Sinusitis and its Complication MCQs

Diagnostic nasal endoscopy is done in three passes. First pass – Examination of nasopharynx and inferior meatus. Second pass - Examination of the sphenoethmoidal recess, superior meatus and openings of sphenoid sinus and posterior ethmoidal cells. Endoscope is passed medial to middle turbinate. Third pass - Examination of the middle meatus in detail. Endoscope is passed from the front into the middle meatus. Can examine uncinate process, bulla ethmoidalis, hiatus semilunaris, sinus of the turbinate (cavity on lateral side of middle turbinate) and the frontal recess. Reference – Diseases of Ear, Nose and Throat & Head and Neck Surgery by P L Dhingra ,8 th Edition, pg. no -492- 493

A long standing history of unilateral foul smelling ear discharge is possibly due to atticoantral CSOM. The onset of severe headache, spontaneous nystagmus and a staggering gait is suggestive of cerebellar abscess. Treatment - High dose antibiotics, neurosurgical approach. Reference: Diseases of Ear, Nose and Throat & Head and Neck Surgery by P L Dhingra, 8 th Edition, Page - 99, 100.

The given clinical scenario is suggestive of Mucormycosis . Mucormycosis is acute invasive fungal infection involving nose and paranasal sinuses, where fungal hyphae invade blood vessels causing ischaemic necrosis. Commonly involves lateral nasal walls and turbinates and quickly spreads to orbit, palate, face and cranium. Treatment is surgical debridement and Amphotericin-B.

Fungal culture is a minor criterion. Bent and Kuhn Classification of Allergic fungal rhinosinusitis - Major Criteria – Type I Hypersensitivity Nasal polyposis Characteristic CT findings Eosinophilic mucin without invasion Positive fungal stain Minor Criteria – Asthma Unilateral disease Bone erosion Fungal culture Serum eosinophilia and charcot- leyden crystals Reference - Scott Brown’s Otolaryngology, Head and Neck Surgery, 8 th edition – Volume 1 – Page - 1040

The most likely cause of the black discharge and nasal mass extending onto the orbit in a post-COVID patient is mucormycosis . Mucormycosis, also known as black fungus , is a rare but serious fungal infection that can affect individuals with weakened immune systems, such as those who have recovered from COVID-19. It typically invades the sinuses and can spread to nearby structures like the orbit. Prompt diagnosis and treatment, including surgical debridement and antifungal therapy , are crucial in managing mucormycosis.

The given description is suggestive of a mucocele . Mucocele of paranasal sinuses - Expansion of bony wall of sinus. Frontal sinus is most commonly affected followed by ethmoidal, maxillary & sphenoidal. Treatment of choice is FESS. Frontal mucocele Usually presents in the superomedial quadrant of orbit - displacing the eyeball forward, downward and laterally. Swelling is cystic, non-tender, egg shell crackling may be present Reference – Diseases of Ear, Nose and Throat & Head and Neck Surgery by P L Dhingra ,8 th Edition, pg. no – 231

Explanation: The most common location for an obstruction caused by a nasal polyp originating from the maxillary sinus is the middle meatus . Nasal polyps are benign, non-cancerous growths that develop in the nasal passages or paranasal sinuses due to chronic inflammation , often associated with chronic rhinosinusitis, asthma, or allergies . When arising from the maxillary sinus , these polyps typically expand into the middle meatus , which is the drainage pathway of the maxillary sinus . Obstruction at this site can lead to blocked sinus drainage, recurrent sinus infections, nasal congestion, and difficulty breathing.

Uncinectomy where the uncinate process is incised with sickle knife and removed with Blakesley forceps is the first definitive surgical step in FESS. Also known as infundibulotomy. Reference – Diseases of Ear, Nose and Throat & Head and Neck Surgery by P L Dhingra ,8 th Edition, pg. no – 495