Category: Quiz

Inferior vena cava

INFERIOR VENA CAVA

Q. 1

A Lecturer is demonstrating a fibrous band that runs on the visceral surface of the liver. It is attached on one end to the inferior vena cava and on the other end to the left branch of the portal vein. In the Adult the structure corresponds to?

 A

Ductus venosus

 B

Ligamentum teres

 C

Ligamentum venosum

 D

Umbilical arteries

Q. 1

A Lecturer is demonstrating a fibrous band that runs on the visceral surface of the liver. It is attached on one end to the inferior vena cava and on the other end to the left branch of the portal vein. In the Adult the structure corresponds to?

 A

Ductus venosus

 B

Ligamentum teres

 C

Ligamentum venosum

 D

Umbilical arteries

Ans. C

Explanation:

Ligamentum Venosum


Q. 2

The posterior relation of epiploic foramen is?

 A

Hepatic artery

 B

Inferior vena cava

 C

Common bile duct

 D

Portal vein

Q. 2

The posterior relation of epiploic foramen is?

 A

Hepatic artery

 B

Inferior vena cava

 C

Common bile duct

 D

Portal vein

Ans. B

Explanation:

Epiploic foramen or aditus to lesser sac communicates lesser sac to greater sac. It is bounded posteriorly by inferior vena cava, suprarenal gland and T12 vertebra.
 
Epiploic foramen: also known as foramen of winslow is a vertical slit like opening, through which the lesser sac communicates with the greater sac. It is situated at the upper wall of lesser sac at the level of T12.
Boundaries of the epiploic foramen:
  • Anteriorly: right free margin of lesser omentum containing portal vein, hepatic artery and bile duct
  • Posteriorly: suprarenal gland, inferior vena cava and T12 vertebra
  • Superiorly: caudate lobe of liver
  • Inferiorly: 1st part of duodenum and hepatic artery

Q. 3

The tributaries of the inferior vena cava include all of the following, EXCEPT?

 A

Left renal vein

 B

Left gonadal vein

 C

Hepatic vein

 D

Right suprarenal vein

Q. 3

The tributaries of the inferior vena cava include all of the following, EXCEPT?

 A

Left renal vein

 B

Left gonadal vein

 C

Hepatic vein

 D

Right suprarenal vein

Ans. B

Explanation:

Left adrenal vein and gonadal vein drain into left renal vein. The left renal vein is single and preaortic in 80% individuals. 

 Right adrenal vein drains into drains directly into the inferior vena cava just superior to the right vein insertion.
 
The tributaries of Inferior vena cava are:
  • Two anterior visceral tributaries: the hepatic veins
  • Three lateral visceral tributaries: Right suprarenal vein, renal veins, right testicular or ovarian vein
  • Five lateral abdominal wall tributaries: Inferior phrenic vein, four lumbar veins
  • Three tributaries of origin: two common iliac veins and median sacral vein.

Q. 4

All of the following veins are formed from vitelline vein except

 A

Hepatic vein

 B

Superior vena cava

 C

Inferior vena cava

 D

Superior mesenteric vein

Q. 4

All of the following veins are formed from vitelline vein except

 A

Hepatic vein

 B

Superior vena cava

 C

Inferior vena cava

 D

Superior mesenteric vein

Ans. B

Explanation:

B i.e. Superior Vena Cava


Q. 5

The most important structure involved in development of inferior vena cava is ‑

 A

Supracardinal vein & Subcardinal vein

 B

Umbilical vein

 C

Anterior cardinal vein

 D

Posterior cardinal vein

Q. 5

The most important structure involved in development of inferior vena cava is ‑

 A

Supracardinal vein & Subcardinal vein

 B

Umbilical vein

 C

Anterior cardinal vein

 D

Posterior cardinal vein

Ans. A

Explanation:

A i.e.

 

Supracardinal

vein & subcardinal vein


Q. 6

True about inferior vena cava:

 A

Passes through diaphragm at level of Du vertebra

 B

Rt. Suprarenal artery directly drains to it.

 C

It lies anterior to the renal vein.

 D

It forms the posterior wall of the epiploic foramen.

Q. 6

True about inferior vena cava:

 A

Passes through diaphragm at level of Du vertebra

 B

Rt. Suprarenal artery directly drains to it.

 C

It lies anterior to the renal vein.

 D

It forms the posterior wall of the epiploic foramen.

Ans. D

Explanation:

D. i.e. It forms posterior wall of epiploic foramen

Right free margin of lesser omentum containing portal vein, hepatic artery & bile duct are situated anteriorly; and Suprarenal gland (right), Inferior vena cava, & T12 vertebra (“SIT” structures) are related posteriorly to Epiploic foramen


Q. 7

‘Obstruction of Inferior vena cava’ presents :

 A

Paraumblical dilatation

 B

Thoraco-epigastric dilatation

 C

Oesophagus varies

 D

Haemorrhoides

Q. 7

‘Obstruction of Inferior vena cava’ presents :

 A

Paraumblical dilatation

 B

Thoraco-epigastric dilatation

 C

Oesophagus varies

 D

Haemorrhoides

Ans. B

Explanation:

B i.e. Thoraco-epigastric dilation


Q. 8

The right suprarenal vein drains into the

 A

Inferior vena cava

 B

Right renal vein

 C

Right Gonadal vein

 D

Left Renal vein

Q. 8

The right suprarenal vein drains into the

 A

Inferior vena cava

 B

Right renal vein

 C

Right Gonadal vein

 D

Left Renal vein

Ans. A

Explanation:

A i.e. Inferior vena cava

Left testicular, ovarian or suprarenal vein usually drains into left renal veinQ, before entering the IVC

                             Organ

Vein

Drain into

Rt. Suprarenal gland

Rt. Suprarenal vein

IVCQ

Lt. Suprarenal gland

Lt. Suprarenal vein

Left Renal VeinQ

  • Same is true for gonads (testis /ovary) i.e.

Lt. Gonad (testis or ovary)

Lt. Gonadal (testicular or ovarian) vein

Left renal veinQ

Rt. Gonad (testis or ovary)

Rt. Gonadal (testicular or ovarian)

vein

IVCQ


Q. 9

Double inferior vena cava is formed due to‑

 A

Persistence of sacrocardinal veins

 B

Persistance of supracardinal veins

 C

Persistance of subcardinal veins

 D

Persistance of both supracardinal and subcardinal veins

Q. 9

Double inferior vena cava is formed due to‑

 A

Persistence of sacrocardinal veins

 B

Persistance of supracardinal veins

 C

Persistance of subcardinal veins

 D

Persistance of both supracardinal and subcardinal veins

Ans. D

Explanation:

Ans. is ‘d’ i.e., Persistance of both supracardinal and subcardinal veins

Developmental anomalies of veins

A. Anomalies of SVC

  • Left superior vena cava is formed when left anterior cardinal and common cardinal veins persist and the right ones obliterate. Left SVC opens into right atrium through the coronary sinus.
  • Double superior vena cava occurs due to persistence of left anterior cardinal vein. The right SVC opens directly into right atrium while left one opens through coronary sinus.

B. Anomalies of IVC

  • Absence of inferior vena cava above renal veins occurs when the anastomotic channel between right subcardinal vein and right lepatocardinal channel fails to develop.
  • Double inferior vena cava is formed below renal veins due to persistence of both the subcardinal and supracardinal veins below the kidney.
  • Left inferior vena cava, i.e. infrarenal part of IVC is formed on left side instead of right.
  • Preureteric IVC is formed when infrarenal part of IVC develops from subcardinal vein (which lies anterior to ureter) instead of supracardinal vein (which lies posterior to ureter).


Acute Layngo-tracheo-bronchitis

Acute Layngo-tracheo-bronchitis

Q. 1

A 4 year old boy, with three days history of upper respiratory tract infection presents with stridor, which decreases on lying down. What is the most probable diagnosis?

 A

Acute Epiglottitis

 B

Laryngotracheobronchitis

 C

Foreign body Aspiration

 D

Retropharyngeal Abscess

Q. 1

A 4 year old boy, with three days history of upper respiratory tract infection presents with stridor, which decreases on lying down. What is the most probable diagnosis?

 A

Acute Epiglottitis

 B

Laryngotracheobronchitis

 C

Foreign body Aspiration

 D

Retropharyngeal Abscess

Ans. B

Explanation:

Prodromal symptoms of upper respiratory tract infection preceding sings of respiratory tract obstruction is characteristic of croup.

Ref: Nelson 17th Edition, Page 1405;1406,14; Respiratory Care: Principles And Practice By Dean Hess, Neil MacIntyre, Shelley Mishoe, William Galvin, 2011, Page 1019.


Q. 2

Laryngotracheobronchitis is caused most commonly by:

 A

Adenovirus

 B

Parainfluenza virus

 C

Rhinovirus

 D

None of the above

Q. 2

Laryngotracheobronchitis is caused most commonly by:

 A

Adenovirus

 B

Parainfluenza virus

 C

Rhinovirus

 D

None of the above

Ans. B

Explanation:

Laryngotracheobronchitis is the most common infectious cause of airway obstruction in children, usually occurring between the ages of 6 months and 3 years. It is a viral infection most commonly caused by the parainfluenza virus, although numerous other organisms have been reported.


Q. 3

Croup N most commonly due to –

 A

The respiratory syncytial virus 

 B

The para influenza virus

 C

The adenovirus

 D

The coronavirus

Q. 3

Croup N most commonly due to –

 A

The respiratory syncytial virus 

 B

The para influenza virus

 C

The adenovirus

 D

The coronavirus

Ans. B

Explanation:

Ans. is ‘b’ i.e., The para influenza virus 

Croup (Laryngotracheobronchitis)

  • Croup is a viral infection of upper respiratory tract.
  • Children between the age of 1-5 years are affected.
  • Para-influenza type I virus is the most common causative organism.
  • Other viruses implicated in causaction are RSV, influenza virus, Adneovirus and Rhinovirus.

Q. 4

Croup syndrome is usually caused by-

 A

Rhinoviruses

 B

Coxsackie A virus

 C

Coxsackie B virus

 D

All

Q. 4

Croup syndrome is usually caused by-

 A

Rhinoviruses

 B

Coxsackie A virus

 C

Coxsackie B virus

 D

All

Ans. A

Explanation:

Ans. is ‘a’ i.e., Rhinoviruses

Croup (Laryngotracheobronchitis)

o Croup is a viral infection of upper respiratory tract.

o Children between the age of 1-5 years are affected.


Q. 5

A child with three days history of upper respiratory tract infection presents with stridor, which decreases on lying down postion. What is the most probable diagnosis –

 A

Acute Epiglottitis

 B

Laryngotracheobronchitis

 C

Foreign body aspiration

 D

Retropharyngeal abscess

Q. 5

A child with three days history of upper respiratory tract infection presents with stridor, which decreases on lying down postion. What is the most probable diagnosis –

 A

Acute Epiglottitis

 B

Laryngotracheobronchitis

 C

Foreign body aspiration

 D

Retropharyngeal abscess

Ans. B

Explanation:

Ans. is ‘b’ i.e., Laryngotracheobronchitis

This child has : –

i)           3 days history of upper respiratory tract infection.

ii)          Followed by stridor

These features suggest the diagnosis of croup.

