HNS Week 1

Practice Questions
 Table of Content:
Anatomy:
1. Skull
2. Scalp and Face
3. Nose and Paranasal Sinuses

Microbiology:
1. Bacterial, viral and fungal infections of
the oral cavity
2. Ear & Sinus Infections

Pathology:
- Lesions of the Oral
Cavity

Clinical:
- Rhinorrhea and
Epistaxis
Anatomy
Lecture: Skull
Source: Gray’s Anatomy
Q) A 21-year-old man has suspected intracranial inflammation from an infection.
A CT scan showed an abscess compressing the ophthalmic branch of the tri-
geminal nerve. Which of the following would be a plausible complaint of this
individual?
A. Pain in the hard palate
B. Anesthesia of the upper lip
C. Pain over the lower eyelid
D. Tingling sensation over the buccal region of the face

Ans: C
Explanation: Ophthalmic nerve (ophthalmic division of the trigeminal nerve, CN
V1) carries sensory branches from the eye, conjunctiva, and orbital contents,
including the lacrimal gland. It also receives sensory branch from the nasal cavity,
frontal sinus, ethmoidal cells, falx cerebri, dura in the anterior cranial fossa and
superior part of the tentorium cerebelli, upper lid, dorsum of the nose, and anterior
part of the scalp. Branches of ophthalmic nerve are lacrimal, supraor- bital,
supratrochlear, infratrochlear, and external nasal nerves. Maxillary nerve (CN V2)
and mandibular nerve (CN V3) carry sensory information from other regions of the
face.

Q) The goalkeeper of a soccer team accidentally hit his head against the goal post
while trying to reach for the ball. He was confused for several minutes and later
resumed playing. Four hours later, he was found uncon- scious and was
immediately rushed to the emergency department. A CT scan of his head shows a
hemor- rhage (Fig. 7-19, arrows). The vessel that was ruptured to produce this
hemorrhage enters the skull through which of the following openings?
A. Foramen spinosum
B. Foramen ovale
 C. Jugular foramen
D. Hypoglossal canal
E. Foramen lacerum

Ans: A
Explanation: Extradural (epidural) hemorrhage is arterial in origin. Blood from
torn branches of a middle men- ingeal artery (which passes through foramen spino-
sum) collects between the external periosteal layer of the dura and the calvaria.
The extravasated blood strips the dura from the cranium. Usually this follows a
hard blow to the head; an extradural (epidural) hematoma then forms. Typically, a
brief concussion (loss of consciousness) occurs, followed by a lucid interval of
some hours. Later, drowsiness and coma (profound unconsciousness) occur, and if
the pres- sure is not relieved the patient will die

Q) A 63-year-old man with hearing loss in his left ear complains of a loss of taste
and drooling from the left side of his mouth. A CT scan shows a tumor com-
pressing the nerve exiting the skull through which of the following openings?
A) Foramen ovale
B) Foramen rotundum
C) Internal acoustic meatus
D) Jugular foramen
E) Superior orbital fissure

Ans: C

Q) An 87-year-old woman underwent surgery to remove a vestibular schwannoma

(tumor at the internal acoustic meatus). Resection was successful but resulted in
the following findings postoperatively: drooping of the right corner of the mouth,
inability to close the right eye, and food collection in the right oral vestibule.
Which cranial nerve was injured during the surgery?

A. IX
B. X
C. VII
 D. V2
E. V3

Ans: C. VII
Explanation: The facial nerve is a mixed cranial nerve, which carries both motor
and (special) sensory fibers. The motor component of the facial nerve arises from
the facial nerve nucleus and forms the facial nerve proper, while the sensory and
parasympathetic parts of the facial nerve emerge from the brain as nervus
intermedius. The motor and sensory parts of the facial nerve enter the petrous part
of the temporal bone via the internal auditory meatus, which is very close to the
inner ear; it then courses through the facial canal, after which it emerges from the
stylomastoid foramen and passes through the parotid gland, where it divides into
five major branches. The facial nerve provides special sensory to the anterior one
third of the tongue, motor to the muscles of facial expression and posterior belly of
the digastric

Q) A 51-year-old man complains of hearing loss in his left ear, poor balance, a loss
of taste, and drooling from the left side of his mouth. A CT scan shows a tumor on
the left side of the posterior cranial fossa. Where would the tumor be located to
result in the symptoms?

A. Foramen Ovale
B. Foramen Rotundum
C. Internal Acoustic Meatus
D. Jugular Foramen
E. Superior Orbital Fissure

Ans: C. Internal Acoustic Meatus

Explanation: The internal acoustic meatus is a canal in the petrous part of the
temporal bone. The facial nerve (CN VII) and VIII course through this canal. The
vestibulocochlear nerve (CN VIII) consists of the cochlear nerve, carrying special
sensory hearing, and the vestibular nerve, carrying signals for balance and
equilibrium. The facial nerve (CN VII) carries special sensory taste to the anterior
one third of the tongue and motor fibers that control the muscles of facial
expression.

Q) A physician palpates the mastoid process of an adolescent complaining of pain

behind the ear. Which bone is the physician palpating?

A. Occipital
B. Zygomatic
C. Temporal
D. Parietal
E. Sphenoid

Ans: C
Explanation: The temporal bone parts include mastoid, petrous, squamous, and
tympanic portions. The mastoid process is part of the mastoid portion of the
temporal bone.

Q) A 20-year-old man fell off a motorcycle and sustained a head injury. A CT scan
of his head revealed a fracture of the sella turcica. Which of the following bones
was most likely damaged in this patient?

A) Sphenoid
B) Temporal
C) Occipital
D) Ethmoid
E) Frontal

Ans: A
Explanation: The butterfly-shaped middle cranial fossa has a central part composed
of the sella turcica on the body of the sphenoid and large, depressed lateral parts on
each side. The temporal bones are situated at the sides and base of the skull and
consist of the squama temporalis, mastoid portion, petrous portion, tympanic part,
zygomatic process, and styloid process. The occipital bone is situated at the back
and lower part of the skull and is pierced by a large oval opening, the foramen
magnum. The ethmoid and frontal bones are found in the anterior cranial fossa.

Q) A 20-year-old man was in a bar fight and sustained a deep laceration to his face
after being slashed with a broken glass bottle. Physical examination revealed a
deep, 10-cm laceration running obliquely across his right cheek. He is now unable
to close his right eye and cannot smile on the right side. Which additional structure
was most likely damaged in this patient?

A. Vertebral artery
B. Common carotid artery
C. Parotid Gland
D. Lateral pterygoid muscle
E. Temporalis muscle

Ans: C
Explanation: The muscles of facial expression are supplied by the facial nerve,
which emerges from the stylomastoid foramen and passes through the parotid
gland. The nerve gives off five major branches within the parotid gland from
superior to inferior: temporal, zygomatic, buccal, marginal mandibular, and
cervical. A fun mnemonic for these five branches is To Zanzibar By Motor Car.
(This not only rhymes, but it’s a geographical joke. You can’t get to Zanzibar by
motor car!). The lateral pterygoid and temporalis muscles are muscles of
mastication and are supplied by the mandibular division of the trigeminal nerve
(CN V3). The common carotid artery provides branches to supply the neck and the
face while the vertebral artery supplies the spinal cord and the posterior part of the
brain

Q) A 25-year-old man sustains a blow to the back of the head during a fight and is
brought to the emergency department unconscious. A CT scan of the head reveals
a fracture in the occipital bone extending superiorly from the foramen magnum.
Which of the following is transmitted through the foramen magnum?

A. CN I
B. CN IX
C. CN X
 D. CN XI
E. CN XII

Ans: D
Explanation: The area behind the foramen magnum consists of the squamous part
of the occipital bone. The foramen magnum is in the basilar part of the occipital
bone (basiocciput). The dura mater is attached to the margins of the foramen as it
sweeps down from the posterior cranial fossa. Within the tube of dura mater, the
lower medulla with the vertebral and spinal arteries and the spinal roots of the
accessory nerves traverse the foramen in the subarachnoid space. CN 1 passes
through the cribriform plate of the ethmoid bone. The glossopharyngeal, vagus,
and accessory nerves arise from the side of the medulla oblongata. The three
nerves run laterally across the occipital bone and pass through the jugular foramen.

Q) A 57-year-old man is admitted to the emergency department with dizziness and

severe headaches. A CT scan evaluation reveals a tumor in the superior orbital
fissure. Upon physical examination the patient’s eyeball is fixed in an abducted
position, slightly depressed, and the pupil is dilated. In addition, the upper lid is
droopy. When the patient is asked to move the pupil toward the nose, the pupil
rotates medially. Consensual corneal reflexes are normal. Which of the following
nerves is most likely affected?

A. Trochlear nerve
B. Oculomotor nerve
C. Abducens nerve and sympathetic nerve plexus accompanying the
ophthalmic artery
D. Ophthalmic nerve and short ciliary nerve
E. Superior division of oculomotor nerve and the nasociliary nerve

Ans: B
Explanation: A lesion of the oculomotor nerve will cause the eye to remain in a
“down and out” position. This is due to the actions of the unopposed lateral rectus
(supplied by the abducens nerve) and the superior oblique (supplied by the
trochlear nerve). The tertiary function of the superior oblique is to cause intorsion
(internal rotation) of the eyeball, a function that is not usually seen unless the
oculomotor nerve is para- lyzed. The patient is also likely to present with a full or
partial ptosis due to paralysis of the levator palpebrae muscle. The pupil will
remain dilated because of loss of stimulation by parasympathetic fibers that
innervate the constrictor pupillae muscle. Damage to the other nerves listed will
not lead to the conditions described.

Q) A 57-year-old man is transported to the emergency department after falling

from a tree. A CT scan reveals a fracture of the cribriform plate (Fig. 7-5). Which
of the following conditions will most likely be present during the physical
examination?

A. Entrapment of the eyeball

B. Anosmia
C. Hyperacusis
D. Tinnitus
E. Deafness

Ans: B
Explanation: The axons of olfactory nerves run directly through the cribriform
plate to synapse in the olfac- tory bulb. Damage to this plate can damage the nerve
axons, causing anosmia (loss of the sense of smell). A fracture of the cribriform
plate is not likely to entrap the eyeball. Hyperacusis can occur following paralysis
of the stapedius muscle. A lesion of the vestibuloco- chlear nerve can cause
tinnitus and/or deafness.

Q) A 40-year-old woman presented to her family practitioner with complaints of

vertigo and nausea and reduced hearing through her left ear for 3 months. She also
complained of a dry mouth and dryness of the left eye. CT scan of the head showed
thickening of the bones of the skull. Which of the following areas was most likely
affected to produce this patient’s symptoms?

A. Petrous temporal bone

B. Infratemporal fossa
C. Facial canal
D. Middle ear
E. Inner ear
Ans: A. The petrous part of the temporal bone houses the middle and inner ear and
has the facial canal with the facial nerve passing through it. Damage to the
infratemporal fossa will not cause hearing loss or vertigo but will produce
additional symptoms. The middle ear could account for the hearing loss, and the
inner ear for hearing loss and vertigo, but not the facial palsy or lack of
lacrimation.

Source: BRS Gross Anatomy

Q) A 33-year-old woman develops Bell palsy. She must be cautious because this
can result in corneal inflammation and subsequent ulcer-ation. This symptom
results from which of the following conditions?
A. Sensory loss of the cornea and conjunctiva
B. Lack of secretion of the parotid gland
C. Absence of the corneal blink reflex
D. Absence of sweating on the face
E. Inability to constrict the pupil

Ans: C
Explanation: The answer is C. Bell palsy (facial paralysis) can involve
inflammation of the cornea, leading to corneal ulceration, which probably is
attributable to an absence of the corneal blink reflex. This is due to paralysis of the
orbicularis oculi, which closes the eyelid. Sensory loss of the cornea and
conjunctiva is due to injury of the ophthalmic nerve. Lack of secretion of the
parotid salivary gland is due to injury of the glossopharyngeal, tympanic, or lesser
petrosal nerve. Absence of sweating is due to damage of the sympathetic nerve.
Inability to constrict the pupil is due to paralysis of the sphincter pupillae or
damage of parasympathetic nerve fibers to the sphincter.

Q) A 14-year-old boy hits his head on the asphalt road after falling off his
skateboard. His radiograph reveals damage to the sella turcica.
This is probably due to fracture of which of the following bones?
A. Frontal bone
 B. Ethmoid bone
C. Temporal bone
D. Basioccipital bone
E. Sphenoid bone

Ans: E
Explanation: The answer is E. The sella turcica is part of the sphenoid bone and
lies superior to the sphenoid sinus. Therefore, none of the other bones listed is
fractured.

Q) During a game, a 26-year-old baseball player is hit in the head by a baseball,

which fractures the optic canal. Which of the following pairs of structures is most
likely to be damaged?
A. Optic nerve and ophthalmic vein
B. Ophthalmic vein and ophthalmic nerve
C. Ophthalmic artery and optic nerve
D. Ophthalmic nerve and optic nerve
E. Ophthalmic artery and ophthalmic vein

Ans: C
Explanation: The answer is C. The optic canal transmits the optic nerve and
ophthalmic artery. The ophthalmic nerve and ophthalmic vein enter the orbit
through the superior orbital fissure.

