracranial spread (rare) - meningitis, cavernous sinus thrombosis

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Q7. Rhinosporidiosis

• Unilateral nasal polyp - soft, pink/red, friable, bleeds on touch
• Looks like a strawberry (warty surface with white dots = sporangia)
• Nasal obstruction, epistaxis, watery discharge
• Can also affect conjunctiva, larynx, urethra

• Clinical appearance (strawberry-like polyp)
• Biopsy - sporangia seen (100-350 microns) with spores inside; PAS stain positive
• Sporangia are pathognomonic

• Surgical excision at the base (wide base excision to prevent recurrence)
• Cauterize the base with electrocautery
• Dapsone (diaminodiphenyl sulphone) - may reduce recurrence rate

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Q8. Rhinoscleroma

• Mikulicz cells - large vacuolated macrophages containing K. rhinoscleromatis
• Russell bodies - homogeneous eosinophilic hyaline bodies (plasma cells)

• Antibiotics (long course): Tetracycline, ciprofloxacin, rifampicin (for 6+ months)
• Surgery for stenosis

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SHORT ANSWER QUESTIONS (3 Marks Each)

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Q9. CSF Rhinorrhea

• Leak of cerebrospinal fluid from the nose due to defect in the anterior cranial fossa dura and skull base
• Causes: Post-traumatic (most common), post-surgical, spontaneous (raised ICP)
• Test: Beta-2 transferrin in nasal secretion (most specific); halo sign on filter paper (ring of CSF around blood); glucose >30 mg/dL in secretion
• Management: Conservative (head elevation, avoid straining, lumbar drain) for 2 weeks; surgical repair (endoscopic - graft of fat/fascia/mucosal flap) if it persists

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Q10. Functions of the Nose

1. Airway - main air passage (nasal resistance = 50% of total airway resistance)
2. Filtration - nasal hairs (vibrissae) filter large particles; mucus traps small ones
3. Humidification - adds moisture to inspired air (up to 100% at pharynx)
4. Warming - warms inspired air to body temperature
5. Olfaction - sense of smell (olfactory neuroepithelium in roof of nasal cavity)
6. Mucociliary clearance - cilia beat at 12-15 Hz; clears mucus posteriorly
7. Voice resonance - nasal cavity acts as resonating chamber
8. Reflex functions - sneezing, nasolacrimal reflex, nasopulmonary reflex

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Q11. Anatomy of Lateral Wall of Nose (with diagram)

• 3 turbinates (conchae): Inferior, Middle, Superior (sometimes Supreme)
• 3 meatuses beneath each turbinate

• Blood supply: Sphenopalatine artery (main), anterior/posterior ethmoidal arteries, facial artery, greater palatine artery
• Never-ending supply nerve: V2 (maxillary) branches

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Q12. Nasal Myiasis

• Infestation of nasal cavity by fly larvae (maggots) of Chrysomya bezziana (most common in India)
• Occurs in debilitated patients, poor hygiene, wounds around nose
• Features: crawling sensation in nose, foul-smelling bloody discharge, visible maggots
• Treatment: Turpentine oil drops (kills larvae), manual removal with forceps, chloroform drops; antibiotics; ivermectin

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Q13. Rhinolith

• A calcified foreign body in the nasal cavity; forms around a nidus (piece of paper, bean, blood clot)
• Mineral salts (calcium carbonate/phosphate, magnesium) deposit over years
• Features: unilateral foul-smelling discharge, nasal obstruction, occasionally epistaxis
• Appears radiopaque on X-ray
• Treatment: Surgical removal (may need to crush large ones first)

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Q14. Antral Wash (Antral Puncture / Proof Puncture)

• Diagnostic and therapeutic procedure for maxillary sinusitis
• Technique: Under LA, a trocar and cannula inserted under inferior turbinate through medial wall of inferior meatus into maxillary antrum; fluid aspirated, then saline irrigation done
• Indications: Chronic maxillary sinusitis, to obtain material for culture
• Complications: Orbital injury (if too high), facial hematoma, air embolism, emphysema of cheek

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Q15. Diagnostic Nasal Endoscopy (DNE)

• Instrument: 0° and 30° Hopkins rod nasal endoscopes
• Indications: Nasal polyps, sinusitis, suspected tumor, CSF rhinorrhea, epistaxis, post-operative assessment
• What is seen: Middle meatus, osteomeatal complex, spheno-ethmoidal recess, nasopharynx, Eustachian tube orifices
• Performed under topical anesthesia (xylocaine + decongestion)
• Gold standard for evaluation of nasal pathology

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HIGH-YIELD RGUHS REPEATER TOPICS (Know These Well)

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• Always define the condition in your first line
• Write etiology, clinical features, investigations, treatment for Long Essays - one paragraph each
• Draw labeled diagrams wherever asked (lateral wall of nose, Kiesselbach's plexus, Young's operation)
• For Short Essays - write in points, not paragraphs
• Short Answers must be crisp - 5 to 6 bullet points max