Clinical manifestations of Croup

  • Most patients have an upper respiratory tract infection with some combination of –
  • Rhinorrhea               
  • Pharyngitis
  • Mild cough               
  • Low grade fever

o After 1-3 days signs and symptoms of upper respiratory tract obstruction become apparent –

  • Barking cough  
  • Hoarseness  
  • Inspiratory stridor

Q. 6

A 4 yr old child has ‘seal barking’ like croupy cough. Management includes A/E –

 A

O2 inhalation

 B

Antibiotic

 C

Hydration

 D

ALL

Q. 6

A 4 yr old child has ‘seal barking’ like croupy cough. Management includes A/E –

 A

O2 inhalation

 B

Antibiotic

 C

Hydration

 D

ALL

Ans. B

Explanation:

Ans. is `b’ i.e., Antibiotic

o Seal barking like croupy cough is a feature of laryngotracheobronchitis (Croup).


Q. 7

Steeple sign is seen in:

 A

Croup

 B

Acute epiglottitis

 C

Laryngomalacia

 D

Quinsy

Q. 7

Steeple sign is seen in:

 A

Croup

 B

Acute epiglottitis

 C

Laryngomalacia

 D

Quinsy

Ans. A

Explanation:

 

 Chest X-ray in croup (Laryngotracheobronchitis) reveals a characteristic narrowing of the subglottic region called steeple sign.

– Current Otolaryngology 2nd/ed p 472


Q. 8

Most common cause of Croup ‑

 A

H influenza

 B

S pneumoniae

 C

Influenza virus

 D

Parainfluenza virus

Q. 8

Most common cause of Croup ‑

 A

H influenza

 B

S pneumoniae

 C

Influenza virus

 D

Parainfluenza virus

Ans. D

Explanation:

Ans. is `d.’ i.e., Parainfluenza virus

Croup (Laryngotracheobronchitis)

  • Laryngotracheobronchitis is the most common infectious cause of obstruction in children usually occurring between the ages of 6 months and 3 years.
  • Male children (boys) are characteristically more frequently involved than females (girls)

Etiology

  • It is a viral infection most frequently caused by Parainfluenza virus

Pathology

  • The most characteristic pathological feature is edema formation in the subglottic area
  • The loose areolar tissue in the subglottic area swells up and causes predominant signs of upper airway obstruction.

Presentation

  • Gradual onset with a prodrome of upper respiratory symptoms
  • Hoarseness and barking cough (croupy cough)
  • Stridor (initially inspiratory than biphasic)
  • Fever is usually low grade (or absent) although may occasionally be high grade
  • Droolings is characteristically absent and there is no dysphagia (seen in epiglottitis)
  • Imaging (X ray)
  • Symmetric ‘steeple’ or ‘funnel shaped’ narrowing of the subglottic region (steeple sign)
  • Hypopharyngeal widening or distension
  • Normal epiglottis and aryepiglottic folds

Treatment

  • Mild symptoms (barking cough but no stridor at rest)
  • Supportive therapy alone with humified oxygen, oral hydration and minimal handling.
  • Moderate symptoms (barking cough with stridor at rest)
  • Active intervention with humified oxygen, Nebulized racemic epinephrine and glucocorticoids (steroids).
  • Severe symptoms (impending respiratory failure)
  • Require an artificial airway (Intubation with endotracheal tube or tracheostomy may be required).
  • Antibiotics are not routinely indicated in the treatment of Acute Laryngotracheobronchitis. Their use is limited if there is evidence of secondary bacterial infection.


Acute Epigottitis

Acute Epigottitis

Q. 1

Most common cause of acute epiglottitis in children is:

 A Hemophilus influenzae type B
 B

Klebsiella

 C Para influenza virus type I and II
 D

Streptococcus pneumoniae

Q. 1

Most common cause of acute epiglottitis in children is:

 A Hemophilus influenzae type B
 B

Klebsiella

 C Para influenza virus type I and II
 D

Streptococcus pneumoniae

Ans. A

Explanation:

Hemophilus influenzae type B REF: P L Dhingra 4th edition page 266, 399

“Acute epiglottitis in children is caused by Hemophilus influenzae type B. It produces a typical “Thumb sign” on lateral X-ray film. Ampicillin was considered the drug of choice but now many organisms have become resistant to it and ceftriaxone is preferred”

“It is a serious condition and affects children of 2-7 years of age but can also affect adults H. influenzae B is the most common organism responsible for this condition in children”


Q. 2

Thumb sign is seen in __________________

 A

Acute epiglottitis 

 B

Acute laryngo trachea bronchitis

 C

Acute tonsillitis

 D

Acute laryngitis

Q. 2

Thumb sign is seen in __________________

 A

Acute epiglottitis 

 B

Acute laryngo trachea bronchitis

 C

Acute tonsillitis

 D

Acute laryngitis

Ans. A

Explanation:

 

DIFFERENCES BETWEEN ACUTE EPIGLOTTITIS AND ACUTE LARYNGO-TRACHEO­BRONCHITIS IN CHILDREN:

 

Acute epiglottitis

Acute laryngo-tracheo-bronchitis (or group)

Causative organism

Haemophilus influenzae type B

Para influenza virus type I and II

Age

2-7 years

3 months to 3 years

Pathology

Supraglottic larynx

Subglottic area

Prodromal symptoms

Absent

Present

Onset

Sudden

Slow

Fever

High

Low grade or no fever

Patient’s look

Toxic

Non-toxic

Cough

Usually absent

Present, (Barking seal-like)

Strider

Present and may be marked

Present

Odynophagia

Present, with drooling of secretions

Usually absent

Radiology

Thumb sign on lateral view

Steeple sign on anteroposterior view of neck

Treatment

Humidified oxygen, third

generation cephalosporin

(ceftriaxone) or amoxicillin

Humidified 0 2 tent, steroids


Q. 3

Acute laryngeal spasm during indirect laryngoscopy is seen in?

 A

Acute epiglottitis

 B

Acute laryngo tracheo bronchitis

 C

Acute tonsillitis

 D

Acute laryngitis

Q. 3

Acute laryngeal spasm during indirect laryngoscopy is seen in?

 A

Acute epiglottitis

 B

Acute laryngo tracheo bronchitis

 C

Acute tonsillitis

 D

Acute laryngitis

Ans. A

Explanation:

Q. 4

Most common cause of acute epiglottitis is

 A

Staphylococcus aureus

 B

H influenza

 C

Streptococcus

 D

Pseudomonas

Q. 4

Most common cause of acute epiglottitis is

 A

Staphylococcus aureus

 B

H influenza

 C

Streptococcus

 D

Pseudomonas

Ans. B

Explanation:

Q. 5 “Epiglottitis” is mainly caused by:
 A Streptococcus
 B Staphylococcus
 C Haemophilus
 D Mycoplasma
Q. 5 “Epiglottitis” is mainly caused by:
 A Streptococcus
 B Staphylococcus
 C Haemophilus
 D Mycoplasma
Ans. C

Explanation:

Haemophilus


Q. 6

Epiglottitis is caused by:

 A

H. influenzae

 B

Para influenzae

 C

Streptococcus

 D

Staphylococcus 

Q. 6

Epiglottitis is caused by:

 A

H. influenzae

 B

Para influenzae

 C

Streptococcus

 D

Staphylococcus 

Ans. A

Explanation:

Q. 7

A previously healthy 18-month-old girl is brought to the office with 2 days of irritability, poor appetite, and pulling at her left ear. She has no known allergies, and her temperature is 102.8 F. She is easily consoled by the mother and moves her neck spontaneously without discomfort. There is a clear discharge from the nares. The left tympanic membrane is erythematous, dull, and bulging. Which of the following virulence factors is generally absent in the strains of the causative organism that produce otitis media, compared with those that produce epiglottitis or meningitis?

 A

Beta-Lactamase

 B

IgA protease

 C

Lipopolysaccharide

 D

Polyribitol phosphate

Q. 7

A previously healthy 18-month-old girl is brought to the office with 2 days of irritability, poor appetite, and pulling at her left ear. She has no known allergies, and her temperature is 102.8 F. She is easily consoled by the mother and moves her neck spontaneously without discomfort. There is a clear discharge from the nares. The left tympanic membrane is erythematous, dull, and bulging. Which of the following virulence factors is generally absent in the strains of the causative organism that produce otitis media, compared with those that produce epiglottitis or meningitis?

 A

Beta-Lactamase

 B

IgA protease

 C

Lipopolysaccharide

 D

Polyribitol phosphate

Ans. D

Explanation:

This is most likely a case of Haemophilus influenzae otitis media. 95% of all cases of invasive disease (epiglottitis, meningitis) due to H. influenzae are caused by type b organisms that possess a polyribitol phosphate capsule. Otitis media is generally not caused by type b organisms.
 
Beta-Lactamase is an important pathogenic feature of Moraxella catarrhalis, which is another important cause of otitis media, but would not be an agent of epiglottitis or meningitis.
 
IgA protease is produced by Streptococcus pneumoniae and Neisseria meningitidis. Both of these cause meningitis, but not as commonly in this age group, and would not be the most common causes of otitis media in this case.
 
Lipopolysaccharide (choice C) is present in all gram-negative bacteria and would not be a distinguishing feature between those that cause otitis media and epiglottitis.
 
Ref: Brooks G.F. (2013). Chapter 18. Haemophilus, Bordetella, Brucella, and Francisella. In G.F. Brooks (Ed), Jawetz, Melnick, & Adelberg’s Medical Microbiology, 26e.

Q. 8

Which among the following causes ‘thumb sign’ on an X-ray lateral view of the neck?

 A

Acute epiglottitis

 B

Acute laryngo trachea bronchitis

 C

Acute tonsillitis

 D

Acute laryngitis

Q. 8

Which among the following causes ‘thumb sign’ on an X-ray lateral view of the neck?

 A

Acute epiglottitis

 B

Acute laryngo trachea bronchitis

 C

Acute tonsillitis

 D

Acute laryngitis

Ans. A

Explanation:

Thumb sign is typically seen in acute epiglottitis due to swollen epiglottis.

It is better appreciated in lateral view of neck.

Normally, the epiglottis is quite thin in the anteroposterior (AP) dimension, resembling a little finger, whereas the abnormal, inflamed epiglottis appears shorter and has an increased AP dimension, resembling a thumb.

Acute epiglottitis is usually caused by infection with H influenzae type B.


Q. 9

Disease caused by hemophilus –

 A

Chancroid

 B

Influenza

 C

Acute epiglottitis

 D

a and c

Q. 9

Disease caused by hemophilus –

 A

Chancroid

 B

Influenza

 C

Acute epiglottitis

 D

a and c

Ans. D

Explanation:

Ans. is ‘a’ i.e., Chancroid; ‘c’ i.e., Acute epiglottitis


Q. 10

Which of the following is the aetiological agent most often associated with Epiglottitis in children –

 A

Streptococcus pneumoniae

 B

Haemophilus influenzae type b

 C

Neisseria sp

 D

Moraxella catarrhalis

Q. 10

Which of the following is the aetiological agent most often associated with Epiglottitis in children –

 A

Streptococcus pneumoniae

 B

Haemophilus influenzae type b

 C

Neisseria sp

 D

Moraxella catarrhalis

Ans. B

Explanation:

Ans. is `b’ i.e., Haemophilus influenzae type b

“In published case series, it is almost always caused by Haemophilus influenzae type B”. – CPDT

Epiglottitis

  • It is the inflammation of epiglottis with inflammatory edema of hyopharynx.

o It is a true medical emergency.

o H.influenzae is the most common causative organism.

o Other organisms are —> Pneumococci, Streptococcus pyogenes, N.meningitidis, Staphylococcus

Clinical manifestations

  • Onset is sudden
  • Symptoms are —-> fever, dysphagia, drooling, muffled voice, inspiratory retractions, cyanosis and soft stridor.

o Patients often sit in sniffing dog position.

o Respiratory arrest may occur.