Q) A 58-year-old woman comes to the hospital and complains of progressive loss

of voice, numbness, loss of taste on the back part of her tongue, and difficulty in
shrugging her shoulders. Her MRI scan reveals a dural meningioma that
compresses the nerves leaving the skull. These nerves leave the skull through
which of the following openings?

A. Foramen spinosum
B. Foramen rotundum
C. Internal auditory meatus
D. Jugular foramen
 E. Foramen lacerum

Ans: D
Explanation: A loss of voice is due to an injury to the recurrent laryngeal nerve of
the vagus nerve; numbness and loss of taste on the posterior part of the tongue are
due to a lesion of the glossopharyngeal nerve; an inability to shrug the shoulder is
due to damage of the accessory nerve. These three CNs exit the skull through the
jugular foramen. The foramen spinosum transmits the middle meningeal artery.
The foramen rotundum transmits the maxillary division of the trigeminal nerve.
The internal auditory meatus transmits the facial and vestibulocochlear nerves. The
foramen lacerum transmits nothing, but its upper part is traversed by the internal
carotid artery with sympathetic nerve plexus.

Source: Lippincott’s Anatomy Review

Q) A 7-year-old boy was kicked in the right side of his head during a sledding
accident. He arrived at the ER with no loss of consciousness but complained of a
severe headache and vomiting. A computed tomography (CT) scan revealed a
biconvex hyperdense extraaxial collection of blood, indicated by the arrows in the
fi gure. What blood vessel is the most likely source of the bleed?

(A) Superficial temporal artery

(B) Middle meningeal artery
(C) Superior cerebral veins
(D) Cerebral arterial circle (of Willis)
(E) Middle cerebral artery (MCA)

Ans: B. Middle meningeal artery.

The middle meningeal artery is often torn following impact to the side of the head,
fracturing the skull in the area of the pterion. The pterion, an osteological feature
on the side of the head that marks the junction of the parietal, frontal, squamous
temporal, and sphenoid bones, is prone to fracture following traumatic impact to
the side of the head, which this boy experienced during his sledding accident. The
middle meningeal artery, specifi cally its anterior division, runs in close proximity
to the pterion, so a fracture of this weakened area of the lateral skull may lacerate
the middle meningeal artery, which frequently leads to an epidural hemorrhage as
the blood pools between the endosteal layer of the dura mater and the calvaria.
This epidural hemorrhage was confi rmed by the CT scan showing a biconvex
hyperdense extraaxial collection of blood pooling beneath the pterion in the
epidural space, which is characteristic of an epidural hematoma. Also, note the
edema at the place of impact located extracranially in this patient’s scalp.
Remember that a CT scan reveals “blood and bone,” and due to it being
inexpensive relative to an MRI, it is the perfect diagnostic tool in trauma. The
symptoms displayed in this patient, including a severe headache and vomiting, are
signs of increased intracranial pressure (ICP) due to the extravasation of blood
from the middle meningeal artery compressing brain tissue within the skull. Choice
A (Superfi cial temporal artery) is incorrect. The superfi cial temporal artery, the
terminal branch of the external carotid artery, lies outside of the skull. If this artery
were lacerated, bleeding of the scalp would be profuse. Due to its extracranial
location, damage to the superfi cial temporal artery would not cause the vomiting
seen in this patient, which is indicative of increased ICP. Choice C (Superior
cerebral veins) is incorrect. Traumatic impact to the front of the head can tear the
superior cerebral veins. The impact shears the superior cerebral veins as they
empty into the superior sagittal sinus, leading to a subdural hemorrhage (or dural
border hematoma). Due to the location of the trauma and the pooling blood
revealed on the CT scan, these veins were not damaged. Choice D (Cerebral
arterial circle) is incorrect. The cerebral arterial circle (of Willis) is an anastomoses
of arteries located on the ventral surface of the brain in the area of the
interpeduncular fossa, optic chiasm, and hypothalamus. These vessels are prone to
saccular (berry) aneurysm, particularly where the arteries join together. Upon
rupturing, blood spills into the subarachnoid space because all major vessels of the
brain travel within the subarachnoid space. Subarachnoid hemorrhages are often
seen in the absence of trauma, and the three cardinal signs and symptoms of a
subarachnoid hemorrhage are (1) loss of consciousness (lethargy), (2) nuchal
rigidity (stiff neck), and (3) a sudden onset of the “worst headache of your life”,
which were not present in this patient. Choice E (Middle cerebral artery [MCA]) is
incorrect. The MCA travels deep within the brain in between the frontal and
temporal lobes, so it should not be involved in fracture in the area of the pterion. If
the MCA was compromised, it would lead to a subarachnoid hemorrhage, which
was not evident on the provided CT scan.

Q) A 36-year-old man flips over the handlebars of his motorcycle and falls on the
asphalt pavement, striking his head. He was not wearing a helmet. Although alert
after the fall, he has a clear nasal discharge that tests positive for glucose. The
patient most likely has a fracture of which of the following bones?

A. Ethmoid
B. Vomer
C. Sphenoid
D. Maxilla
E. Frontal

Ans: A. Ethmoid.
A fracture of the ethmoid bone, specifi cally its cribiform plate, which separates
the nasal cavity from the anterior cranial fossa, would enable cerebrospinal fl uid
(CSF), the clear discharge that tests positive for glucose, to leak from the nose. The
traumatic blow to the head has broken the cribiform plate of the ethmoid bone,
which caused a communication between the patient’s anterior cranial fossa and
nasal cavity, which is noted by the black arrow in the given sagittal CT scan. This
patient presents with CSF rhinorrhea, when can lead to meningitis and other
intracranial complications, and this condition can be lethal if not properly treated.
The given sagittal CT shows several fracture sites, including within the cribiform
plate of the ethmoid bone as well as fractures of the anterior and posterior walls of
the frontal sinus. The cribiform plate is fractured in several locations, and one of
these fracture sites is indicated by the white arrow in the given CT. Choice B
(Vomer) is incorrect. The unpaired vomer bone forms the bony posteroinferior
component of the nasal septum. So, fracturing the vomer bone would not lead to
the CSF rhinorrhea presentation of this patient. Choice C (Sphenoid) is incorrect.
Portions of the sphenoid bone, specifi cally the crest and anterior part of the
sphenoid body, do form a small component of the posterior roof of the nasal
cavity. When a patient presents with CSF rhinorrhea, the cribiform plate of the
ethmoid bone is the most likely fracture site, which will lead to a communication
between the anterior cranial fossa and the nasal cavity. The given CT was added
for visual evidence of this type of fracture. It should be noted that the sphenoid
bone is fractured in this individual, which is typical of this type of trauma to the
anterior skull base. Remember that the thinness of the cribiform plate of the
ethmoid bone makes it more susceptible to injury, so the sphenoid bone is not the
best answer for this question. Choice D (Maxilla) is incorrect. The maxilla
contributes to the anterolateral walls of the nasal cavity and forms most of the
boundary between the nasal and oral cavities. Though it is susceptible to injury,
fracturing the maxilla would not provide a communication between the anterior
cranial fossa and the nasal cavity or the CSF rhinorrhea seen in this patient. Choice
E (Frontal) is incorrect. The nasal spine of the frontal bone does form a small part
of the roof of the nasal cavity. However, this bone is not the BEST selection for
this question as it does not contribute nearly as much to the roof as the ethmoid
bone. The thinness of the cribiform plate of the ethmoid bone makes it a more
likely candidate to cause CSF rhinorrhea after a fracture. The given CT was added
for visual evidence of a fracture to the cribiform plate of the ethmoid bone. It
should be noted that the frontal bone, specifi cally the anterior and posterior walls
of the frontal sinus, is fractured in this individual.
Q) A tumor growing at the base of the skull impinges upon the opening indicated
by the arrow, severely compressing its contents. Which of the following conditions
is the most likely result?
 A. Venous drainage from the base of the brain is obstructed
B. Mucus secretion in the oral floor is reduced
C. Sensation from the mandibular teeth is lost
D. Motor control of the upper pharynx is lost
E. Arterial supply to the dura mater is reduced

Ans: E. Arterial supply to the dura mater is reduced.

The indicated opening is the foramen spinosum. This small foramen conveys the
middle meningeal artery (a branch of the maxillary artery) and the spinous nerve (a
branch of the mandibular division of the trigeminal nerve, or CN V3) from the
infratemporal fossa into the cranium, in the floor of the middle cranial fossa. The
middle meningeal artery provides the major blood supply to the dura mater and the
cranial bones. It does not supply the brain. The middle meningeal artery is often
involved with epidural hematomas. Choice A (Venous drainage from the base of
the brain is obstructed) is incorrect. The main venous drainage of the brain is
through the dural venous sinuses into the internal jugular veins, which exit the
cranial cavity through the jugular foramina. This pri- mary drainage route is
supplemented by several emissary veins that pass through various other openings
in the skull, includ- ing the foramen ovale and carotid canal in the floor of the
middle cranial fossa. However, the foramen spinosum does not normally carry
emissary veins. Choice B (Mucus secretion in the oral floor is reduced) is
incorrect. Mucus secretion in the oral floor is controlled by parasympathetic
neurons within the chorda tympani nerve. The chorda tympani branches from the
facial nerve in the facial canal, passes through the tympanic (middle ear) cavity,
and leaves that space through a small opening (petrotympanic fissure) to enter the
infratem- poral fossa. Choice C (Sensation from the mandibular teeth is lost) is
incorrect. Afferent neurons from the mandibular teeth are carried in the inferior
alveolar nerve, a branch of the mandibular division of the trigeminal nerve (CN
V3). CN V3 passes through the foramen ovale in the base of the skull. The inferior
alveolar nerve passes through the mandibular fora- men as it leaves the mandible
conveying sensation from the mandibular teeth. Choice D (Motor control of the
pharyngeal constrictor muscles is lost) is incorrect. Motor control of the
pharyngeal constrictor muscles is from branches of the vagus nerve (CN X). The
vagus exits the cranial cavity through the jugular foramen, in company with the
glossopharyngeal (CN IX) and accessory (CN XI) nerves.

Q)While participating in a bar fight, the orbit of a 25-year-old man is pierced by a

broken pool cue stick, which extends back to the superior orbital fissure. Which of
the following nerves is most likely damaged?

A. Optic Nerve
B. Facial Nerve
C. Mandibular division of trigeminal
D. Maxillary division of trigeminal
E. Ophthalmic division of trigeminal

Ans: E. Ophthalmic division of trigeminal. The oph- thalmic (first) division of

trigeminal nerve (CN V1) supplies sensory (cutaneous) innervation to the skin of
the upper eye- lid, anterior aspect of the nose, forehead, and anterior scalp. CN V1
enters the middle cranial fossa through the superior orbital fissure, and its three
terminal branches (lacrimal, naso- ciliary, and frontal nerves) are distributed
throughout the orbit, anterior cranial fossa, anterior scalp, and nasal cavity. Other
cranial nerves traverse the superior orbital fissure, including the oculomotor (CN
III), trochlear (CN IV), and abducent (CN VI) nerves, to supply extraocular eye
muscles. The supe- rior orbital fissure also contains the superior and inferior oph-
thalmic veins and sympathetic fibers from the carotid plexus. With the broken pool
cue residing in close proximity to the superior orbital fissure, the ophthalmic
division of the trigem- inal nerve is most likely damaged in this question. Choice A
(Optic nerve) is incorrect. The optic nerve (CN II) leaves the orbit via the optic
canal to relay vision from the retina to the brain. Because only the superior orbital
fissure is involved in this patient, the optic nerve is not likely damaged. Choice B
(Facial nerve) is incorrect. The facial nerve enters the petrous temporal bone
through the internal acoustic meatus, traveling through this foramen with the
vestibulocochlear nerve (CN VII). It has three terminal branches (chorda tympani,
greater petrosal, and the main branch of the facial nerve), and none of these
branches traverse the superior orbital fissure, which was involved in this patient.
Choice C (Mandibular division of trigeminal nerve) is incorrect. The mandibular
(third) division of the trigeminal nerve (CN V3) supplies general sensation to the
skin of the lower lip, chin, cheek, and even the anterior auricular and lateral scalp.
This sensory innervation is sup- plied via three cutaneous nerves: mental, buccal,
and auricu- lotemporal. The mandibular division of the trigeminal nerve also
supplies innervation to the mandibular teeth and gingivae via the inferior alveolar
nerve, and it is the only division of CN V that supplies motor innervation. CN V3
enters the middle cranial fossa through the foramen ovale, so it would not be
affected by damage in the superior orbital fissure. Choice D (Maxillary division of
trigeminal nerve) is incorrect. The maxillary (second) division of the trigeminal
nerve (CN V2) supplies sensory (cutaneous) innervation to the skin to the lower
eyelid, cheek, upper lip, upper dentition and gingivae, and lateral aspects of the
nose. CN V2 enters the middle cra- nial fossa through the foramen rotundum, so it
would not be affected by damage in the superior orbital fissure.