Imaging

  • “Cherry red” swollen epiglottis by laryngoscope.

o Radiograph —> “Thumbprint” sign. Treatment

o Immediate endotracheal intubation.

o IV antibiotics to cover H.influenzae.


Q. 11

Epiglottitis in a 2-year-old child occurs most commonly due to infection with:

 A

Influenza virus

 B

Staphylococcus aureus

 C

Haemophilus influenzae 

 D

Respiratory syncytial virus

Q. 11

Epiglottitis in a 2-year-old child occurs most commonly due to infection with:

 A

Influenza virus

 B

Staphylococcus aureus

 C

Haemophilus influenzae 

 D

Respiratory syncytial virus

Ans. C

Explanation:

 

 

Though the introduction of Hib vaccine has reduced the annual incidence of acute epiglottitis but still most of the pediatric cases seen today are due to haemophilus influenzae B. —Harrison 17th/ed p212

In adults it can be caused by group A streptococcus, S. pneumoniae, S. aureus and Klebsiella pneumoniae



Q. 12

A child presents with features of upper respiratory tract infection. On investigation,it is found to have ‘thumbprint sign’. Diag­nosis is:

 A

Acute laryngotracheobronchitis

 B

Acute epiglottitis

 C

Acute laryngeal diphtheria

 D

Laryngomalacia

Q. 12

A child presents with features of upper respiratory tract infection. On investigation,it is found to have ‘thumbprint sign’. Diag­nosis is:

 A

Acute laryngotracheobronchitis

 B

Acute epiglottitis

 C

Acute laryngeal diphtheria

 D

Laryngomalacia

Ans. B

Explanation:

Q. 13

Thumb sign in lateral X-ray of neck seen in: 

 A

Epiglottitis

 B

Internal hemorrhage

 C

Saccular cyst

 D

Ca epiglottis

Q. 13

Thumb sign in lateral X-ray of neck seen in: 

 A

Epiglottitis

 B

Internal hemorrhage

 C

Saccular cyst

 D

Ca epiglottis

Ans. A

Explanation:

 

In epiglottis: A plain lateral soft tissue radiograph of neck shows the following specific features

  • Thickening of the epiglottis—the thumb sign
  • Absence of a deep well-defined vallecula—the vallecula sign

 

Steeple sign i.e. Narrowing of subglottic region is seen in chest X-ray of patients of laryngotracheobronchitis (i.e. croup).



Q. 14

In acute epiglottitis, common cause of death is: 

 A

Acidosis

 B

Respiratory obstruction

 C

Atelactasis

 D

Laryngospasm

Q. 14

In acute epiglottitis, common cause of death is: 

 A

Acidosis

 B

Respiratory obstruction

 C

Atelactasis

 D

Laryngospasm

Ans. B

Explanation:

 

Acute Epiglottitis         

  • Respiratory arrest is more likely in patients with rapidly progressive disease arid occurs within hours of onset of the illness
  • Other complications are rare but include epiglottic abscess, pulmonary edema secondary to relieving airway obstruction and thrombosis of internal jugular vein (Lemierre’s syndrome)
  • The main complication is death from respiratory arrest due to acute airway obstruction

Q. 15

The antibiotic of choice in acute epiglottitis pending culture sensitivity report is:

 A

Erythromycin

 B

Rolitetracycline

 C

Doxycycline

 D

Ampicillin

Q. 15

The antibiotic of choice in acute epiglottitis pending culture sensitivity report is:

 A

Erythromycin

 B

Rolitetracycline

 C

Doxycycline

 D

Ampicillin

Ans. D

Explanation:

 

 

  • Ampicillin or third generation cephalosporin are effective against H. influenzae and are given by parenteral route. – Dhingra 5/e, p 308
  • According to Harrison DOC are:

Ampicillin + Sulbactam (Not ampicillin alone)

Cefuroxime

Cefotaxime

Ceftriaxone

  • According to Scott’s Brown 7/ed vol-2 pg-2251

The antibiotics of choice are second and third generation cephalosporin. Ampicillin was often prescribed but resistant H.influenza are now emerging

  • According to Turner 10/e, p 390 

Chloramphenicol is the antibiotic of choice and it should be given intramuscularly or preferably intravenously. Amoxycillin or ampicillin is no longer advised as haemophilus organism are now sufficiently often resistant to make its use inappropi­rate.

 



Q. 16

Drug of choice for treatment of epiglottitis is 

 A

Ceftriaxone

 B

Ampicillin

 C

Chloramphenicol

 D

Clindamycin

Q. 16

Drug of choice for treatment of epiglottitis is 

 A

Ceftriaxone

 B

Ampicillin

 C

Chloramphenicol

 D

Clindamycin

Ans. A

Explanation:

 

Treatment of epiglottitis

  • Once the diagnosis of epiglottitis is made, endotracheal intubation must be performed immediately.
  • After an airway is established, cultures of the blood and epiglottis should be obtained and patient started on appropriate intravenous antibiotics to cover H. influenzae (Ceftriaxone or equivalent cephalosporins).

Third generation cephalosporins are preferred as first line agents because of increasing resistance to ampicillin. Ceftriaxone is the treatment of choice for epiglottitis.

Other antibotic options are :-

  • Ampicillin plus sulbactam
  • Cefuroxime
  • Clindamycin
  • Chloramphenicol
  • Cefotaxime

Intravenous antibiotics should be continued for 2-3 days, followed by oral antibiotics to complete a 10 days course.



Snoring and Obstructive Sleep Apnea

Snoring and Obstructive Sleep Apnea

Q. 1 A 45 year old male patient complains that he is often tired and has a headache almost every morning His wife says that her sleep is disturbed because of the patient’s loud snoring. Physical examination reveals leg edema. Hypertension, and cardiac arrhythmia. From which disorder is this patient most likely suffering?

 A Sleep wake schedule disorder
 B Obstructive sleep apnea
 C Narcolepsy
 D Delayed sleep phase syndrome
Q. 1 A 45 year old male patient complains that he is often tired and has a headache almost every morning His wife says that her sleep is disturbed because of the patient’s loud snoring. Physical examination reveals leg edema. Hypertension, and cardiac arrhythmia. From which disorder is this patient most likely suffering?

 A Sleep wake schedule disorder
 B Obstructive sleep apnea
 C Narcolepsy
 D Delayed sleep phase syndrome
Ans. B

Explanation:

In obstructive sleep apnea, airway obstruction results in snoring as well as failure to breathe during the night. The resulting anoxia causes frequent awakenings during the night so that the patient feels tired in the morning. Decreased oxygen availability may result in leg edema, hypertension, morning headaches, cardiac arrhythmias, and stroke in patients with obstructive sleep apnea. myocardial infarction by 50% to 75% within 5 years of cessation. The reduced risk for the other therapies are as follows:
•Postmenopausal estrogen replacement has a 44% decreased risk
• Mild to moderate alcohol consumption has a 25% to 45% decreased risk
• Exercise has a 45% decreased risk.
•Prophylactic low dose aspirin has a 33% decreased risk, particularly in the incidenc of the first acute myocardial infarction in middle aged men and women; however, there is no reduction in overall total cardiovascular mortality. Patients over 50 years of age with risk factors for coronary artery disease are the group most likely to benefit, it is not good for prophylaxis if the patient has poorly controlled
hypertension, because there is a danger for a hemorrhagic stroke.


Q. 2

Modafinil is approved by FDA for treatment of all, except:

 A

Narcolepsy

 B

Shift work syndrome (SWS)

 C

Obstructive sleep apnea syndrome (OSAS)

 D

Lethargy in depression

Q. 2

Modafinil is approved by FDA for treatment of all, except:

 A

Narcolepsy

 B

Shift work syndrome (SWS)

 C

Obstructive sleep apnea syndrome (OSAS)

 D

Lethargy in depression

Ans. D

Explanation:

Modafinil is an FDA approved drug in the treatment of obstructive sleep apnea, shift work disorder and narcolepsy.

It is not FDA approved in the treatment of lethargy in major depression.

Ref: Sleepiness: Causes, Consequences and Treatment By Michael J. Thorpy, Pages 415-6


Q. 3

Which of the following condition is treated by laser-assisted uvulopalatoplasty?

 A

Snoring

 B

Pharyngotonsillitis

 C

Cleft palate

 D

Stammering

Q. 3

Which of the following condition is treated by laser-assisted uvulopalatoplasty?

 A

Snoring

 B

Pharyngotonsillitis

 C

Cleft palate

 D

Stammering

Ans. A

Explanation:

Laser uvulopalatoplasty (LAUP) is the treatment for snoring.

In LAUP, the redundant soft tissue is either excised or ablated.

It helps to avoid most of the postoperative morbidity, as well as providing a good hemostatic benefit during surgery.

The CO2 laser is the laser most commonly used by otolaryngologists for this operation.


Q. 4

Modafinil is approved by FDA for treatment of all except:

 A

Obstructive sleep apnea syndrome (OSAS)

 B

Shift work syndrome (SWS)

 C

Narcolepsy

 D

Lethargy in depression

Q. 4

Modafinil is approved by FDA for treatment of all except:

 A

Obstructive sleep apnea syndrome (OSAS)

 B

Shift work syndrome (SWS)

 C

Narcolepsy

 D

Lethargy in depression

Ans. D

Explanation:

D i.e. Lethargy in major depression

Modafinil is not approved by FDA for treatment of lethargy in depression.

Modafinil is a novel wake promoting agent that has FDA approval for narcolepsy, shift work sleep disorder and as adjunctive treatment of obstructive sleep apnea/hypopnea syndrome.

  • Modafinil is a schedule IV medication, FDA approved for treating the excessive day time fatigue of narcolepsyQ.
  • (CMDT). Modafinil is now the drug of choice, principally because it is associated with fewer side effects than older stimulants and has a long half life (Harrison).
  • Modafinil (200 mg, taken 30-60 min before the stant of each night shift) is approved by US-FDA for excessive sleepiness during night work in patients with shift work disorder (SWD). Although treatment with modafinil significantly increases sleep latency & reduces the risk of lapses of attention during night work in patients with SWD (Harrison).
  • Pharmacological therapy for obstructive sleep apnea syndrome (OSAS) is disappointing (CMDT). Unfortunately, no drugs are clinically useful in the prevention or reduction of apneas & hyponeas. A marginal improvement in sleepiness in patients who remain sleepy despite continuous positive airway pressure (CPAP) can be produced by modafinil, but the clinical value is debatable and the financial cost significant (Harrison). CPAP and MRS (mandibular repositioning split) are the two most widely used and best endence based therapies.
  • Modafinil (provigil / aleretec / modavigil) is a stimulant drug by cephalon & is approved US-Food & drug administration (US – FDA) for the treatment of narcolepsy, shift work disorder, and excessive day time sleepiness (idiopathic hypersomnia) associated with obstructive sleep apneaQ.
  • Although modafinil is thought to be effective in t/t of attention defecit hyperactinity disorder (ADHD), it was rejected by FDA for use by children for that purpose. It is also used off label to treat sedation & fatigue in depression, fibrmyalgia, chronic fatigue syndrome, myotonic dystrophy, opioid induced sleepiness, spastic cerebral palsy, parkihson’s disease, Schizophrenia and cocaine addiction.

Q. 5

Modafinil is used as an adjunct in the treatment of?

 A

Sleep apnea syndrome

 B

Narcolepsy

 C

AMID

 D

Imsomnia

Q. 5

Modafinil is used as an adjunct in the treatment of?

 A

Sleep apnea syndrome

 B

Narcolepsy

 C

AMID

 D

Imsomnia

Ans. A

Explanation:

Ans. is ‘a’ i.e., Sleep apnea syndrome

Modatinil is approved for treatment of : (i) narcolepsy, (ii) multiple sclerosis (to relieve fatigue), (iii) shift workers and, (iv) obstructive sleep apnea.


Q. 6

Laser uvulopharyngopalatoplasty is the surgery done for which of the following?

 A

Snoring

 B

Recurrent pharyngotonsilitis

 C

Cleft palate

 D

Stammering

Q. 6

Laser uvulopharyngopalatoplasty is the surgery done for which of the following?

 A

Snoring

 B

Recurrent pharyngotonsilitis

 C

Cleft palate

 D

Stammering

Ans. A

Explanation:

Snoring : Noisy breathing, a rough, rattling inspiratory noise produced by vibration of pendulous soft palate or occasionally of vocal cords, during sleep.

  • Snoring indicates some obstruction in upper airway and represents a continum of the similar pathology as of Obstructive Sleep Apnea (OSA), where snoring is on one end and OSA on the other.
  • Management of snoring without Obstructive Sleep Apnea.
  • Uvulopalatoplasty-Laser Assisted Uvulopalatoplasty (LAUP) or Bovie-Assisted Uvulopalatoplasty (BAUP). It can be performed under Local A naesthesia in OPD. In this procedure uvula is amputated and 1 cm trenches are created in the soft palate on either side of uvula. The soft palate elevates and stiffens after healing.
  • Uvulopalatopharyngoplasty- It is the M/C surgery performed for Obstructive Sleep Apnea. It is also very effective in treating snoring.

Q. 7

All of the following are true about obstructive sleep apnea syndrome except:

 A

Females affected more than males

 B

Commonly associated with hypertension

 C

Day time sleepiness is seen

 D

>5 episodes of apnea per hour

Q. 7

All of the following are true about obstructive sleep apnea syndrome except:

 A

Females affected more than males

 B

Commonly associated with hypertension

 C

Day time sleepiness is seen

 D

>5 episodes of apnea per hour

Ans. A

Explanation:

 

OSAHS occurs in around 1-4% of middle-aged males and is about half as common in women.


Q. 8

A 36 years old obese man was suffering from hyperten­sion and snoring. Patient was a known smoker. In Sleep test, there were 5 apnea/hyperapneas episodes per hour. He was given antihypertensives and advised to quit smoking. Next line of management:

 A

Uvulopalatopharyngeoplasty

 B

Weight reduction and diet plan

 C

Nasal CPAP

 D

Mandibular repositioning sling

Q. 8

A 36 years old obese man was suffering from hyperten­sion and snoring. Patient was a known smoker. In Sleep test, there were 5 apnea/hyperapneas episodes per hour. He was given antihypertensives and advised to quit smoking. Next line of management:

 A

Uvulopalatopharyngeoplasty

 B

Weight reduction and diet plan

 C

Nasal CPAP

 D

Mandibular repositioning sling

Ans. B

Explanation:

 

 

The primary treatments of obstructive sleep apnea are: weight loss in those who are overweight, continuous positive airway pressure, and mandibular advancement devices. There is little evidence to support the use of medications or surgery.

Continuous positive airway pressure (CPAP) is effective for both moderate and severe disease. It is the most common treatment for obstructive sleep apnea.

Adherence to CPAP is generally better than that to an MRS, and there is evidence that CPAP improves driving, whereas there are no such data on MRSs. Thus, CPAP is the current treatment of choice (for both moderate and severe disease). However, MRSs are evidence-based second-line therapy in those who fail CPAP.- Harrison 18/p2189

There is no proven evidence that pharyngel surgery, including uvulopalatopharyngoplasty (whether by scalpel, laser or thermal techniques) helps OSAHS patients.


Q. 9

Associated with obstructive sleep apnea are all of the following except:   

March 2011

 A

Acromegaly

 B

Obese

 C

Males

 D

Protruding jaw

Q. 9

Associated with obstructive sleep apnea are all of the following except:   

March 2011

 A

Acromegaly

 B

Obese

 C

Males

 D

Protruding jaw

Ans. D

Explanation:

Ans. D: Protruding jaw

Predisposing factors to the sleep apnea/ hypoapnea syndrome include being male, which doubles the risk probably due to a testosterone effect on the upper airway, and obesity, found in about half of the patients, because parapharyngeal fat deposits tend to narrow the pharynx.

Nasal obstruction or a recessed mandible can further exacerbate the problem

Acromegaly and hypothyroidism also predispose by causing submucosal infiltration and narrowing of the upper airway



Ventricular system

Ventricular system

Q. 1

Junction of the anterior horn and posterior horn of lateral ventricle is called as?

 A

Trigone of lateral ventricle

 B

Body of lateral ventricle

 C

Foramen of Monro

 D

Cerebral Aqueduct

Q. 1

Junction of the anterior horn and posterior horn of lateral ventricle is called as?

 A

Trigone of lateral ventricle

 B

Body of lateral ventricle

 C

Foramen of Monro

 D

Cerebral Aqueduct

Ans. A

Explanation:

Trigone of lateral ventricle

Trigone of the lateral ventricle is a triangular prominence of the floor of the lateral ventricle at the transition between occipital (posterior) and temporal (anterior) horn

The lateral ventricles connect to the central third ventricle through the interventricular foramen of Monro.


Q. 2

Drainage of CSF from lateral to third ventricle is through:

 A

Foramen of munro

 B

Foramen of lushka

 C

Foramen of magendi

 D

Aqueduct of sylvius

Q. 2

Drainage of CSF from lateral to third ventricle is through:

 A

Foramen of munro

 B

Foramen of lushka

 C

Foramen of magendi

 D

Aqueduct of sylvius

Ans. A

Explanation:

Foramen of munro


Q. 3

Magendie foramen or the median aperture drains CSF from which of the following structures to the cisterna magna?

 A

Lateral ventricle

 B

3rd ventricle

 C

4th ventricle

 D

Interpeduncular fossa

Q. 3

Magendie foramen or the median aperture drains CSF from which of the following structures to the cisterna magna?

 A

Lateral ventricle

 B

3rd ventricle

 C

4th ventricle

 D

Interpeduncular fossa

Ans. C

Explanation:

The median aperture (“Foramen of Magendie”) drains CSF from the fourth ventricle into the cisterna magna. Cisterna magna occupies the interval between inferior surface of cerebellum and posterior aspect of medulla oblongata.

The two lateral apertures (foramina of Luschka), one on the left and one on the right, are the primary routes for drainage of cerebrospinal fluid from the fourth ventricle into the cerebellopontine angle cistern. The foramen on axial images is posterior to the pons and anterior to the caudal cerebellum.


Q. 4

What is the junction of anterior horn and posterior horn of lateral ventricle called?

 A

Trigone of lateral ventricle

 B

Body of lateral ventricle

 C

Foramen of Monro

 D

Cerebral Aqueduct

Q. 4

What is the junction of anterior horn and posterior horn of lateral ventricle called?

 A

Trigone of lateral ventricle

 B

Body of lateral ventricle

 C

Foramen of Monro

 D

Cerebral Aqueduct

Ans. A

Explanation:

The lateral ventricle comprises a cavity within the telencephalon. It is divided into anterior horn, body, a posterior horn and an inferior horn. The junction between the body of lateral ventricle and its posterior and inferior horn is known as the atrium or collateral trigone. 

  • Bodies of the lateral ventricle are separated by paired septi pellucidi.
  • Choroid plexus of the lateral ventricle is located anteromedially in the body and superomedially in the temporal horn. The anterior horn and posterior horn do not contain elements of the choroid plexus.
  • Lateral ventricle communicate with the third ventricle via the paired foramina of Monro at the junction of anterior horn and body of the lateral ventricle inferiorly. 

Q. 5

Foramen of magendie, drains CSF from which midline structure and exits from it?

 A

Third ventricle

 B

Fourth ventricle

 C

Lateral ventricle

 D

All of the above

Q. 5

Foramen of magendie, drains CSF from which midline structure and exits from it?

 A

Third ventricle

 B

Fourth ventricle

 C

Lateral ventricle

 D

All of the above

Ans. B

Explanation:

Fourth ventricle is the last ventricle in the cerebellum, its T shaped roof has three apertures which communicates with the subarachonoid space. Foramen of magendi a median aperture is present doraslly in the roof, it communicates with the cisterna magna. Foramen of luschka is a lateral aperture which is present on right and left side. It drains into the cerebellopontine angle cistern.


Q. 6

Fourth ventricle develops from?

 A

Telencephalon

 B

Mesencephalon

 C

Diencephalon

 D

Rhombencephalon

Q. 6

Fourth ventricle develops from?

 A

Telencephalon

 B

Mesencephalon

 C

Diencephalon

 D

Rhombencephalon

Ans. D

Explanation:

Lateral ventricle develops from the cavity of telencephalon. Third ventricle develops from diencephalon. Cavity of mesencephalon remains narrow and forms the aqueduct, while the cavity of rhombencephalon forms the fourth ventricle.


Q. 7

Which of the following foramen is responsible for the drainage of CSF from lateral to third ventricle?

 A

Foramen of Monro

 B

Foramen of Luschka

 C

Foramen of Magendie

 D

Cerebral aqueduct

Q. 7

Which of the following foramen is responsible for the drainage of CSF from lateral to third ventricle?

 A

Foramen of Monro

 B

Foramen of Luschka

 C

Foramen of Magendie

 D

Cerebral aqueduct

Ans. A

Explanation:

The two interventricular foramens, or foramens of Monro, are apertures between the column of the fornix and the anterior end of the thalamus. The two lateral ventricles communicate with the third ventricle through these foramens and drainage of CSF occurs.

 
The lateral aperture (foramen of Luschka) is the opening of the lateral recess into the subarachnoid space near the flocculus of the cerebellum. A tuft of choroid plexus is commonly present in the aperture and partly obstructs the flow of CSF from the fourth ventricle to the subarachnoid space. 
 
The medial aperture (foramen of Magendie) is an opening in the caudal portion of the roof of the ventricle. Most of the outflow of CSF from the fourth ventricle passes through this aperture.
 
The cerebral aqueduct is a narrow, curved channel running from the posterior third ventricle into the fourth.
 
Ref: Waxman S.G. (2010). Chapter 11. Ventricles and Coverings of the Brain. In S.G. Waxman (Ed), Clinical Neuroanatomy, 26e.