Q) A tumor is discovered embedded in the posterior wall of the tympanic cavity in

a 45-year-old man. If the tumor erodes through this wall, which of the following
structures will it first encounter?

A. Internal jugular vein

B. Tympanic membrane
C. Internal carotid artery
D. Brain
E. Facial nerve
Ans: E. Facial nerve. The tympanic (middle ear) cavity is a small air-filled space
within the petrous part of the temporal bone. Its position, shape, and relations make
for challenging spatial concepts in anatomy because it is buried so deeply within
the skull. It has six walls: the roof (tegmental wall), floor (jugular wall), anterior
(carotid) wall, posterior (mastoid) wall, medial (labyrinthine) wall, and lateral
(membranous) wall. Each wall has a close relationship to one or more significant
neighboring structures. The upper part of the posterior wall contains an opening
(aditus) that leads to the mastoid antrum and air cells. The distal limb of the facial
canal (containing the main branch of the facial nerve) descends below the aditus,
behind the posterior wall, on its way to its termination at the stylomastoid foramen.
Thus, a tumor pierc- ing the posterior wall may invade the facial canal and/or the
mastoid air sinuses. Choice A (Internal jugular vein) is incor- rect. The superior
bulb of the internal jugular vein lies beneath the floor (jugular wall) of the
tympanic cavity. Because this tumor is embedded in the posterior wall of the
middle ear cav- ity, the internal jugular vein would not be affected. Choice B
(Tympanic membrane) is incorrect. The tympanic membrane (eardrum) forms
most of the lateral (membranous) wall. The epitympanic recess, situated above the
tympanic membrane, completes the lateral wall. The handle of the malleus and the
crossing chorda tympani nerve lie against the inside of the tympanic membrane.
Because this tumor is embedded in the posterior wall of the tympanic cavity, the
tympanic membrane would not be affected. Choice C (Internal carotid artery) is
incorrect. The carotid canal (containing the internal carotid artery) lies outside the
anterior (carotid) wall. Also, the phar- yngotympanic (auditory) tube and the canal
for the tensor tympani muscle open into the upper part of the anterior wall.
Because this tumor is embedded in the posterior wall of the tympanic cavity, the
internal carotid artery would not be affected. Choice D (Brain) is incorrect. The
roof (tegmental wall) of the tympanic cavity is the tegmen tympani (roof of
tympanum). This thin bony layer forms part of the floor of the middle cranial
fossa, separating the dura mater and temporal lobe of the brain from the middle
ear. Thus, fractures here may result in leakage of cerebrospinal fluid into the
tympanic cav- ity and subsequently into the nasopharynx (via the pharyngo-
tympanic tube) or external acoustic meatus (if the tympanic membrane is
ruptured). The sixth wall (medial; labyrinthine) separates the middle ear from the
internal ear. Its main fea- tures are the promontory, oval window, and round
window.

Q)A 43-year-old man presents with loss of control of facial expression across the
entire right side. The corner of his mouth droops on the right side, but he can
clench his jaw and chew on demand. During examination, his physician also notes
loss of hearing on the right side, and the patient has dif- ficulty maintaining
balance while standing on one foot. The patient’s corneal (blink) reflex is absent in
the right eye, but cutaneous sensation is normal on the entire face. The physician
orders radiographic imaging in anticipation of finding a tumor. What is the most
likely location of the tumor?

(A) Internal acoustic meatus

(B) Foramen ovale
(C) Foramen rotundum
(D) Geniculum of the facial canal
(E) Stylomastoid foramen

Ans: A. Internal acoustic meatus. The loss of facial expression and drooping corner
of the mouth indi- cate paralysis of the facial muscles and damage to the facial
nerve (CN VII). The intact ability to clench the jaw and chew denotes proper
functioning of the muscles of mastication and an intact mandibular division of the
trigeminal nerve (CN V3). The hearing loss and unsteady balance indicate failure
in the inner ear complex implicating the right ves- tibulocochlear nerve (CN VIII;
auditory nerve). The absence of the blink reflex is related to loss of the orbicularis
oculi muscle, the facial muscle responsible for closing the eye- lids, and this
evidence reinforces a problem with the facial nerve. Normal cutaneous sensation
across the face indicates the entire trigeminal pathway is intact. Therefore, the sus-
pected tumor affects both CN VII and CN VIII, but not the trigeminal nerve (CN
V). The only location where CN VII and CN VIII can be affected simultaneously is
at the internal acoustic meatus (in the wall of the posterior cranial fossa), where the
paired nerves leave the cranial cavity to enter the petrous part of the temporal bone.
Very quickly thereafter, the nerves diverge and follow separate pathways to their
target regions. The given contrast-enhanced T1-weighted MRI demonstrates a
right-sided vestibular schwannoma (acoustic neuroma), located at the internal
acoustic meatus and identified by the arrow, which confirms this diagnosis. This
vestibular schwannoma, which is clearly seen in white due to the gadolinium-based
intravenous contrast, resides at the cerebellopontine angle and affects the facial and
ves- tibulocochlear nerves as they emerge from this location. This tumor would
also increase intracranial pressure potentially causing pontomedullary brain stem
compression. Choice B (Foramen ovale) is incorrect. The mandibular division of
the trigeminal nerve (CN V3) passes through the foramen ovale in the floor of the
middle cranial fossa. At this location, a tumor would affect the muscles of
mastication and cutane- ous sensation over the mandibular region of the face,
which is not evident in this patient. Choice C (Foramen rotundum) is incorrect. The
maxillary division of the trigeminal nerve (CN V2) passes through this opening in
the anterior wall of the middle cranial fossa. Nerve damage here would affect
cutaneous sensation across the midfacial region, which is not evident in this
patient. Choice D (Geniculum of the facial canal) is incorrect. The facial nerve
travels through the facial canal within the petrous part of the temporal bone,
including the knee-like bend (geniculum) of the canal. Thus, tumor growth in this
location would affect the facial nerve and pro- duce the facial paralysis described
in this case. However, the vestibulocochlear nerve would not be affected at this
site, as it has already separated from the facial nerve. Choice E (Stylomastoid
foramen) is incorrect. The main branch of the facial nerve exits the skull through
the stylomastoid foramen at the base of the skull. Tumor growth here would affect
the facial nerve, producing the described facial paralysis. How- ever, the
vestibulocochlear nerve would not be affected by problems at this location.

Q) An 8-year-old boy suffers a fracture at the base of the skull from the impact of a
terrorist bomb explosion. The skull trauma includes a lesion of the vagus nerve.
Damage at which of the indicated openings would injure the vagus nerve?
The answer is E: Jugular foramen.The jugular foramen is a large opening that
connects the posterior cranial fossa with the exterior base of the skull. It is divided
into an anterior and a pos- terior compartment for its major contents. The anterior
com- partment transmits a bundle of three cranial nerves out of the cranial cavity:
the glossopharyngeal nerve (CN IX), the vagus nerve (CN X), and the (spinal)
accessory nerve (CN XI). The superior ganglia of the glossopharyngeal and vagus
nerves are located within the jugular foramen, whereas the inferior ganglia are
situated just outside it. Upon exiting the jugular foramen, the nerves immediately
diverge from one another to pass to their target regions. The posterior compartment
transmits the internal jugular vein. This large vessel originates at the terminal end
of the sigmoid dural sinus, at the internal opening of the jugular foramen. Thus,
trauma to the jugular foramen can have significant and widespread vascular and
neural consequences. Choice A (Foramen ovale) is incorrect. This large, oval-
shaped opening connects the middle cranial fossa with the exterior base of the
skull. It transmits the mandibular division of the trigeminal nerve (CN V3) from
the trigeminal ganglion into the infratemporal fossa. A small accessory meningeal
artery (a branch of the maxillary artery) typically accompanies the nerve through
the foramen ovale. Choice B (Foramen spinosum) is incorrect. This small foramen
conveys the middle meningeal artery (a branch of the maxillary artery) and the
spinous nerve (a branch of the mandibular division of the trigeminal nerve) from
the infratemporal fossa into the cranium. Choice C (Fora- men lacerum) is
incorrect. The foramen lacerum is a large open- ing that connects the floor of the
middle cranial fossa with the exterior base of the skull. Its irregular form gives the
appear- ance of a roughly torn area (a laceration) in the skull, hence its name.
However, in life, it is almost entirely filled with cartilage, and the true foramen is
very small. The greater petrosal nerve (a parasympathetic branch of the facial
nerve) traverses this foramen lacerum in passing from the floor of the middle
cranial fossa to the mouth of the pterygoid canal at its anterior margin

Source: Member-made questions

Q) A 24-year-old man is brought to the emergency department after a severe head
trauma from a motorcycle accident. On examination, clear fluid is noticed draining
from his nose, and periorbital bruising is present. The patient also complains of
inability to smell. A CT scan reveals a fracture in the anterior cranial fossa. Which
of the following bones is most likely fractured in this patient?

A. Frontal bone
B. Ethmoid bone
C. Sphenoid bone
D. Temporal bone
E. Occipital bone

Ans: B
Explanation: The patient's presentation of anosmia (inability to smell), periorbital
bruising (raccoon eyes), and CSF leakage from the nose (rhinorrhea) suggests a
fracture of the anterior cranial fossa, specifically the cribriform plate of the
ethmoid bone. The cribriform plate is perforated by olfactory foramina for
olfactory nerve fibers, which can be damaged in such fractures, leading to anosmia.
The thin cribriform plate is susceptible to fractures, allowing CSF to leak into the
nasal cavity

Collected by: Noha, Mariam Alissa, Abady, Majd, Mada, Safi, Affan, Ali,
Fateena, Amr, Wajd, Mushtaha, Munya

Edited by: Qusai Helal

Lecture: Scalp and Face

Source: Gray’s Anatomy Review
Q) A 55-year-old man is admitted to the emergency department after slipping on
wet pavement and falling. Physical examination reveals that the patient has a
hematoma that formed in the danger zone of the scalp, spreading to the area of the
eyelids. Which of the following layers is regarded as the “danger zone”?

A) Loose, areolar layer

B) Skin
C) Galea aponeurotica
D) Pericranium
E) Subcutaneous layer

Ans: A
Explanation: The loose areolar connective tissue layer is known as the “danger
zone” because hematoma can spread easily from this layer into the skull by means
of emissary veins that pass into and through the bones of the skull. None of the
other scalp layers listed is referred to as the “danger zone.”

Q) A 17-year-old girl visits a dermatologist because of severe facial acne. During

physical examination a rather obvious and painful lesion on the side of her nose
was found. The patient was given antibiotics and warned not to press or pick at the
large, inflamed swelling. If she were to squeeze, prick, or incise such a lesion in
the area between the eye and the upper lip, or between the eye and the side of the
nose, the infecion could spread to the cavernous sinus. Which of the following
pathways of spread of infection would be most typical?

A) Nasal venous tributary to angular vein, to superior ophthalmic vein, then to

cavernous sinus
B) Retromandibular vein to supraorbital vein, then to inferior ophthalmic vein,
then to cavernous sinus
C) Dorsal nasal vein to superior petrosal vein, then inferior ophthalmic vein to
cavernous sinus
D) Facial vein to maxillary vein, then middle meningeal vein to cavernous sinus
E) Transverse facial vein to superficial temporal vein to emissary vein to
cavernous sinus

Ans: A
Explanation: Infection in the “danger area of the face” can lead to cavernous sinus
thrombosis because infection spreads from the nasal venous tributary to the angular
vein, then to the superior ophthalmic vein, which passes into the cavernous sinus.
None of the other routes listed would be correct for drainage from the danger area
of the face.

Q) A newborn infant is delivered with forceps after a difficult delivery. Upon

physical examination of the newborn a cephalohematoma is noted from rupture of
small periosteal arteries. Between which of the following layers of tissue does the
blood accumulate?

A) Between skin and dense connective tissue layer

B) Between loose connective tissue layer and galea aponeurotica
C) Between galea aponeurotica and pericranium
D) Between pericranium and calvaria in the subcutaneous layer

Ans: D
Explanation: Rupture of the periosteal arteries resulting in a cephalohematoma is
defined as a collection of blood underneath the periosteum. On the head, it is
located between the pericranium (periosteum of the skull) and the calvaria (skull).
The galea aponeurotica, skin and areolar connective tissue are all located
superficial to the site of bleeding and hematoma.

Q) A 35-year-old woman is hospitalized due to cavernous sinus thrombosis

resulting from an infection on her face. Which of the following is the most direct
route for spread of infection from the face to the cavernous sinus?