Q. 8

Floor of 4th ventricle is not formed by ?

 A

Sulcus limitans

 B

Anterior medullary velum

 C

Posterior surface of pons

 D

Posterior surface of medulla

Q. 8

Floor of 4th ventricle is not formed by ?

 A

Sulcus limitans

 B

Anterior medullary velum

 C

Posterior surface of pons

 D

Posterior surface of medulla

Ans. C

Explanation:

Floor of the fourth ventricle is not formed by Anterior medullary velum.Anterior medullary velum forms the roof.All the other options are associated with the floor of the ventricle.
 
Fourth ventricle: It is a tent like structure, it is situated in front of the cerebellum and behind the pons and upper half of the medulla oblongata. It is lined by ciliated epithelium.
 
Communications:
1. Cerebral aqueduct (of Sylvius): in the superior median plane (superior angle), it communicates with third ventricle.
2. Central spinal canal: in the inferior median plane (inferior angle).
 
Boundries:
 
1. Roof consists of
  • Upper portion of roof: The superior peduncle and the anterior medullary velum; 
  • Lower portion of roof: The posterior medullary velum, the epithelial lining of the ventricle covered by the tela chorioidea inferior and the taeniae of the fourth ventricle.
2. Floor:
  • Upper part :Fascial colliculus on the dorsal surface of pons.
  • Intermediate part:Vestibular nuclei medulllary striae.
  • Lower part:Upper part of medulla oblongata containing hypoglossal and vagal triangles.
3. Laterally: bounded by superior and inferior cerebellar peduncles,gracile tubercle and cuneate tubercle.
 
Apertures: Through these, the CSF leaves the fourth ventricle to the subarachnoid space
  • One median foramen (foramen of Magendie): in the lower part of the inferior medullary velum.
  • Two lateral foramens (foramens of Lushka): one in each lateral recess.
Ref:
1. Color atlas of neuroscience: neuroanatomy and neurophysiology, By Ben Greenstein, Adam. Greenstein, Page 16
2. BD Chaurasia’s Human Anatomy,Volu III, 4Th edition, Page 397

Q. 9

All are seen in the floor of 3rd ventricle except?

 A

Infundibulum

 B

Oculomotor nerve

 C

Mammillary body

 D

Optic chiasmaFourth Ventricle

Q. 9

All are seen in the floor of 3rd ventricle except?

 A

Infundibulum

 B

Oculomotor nerve

 C

Mammillary body

 D

Optic chiasmaFourth Ventricle

Ans. B

Explanation:

B i.e. Occulomotor Nerve 


Q. 10

True about 4thventricle is-

 A

Rhomboid fossa forms floor

 B

Choroid plexus lies at its floor

 C

Connection between two cerebral hemispheres

 D

Lies inferior to inferior cerebellar peduncle

Q. 10

True about 4thventricle is-

 A

Rhomboid fossa forms floor

 B

Choroid plexus lies at its floor

 C

Connection between two cerebral hemispheres

 D

Lies inferior to inferior cerebellar peduncle

Ans. A

Explanation:

A i.e., Rhomboid fossa forms the floor


Q. 11

Which nucleus is not found in the floor of the fourth ventricle

 A

Abducens N

 B

Dorsal vagal nuclei

 C

Dorsal vagal nuclei

 D

None

Q. 11

Which nucleus is not found in the floor of the fourth ventricle

 A

Abducens N

 B

Dorsal vagal nuclei

 C

Dorsal vagal nuclei

 D

None

Ans. D

Explanation:

D i.e., None


Q. 12

Cerebral aqueduct (Duct of Sylvius) – which is true:

 A

3 cms in length

 B

Connects III. ventricle to IV ventricle

 C

Connects III. ventricle to IV ventricle

 D

Connects two lateral ventricles

Q. 12

Cerebral aqueduct (Duct of Sylvius) – which is true:

 A

3 cms in length

 B

Connects III. ventricle to IV ventricle

 C

Connects III. ventricle to IV ventricle

 D

Connects two lateral ventricles

Ans. B

Explanation:

B i.e., Connects HI ventricle to IV ventricle

Rhomboid fossa or floor of 4th ventricle has abducent motor nucleus, dorsal motor nucleus of vagus, hypoglossal nucleus, and facial nucleus.

– 4th ventricle communicates through cerebral aqueduct of sylvius with 3rd ventricle.


Q. 13

CSF is principally secreted by ‑

 A

Choroid plexus

 B

Arachnoid granulation

 C

Floor of fourth ventricle

 D

Periaqueductal grey

Q. 13

CSF is principally secreted by ‑

 A

Choroid plexus

 B

Arachnoid granulation

 C

Floor of fourth ventricle

 D

Periaqueductal grey

Ans. A

Explanation:

A i.e. Choroid plexus


Q. 14

Obstruction to the flow of CSF at the aqueduct of sylvius will most likely lead to enlargement of ‑

 A

All of the ventricles

 B

Only lateral ventricle

 C

Only fourth ventricle

 D

Both lateral and third ventricles

Q. 14

Obstruction to the flow of CSF at the aqueduct of sylvius will most likely lead to enlargement of ‑

 A

All of the ventricles

 B

Only lateral ventricle

 C

Only fourth ventricle

 D

Both lateral and third ventricles

Ans. D

Explanation:

Ans. is `d’ i.e., Both lateral and third ventricle

o CSF is produced by choroid plexus in the lateral and III ventricles. Then it flows through the aqueduct ofsylvius into the 4th ventricle and from there into the subarachnoid space to be absorbed by the arachnoid villi.

o Obviously any obstruction in the aqueduct of sylvius will lead to enlargement of the proximal ventricles (i.e. both lateral and HP’ ventricles).


Q. 15

Floor of 4th ventricle has ‑

 A

Infundibulum

 B

Vagal triangle

 C

Mammillary body

 D

Tuber cincrium

Q. 15

Floor of 4th ventricle has ‑

 A

Infundibulum

 B

Vagal triangle

 C

Mammillary body

 D

Tuber cincrium

Ans. B

Explanation:

Floor of 4th ventricle (Rhomboid fossa)

  • It is diamond or rhomboidal shaped and is formed by posterior surface of pons (upper triangular part or pontine part) and dorsal surface of medulla (lower triangular part or medullary part) junction of pons and medulla forms intermediate part. Features of 4th ventricle are :‑
  1. Median sulcus (a midline groove) divides the floor into two symmetrical halves.
  2. Medial eminence is present an each side of median sulcus. It presents facial colliculus formed by genu (recurving fibers) of facial nerve looping around abducent nucleus. Facial colliculus lies in pons (i.e. in pontine part of floor).
  3. Hypoglossal triangle overlying hypoglossal nucleus and vagal triangle overlying dorsal nucleus of vagus. Both of these triangle lie in the medulla (medullary part of floor).
  4. Vestibular area overlies vestibular nuclei, partly in pons and partly in medulla.
  5. Sulcus coeruleus, a bluish area due to presence of pigmented neurons containing substantia ferruginea.
  6. Superior and inferior favea.

Q. 16

Anterior horn of lateral ventricle is closed anteriorly by –

 A

Thalamus

 B

Septum pellucidum

 C

Lamina terminalis

 D

Corpus callosum

Q. 16

Anterior horn of lateral ventricle is closed anteriorly by –

 A

Thalamus

 B

Septum pellucidum

 C

Lamina terminalis

 D

Corpus callosum

Ans. D

Explanation:

Anterior horn of lateral ventricle is closed anteriorly by the genu and rostrum of corpus callosum.

Lateral ventricle

Two lateral ventricles are the cavities of cerebral hemisphere (one in each hemisphere). Each lateral ventricle communicates with third ventricle through interventricular foramen of Monro.

It is divisile into four parts :‑

1) Central part (body) : It is located in the medial parts of frontal and parietal lobes. It extends from interventricular foramen (of Monro) in front to splenium of corpus callosum behind. It has choroid plexus. It has :- o Roof : Formed by corpus callosum.

  1. Floor : Formed form lateral to medial by caudate nucleus (body), stria terminalis, thalamostriate vein, and lateral part of upper surface of thalamus.
  2. Medial wall (partition between two lateral ventricles) : By septum pellucidum and body of fornix.

2) Anterior horn : It lies in front of interventricular foramen of Monro extending into the frontal lobe. It has no choroid plexus. Its bondries are :-

  • Anterior : Posterior surface of genu and rostrum of corpus callosum.
  • Roof : Anterior part of trunk of corpus callosum.
  • Floor : Head of caudate nucleus and upper surface of rostrum of corpus callosum.
  • Medial (partition) : Septum pellucidum and column of fornix.

3) Posterior horn : It lies behind splenium of corpus callosum and extends into occipital lobe. It may be variable in size (may be absent). It has no choroid plexus. Its boundries are :-

  1. Floor and medial wall : Bulb of posterior horn raised by forceps major and calcar avis, an elevation raised by calcarine sulcus (anterior part).
  2. Roof and lateral wall : Tapetum

4) Inferior horn : It is the largest horn and extends into temporal lobe. It has choroid plexus. Its boundries are

  1. Roof and lateral wall : Tapetum, tail of caudate nucleus, stria terminalis and amygdaloid body.
  2. Floor : Collateral eminence (elevation by collateral sulcus) and hippocampus medially.

Q. 17

Ventricles of brain are lined by ‑

 A

Ependymocytes

 B

Astrocytes

 C

Oligodendrocytes

 D

Podocytes

Q. 17

Ventricles of brain are lined by ‑

 A

Ependymocytes

 B

Astrocytes

 C

Oligodendrocytes

 D

Podocytes

Ans. A

Explanation:

Ventricles of brain are lined by ependyma (ependymocytes).

Ventricles of brain

These are cavities in the brain lined by ependyma and filled with CSF.

They contain choroid plexuses wich secrete CSF.

These are four fluid filled intercommunicating cavities within the brain :-

i) Two lateral ventricles (right and left),

ii) Third ventricle, and

iii) Fourth ventricle. o Lateral ventricle communicates with third ventricle by interventricular foramen (foramen of Monro).

Third ventricle communicates with fourth ventricle by cerebral aqueduct (aqueduct of sylvius).

Fourth ventricle communicates with subarachnoid space by a median foramen (Mangendie) and two lateral (Luschka) foramina.




Peritoneal folds- lesser omentum & greater omentum

PERITONEAL FOLDS- LESSER OMENTUM & GREATER OMENTUM

Q. 1

What will be the initial management in a hemodynamically stable patient with an anterior abdominal stab injury presenting with a tag of omentum protruding through the abdominal wall near the umbilicus and showing no signs of peritonitis?

 A

FAST

 B

CECT Abdomen

 C

Exploratory Laparotomy

 D

Local Wound Exploration and Suturing

Q. 1

What will be the initial management in a hemodynamically stable patient with an anterior abdominal stab injury presenting with a tag of omentum protruding through the abdominal wall near the umbilicus and showing no signs of peritonitis?

 A

FAST

 B

CECT Abdomen

 C

Exploratory Laparotomy

 D

Local Wound Exploration and Suturing

Ans. B

Explanation:

emodynamically Stable patients with omental protrusion should be investigated thoroughly first  with an abdomino-pelvic contrast enhanced CT scan, before proceeding to surgery.

Exploratory Laparotomy is not an absolute indication for this case.

 
Ref: Reference: Trauma: A Comprehensive Emergency Medicine Approach By Eric Legome, Page222; Imaging & Intevention in Abdominal trauma (springer) 2004, Page 394; Emergency management of Trauma Patient: Cases, Algorihm, Evidence (Lippincott- Williams) 2006, Page 97; Imaging and intervention in abdominal trauma R. F. Dondelinger, Gina M. Allen, Page 392.

Q. 2

Blood supply to greater omentum is provided by:

 A

Gastric artery

 B

Gastroepiploic artery

 C

Splenic artery

 D

All of the above

Q. 2

Blood supply to greater omentum is provided by:

 A

Gastric artery

 B

Gastroepiploic artery

 C

Splenic artery

 D

All of the above

Ans. B

Explanation:

The blood supply to the greater omentum is derived from the right and left gastroepiploic arteries.

The venous drainage parallels the arterial supply to a great extent, with the left and right gastroepiploic veins ultimately draining into the portal system.
Ref: Schwartz’s principle of surgery 9th edition, chapter 35.

 


Q. 3

The greater omentum is derived from which of the following embryonic structures?

 A

Dorsal mesoduodenum

 B

Dorsal mesogastrium

 C

Pericardioperitoneal canal

 D

Pleuropericardial membranes

Q. 3

The greater omentum is derived from which of the following embryonic structures?

 A

Dorsal mesoduodenum

 B

Dorsal mesogastrium

 C

Pericardioperitoneal canal

 D

Pleuropericardial membranes

Ans. B

Explanation:

Both the omental bursa and the greater omentum are derived from the dorsal mesogastrium, which is the mesentery of the stomach region.

Must know:

The dorsal mesoduodenum is the mesentery of the developing duodenum, which later disappears so that the duodenum and pancreas come to lie retroperitoneally.

The pericardioperitoneal canal embryologically connects the thoracic and peritoneal canals.
The pleuropericardial membranes become the pericardium and contribute to the diaphragm.

Q. 4

What is the number of layers in greater omentum?

 A

1

 B

2

 C

3

 D

4

Q. 4

What is the number of layers in greater omentum?

 A

1

 B

2

 C

3

 D

4

Ans. D

Explanation:

The greater omentum is folded back on itself and is therefore made up of four layers of closely applied visceral peritoneum, which are separated by variable amounts of adipose tissue.


Q. 5

Lesser omentum has following contents except

 A

Hepatic vein

 B

Hepatic artery

 C

Portal vein

 D

Bile duct

Q. 5

Lesser omentum has following contents except

 A

Hepatic vein

 B

Hepatic artery

 C

Portal vein

 D

Bile duct

Ans. A

Explanation:

A. i.e. Hepatic vein



Infrahyoid muscles

INFRAHYOID MUSCLES

Q. 1  All  of  the  following  muscles are  attached to oblique line of thyroid cartilage except
 A Superior constrictor
 B Inferior constrictor
 C Thyrohyoid
 D Stern thyroid
Q. 1  All  of  the  following  muscles are  attached to oblique line of thyroid cartilage except
 A Superior constrictor
 B . Inferior constrictor
 C Thyrohyoid
 D Stern thyroid
Ans. A

Explanation:

Superior constrictor

MUSCLE

Superior constrictor (Constrictor

of pharynx)

ORIGIN

i. Pterygoid hamulus

ii. Pterygomandibular raphe

iii. Medial surface of mandible (near lower      attachment of pterygomandibular raphe

INSERTION

Median raphe on posterior wall of

pharynx

Inferior constrictor (Constrictor of

Two parts: pharynx)

i. Thyropharyngeus – from thyroid

cartilage (oblique line of thyroid cartilage)

ii. Cricopharyngeus  –  from  cricoid

cartilage

Median raphe on posterior wall of

pharynx

Sternothyroid (Infrahyoid muscle)

i. Posterior surface of manubrium

sterni

ii. Adjoining  part  of  first  costal cartilage

Oblique line of thyroid cartilage

Thyrohyoid (Infrahyoid muscle)

Oblique line of thyroid cartilage

Lower border of body and greater

cornua of hyoid bone


Q. 2

All of the following are Digastric muscles, except?

 A

Muscle fibers in the ligament of Treitz

 B

Omohyoid

 C

Occipitofrontalis

 D

Sternocleidomastoid

Q. 2

All of the following are Digastric muscles, except?

 A

Muscle fibers in the ligament of Treitz

 B

Omohyoid

 C

Occipitofrontalis

 D

Sternocleidomastoid

Ans. D

Explanation:

Digastric muscles refers to muscles with two bellies. Sternocleidomastoid has two heads but it does not have two bellies and hence this muscle cannot be termed as a digastric muscle.


Q. 3

Which of the following hyoid muscles is an important landmark in both the anterior and posterior triangles of the neck?

 A

Geniohyoid

 B

Mylohyoid

 C

Omohyoid

 D

Sternohyoid

Q. 3

Which of the following hyoid muscles is an important landmark in both the anterior and posterior triangles of the neck?

 A

Geniohyoid

 B

Mylohyoid

 C

Omohyoid

 D

Sternohyoid

Ans. C

Explanation:

The omohyoid muscle is an important landmark in both the anterior and posterior triangles of the neck. In the anterior triangle, the superior belly of the omohyoid muscle serves as the superolateral border of the muscular triangle and the anterior border of the carotid triangle. In the posterior triangle, the inferior belly of the omohyoid muscle divides the omoclavicular triangle from the occipital triangle. So, in both the anterior and posterior triangles, the omohyoid is an important muscle that subdivides the triangles.
 
All of the other listed muscles are associated with the anterior triangle only. Geniohyoid runs from the hyoid bone to the genu of the mandible.it is a deep muscle on the floor of the mouth. It is found deep to the submental triangle. Mylohyoid is another muscle associated with the floor of the mouth.It is in the submandibular triangle and the submental triangle. Sternohyoid is a strap muscle;it is in the muscular triangle. 

Q. 4

Which muscle is innervated by a branch of the ansa cervicalis?

 A

Sternocleidomastoid

 B

Platysma

 C

Sternohyoid

 D

Trapezius

Q. 4

Which muscle is innervated by a branch of the ansa cervicalis?

 A

Sternocleidomastoid

 B

Platysma

 C

Sternohyoid

 D

Trapezius

Ans. C

Explanation:

The sternohyoid muscle is one of the strap muscles which runs from the manubrium and the sternal end of the clavicle to the hyoid bone. It is innervated by the ansa cervicalis, and it depresses and stabilizes the hyoid bone. Platysma is a muscle of facial expression; it is innervated by the cervical branch of CN VII, the facial nerve. Sternocleidomastoid and trapezius are both innervated by the accessory nerve (CN XI). Sternocleidomastoid receives fibers from C2 and C3 for proprioception, while trapezius receives proprioceptive fibers from C3 and C4.

Q. 5

All are elevators of larynx except:

 A

Thyrohyoid

 B

Digastric

 C

Stylohyoid

 D

mylohyoid

Q. 5

All are elevators of larynx except:

 A

Thyrohyoid

 B

Digastric

 C

Stylohyoid

 D

mylohyoid

Ans. A

Explanation:

 

 The main laryngeal elevators are: Digastric anterior and posterior, the stylohyoid, mylohyoid, geniohyoid, genioglossus, hyoglossus, and thyropharyngeus muscles



Nasopharyngeal Angiofibroma

Nasopharyngeal Angiofibroma

Q. 1

A 15 year old boy presents with unilateral nasal blockage, mass in the cheek and epistaxis; likely diagnosis is:

 A

Nasopharyngeal ca

 B

Angiofibroma

 C

Inverted papilloma

 D

None of the above

Q. 1

A 15 year old boy presents with unilateral nasal blockage, mass in the cheek and epistaxis; likely diagnosis is:

 A

Nasopharyngeal ca

 B

Angiofibroma

 C

Inverted papilloma

 D

None of the above

Ans. B

Explanation:

Q. 2

A 14 year boy presented with unilateral nasal blockade, mass in the cheek and epistaxis. What is the likely diagnosis?

 A

Nasopharyngeal Ca

 B

Inverted papilloma

 C

Angiofibroma

 D

Thrombocytopenia

Q. 2

A 14 year boy presented with unilateral nasal blockade, mass in the cheek and epistaxis. What is the likely diagnosis?

 A

Nasopharyngeal Ca

 B

Inverted papilloma

 C

Angiofibroma

 D

Thrombocytopenia

Ans. C

Explanation:

Q. 3

Nasopharyngeal angiofibromas are most frequently seen –

 A

In the second decade

 B

In the third decade

 C

In the fourth

 D

In the fifth and sixth decades

Q. 3

Nasopharyngeal angiofibromas are most frequently seen –

 A

In the second decade

 B

In the third decade

 C

In the fourth

 D

In the fifth and sixth decades

Ans. A

Explanation:

Ans. is ‘a’ i.e., In the Second decade

o Nasopharyngeal angiofibroma is a highly vascular tumor that occurs almost exclusively in adolescent males.


Q. 4

Hypotensive Anesthesia in nasopharyngeal angiofibroma is/are given by:

 A

Propofol

 B

Phentolamine

 C

Halothane

 D

b and c

Q. 4

Hypotensive Anesthesia in nasopharyngeal angiofibroma is/are given by:

 A

Propofol

 B

Phentolamine

 C

Halothane

 D

b and c

Ans. D

Explanation:

B, C i.e. Phentolamine; Halothane

Hypotensive anesthesia used to facilitate vessel surgery such as clipping of intracranial aneurysm, excision of highly vascular tumor (eg nasopharyngeal angiofibroma)(2 is given by variable combinations of vasodialators (sodium nitroprusside, nitroglycrine), ganglion blocker (phentolamine, trimethaphan), inhalation agent (isoflurane, halothane) and /3-blockersQ.


Q. 5

A child with unilateral nasal obstruction along with a mass in cheek and profuse and recurrent epistaxis. Diagnosis is 

 A

Glomus tumor

 B

Antrochoanal polyp

 C

Juvenile nasal angiofibroma

 D

Rhinolith

Q. 5

A child with unilateral nasal obstruction along with a mass in cheek and profuse and recurrent epistaxis. Diagnosis is 

 A

Glomus tumor

 B

Antrochoanal polyp

 C

Juvenile nasal angiofibroma

 D

Rhinolith

Ans. C

Explanation:

Q. 6

Nasopharyngeal angiofibroma is:

 A

Benign

 B

Malignant

 C

Benign but potentially malignant

 D

None of the above

Q. 6

Nasopharyngeal angiofibroma is:

 A

Benign

 B

Malignant

 C

Benign but potentially malignant

 D

None of the above

Ans. A

Explanation:

 

  • Nasopharyngeal fibroma is the most common benign tumor of nasopharynx.
  • Most common site is posterior part of nasal cavity close to the margin of Sphenopalatine foramen.
  • Though it is a benign tumor, it is locally invasive and destroys the adjoining structures.
  • Juvenine Angiofibroma is uncommon, benign and extremely vascular tumor that arises in the tissues within the sphenopalatine foramen.