A) Pterygoid venous plexus

B) Superior ophthalmic vein
C) Frontal venous plexus
D) Basilar venous plexus
E) Parietal emissary vein

Ans: B
Explanation: The superior ophthalmic vein drains directly into the cavernous
sinus. The danger area of the face is located in the triangular region from the lateral
angle of the eye to the middle of the upper lip, near the nose, and is drained by the
facial vein. The facial vein communicates directly with the cavernous sinus
through the superior ophthalmic vein. The pterygoid venous plexus communicates
with the cavernous sinus through the inferior ophthalmic vein, but it is not directly
connected to the cavernous sinus. The basilar venous plexus connects the inferior
petrosal sinuses and communicates with the internal vertebral venous plexus. The
parietal emissary veins and frontal venous plexus do not communicate directly
with the cavernous sinus

Q) A 70-year-old man has a biopsy of a growth on his lower lip. The biopsy
reveals a squamous cell carcinoma. Which lymph nodes will most likely be first
involved in the spread of the cancer cells?

A) Occipital
B) Parotid
C) Retropharyngeal
D) Jugulodigastric
E) Submental
Ans: E
Explanation: The submental lymph nodes drain approximately the anterior two
thirds of the mouth and tongue, including the lower lips. The occipital nodes serve
the inferoposterior aspect of the head. The parotid nodes lie anterior to the ear and
serve the region of the lateral aspect of the eye, the parotid gland, and anterior ear.
The retropharyngeal nodes lie posterior to the pharynx and drain the posterior
aspect of the throat and pharynx. The jugulodigastric node is a large node posterior
to the parotid gland and just below the angle of the mandible, and it receives lymph
from much of the face and scalp and is commonly enlarged in tonsillitis.

Q) A 54-year-old man is admitted to the hospital due to severe headaches. A CT

examination reveals an internal carotid artery aneurysm inside the cavernous sinus.
Which of the following nerves would be typically affected first?

A) Abducens nerve
B) Oculomotor nerve
C) Ophthalmic nerve
D) Maxillary nerve
E) Trochlear nerve

Ans: A
Explanation: The abducens nerve would be affected first due to aneurysmal
dilation of the internal carotid artery (ICA) because the nerve runs in closest
proximity to the artery within the cavernous sinus. The other nerves running in the
wall of the cavernous sinus are the oculomotor nerve, trochlear nerve, and both the
maxillary and ophthalmic branches of the trigeminal nerve. Each of these nerves,
however, courses along, or within, the lateral walls of the cavernous sinus and may
not be immediately affected by an aneurysm of the ICA

Q)A 34-year-old man is admitted to the emergency department after falling off his
motorbike, suffering an injury to his head because he was not wearing a helmet.
The patient has multiple lacerations in the skin over the frontal bone. Which of the
following veins could most likely provide a pathway of transmission of infection
from the veins of the scalp to the underlying dural venous sinuses?

A) Supratrochlear vein
B) Diploic veins
C) Anterior cerebral veins
D) Superior sagittal sinus
E) Supraorbital vein

Ans: B
Explanation: Diploic veins are responsible for communication between the veins
of the scalp and the venous sinuses of the brain. Diploic veins are situated within
the layers of bone of the skull and connect the emissary veins of the scalp to the
venous sinuses located between two layers of dura. The diploe are of clinical
significance in that the diploic veins within this layer provide a pathway of
communication between the Investing layer, Infrahyoid muscles, Pretracheal fascia
Manubrium of sternum, Pretracheal space, Fascial space within prevertebral layer,
Retropharyngeal space, Prevertebral layer, Buccopharyngeal fascia (posterior
portion of pretracheal layer) veins of the scalp and underlying venous sinuses of
the brain, by means of emissary veins. The emissary veins and diploe provide a
potential vascular pathway of infection. The supratrochlear and supraorbital veins
are located superficially on the scalp, immediately superior to the upper eyelid, and
do not communicate directly with the venous sinuses of the brain. The anterior
cerebral vein is an intracranial vein and, as such, does not maintain a direct
communication with the external veins of the scalp. The superior sagittal sinus
receives blood from the cerebral, diploic, and emissary veins; however, it does not
provide a pathway of communication to the veins of the scalp.

Q) A 16-year-old boy is admitted to the hospital with fever, a confused mental

state, and drowsiness. During physical examination it is noted that the boy suffers
from severe acne. Radiologic examination reveals cav- ernous sinus thrombosis.
Which of the following routes of entry to the cavernous sinus would most likely be
responsible for the infection and thrombosis?

A) Carotid artery
B) Mastoid emissary vein
C) Middle meningeal artery
D) Ophthalmic vein
E) Parietal emissary vein
Ans: D
Explanation: Cavernous sinus thrombosis can often result from squeezing pimples
or other infectious processes located around the danger area of the face, which
includes the area of the face directly surrounding the nose. This physical pressure
has the potential to move infectious agents from the pimple into the ophthalmic
vein, which then carries it to the cavernous sinus. The pterygoid venous plexus and
ophthalmic vein both communicate with the cavernous sinus and therefore offer a
route of travel for the spread of infection, but the path provided by the superior
ophthalmic vein is a more direct route. Additionally, the superior oph- thalmic vein
receives blood supply from the supraor- bital, supratrochlear, and angular veins
that supply the area around the nose and lower forehead. (Venous blood in the head
can flow in either direction because these veins do not possess valves.) The
emissary veins communicate between the venous sinuses and the veins of the scalp
and would therefore not be involved in the spread of infection between the nose
and cavernous sinus. The middle meningeal artery courses between the dura and
periosteum, whereas the carotid artery, specifically the ICA, traverses through the
cavernous sinus and provides origin to the ophthalmic artery. As with the middle
meningeal artery, the carotid artery would not offer a route of communication
between the area of infection and the cavernous sinus.

Q) An 8-year-old boy was suffering from a severe infection of the right middle ear.
Within the course of a week, the infection had spread to the mastoid antrum and
the mastoid air cells. The organisms did not respond to antibiotics, so the surgeon
decided to per- form a radical mastoid operation. Following the opera- tion, it was
noticed that the boy’s face was distorted. The mouth was drawn upward to the left,
and he was unable to close his right eye. Saliva tended to accumu- late in his right
cheek and dribble from the corner of his mouth. What structure was most likely
damaged during the operation?

A) Mandibular nerve
B) Parotid duct
C) Vagus nerve
D) Facial nerve
E) Glossopharyngeal nerve
Ans: D
Explanation: Of the answer choices listed, the left facial nerve of the patient is the
most likely to be damaged during the mastoidectomy. The facial nerve exits the
skull via the stylomastoid foramen, just anterior to the mastoid process. A lesion of
the facial nerve is likely to cause the symptoms described as a result of paralysis of
the facial muscles. Depending upon the site of injury, the patient could also lose
the chorda tympani branch of the facial nerve, leading to loss of taste from the
anterior two thirds of the tongue ipsi- laterally as well as loss of functions of the
subman- dibular and sublingual salivary glands. The other nerves listed are not
likely to be damaged during a mastoidectomy.

Q) Following from the previous question, one of the features was the accumulation
of saliva in the vestibule of his oral cavity and dribble from the corner of his
mouth. Which of the following muscles was most likely paralyzed?

A) Zygomaticus major
B) Orbicularis oculi
C) Buccinator
D) Levator palpebrae superioris
E) Orbicularis oris

Ans: C
Explanation: Normally the tonus of the buccinator muscle prevents the
accumulation of saliva and foodstuffs in the oral vestibule. Although a lesion of the
facial nerve would paralyze the other muscles listed, the buccinator is the
predominant muscle of the cheek.

Q) A severe mandibular fracture in a 22-year-old woman requires surgical

reconstruction. Postoperatively, she complains of numbness of the lower lip and
chin. Which nerve was most likely injured?

A) Auriculotemporal
B) Buccal
 C) Lesser petrosal
D) Mental
E) Infraorbital

Ans: D
Explanation: The mental nerve is a branch of the Mandibular division of the
Trigeminal nerve (V3). (Transcription slide 18)

Source: BRS Gross Anatomy

Q) A 57-year-old man comes to the local hospital with fever, headache, nausea,
and vomiting. Laboratory tests reveal an infection, and radiologic examination
localizes the infection to the cavernous sinus. Which of the following nerves would
be unaffected by this condition?

A) Oculomotor nerves
B) Abducens nerves
C) Trochlear nerves
D) Mandibular nerves
E) Ophthalmic nerves

Ans: D
Explanation: The mandibular division of the trigeminal nerve does not lie in the
wall of the cavernous sinus, whereas the oculomotor, abducens, trochlear, and
ophthalmic nerves do.

Q) After ingesting a toxic substance found in her friend’s home, a 12-year-old girl
is unable to close her lips. Which of the following muscles may be paralyzed?
 A) Levator labii superioris
B) Zygomaticus minor
C) Orbicularis oris
D) Lateral pterygoid
E) Depressor labii inferioris

Ans: C
Explanation: The lips are closed by the orbicularis oris muscles. The lips are
opened by the levator labii superioris, zygomaticus minor, and depressor labii
inferioris muscles. The lateral pterygoid muscle can open the mouth by depressing
the lower jaw.

Q) A 60-year-old man is unable to open his eye because of a rare neuromuscular

disease. Which of the following muscles would most likely be paralyzed?

A) Orbicularis oculi
B) Orbicularis oris
C) Frontalis
D) Levator palpebrae superioris
E) Superior rectus

Ans: D
Explanation: The levator palpebrae superioris muscle opens the eye by elevating
the upper eyelid. The orbicularis oculi closes the eye, the orbicularis oris closes the
lips, the frontalis elevates the eyebrow, and the superior rectus elevates the eyeball.

Q. A 45-year-old woman is suffering from numbness over the tip of her nose.
Which of the following nerves is most likely to be damaged?

A) Ophthalmic division of the trigeminal nerve

B) Maxillary division of the trigeminal nerve
C) Mandibular division of the trigeminal nerve
D) Facial nerve
E) Auriculotemporal nerve
Ans: A
Explanation: The skin over the tip of the nose is innervated by the external nasal
branch of the nasociliary branch of the ophthalmic division of the trigeminal nerve.
The maxillary divi- sion of the trigeminal nerve innervates the skin of the face
above the upper lip but below the lower eyelid. The mandibular division of the
trigeminal nerve supplies the lower part of the face below the lower lip. The facial
nerve provides no cutaneous sensation on the face but innervates muscles of facial
expression. The auriculotemporal nerve is a branch of the mandibular division of
the trigeminal nerve and innervates the skin of the auricle and the scalp.

Source: Lippincott Review of Anatomy

Q) A 64-year-old male professional angler is diagnosed with a skin melanoma

above his right eyebrow after years of excessive sun exposure. His dermatologist
removes this cancerous lesion, but the doctor needs to rule out possible metastasis.
What group of lymph nodes would his physician first check for possible spread of
the cancer?

A) Deep cervical
B) Retroauricular
C) Parotid
D) Submental
E) Submandibular

Ans: C
Explanation: The parotid lymph nodes receive lymphatic drainage from the lateral
part of the anterior scalp, anterior part of the auricle, and the lateral part of the face,
including the upper and lower eyelids. Due to the site of the skin melanoma above
the right eyebrow, the physician must first check the parotid lymph nodes for
spread of cancer. This task can be accomplished by sentinel lymph node mapping,
which is a technique for locating the lymph node that is most likely to receive
primary drainage from the melanoma. The sentinel node, identified by this
procedure, is the most likely lymph node to contain cancer and can be surgically
removed if lymphogenous spread of cancer is suspected.

Q) A 45-year-old man is in surgery. While seated at the head of the operating

table, the anesthesiologist periodically checks the patient’s pulse by palpating the
artery located anterior to the tragus of the external ear. Which of the following
arteries is being utilized to monitor the patient’s pulse?

A) Maxillary
B) Posteriorauricular
C) Superficialtemporal
D) Facial
E) internalcarotid

Ans: C
Explanation: The superficial temporal artery is the smaller terminal branch of the
external carotid artery. It ascends through the parotid gland, anterior to the auricle,
and crosses the zygomatic arch to reach the temporal fossa and scalp. Its pulse (the
temporal pulse) can be palpated anterior to the tragus of the external ear where the
artery lies against the underlying zygomatic arch. Choice A (Maxillary) is
incorrect. The maxillary artery is the larger terminal branch of the external carotid
artery. From its origin within the substance of the parotid gland, it passes anterior,
deep to the ramus of the mandible, to enter the infratemporal fossa. Its deep
location makes this artery an unlikely candidate for taking a pulse. Choice B
(Posterior auricular) is incorrect. The posterior auricular artery is a branch of the
external carotid artery that runs posterior, near the styloid process to pass behind
the ear. It supplies the auricle and the scalp, posterior to the auricle. It does not
provide a palpable pulse location. Choice D (Facial) is incorrect. The facial artery
is another branch of the external carotid artery.

Q) A 35-year-old woman comes to her dentist complaining of tenderness and pain

in her cheek near the parotid gland, as well as bad breath and a foul-tasting mouth
at mealtimes. A radiopaque fluid is injected into the parotid duct system through
cannulation, and this sialography of the parotid duct confirms blockage by a
calculus (sialolith). What muscle, through which the parotid duct passes, is most
likely causing the stenosis where the sialolith now resides, blocking the drainage of
the parotid duct?