Q. 7

A 10 years child has unilateral nasal obstruction epistaxis, swelling over cheek, the diagnosis is:

 A

Nasal polyp

 B

Nasopharyngeal carcinoma

 C

Angiofibroma

 D

Foreign bodies

Q. 7

A 10 years child has unilateral nasal obstruction epistaxis, swelling over cheek, the diagnosis is:

 A

Nasal polyp

 B

Nasopharyngeal carcinoma

 C

Angiofibroma

 D

Foreign bodies

Ans. C

Explanation:

Q. 8

A 15-year-aged boy presents with unilateral nasal blockade mass in the cheek and epistaxis; likely diagnosis is:

 A

Nasopharyngeal Ca

 B

Angiofibroma

 C

Inverted papilloma

 D

None of the above

Q. 8

A 15-year-aged boy presents with unilateral nasal blockade mass in the cheek and epistaxis; likely diagnosis is:

 A

Nasopharyngeal Ca

 B

Angiofibroma

 C

Inverted papilloma

 D

None of the above

Ans. B

Explanation:

This is Typical Presentation of Nasopharyngeal Fibroma/Angiofibroma

  • Nasopharyngeal fibroma is most common benign tumor of nasopharynx.
  • Most common site is posterior part of nasal cavity close to the margin of sphenopalatine foramen.
  • Sex : Seen almost exclusively in males (testosterone dependent).
  • Age : 10-20 years (2nd decade).
  • Clinical features:   – Most common symptom is profuse and recurrent epistaxis Progressive nasal obstruction

Denasal speech

Conductive hearing loss and serous otitis media Mass in nasopharynx

Broadening of nasal bridge

Proptosis

Frog-face deformity

Swelling of cheek

Involvement of cranial nerves II, Ill, IV, VI


Q. 9

Clinical features of nasopharyngeal angiofibroma are:

 A

3rd to 4th decades

 B

Adolescent male

 C

Epistaxis and nasal obstruction is the cardinal symptom

 D

b and c

Q. 9

Clinical features of nasopharyngeal angiofibroma are:

 A

3rd to 4th decades

 B

Adolescent male

 C

Epistaxis and nasal obstruction is the cardinal symptom

 D

b and c

Ans. D

Explanation:

 

Nasopharyngeal Angiofibroma

Most commonly seen in adolescent males 

Most common age of presentation = second decade of life 

Arises from posterior nasal cavity close to sphenopalatine foramen 

Epistaxis and nasal obstruction are the most common presentation. 

Recurrent severe epistaxis accompanied by progressive nasal obstruction are the classical symptoms ofjuvenile angiofibromas at the time of presentation. – Scott-Brown 7th/ed Vol 2 p 2438

TOC is surgical excision 



Q. 10

A 14 years boy presented with repeated epistaxis, and a swelling in cheek. Which of these statements may be correct?

 A

Diagnosis is nasopharyngeal angiofibroma

 B

Contrast CT scan should be done to see the extent

 C

High propensity to spread via lymphatics

 D

a and b 

Q. 10

A 14 years boy presented with repeated epistaxis, and a swelling in cheek. Which of these statements may be correct?

 A

Diagnosis is nasopharyngeal angiofibroma

 B

Contrast CT scan should be done to see the extent

 C

High propensity to spread via lymphatics

 D

a and b 

Ans. D

Explanation:

Q. 11

True about juvenile nasopharyngeal angiofibroma:

 A

Surgery is treatment of choice

 B

It is malignant tumor

 C

Incidence in females

 D

Hormones not used in Rx

Q. 11

True about juvenile nasopharyngeal angiofibroma:

 A

Surgery is treatment of choice

 B

It is malignant tumor

 C

Incidence in females

 D

Hormones not used in Rx

Ans. A

Explanation:

Q. 12

True about nasopharyngeal angiofibroma: 

 A

Commonly seen in girls

 B

Hormonal etiology

 C

Surgery is treatment of choice, Radiotherapy can be given

 D

b and c

Q. 12

True about nasopharyngeal angiofibroma: 

 A

Commonly seen in girls

 B

Hormonal etiology

 C

Surgery is treatment of choice, Radiotherapy can be given

 D

b and c

Ans. D

Explanation:

Q. 13

A 9 years boy presents with nasal obstruction, proptosis, recurrent epistaxis from 3-4 years. Management includes:

 A

Routine radiological investigations

 B

Embolization alone should be done

 C

Surgery is treatment of choice

 D

a and c

Q. 13

A 9 years boy presents with nasal obstruction, proptosis, recurrent epistaxis from 3-4 years. Management includes:

 A

Routine radiological investigations

 B

Embolization alone should be done

 C

Surgery is treatment of choice

 D

a and c

Ans. D

Explanation:

 

  • Surgical excision is the treatment of choice.
  • Before surgery at least 2-3 liters of blood should be given.                                                                              
  • Preoperative embolization and estrogen therapy or cryotherapy reduce blood loss in surgery.

Approach

  • Transpalatine approach—done for tumor confined to nasopharynx.
  • Lateral rhinotomy approach—done for large tumors involving, nasal cavity, paranasal sinuses and orbit. 

Other Approaches

  • Sardana’s approach – Transpalatine + Sublabial.
  • Transhyoid and transmandibular approach.
  • Transzygomatic approach.

Q. 14

A 14-year old boy presents with history of frequent nasal bleeding. His Hb was found to be 6.4 g/dL and peripheral smear showed normocytic hypochromic anemia. The most probable diagnosis is:

 A

Juvenile nasopharyngeal angiofibroma

 B

Hemangioma

 C

Antrochonal polyp

 D

Carcinoma of nasopharynx

Q. 14

A 14-year old boy presents with history of frequent nasal bleeding. His Hb was found to be 6.4 g/dL and peripheral smear showed normocytic hypochromic anemia. The most probable diagnosis is:

 A

Juvenile nasopharyngeal angiofibroma

 B

Hemangioma

 C

Antrochonal polyp

 D

Carcinoma of nasopharynx

Ans. A

Explanation:

A 14-year-old boy presents with history of frequent nasal bleeding. His Hb was found to be 6.4 g/dL and peripheral smear showed normocytic hypochromic anemia. The most probable diagnosis is juvenile nasopharyngeal angiofibroma.

As the age of the patient (14 years), Sex: (male) and presentation (nasal bleeding) all favour it.

In antrochoanal polyps, the presenting symptom is U/L nasal obstruction and not bleeding.

Age of the patient goes against Nasopharyngeal cancer.

As far as hematoma are concerned, a swelling is generally seen.



Q. 15

A child with unilateral nasal obstruction along with a mass in cheek and profuse & recurrent epistaxis:

 A

Juvenile Nasal angiofibroma

 B

Glomus tumour

 C

Antrochoanal polyp

 D

Rhinolith

Q. 15

A child with unilateral nasal obstruction along with a mass in cheek and profuse & recurrent epistaxis:

 A

Juvenile Nasal angiofibroma

 B

Glomus tumour

 C

Antrochoanal polyp

 D

Rhinolith

Ans. A

Explanation:

 

Nasopharyngeal angiofibroma/ Juvenile nasopharyngeal angiofibroma

  • It is a histologically benign but locally aggressive vascular tumor that grows in the back of the nasal cavity.
  • It most commonly affects adolescent males.
  • Patients with nasopharyngeal angiofibroma usually present with one-sided nasal obstruction and recurrent bleeding.

Q. 16

A 15 year aged boy presents with unilateral nasal blockade,mass in the cheek and epistaxis, the  likely diagnosis is ‑

 A

Nasopharyngeal carcinoma

 B

Nasopharyngeal Angiofibroma

 C

Inverted papilloma

 D

None of the above

Q. 16

A 15 year aged boy presents with unilateral nasal blockade,mass in the cheek and epistaxis, the  likely diagnosis is ‑

 A

Nasopharyngeal carcinoma

 B

Nasopharyngeal Angiofibroma

 C

Inverted papilloma

 D

None of the above

Ans. B

Explanation:

 

Recurrent epistaxis, nasal obstruction and swelling over cheek in a 15 years boy suggest the diagnosis of nasopharyngeal angiofibroma.

Juvenile nasopharyngeal angiofibroma (JNA) is a benign, but locally aggresive, tumor of nasopharynx seen in prepubertal and adolescent males. It is the most common benign neoplasm of nasopharynx. It is a highly vascular tumor and blood supply of the tumor most commonly arises from the internal maxillary artery. Juvenile nasopharyngeal angiofibroma (JNA) occurs almost exclusively in males. Female with Juvenile nasopharyngeal angiofibroma (JNA) should undergo genetic testing. Onset is most commonly in the second decades, the range is 7-19 years.

The exact cause is unknown. As the tumour is predominantly seen in adolescent males in the second decade of life, it is thought to be testosterone dependent.

Such patients have a hamartomatous nidus of vascular tissue in the nasopharynx and this is activated to form angiofibroma when male sex hormone appears.



CSF Rhinorrhea

CSF Rhinorrhea

Q. 1

CSF rhinorrhea “immediate” management is

 A

Plugging with petrolleum jelly plugs

 B

Wait & watch for 7 days + antibiotics

 C

Blow the nose repeatedly

 D

Surgery

Q. 1

CSF rhinorrhea “immediate” management is

 A

Plugging with petrolleum jelly plugs

 B

Wait & watch for 7 days + antibiotics

 C

Blow the nose repeatedly

 D

Surgery

Ans. B

Explanation:

 

CSF rhinorrhea may be classified as:

  • Traumatic (>90%) – Approximately 80% of all traumatic leaks occur in the setting of accidental trauma, and the remaining traumatic leaks occur after neurosurgical and rhinological procedures
  • Nontraumatic (Nontraumatic etiologies include neoplasms and hydrocephalus

High pressure flow- intracranial tumours & hydrocephalous

Low pressure flow- congenital defects

  • Most common site for leak is through cribrtform plate and ethmoidal air sinuses.
  • Less common sites are through frontal and sphenoidal sinuses.

Rarely, the leak can originate in the middle or posterior cranial fossa and can reach the nasal cavity by way of the middle ear and eustachian tube

Diagnosis:

  • Basic clinical tests

– Rhinoscopy-visualisation of CSF leakage from paranasal sinuses

– Tissue test-unlike nasal mucous ,CSFdoes not cause a tissue to stiffen

– Filter paper test-sample of nasal discharge on a filter paper exhibits a light CSF border and a dark central area of blood ‘double ring sign’ or ‘ halo sign’ (in cases of traumatic CSF leak where blood and CSF are mixed.) – Queckenstedt test-compression of jugular veins leads to increased CSF leakage d/t increase in 1CP

  • Biochemical tests:

– Concentrations of glucose & protein are higher in CSF than in nasal discharge.

– 12-transferrin is the preferred biochemical marker of CSF. It helps in distinguishing CSF from other nasal secretions.

Beta-trace protein (11TP) is another chemical marker that could be used for the detection of CSF

  • CSF tracers:

Intrathecal fluorescein dye administration, radionuclide cisternography, CTcisternography

  • Radiological studies:

High-resolution CT provides detailed information about the bony skull base anatomy, and MR1 assesses soft tissues , including unrecognized tumors and coincidental meningoencephaloceles

Treatment:

  • Traumatic rhinorrhea often stops spontaneously
  • Conservative treatment consists of 1-2 weeks trial of?