A) Buccinator
B) Mentalis
C) Temporalis
D) Orbicularis Oris
E) Masseter

Ans: A
Explanation: The buccinator muscle is pierced by the parotid duct, leading to the
oral cavity opposite the second maxillary molar teeth. Its tone can cause stenosis or
obstruction by a sialolith. Sour foods or surgery may treat sialolithiasis. Choices B
to E are incorrect as they are not pierced by the parotid duct or involved in its
stenosis or obstruction.

Collectors: Alotaibi, Abbas, Alsatli, Raniya, Amjad, Areeba, Maryam

Abdullah, Mahdi, Aljumaa

Editors: Marwa Kaidali

Source: Nose & Paranasal Sinuses

Source: Lippincott Review of Anatomy
Q) A 65-year-old man complains of a persistent nosebleed. His physician uses a
cotton swab to apply pressure at the source, the inferior and posterior aspects of the
lateral nasal wall. Which artery is the most likely source of the bleeding?

A. Greater palatine
B. Infraorbital
C. Facial
D. Anterior ethmoidal
E. Sphenopalatine

Ans: E. Sphenopalatine.
The sphenopalatine artery supplies most of the blood to the nasal cavity,
particularly the inferior and posterior aspects of the nasal cavity. Therefore, it is
highly probable that the sphenopalatine artery, a terminal branch of the maxillary
artery, was the source of the epistaxis (nosebleed) in this patient, as seen in the
given illustration located on the next page. Choice A (Greater palatine) is incorrect.
The greater palatine artery supplies blood primarily to the hard palate; however, it
may supply a small amount of blood to the anterior and inferior aspects of nasal
cavity via its communication with the sphenopalatine artery through the incisive
canal. However, due to the location of the injury in this patient, the greater palatine
artery would not be involved with this persistent nosebleed. Choice B (Infraorbital)
is incorrect. The infraorbital artery courses in the roof of the maxillary sinus to
give blood to this area as well as the superior canine and incisor teeth, inferior
aspect of the orbit, and superior aspect of the lip. The infraorbital artery would not
be responsible for the nosebleed seen in this patient. Choice C (Facial) is incorrect.
The lateral nasal branch of the facial artery would supply the anterior and inferior
aspects of the nasal cavity in the region of the vestibule; however, bleeding of this
artery would be easily stopped by applying pressure to the alae of the nose. Choice
D (Anterior ethmoidal) is incorrect. The anterior ethmoidal artery supplies the
anterior, superior aspect of the nasal cavity after entering the nasal cavity through
the cribiform plate of the ethmoid bone. This artery does not supply blood to
posterior and inferior aspect of the lateral nasal wall, which is the location of the
bleed in this patient.

Source: BRS Gross Anatomy

Q) A 45-year-old woman is suffering from numbness over the tip of her nose.
Which of the following nerves is most likely to be damaged?
A. Ophthalmic division of the trigeminal nerve
B. Maxillary division of the trigeminal nerve
C. Mandibular division of the trigeminal nerve
D. Facial nerve
E. Auriculotemporal nerve

Ans: A
Explanation: The answer is A. The skin over the tip of the nose is innervated by the
external nasal branch of the nasociliary branch of the ophthalmic division of the
trigeminal nerve. The maxillary division of the trigeminal nerve innervates the skin
of the face above the upper lip but below the lower eyelid. The mandibular division
of the trigeminal nerve supplies the lower part of the face below the lower lip. The
facial nerve provides no cutaneous sensation on the face but innervates muscles of
facial expression. The auriculotemporal nerve is a branch of the mandibular
division of the trigeminal nerve and innervates the skin of the auricle and the scalp.

Q) A young girl complains of dryness of the nose and the palate. This would
indicate a lesion of which of the following ganglia?

(A) Nodose ganglion

(B) Otic ganglion
(C) Pterygopalatine ganglion
(D) Submandibular ganglion
(E) Ciliary ganglion

Ans: C
Explanation: The answer is C. Postganglionic parasympathetic fibers originating in
the pterygopalatine ganglion innervate glands in the palate and nasal mucosa. The
postganglionic parasympathetic fibers from the otic ganglion supply the parotid
gland, those from the submandibular ganglion supply the submandibular and
sublingual glands, and those from the ciliary ganglion supply the ciliary muscle
and sphincter pupillae. The nodose (inferior) ganglion of the vagus nerve is a
sensory ganglion.

Q) A 67-year-old woman comes to her physician complaining of visual loss. Her

MRI scan shows an enlarged pituitary gland that lies in the sella turcica,
immediately posterior and superior to which of the following structures?
A. Frontal sinus
B. Maxillary sinus
C. Ethmoid air cells
D. Mastoid air cells
E. Sphenoid sinus
Ans: E
Explanation: The answer is E. The pituitary gland lies in the hypophyseal fossa of
the sella turcica of the sphenoid bone, which lies immediately posterior and
superior to the sphenoid sinus and medial to the cavernous sinus. The frontal sinus
lies in the frontal bone; the maxillary sinus lies in the maxilla lateral to the lateral
wall of the nasal cavity; the ethmoid sinus (composed of air cells) lies between the
orbit and the nasal cavity; and the mastoid air cells lie in the mastoid process of the
temporal bone.

Source: Gray’s anatomy

Q) A 55-year-old man with a history of cocaine abuse is brought to the emergency
department because of severe uncontrolled epistaxis. Flexible nasal endoscopy
reveals the source of bleeding to be in Kiesselbach’s area. Anastomotic
connections between which arteries are involved in this condition?

A. Descending palatine and ascending pharyngeal

B. Posterior superior alveolar and accessory meningea
C. Lateral branches of posterior ethmoidal and middle meningeal
D. Branches of sphenopalatine, superior labial, and anterior ethmoidal
E. Descending palatine and tonsillar branches of the ascending pharyngeal

Ans: D
Explanation: Branches of the sphenopalatine, superior labial, and anterior
ethmoidal anastomose anteriorly on the nasal septum are prone to bleeding. The
descending palatine and ascending pharyngeal arteries are located posteriorly in
the pharynx. The posterior superior alveolar artery travels within the maxilla and
the accessory meningeal artery is found within the cranial cavity

Q) A 12-year-old boy complains of symptoms suggestive of sinusitis. During the

physical examination the physician taps the area slightly superior to the midportion
of the patient’s eyebrows and this maneuver elicits pain. Which anatomic area is
the physician most likely examining?
 A. Maxillary sinus
B. Temporal bone
C. Frontal sinus
D. Sphenoid sinus
E. Ethmoid sinus

Ans: C
Explanation: The frontal sinuses are located in the frontal bone above the orbital
margin. The maxillary sinus in the cheek region is within the maxillary bone. The
ethmoid sinus is located between the nose and the eye. The sphenoidal sinus is
within the sphenoid bone and cannot be palpated externally

Q) A patient with a brain tumor near the crista galli and cribriform plate of the
ethmoid bone most likely experiences which of the following symptoms?

A. Paralysis of facial muscles

B. Loss of vision
C. Difficulty swallowing
D. Loss of smell
E. Loss of hearing

Ans: D
Explanation: The olfactory nerves arise from cells in the superior part of the lateral
and septal walls of the nasal cavity. The processes of these cells (forming the
olfactory nerve) pass through the cribriform plate and end in the olfactory bulbs,
which lie on either side of the crista galli. Therefore a tumor here compresses the
nerves, and the sense of smell will be affected. The optic tract and chiasm are not
likely to be affected. Similarly, the vagus, vestibulocochlear, and facial nerves are
not in close proximity

Q) A 1-year-old infant is admitted to the hospital with fever. His parents explain
that the infant fell several times in the playground the day before. Meningitis is
suspected and radiographic examination reveals a sinus infection. Which of the
following sinuses is present at this age?
A. Frontal sinus
B. Maxillary sinus
C. Sphenoid sinus
D. Middle ethmoidal air cells
E. Posterior ethmoidal air cells

Ans: B. The maxillary sinus arises late in fetal development and is the only sinus
present at birth. The frontal and sphenoid sinuses often develop at approximately 2
years of age from the anterior ethmoid air cells and the posterior ethmoid air cells,
respectively

Q) A 22-year-old woman visits the outpatient clinic with a sinus infection of 2

weeks duration. Physical examination reveals that the patient has focal
inflammation, with mucosal edema in the inferior nasal meatus. Drainage from
which of the following structures is most likely to be obstructed by this
inflammation and edema?

A. Anterior ethmoidal air cells

B. Frontonasal duct
C. Maxillary sinus
D. Middle ethmoidal air cells
E. Nasolacrimal duct

Ans: E
Explanation: The nasolacrimal duct is the only duct that normally drains into the
inferior meatus of the nose and therefore would be affected by a focal
inflammation in this region.

Source: Member-Made
Q) A 45-year-old patient presents to the clinic with complaints of persistent tearing
in the left eye and recurrent episodes of nasal congestion. Upon further
examination, it is noted that the patient has a history of chronic sinusitis. Which of
the following nasal passages receives the opening of the nasolacrimal duct?

(A) Superior meatus

(B) Middle meatus
(C) Inferior meatus
(D) Sphenoethmoidal recess

Ans: C
Explanation: The nasolacrimal duct drains tears from the eye into the nasal cavity.
It opens into the inferior meatus of the nasal cavity, which is located on the lateral
wall of the nasal cavity beneath the inferior nasal concha. Tears travel through the
nasolacrimal duct and drain into the nasal cavity, ultimately contributing to the
drainage of excess tears from the eye. Therefore, obstruction or inflammation in
the inferior meatus can lead to symptoms such as tearing and recurrent nasal
congestion, as observed in the clinical presentation described.

Q) A 42-year-old woman presents with a severe headache, fever, and purulent

nasal discharge. She reports a history of recurrent sinusitis and recent extraction of
an upper molar tooth. On examination, there is tenderness over the maxillary
sinuses. A CT scan reveals an air-fluid level in the left maxillary sinus and a small
communication between the sinus and the oral cavity. Which of the following is
the most likely explanation for the findings in this patient?

A) The extraction of the molar tooth created a fistula between the maxillary sinus
and the oral cavity.
B) The infection has eroded the walls of the maxillary sinus, reaching the
cavernous sinuses.
C) The infection has spread to the pituitary gland, causing the presenting
symptoms.
D) The infection has eroded the thin bone of the anterior cranial fossa, leading to
meningitis.

Ans: A
Explanation: only a thin layer of bone and mucous membrane may separate the
roots of the maxillary teeth from the maxillary sinus cavity. If only a thin layer of
bone covers the roots of the molars, extraction may create a fistula between the
sinus and oral cavity, resulting in infection (maxillary sinusitis). B, C, and D are
not correct because they are related to the spread of infection from the sphenoidal
sinus, not the maxillary sinus.

Collected by: Noha, Mariam Alissa, Abady, Majd, Mada, Safi, Affan, Ali,
Fateena, Amr, Wajd, Mushtaha, Munya

Edited by: Qusai Helal

Microbiology:
Lecture: Bacterial, viral and fungal infections of
the oral cavity
Source: Lippincott Microbiology and Immunology
Q) A 5-year-old girl from an orphanage in Ukraine was about to leave for the United
States with her adoptive parents when she developed a fever, sore throat, cough, and
malaise. A few days later, she was brought to the emergency room in respiratory
distress. Physical examination revealed pronounced, bilateral cervical
lymphadenopathy, inflamed pharyngeal area, and a thick, grayish, leathery exudate
on the tonsils as shown in the photograph. Part of the exudate had become loose
revealing bleeding of the underlying mucosal tissue. The etiologic agent was isolated
on tellurite medium. What virulence factor accounts for the pathogenesis of this
infection?
 A. Immune evasion following production of IgA protease
B. Lipopolysaccharide-induced inflammation
C. M protein-mediated resistance to phagocytosis
D. Secretion of coagulase to facilitate invasion into mucosa
E. Toxin-mediated inhibition of protein synthesis

Ans: E
Explanation: Toxin-mediated inhibition of protein synthesis. The case is descriptive
of diphtheria caused by Corynebacterium diphtheria. This bacterium produces a
toxin that inhibits protein synthesis by inactivating elongation factor-2. It does not
express any of the other virulence factors listed. It is not known to secrete an IgA
protease as does Neisseria. As a Gram-positive organism, C. diphthe-riae lacks
lipopolysaccharide. Streptococcus pyogenes produces M protein as an important
virulence factor. C. diphtheriae is not known to produce coagulase as does
Staphylococcus aureus.

Source: Review of medical microbiology and immunology

Q) Your patient presents to the clinic complaining of a sore throat, difficulty
swallowing, and fever for the past two days. Upon examination, you note erythema
and swelling of the pharynx, along with tonsillar exudates. The patient also has
tender cervical lymphadenopathy. You do a Gram stain on pus from the ulcer and
see gram-positive cocci in chains. Culture of the pus grows small β-hemolytic
colonies that are catalase-negative and are inhibited by bacitracin. These results
indicate that the organism causing her lesion is most likely:

A. Enterococcus faecalis.
B. Staphylococcus aureus.
C. Streptococcus agalactiae.
D. Streptococcus pneumoniae.
E. Streptococcus pyogenes.

Ans: E
Q) Which one of the following is a club-shaped, gram-positive rod that causes
disease by producing an exotoxin that kills cells by inhibiting elongation factor-2,
resulting in the inhibition of protein synthesis?

A. Bacillus anthracis
B. Bacillus cereus
C. Clostridium perfringens
D. Corynebacterium diphtheriae
E. Listeria monocytogenes

Ans: D

Member-Made Questions:
Q) A 55-year-old female patient presents to the clinic with complaints of pain and
difficulty swallowing for the past week. Upon examination, you observe white,
adherent plaques on the buccal mucosa and tongue, which, when scraped, reveal
underlying erythematous mucosa. The patient reports a history of recent antibiotic
use for a respiratory infection.

A. Pseudomembrane Candidiasis
B. Erythematous Candidiasis
C. C.diphtheriae
D. S.pyogenes

Ans: A

Q) A 30-year-old male patient presents to the clinic with complaints of severe sore
throat and difficulty swallowing. On examination, you observe grayish-white
membranes on the tonsils and posterior pharynx, along with halitosis. The patient
reports recent dental neglect and poor oral hygiene. What could be the cause?

A. Underlying Fungal infection

B. Polymicrobial
C. C. Diphtheriae
D. Viral Infection
E. S. aureus

Ans: B, Vincent’s Angina

Q) A 45-year-old female patient visits the dental clinic complaining of discomfort

and burning sensation in her mouth, especially while eating or drinking. On
examination, you observe diffuse erythema of the oral mucosa, particularly on the
palate and buccal mucosa. There are no visible plaques or lesions. What is the
Diagnosis?

A. Pseudomembrane Candidiasis
B. Erythematous Candidiasis
C. C.diphtheriae
D. S.pyogenes
E. Measles

Ans: B

Q) A 50-year-old male patient presents to the emergency room with severe neck
pain, difficulty swallowing, and swelling under the chin. On examination, you note
significant swelling of the floor of the mouth, causing elevation of the tongue and
difficulty in breathing. The patient appears anxious and has a high fever. Given the
clinical presentation and rapidly progressing symptoms, What is the most important
course of action?

A. Start Empiric antibiotic therapy

B. Airway Protection
C. Treat Underlying cause
D. Start Antifungal Medication
Ans: B, Ludwig’s Angina

Q) 14 years-old Aditya was taken to the clinic

after he noticed caries on his teeth. His mother
tells that he likes to eat a lot of sweets. Which
of the following is the dominant organism for
the initiation of caries?

A. Staphylococcus epidermidis
B. Epstein Barr Virus
C. Corynebacterium diphtheriae
D. Candida albicans
E. Streptococcus mutans

Answer: E
Explanation: Streptococcus mutans is the dominant organism for the initiation of
caries. A caries is a disintegration of the teeth beginning at the surface and
progressing inward. Subsequent decomposition of the dentin & cementum of the
exposed root surface involves bacterial digestion of the protein matrix (excessive
acidification).

Q: Inflammation of the throat in known as pharyngitis. It is spread primarily by:

A) Feco-oral
B) Sexual contact
C) Respiratory droplets
D) Blood transfusions
E) Skin contact
Answer: C
Explanation: Pharyngitis is spread primarily by respiratory droplets.

Q: Molecular mimicry is a mechanism where the bacterium’s antigens share

similarities with human self-antigens. Post-infection sequelae of a certain
microorganism can include immune-mediated diseases such as acute rheumatic
fever and glomerulonephritis. Which of the following is most likely the organism
described above?
A. Streptococcus pyogenes
B. Epstein Barr Virus
C. Corynebacterium diphtheriae
D. Candida albicans
E. Streptococcus mutans

Answer: A
Explanation: “Post-infection sequelae” refers to conditions or symptoms that occur
after and as a result of an infection. The concept of molecular mimicry is one of the
mechanisms thought to contribute to these conditions, where the immune system
confuses bacterial antigens with the body’s own tissues, leading to an autoimmune
response.

Q: A 22-year-old male complains of throat

pain and headaches. Physical examination
revealed white patches on the throat and
rashes on the body. A throat swab was
collected and sent for diagnosis which later
showed cocci. It was diagnosed as a case of
strep throat. Which of the following is a
feature of the microorganism which was
responsible for the symptoms mentioned
above?
 A) Endotoxin
B) Gram Negative
C) Catalase Positive
D) Beta Hemolysis
E) Bacitracin Resistant
F) ASO Negative

Answer: D
Explanation: Pharyngitis (strep throat). From the symptoms and the lab results, it is
most likely Streptococcus pyogenes which is a gram-positive coccus. Endotoxin is
a feature of gram negative LPS. Streptococcus pyogenes is Catalase negative,
Bacitracin susceptible and ASO positive. Blood agar would show Beta hemolysis.

Q) Which of the following produces a toxin that acts by inhibiting host cell protein
synthesis which is achieved by the inactivation of elongation factor-2 (EF-2)?

A) Staphylococcus epidermidis
B) Corynebacterium diphtheria
C) Streptococcus pyogenes
D) Candida albicans
E) Epstein Barr Virus

Ans: B
Collected by: Mohammad Yusuf Altaf and AbdulRahman Farahat
Edited by: Shoaeve

Lecture: Ear & Sinus Infections

Source: Lippincott Microbiology and Immunology
Q) A 74-year-old woman is hospitalized with community-acquired pneumonia.
Blood and sputum cultures grew the a-hemolytic catalase-negative, bile-soluble,
optochin-sensitive organism shown in the photograph. It showed an intermediate
degree of resistance to penicillin. What are the other important virulence factors of
this organism?

A) Capsule and pneumolysin

B) Filamentous hemagglutinin and superantigen
C) Neuraminidase and hemagglutinin
D) Pyocyanin and endotoxin
E) Tracheal cytotoxin and pertactin

Ans: A
Explanation: Capsule and pneumolysin. The organism described in this case is
Streptococcus pneumonide. It is an important cause of community-acquired
pneumonia and strains range in sensitivity to penicillin from fully susceptible to
intermediately susceptible to highly resistant. Virulent strains of
S. pneumonia, also called pneumococcus, produce a thick, polysaccharide capsule
that provides protection against complement activation and phagocytosis.
Pneumolysin is a unique cytotoxin elaborated by pneumococci. It induces pores in
host cell plasma membranes following binding to cholesterol
residues, thereby damaging ciliated respiratory epithelial cells and neutrophils. The
organism does not elaborate any of the other virulence factors listed.
Filamentous hemagglutinin, tracheal cytotoxin, and pertactin are virulence factors
of Bordetella pertus-sis. Neuraminidase and hemagglutinin are envelope
glycoproteins of influenza virus. Pyocyanin and endotoxin are two of the multiple
virulence factors of Pseudomonas aeruginosa.

Q) An 18-month-old male presents with fever, lethargy, malaise, productive

coughing, and vomiting. Culture of cerebral spinal fluid samples with
Staphylococcus aureus on blood agar reveals the presence of “satellite” colonies.
Serology has indicated that the organism is polyribitol phosphate (PRP) positive.
Gram stain of the colonies indicates the presence of a Gram-negative coccobacillus.
Which one of the following organisms is most likely responsible for the disease?

A) Bordetella pertussis
B) Campylobacter jejuni
C) Escherichia coli
D) Haemophilus influenzae b
E) Pasteurella multocida

Ans: D
Explanation: The child in the case has meningitis. Organisms that cause meningitis
in a child of this age include Streptococcus pneumoniae, Neisseria meningitides, and
H. influenzae b. No other organism shares the culture characteristics of
Haemophilus. This group of organisms is nutritionally fastidious and able to grow
on chocolate agar (which supplies necessary nutrients from lysed red blood
cells) or as satellite colonies surrounding b-hemolytic colonies of S. aureus on blood
agar.
Q) An elderly woman, with uncontrolled diabetes, has a yellowish-green discharge
that chronically drains from her left ear canal (shown). The external canal is
inflamed and the tympanic membrane appears to be ruptured. The attending
physician empirically diagnoses the condition and orders a combination antibiotic
regimen of an IV aminoglycoside and a third-generation cephalosporin. She
initially responds, but when treatment is suspended, she relapses. Of the following,
which is the most likely diagnosis?

A) Group A pharyngitis with Eustachian tube involvement

B) Haemophilus otitis media
C) Pneumococcal otitis media
D) Pseudomonas malignant otitis externa
E) Staphylococcal abscessed tympanic membrane

Ans: D
Explanation: Pseudomonas malignant otitis externa. This disease occurs in
immune compromised individuals, particularly those with diabetes. It is an
invasive infection of the external ear which can spread to involve nearby cartilage
and bone. Malignant otitis externa is most commonly caused by Pseudomonas. An
aminoglycoside in synergy with a third-generation cephalosporin is commonly
used to treat pseudomonal infections. The other diseases listed do not fit the
clinical picture described in the case, nor would this combination of antibiotics be
typical for treatment.

Source: Review of Medical Microbiology and Immunology

Q) Your patient is a 6-year-old boy who is complaining that his ear hurts. His mother
says this began yesterday and that he has a fever of 103°F. On physical exam, you
see a perforated ear drum that is exuding a small amount of pus. Using a swab, you
obtain a sample of the pus and do a Gram stain and culture. The Gram stain reveals
small coccobacillary rods. There is no growth on a blood agar plate, but a chocolate
agar plate supplemented with X and V factors grows small grey colonies. Which one
of the following bacteria is the most likely cause of his otitis media?

A) Bordetella pertussis
B) Haemophilus influenzae
C) Klebsiella pneumoniae
D) Legionella pneumophila
E) Pseudomonas aeruginosa

Ans: B

Source: Member Made

Q) A mother is worried about her 5-year-old son. She brought her son to the clinic
and told that her son has trouble sleeping at night. Physical examination showed
pus draining from the left ear. HR and temperature were 110 bpm and 38.7 oC
respectively. Which statement best explains the pathophysiology of otitis media?

A) Small tympanic membrane leads to infections as he is a child

B) The eustachian tube is a bit inclined in children which plays a role in infection
C) Accumulation of mucus and fluid in the sinuses leads to pus formation
D) The eustachian tube is relatively horizontal so secretions can track back to the
middle ear
E) Chronic obstruction of the osteomeatal complex

Ans: D
Explanation: Eustachian tube dysfunction results in the accumulation of mucus
and fluid in the middle ear. In infants, the eustachian tube is relatively horizontal,
so if they have oral secretions, it can track back through the eustachian tube to the
middle ear.

Q) Which of the following is not associated with acute otitis media?

A) Staphylococcus aureus
B) Streptococcus pneumonia
C) Haemophilus influenzae
D) Moraxella catarrhalis

Ans: A
Explanation: Staphylococcus aureus is associated with chronic otitis media.

Q) Moraxella catarrhalis is a gram-negative diplococcus that is associated with

acute otitis media or sinusitis. Which of the following can help differentiate
Moraxella catarrhalis from Neisseria?

A) Moraxella catarrhalis is DNase negative while Neisseria is DNase positive

B) Moraxella catarrhalis is DNase positive while Neisseria is DNase negative
C) Moraxella catarrhalis is Oxidase positive while Neisseria is an Oxidase negative
D) Moraxella catarrhalis is Oxidase negative while Neisseria is Oxidase positive

Ans: B

Q) Which of the following organisms is least likely to cause otitis externa

(swimmer's ear)?
A) P. aeruginosa
B) S. epidermidis
C) S. aureus
D) Candida albican
E) M. catarrhalis

Ans: E

Q) Which of the following is Not considered a virulence factor associated with the
bacteria below?
 A) phospholipase C
B) Biofilm
C) Protein A
D) lipopolysaccharide
E) elastase

Ans: C

Collected by: Mohammad Yusu Altaf and AbdulRahman Farahat

Edited by: AbdulRahman Alkhatib

Pathology
Lecture: Lesions of the Oral Cavity
Source: Lippincott Pathology
Q) A 6-year-old boy presents with painful sores on his upper lip. He was seen for a
flu 1 week ago. The lesion appears as 0.2- to 0.4-cm vesicles with focal ulceration.
Which of the following is the most likely histologic feature of this skin lesion?
A) Acute arteritis
B) Caseating granulomas
C) Fungal hyphae
D) Multinucleated epithelial cells
 E) Noncaseating granuloma

Ans: D
Explanation: Herpes labialis (cold sores, fever blisters) and herpetic stomatitis are
caused by herpes virus type 1. They are among the most common viral infections
of the lips and oral mucosa in both children and young adults. The disease starts
with painful inflammation of the affected mucosa, followed shortly by the
formation of vesicles. These vesicles rupture and form shallow, painful ulcers.
Microscopically, the herpetic vesicle forms as a result of “ballooning
degeneration” of the epithelial cells. Some epithelial cells show intranuclear
inclusion bodies. At the edge of the ulcer are large, multinucleated, epithelial cells
with “ground glass” homogenized nuclei, often exhibiting nuclear molding. The
ulcers heal spontaneously without scar formation. Acute arteritis (choice A) does
not cause the described lesions. Choices B, C, and E do not represent acute
vesicular lesions. Diagnosis: Herpes labialis

Q) A 74-year-old man with a 15-year history of diabetes is hospitalized because of

end-stage kidney disease. His tongue, inner side of the lips, and buccal mucosa are
covered with white, slightly elevated, soft patches (shown in the image). What is
the most likely diagnosis

A) Aphthousstomatitis
B) Candidiasis
C) Herpeslabialis
D) Pyogenicgranuloma
E) Xerostomia
Ans: B
Explanation: Candidiasis. Also termed thrush or moniliasis, candidiasis is caused
by a yeast-like fungus, Candida albicans, which is a common surface inhabitant of
the oral cavity, gastrointestinal tract, and vagina. Oral candidiasis is most common
in people with immunocompromised systems or with diabetes, and the incidence in
patients with AIDS is 40% to 90%. The oral lesions typically appear as white,
slightly elevated, soft patches that consist mainly of fungal hyphae. Choices A, C,
and D are generally focal lesions. Diagnosis: Candidiasis

Q) A 2-year-old girl was withdrawn from a day care center for excessive
irritability. On physical examination, she has multiple, small superficial ulcers of
the oral mucosa. The ulcerations heal spontaneously over the next 5 days. Which
of the following is the most likely diagnosis?
A) Aphthous stomatitis
B) Candidiasis
C) Gingivitis
D) Ludwig angina
E) Pyogenic granuloma

Ans: A
Explanation: Aphthous stomatitis describes a common disease that is characterized
by painful, recurrent, solitary, or multiple, small ulcers of the oral mucosa. The
causative agent is unknown. Microscopically, the lesion consists of a shallow ulcer
covered by a fibrinopurulent exudate. Candidiasis (choice B) features white
plaques. Diagnosis: Aphthous stomatitis

Q) A 6-year-old boy presents with a painful sore in his mouth. Physical

examination reveals a small, elevated, and focally ulcerated red-purple gingival
lesion. A soft red mass measuring 1 cm in diameter is surgically removed.
Histologic examination discloses highly vascular granulation tissue, with marked
acute and chronic inflammation. What is the most likely diagnosis?
A) Acute necrotizing gingivitis
B) Aphthous stomatitis
C) Herpes labialis
D) Pyogenic granuloma
 E) Tuberculosis

Ans: D
Explanation: Pyogenic granuloma is a reactive vascular lesion that commonly
occurs in the oral cavity. Usually, some minor trauma to the tissues permits
invasion of nonspecific microorganisms. In the oral cavity, pyogenic granulomas,
ranging from a few millimeters to a centimeter, are most frequent on the gingiva.
The lesion is seen as an elevated, red or purple, soft mass, with a smooth, ulcerated
surface. Microscopically, the nodule consists of highly vascular granulation tissue
that shows varying degrees of acute and chronic inflammation. With time,
pyogenic granuloma becomes less vascular and comes to resemble fibroma.
Choices A, B, and C are ulcerating lesions. Tuberculosis (choice E) features
granulomatous inflammation. Diagnosis: Pyogenic granuloma

Q) A 60-year-old man, who is a chronic alcoholic, is referred by a homeless shelter

for facial ulcers. On physical examination, there are large ulcerations in the mouth
and facial tissues with focal exposure of bone. A culture grows Borrelia vincentii.
Which of the following is the most likely diagnosis?
A) Acute necrotizing ulcerative gingivitis
B) Apical granuloma
C) Ludwig angina
D) Periodontitis
E) Pyogenic granuloma

Ans: A
Explanation: Acute necrotizing ulcerative gingivitis. Acute necrotizing ulcerative
gingivitis (Vincent angina) represents an infection by two symbiotic organisms;
one is a fusiform bacillus, and the other is a spirochete (B. vincentii). The fact that
these organisms are found in the mouths of many healthy persons suggests that
predisposing factors are important in the development of acute necrotizing
ulcerative gingivitis. The most important element appears to be decreased
resistance to infection as a result of inadequate nutrition, immunodeficiency, or
poor oral hygiene. Vincent infection is characterized by punched-out erosions of
the interdental papillae. The ulceration tends to spread and eventually to involve all
gingival margins, which become covered by a necrotic pseudomembrane. None of
the other choices are destructive, ulcerating lesions. Diagnosis: Necrotizing
ulcerative gingivitis

Q) A 67-year-old woman complains of a white discoloration in her mouth. She has

a 60-pack-year history of smoking. Physical examination reveals white plaques on
the buccal mucosa, tongue, and floor of the mouth. A biopsy (shown in the image)
demonstrates severe epithelial dysplasia. What is the appropriate clinical
diagnosis?

A) Actinic keratosis
B) Candidiasis
C) Leukoplakia
D) Malakoplakia
E) Papillomatosis

Ans: C
Explanation: Leukoplakia is a descriptive term for many reactive, preneoplastic,
and neoplastic lesions of the oral mucosa. Leukoplakic lesions are not necessarily
premalignant and demonstrate a spectrum of histopathologic changes, ranging
from increased surface keratinization without dysplasia to invasive keratinizing
squamous carcinoma. Candidiasis (choice B) also presents with whitish plaques
but does not induce dysplasia. Actinic keratosis (choice A) involves sun-exposed
skin and malakoplakia (choice D) occurs in the bladder. Papillomatosis (choice E)
does not present as a flat white lesion. Diagnosis: Leukoplakia

Q) The patient described in Question above is at higher risk of developing which

of the following neoplasms?
A) Adenoid cystic carcinoma
B) Mucoepidermoid carcinoma
C) Nasopharyngeal carcinoma
D) Papilloma
E) Squamous cell carcinoma

Ans: E
Explanation: Squamous cell carcinoma. Although the probability of squamous cell
carcinoma developing in a patient with oral leukoplakia is low, there is still a risk
(10% to 12%) of malignant transformation. Carcinogenic factors that lead to the
induction of cancer usually affect more than one site in the oral mucosa, and the
tumors may therefore be multiple. Choices A, B, and C do not arise from the oral
epithelium and choice D is not a complication of epithelial dysplasia. Diagnosis:
Squamous cell carcinoma

Source: Member Made

Q) A 25 year old female comes into the clinic with the following presentation. On
examination it was found that the white patches were not scrapable. What is the
organism that causes this presentation?
 A) HSV Type 1
B) Candida
C) HIV
D) EBV
E) Aspergillus

Ans: D
Explanation: The condition shown in the picture is hairy leukoplakia which is
characterized with white fluffy patches found on the lateral borders of the tongue.
These patches can’t be scraped as compared to the white patches in candidiasis
which can be scraped off.

Q) A 18 year old male comes to the clinic with non-keratinizing bulky nodules
found within the oropharynx. What is the pathogenesis of this disease?

A) Chemical carcinogens
B) Heavy alcohol intake
C) Causing latency in B lymphocytes
D) Invasion of epithelial mucosa
E) P53 and RB inhibition via E6 and E7 oncoprotein

Ans: E
Explanation: The condition describes HPV associated squamous cell carcinoma.
The pathogenesis is due to E6 and E7 oncoprotein which inhibit p53 and RB
involved in apoptosis and the cell cycle. The main differentiation factors between
HPV associated SCC and non-HPV associated HPV is the age (younger vs. older),
the location (oropharynx vs oral cavity), pathogenesis and clinical outcomes (good
vs poor). Please refer to the table on slide 19 in the Oral cavity lesions lecture for
more information.
Q) The following histological image is seen in which infection and primarily
shows what histological feature?

A) Candidiasis, Macrophagic infiltrations

B) HSV infection, eosinophilic intranuclear inclusions and multinucleated giant
cells
C) EBV infection, eosinophilic intracytoplasmic inclusions in neutrophils
D) HIV infection, eosinophilic intra inclusion and multinucleated giant cells
E) HSV Type 2 infection, eosinophilic intracytoplasmic infiltrates

Ans: B
Explanations: The infection shown is caused by HSV infections characterized by
eosinophilic intranuclear inclusions and multinucleated giant cells. The rest are
things I made up ;)

Source: Pretest Pathology

Q) A 4-year-old boy presents with multiple laryngeal squamous papillomas.
Obtaining a history, you discover this boy has had the same types of lesions
removed in the past, but they have now recurred. Which of the following viruses is
most closely associated with this boy’s condition?
 A) Cytomegalovirus (CMV)
B) Epstein-Barr virus (EBV)
C) Herpes simplex virus (HSV)
D) Human immunodeficiency virus (HIV)
E) Human papillomavirus (HPV)

Ans: E
Explanation: Laryngeal neoplasms may be either benign or malignant. Squamous
papillomas are benign neoplasms that occur in two clinical forms. One form is
typically solitary and occurs in adults (solitary squamous papilloma), while the
other form is multiple and occurs in children (juvenile papillomatosis). The latter
form is associated with human papillomavirus (HPV) and may recur locally after
excision. Malignant neoplasms of the larynx are most often squamous cell
carcinomas.

Source: Robbins & Cotran Review of Pathology

Q) A 55-year-old man visited his dentist for a routine dental examination. The
dentist noticed lesions with the clinical and histologic appearance shown in the
figure. The past medical history showed no major medical problems. Which of the
following etiologic factors most likely contributed to the development of these
lesions?
 A) Dental caries
B) Herpes simplex virus type 1
C) Eating smoked and pickled foods
D) Chronic sialadenitis
E) Smoking tobacco

Ans: E This whitish, well-defined mucosal patch on the tongue has the
characteristic appearance of leukoplakia, a premalignant lesion that can give rise to
squamous cell carcinoma. Pipe smoking and tobacco chewing are implicated in the
development of leukoplakia. Chronic alcohol abuse also is implicated, but the
association is less strong than with tobacco. Ill-fitting dentures may lead to
leukoplakia, but far less commonly than smoking. Dental caries is not a risk factor
for leukoplakia, unless the affected tooth becomes eroded and misshapen.
Infections and inflammation are not recognized risk factors for oral leukoplakia or
oral squamous cell cancers. The type of food eaten has less of a correlation with
cancer of the oral cavity than with cancer of the esophagus.

Q) After a bout of the flu, a 25-year-old man notices several 0.3-cm, clear vesicles
on his upper lip. The vesicles rupture, leaving shallow, painful ulcers that heal over
the course of 4 weeks. Several months later, after a skiing trip, similar vesicles
develop, with the same pattern of healing. Which of the following findings is most
likely to be associated with these lesions?

A) Biopsy specimen showing squamous epithelial hyperkeratosis

B) Positive serologic test for herpes simplex virus type 1
C) Peripheral blood smear showing atypical lymphocytes
D) Cytologic scraping showing budding cells with pseudohyphae
E) Biopsy specimen showing mononuclear inflammatory infiltrate

Ans: B
Explanation: The lesions of herpes simplex virus type 1 (HSV-1), also known as
“cold sores” or “fever blisters,” are common. Many individuals have HSV-1, and
the oral and perianal lesions appear during periods of stress. Recurrence is the
norm. Leukoplakia is marked by hyperkeratosis. Atypical lymphocytes are seen
with infectious mononucleosis. They may be accompanied by a rash, but do not
produce vesicular lesions of the skin. Budding cells with pseudohyphae suggest a
candidal infection with oral thrush. A mononuclear infiltrate is nonspecific and can
be seen with aphthous ulcers.

Q) A 35-year-old, HIV-positive man complains that he has had a "bad" taste in his
mouth and discoloration of his tongue for the past 6 weeks. On physical
examination, there are areas of adherent, yellow-tan, circumscribed plaque on the
lateral aspects of the tongue. This plague can be scraped off as a pseudomembrane
to show an underlying granular, erythematous base. What is the most likely
diagnosis?

A) Aphthous ulcer
B) Cheilosis
C) Hairy leukoplakia
D) Herpetic stomatitis
E) Leukoplakia
F) Glossitis
G) Oral thrush

Ans: G
Explanation: The patient has oral thrush, a lesion resulting from oral candidiasis in
immunocompromised individuals. The lesion is typically superficial. Microscopic
examination shows the typical budding cells and pseudohyphae of Candida.
Aphthous ulcers, or “canker sores,” are very common in young individuals, but can
appear at any age; they tend to be recurrent superficial ulcerations. Cheilosis is
fissuring or cracking of the mucosa, typically at the corners of the mouth, which
may be seen with vitamin B2 (riboflavin) deficiency. Hairy leukoplakia also can be
seen with HIV infection, but it is far less common than oral thrush. It occurs from
marked hyperkeratosis, forming a rough “hairy” surface, and is related to Epstein-
Barr virus infection. Multinucleated cells suggest a herpesvirus infection, which
typically has vesicles that ulcerate. Atypical squamous epithelial cells usually arise
from areas of oral leukoplakia. Glossitis may have an appearance ranging from a
shiny red surface of the tongue to ulceration. It may be seen with vitamin
deficiencies, including vitamin B2, B3, B6, or B12.
Q) A 70-year-old man who has experienced increasing hoarseness for almost 6
months has recently had an episode of hemoptysis. On physical examination, no
lesions are noted in the nasal or oral cavity. There is a firm, nontender anterior
cervical lymph node. The lesion shown in the figure is identified by endoscopy.
The patient undergoes biopsy, followed by laryngectomy and neck dissection.
Which of the following etiologic factors most likely played the greatest role in the
development of this lesion?

A) Human papillomavirus infection

B) Type I hypersensitivity
C) Smoking tobacco
D) Repeated bouts of aspiration
E) Epstein-Barr virus infection

Ans: C
Explanation: The figure shows a large, fungating neoplasm that has the typical
appearance of a laryngeal squamous cell carcinoma. The most common risk factor
is smoking, although chronic alcohol abuse also plays a role. Some patients harbor
human papillomavirus sequences. The etiologic significance is unclear. Allergies
with type I hypersensitivity may result in transient laryngeal edema, but not
neoplasia. Aspiration may result in acute inflammation, but not neoplasia. Epstein-
Barr virus infection is associated with nasopharyngeal carcinomas.

Q) A 49-year-old man has used chewing tobacco and snuff for many years. During
a visit to his dentist, a lesion is seen on the hard palate (see figure). It cannot be
removed by scraping. A biopsy is performed, and microscopic examination of the
lesion shows a thickened squamous mucosa. Several years later, a biopsy specimen
of a similar lesion shows carcinoma in situ. Which of the following is the most
likely diagnosis?

A) Aphthous ulcer
B) Oral thrush
C) Lichen planus
D) Leukoplakia
E) Pyogenic granuloma
F) Xerostomia

Ans: D
Explanation: The raised white patches suggest leukoplakia. This is a premalignant
condition. Risk factors include tobacco use, particularly tobacco chewing, and
chronic irritation. Human papillomavirus infection has been implicated in some
lesions. Aphthous ulcers, or “canker sores,” are very common in young
individuals, but may appear at any age; they tend to be recurrent superficial
ulcerations. Oral thrush appears most often on the tongue of immunocompromised
individuals as a yellowish plaquelike area. Microscopic examination shows
budding cells with pseudohyphae characteristic of Candida infection. Lichen
planus in the oral cavity usually appears in conjunction with similar skin lesions; it
forms whitish patches that may ulcerate. The lesions have intense submucosal
chronic inflammation. A pyogenic granuloma forms a painful gingival nodule of
granulation tissue. Xerostomia, or “dry mouth,” is seen in Sjögren syndrome.

Q) A 17-year-old girl notices a small, sensitive, gray-white area forming along the
lateral border of her tongue 2 days before the end of her final examinations. On
examination by the physician's assistant, the girl is afebrile. There is a shallow,
ulcerated, 0.3-cm lesion with an erythematous rim. No specific therapy is given,
and the lesion disappears within 2 weeks. The past history shows that the girl "does
not smoke or chew tobacco and does not go out with boys who do."
Which of the following is the most probable cause of this lesion?

A) Aphthous ulcer
B) Oral thrush
C) Herpes simplex stomatitis
D) Leukoplakia
E) Sialadenitis

Ans: A
Explanation: An aphthous ulcer is a common lesion that also is known as a “canker
sore.” The lesions are never large but are annoying and tend to occur during
periods of stress. Aphthous ulcers are not infectious; they probably have an
autoimmune origin. Oral thrush is a superficial candidal infection that occurs in
diabetic, neutropenic, and immunocompromised patients. Herpetic lesions are
typically vesicles that can rupture. Leukoplakia appears as white patches of thicker
mucosa from hyperkeratosis. It may be a precursor to squamous cell carcinoma in
a few cases. The temperance ditty mentioned in the history is a cautionary note for
all young people. Inflammation of a salivary gland (sialadenitis), typically a minor
salivary gland in the oral cavity, may produce a localized, tender nodule.

Q) A 54-year-old man, a nonsmoker, has a non-healing ulceration at the right base

of his tongue for 2 months. On examination this lesion is 1 cm in diameter with
irregular borders. Biopsy of the lesion is performed and microscopic examination
shows infiltrating squamous cell carcinoma. Which of the following infectious
agents is most likely to be associated with this lesion?

A) Candida albicans
B) Herpes simplex virus (HSV)
C) Human papillomavirus (HPV)
D) Prevotella intermedia
E) Streptococcus, group A

Ans: C.
Explanation: Smoking and alcoholism are frequent etiologies for oral squamous
cell carcinomas, but in nonsmokers HPV infection may be implicated. The good
news: the oral carcinomas arising with HPV have a better prognosis, though they
may be multifocal and recur. The better news: vaccination against HPV may help
prevent this disease. Oral candidiasis (thrush) may occur in immunocompromised
persons. HSV causes self-limited acute gingivostomatitis (cold sores). The genus
Prevotella includes anaerobes that are associated with periodontitis and with buccal
infections that become cellulitis (Ludwig angina). “Strep” throat is an acute
exudative pharyngitis that has the immunologic complications of rheumatic heart
disease or post infectious glomerulonephritis.

Q) A 42-vear-old man has had a constant bad taste in his mouth for the past month.
On physical examination there are white fluffy patches on the sides of his tongue.
These cannot be scraped off. A biopsy is taken and on microscopic examination
shows squamous epithelial hyperkeratosis, parakeratosis, and koilocytosis.
Immunohistochemical staining for Epstein-Barr virus (EB) is positive. Which of
the following is the most likely risk factor for his oral lesions?

A) Chronic alcohol abuse

B) Diabetes mellitus
C) HIV infection
D) Pernicious anemia
E) Sjögren syndrome

Ans: C
Explanation: He has oral hairy leukoplakia, which is seen in immunocompromised
persons. It presages AIDS in persons who are HIV positive. Chronic alcohol and/or
tobacco use are associated with oral squamous cell carcinomas. Diabetes mellitus
type 1 with ketoacidosis is associated with fungal sinusitis, particularly with
mucormycosis. Pernicious anemia from vitamin B12 deficiency is associated with
glossitis that is mainly atrophic. Sjögren syndrome leads to inflammation and
atrophy of salivary glands leading to xerostomia with atrophy, fissuring, and
ulcerations in the oral cavity mucosa.

Collected By: Duaa, Hala Hejazi, Sidrah Fathima, Maryam Ashraf

Edited By: Khalid Jamiel
Clinical
Lecture: Rhinorrhea & Epistaxis
Source: Member Made
Q) Which of the following would cause Rhinitis Medicamentosa?
A. Propranolol
B. Augmentin
C. Donepezil
D. Phenylephrine

Ans: D

Q) Which of the following statements is true about allergic rhinitis?

A. It is caused by a viral infection and typically does not recur once treated.
B. It is triggered by environmental allergens and can be seasonal or perennial.
C. Antibiotics are the primary treatment to cure allergic rhinitis.
D. Loss of smell is not a symptom associated with allergic rhinitis.

Ans: B

Q) What are common findings in nasal mucosa during allergic reactions?

A. Redness and dry mucosa

B. Pale mucosa with lots of secretion and swollen turbinates
C. Dark and moist mucosa
D. Clear mucosa with minimal secretions
Ans: B
Explanation: In allergic rhinitis, the nasal mucosa typically appears pale due to
edema and vasoconstriction. There is also an increase in secretions and swelling of
the turbinates, particularly the inferior turbinate.

Q) Where should a biopsy be taken if nasopharyngeal carcinoma is suspected?

A. The torus tubarius
B. The opening of the eustachian tube
C. The fossa of Rosenmüller
D. The nasal septum

Ans: C
Explanation: The fossa of Rosenmüller is the most common site for
nasopharyngeal carcinoma. This deep space at the arch of the torus tubarius is
critical for biopsy when nasopharyngeal carcinoma is suspected, making it the
correct site for obtaining diagnostic tissue.

Q) What differentiates vasomotor rhinitis from allergic rhinitis?

A. Vasomotor rhinitis is triggered by chemical reactions to allergens, while

allergic rhinitis is caused by physical stimuli.
B. Vasomotor rhinitis and allergic rhinitis have different symptoms, with
vasomotor rhinitis causing fever and allergic rhinitis causing sneezing.
C. Vasomotor rhinitis is caused by physical stimuli such as changes in
temperature, whereas allergic rhinitis is a chemical reaction to allergens.
D. Allergic rhinitis is treated with antibiotics, while vasomotor rhinitis is treated
with antihistamines.

Ans: C

Q) When does a nasal infection typically become classified as chronic?

A. If symptoms last more than 2 weeks
B. If symptoms last more than 6 weeks
 C. If symptoms last more than 12 weeks
D. If symptoms persist for more than 24 weeks

Ans: C

Q) Which of the following is a classic clinical sign of cerebrospinal fluid

Rhinorrhea?
A. Cotton-wool spots on fundoscopic examination
B. Bull's eye rash on physical examination
C. Halo sign on Valsalva maneuver
D. Honey-colored crusts in the nasal passages

Ans: C

Q) Which statement accurately distinguishes the treatment of anterior and posterior

epistaxis?

A. Anterior epistaxis requires surgical intervention, while posterior epistaxis

can be managed conservatively.
B. Posterior epistaxis is easily treated with nasal packing, while anterior
epistaxis often requires surgery.
C. Posterior epistaxis is more challenging to treat due to significant bleeding,
while anterior epistaxis can be managed with compression or nasal packing.
D. Nasal packing is equally effective for both anterior and posterior epistaxis,
with no distinction in treatment difficulty.

Ans: C

Q) What’s the most common cause of epistaxis?

A. Dryness
B. Allergies
C. High blood pressure
D. Sinus infection
E. Excessive earwax

Ans: A

Q) What is the cause of excessive bleeding in epistaxis?

A. Narrowing of the nasal passages

B. Various anastomosis between arteries and veins
C. Inflammation of the nasal mucosa
D. Formation of blood clots in the nasal cavity

Ans: B

Q) Anterior epistaxis is ______ posterior epistaxis

A. More common than
B. Less common than
C. Equally common to

Ans: A

Q) Posterior epistaxis is more likely in the ______ and its management is ______ .
A. older population, less challenging
B. Younger population, more challenging
C. Older population, more challenging
D. Younger population, less challenging

Ans: C
Q) The congenital cause of epistaxis is
A. Sinusitis
B. Nasal polyps
C. Deviated septum
D. Hereditary telangiectasia
E. Allergic rhinitis

Ans: D

Q) What is the treatment for epistaxis?

A. Trotter’s method
B. Nasal irrigation
C. Steam inhalation
D. Antibiotics

Ans: A

Q) What is the non-allergic cause of rhinorrhea?

A. Vasomotor
B. Bacterial infection
C. Fungal infection
D. Deviated septum
E. Chronic sinusitis

Ans: A

Q) Why does crying cause rhinorrhea?

A. Increased blood flow to the nasal mucosa
B. Constriction of nasal blood vessels
C. Due to nasolacrimal duct
D. Activation of nasal nerve receptors

Ans: C

Q) What organism causes this type of infection?

A. Klebsiella rhinoscleromatis
B. Mycobacterium Leprae
C. Treponema Pallidum
D. Mycobacterium Tuberculosis

Ans: C

Q) Extended use of oxymetazoline, phenylephrine or naphazoline would lead to:

A. Chronic atrophic rhinitis
B. Polypous rhinitis
C. Epistaxis
D. Rhinitis medicamentosa

Ans: D
Source: Past exams
Q) A patient presented with a history of facial pain and rhinorrhea that lasted for
three days. Then he had face fullness, fever, and anterior purulent discharge for the
last 10 days. What’s the most likely diagnosis?
A. Chronic bacterial Rhinorrhea
B. Acute bacterial Rhinorrhea
C. Acute viral Rhinorrhea
D. Allergic rhinitis

Ans: B

Q) The most common cause of acute sinusitis in adults is?

A. Moraxella
B. S. pneumonia
C. H. influenza
D. Viral

Ans: D

Q) A 73-year-old man with a known history of uncontrolled hypertension was

rushed to the hospital after he started spitting fresh blood. On examination his HR
was 145/min with a BP of 230/120 mmHg. The attending physician suspected him
of a case of nosebleed due to hypertension. The attached picture is showing
different lettered areas of the nose. Which one of the lettered slides could be the
most likely bleeding spots?
A. A
B. B
C. C
D. D
E. E

Ans: D, Woodruff’s plexus- Posterior Epistaxis

Q) A 9-year-old boy was brought to the school reception during time by his
friends. He started nose bleeding while playing out in the sun. The school warden
quickly pinched his nose and applied an ice pack on his face to stop bleeding. The
attached picture shows different letter areas of the nose. Which of the lettered sites
could most likely be the bleeding spot?

A. A
B. B
C. C
D. D
E. E

Ans: B

Q) In CSF Rhinorrhea. Which of the bones is fractured?

A. Cribriform plate
B. Maxillary bone
C. Mandible
D. Cervical vertebrae

Ans: A

Collected by: Laith Jnied, Thaabit Raziq, Malak Hassan, Zainab A.

Edited by: Youssef El Shimy