– Strict bed rest – Head elevation – Stool softeners

– Advising patient to avoid coughing, sneezing, nose blowing, and straining

– Prophylactic antibiotics

– Subarachnoid drainage through a lumbar catheter

  • Surgical repair is generally advocated in patients with large fistulas especially in the presence of pneurnocephalous.

 


Q. 2

CSF Rhinorrhea is usually due to fracture of cribriform plate. Cribriform plate is a part of: 

 A

Vomer

 B

Ethmoid

 C

Maxilla

 D Zygomatic bone
Q. 2

CSF Rhinorrhea is usually due to fracture of cribriform plate. Cribriform plate is a part of: 

 A

Vomer

 B

Ethmoid

 C

Maxilla

 D Zygomatic bone
Ans. B

Explanation:

Ethmoid


Q. 3

A patient is brought to the emergency department following head trauma. He is conscious and complaining of fluid is coming out of his nostrils. He didn’t have a running nose before the trauma. 

 
Assertion: CSF examination produces clinically detectable signs of the ring sign, double-ring sign or halo sign in CSF Rhinorrhea.
 
Reason: CSF will separate from blood when the mixture is placed on filter paper resulting in a central area of blood with an outer ring or halo. Blood alone does not produce a ring.
 A

Both Assertion and Reason are true, and Reason is the correct explanation for Assertion

 B

Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion

 C

Assertion is true, but Reason is false

 D

Assertion is false, but Reason is true

Q. 3

A patient is brought to the emergency department following head trauma. He is conscious and complaining of fluid is coming out of his nostrils. He didn’t have a running nose before the trauma. 

 
Assertion: CSF examination produces clinically detectable signs of the ring sign, double-ring sign or halo sign in CSF Rhinorrhea.
 
Reason: CSF will separate from blood when the mixture is placed on filter paper resulting in a central area of blood with an outer ring or halo. Blood alone does not produce a ring.
 A

Both Assertion and Reason are true, and Reason is the correct explanation for Assertion

 B

Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion

 C

Assertion is true, but Reason is false

 D

Assertion is false, but Reason is true

Ans. A

Explanation:

Halo sign/Handkerchief sign is a finding in CSF rhinorrhea when CSF is mixed with Blood.

The best ring is obtained with a 50: 50 mix of blood and CSF.

Ref: Diseases of Ear, Nose and Throat by PL Dhingra, 4th Edition, Pages 155, 156.

Q. 4

A female in the emergency department is found to have CSF rhinorrhea following a motor vehicle accident. What is the first line of treatment for CSF rhinorrhoea in this patient?

 A

Immediate plugging of nose with petroleum gauze

 B

Forceful blowing of nose

 C

Craniotomy

 D

Observation for 7 – 10 days with antibiotic therapy

Q. 4

A female in the emergency department is found to have CSF rhinorrhea following a motor vehicle accident. What is the first line of treatment for CSF rhinorrhoea in this patient?

 A

Immediate plugging of nose with petroleum gauze

 B

Forceful blowing of nose

 C

Craniotomy

 D

Observation for 7 – 10 days with antibiotic therapy

Ans. D

Explanation:

Early cases of post-traumatic CSF rhinorrhea are managed conservatively by placing the patient in semi-sitting position, avoiding blowing of nose, sneezing and straining. Prophylactic antibiotics are also administered to prevent meningitis. 

Persistent cases of CSF rhinorrhoea are treated surgically through nasal endoscopic or intracranial approach. Nasal endoscopic approach is useful for leaks from the frontal sinus, cribriform plate, ethmoid or sphenoid sinuses.


Q. 5

Nasal intubation is contra indicated in

 A

CSF Rhinorrhea

 B

Fracture cervical spine

 C

Fracture mandible

 D

Short neck

Q. 5

Nasal intubation is contra indicated in

 A

CSF Rhinorrhea

 B

Fracture cervical spine

 C

Fracture mandible

 D

Short neck

Ans. A

Explanation:

A i.e. CSF Rhinorrhea

Nasal (naso-tracheal) intubation is required when oral (orotracheal) tube will interfere with surgery (eg intraoral surgery) and may be indicated when oral intubation is difficult (eg inability to open month). It provides good oral hygiene and more secure fixation with less chances of displacement and extubation. But it is more commonly a/w significant nasaVmucosal bleeding, submucosal placement, transient bacteremia (infection), sinusitis and otitis mediaQ. These side effects make nasotracheal intubation contraindicated in base of skull fracture, CSF rhinorrheaQ, nasal abnormalities and trauma and coagulopathy.


Q. 6

Which is not seen in fracture maxilla:

 A

CSF rhinorrhea

 B

Malocclusion

 C

Anesthesia upper lip

 D

Surgical emphysema

Q. 6

Which is not seen in fracture maxilla:

 A

CSF rhinorrhea

 B

Malocclusion

 C

Anesthesia upper lip

 D

Surgical emphysema

Ans. D

Explanation:

 

Clinical Features of Maxilla—Common to All Types

  • Malocclusion of teeth                                                    
  • Elongation of mid face
  • Undue mobility of maxilla

Specific Clinical Features

  • CSF rhinorrhea is seen in Le Fort II and Le Fort III fracture as cribriform plate is injured.
  • Injury to infraorbital nerve is seen in Le Fort II fracture.                                                                                          
  • So anesthesia will be seen in area of supply of infraorbital nerve injury viz. cheek and upper lip (area of supply of infraorbital nerve).

Q. 7

CSF rhinorrhea is seen in:

 A

Lefort’s fracture Type I

 B

Nasal fracture

 C

Nasoethmoid fracture

 D

All

Q. 7

CSF rhinorrhea is seen in:

 A

Lefort’s fracture Type I

 B

Nasal fracture

 C

Nasoethmoid fracture

 D

All

Ans. C

Explanation:

 

CSF Rhinorrhea Occurs in fracture of maxilla in Le Fort type II and type III. (as cribriform plate is injured here) and also in nasal fracture class III



Q. 8

True about CSF rhinorrhea is:

 A

Occurs due to break in cribriform plate

 B

Contains glucose

 C

Requires immediate surgery

 D

a and b

Q. 8

True about CSF rhinorrhea is:

 A

Occurs due to break in cribriform plate

 B

Contains glucose

 C

Requires immediate surgery

 D

a and b

Ans. D

Explanation:

 

 

 

– Early cases of post traumatic CSF rhinorrhea are managed conservatively. Only those cases where CSF rhinorrhea occurs persistently

– Surgical management should be done


Q. 9

Immediate treatment of CSF rhinorrhea requires:

 A

Antibiotics and observation

 B

Plugging with paraffin guage

 C

Blowing of nose

 D

Craniotomy

Q. 9

Immediate treatment of CSF rhinorrhea requires:

 A

Antibiotics and observation

 B

Plugging with paraffin guage

 C

Blowing of nose

 D

Craniotomy

Ans. A

Explanation:

 

  • Early cases of post traumatic CSF rhinorrhea are managed conservatively (by placing the patient in propped up position, avoiding blowing of nose, sneezing and straining) and
  • Prophylactic antibiotics (to prevent meningitis).
  • Persistent cases are treated surgically by nasal endoscopy or by intracranial route.

 

Endoscopic closure of (SF leak is now the treatment of choice in majority of patients but it should not be done immediately. First patient should be subjected to diagnostic evaluation and after site of leakage is confirmed, it should be closed endoscopically. – Scott-Brown


Q. 10

CSF rhinorrhea is diagnosed by:

 A

Beta-2 microglobulin

 B

Beta-2 transferrin

 C

Thyroglobulin

 D

Transthyretin

Q. 10

CSF rhinorrhea is diagnosed by:

 A

Beta-2 microglobulin

 B

Beta-2 transferrin

 C

Thyroglobulin

 D

Transthyretin

Ans. B

Explanation:

Q. 11

Management of persistent cases of CSF rhinorrhea is:

 A

Head low position on bed

 B

Endoscopic repair

 C

Straining activities

 D

All of the above

Q. 11

Management of persistent cases of CSF rhinorrhea is:

 A

Head low position on bed

 B

Endoscopic repair

 C

Straining activities

 D

All of the above

Ans. B

Explanation:

CSF rhinorrhoea

  • It refers to the drainage of cerebrospinal fluid through the nose.
  • Measures of CSF components such as beta-2 transferrin has been shown to have a high positive predictive value.
  • It has also been noted to be characterized by unilateral discharge.
  • It is a sign of basal skull fracture.
  • Management includes watchful waiting – leaks often stop spontaneously; if this does not occur then neurosurgical closure is necessary to prevent the spread of infection to the meninges.

Q. 12

True about CSF rhinorrhea:       

UP 09

 A

Commonly occurs due to break in cribriform plate

 B

Contains less amount of proteins

 C

Decreased glucose content confirms diagnosis

 D

Immediate surgery is required

Q. 12

True about CSF rhinorrhea:       

UP 09

 A

Commonly occurs due to break in cribriform plate

 B

Contains less amount of proteins

 C

Decreased glucose content confirms diagnosis

 D

Immediate surgery is required

Ans. A

Explanation:

Ans. Commonly occurs due to break in cribriform plate


Q. 13

CSF rhinorrhea is diagnosed by:

MP 07

 A

Glucose estimation

 B

Halo sign

 C

Immunoelectrophoresis

 D

All

Q. 13

CSF rhinorrhea is diagnosed by:

MP 07

 A

Glucose estimation

 B

Halo sign

 C

Immunoelectrophoresis

 D

All

Ans. D

Explanation:

Ans. All


Q. 14

Diagnostic test for CSF rhinorrhea is ‑

 A

Beta – 2 microglobulin

 B

Beta – 2 transferrin

 C

Thyroglobulin

 D

Transthyretin

Q. 14

Diagnostic test for CSF rhinorrhea is ‑

 A

Beta – 2 microglobulin

 B

Beta – 2 transferrin

 C

Thyroglobulin

 D

Transthyretin

Ans. B

Explanation:

Ans. is ‘b’ i.e., Beta-2 transferrin



Suprahyoid muscles

SUPRAHYOID MUSCLES

Q. 1

Which of the following muscles is not supplied by mandibular nerve?

 A

Masseter

 B

Buccinator

 C

Tensor veli palati

 D

Posterior belly of digastric

Q. 1

Which of the following muscles is not supplied by mandibular nerve?

 A

Masseter

 B

Buccinator

 C

Tensor veli palati

 D

Posterior belly of digastric

Ans. D

Explanation:

Mandibular nerve supplies muscles of mastication, mylohyoid, anterior belly of digastric, tensor tympani and tensor veli palati. Nerve to the medial pterygoid is a small branch of mandibular nerve that supplies the medial pterygoid muscle. It gives off two branches which pass without interruption through the otic ganglion to supply tensor tympani and tensor veli palati.


Q. 2

Which of the following nerve innervates the anterior belly of the digastric muscle?

 A

Facial nerve

 B

Trigeminal nerve

 C

Vagus nerve

 D

Abducens nerve

Q. 2

Which of the following nerve innervates the anterior belly of the digastric muscle?

 A

Facial nerve

 B

Trigeminal nerve

 C

Vagus nerve

 D

Abducens nerve

Ans. B

Explanation:

The anterior belly of the digastric muscle is innervated by the mandibular division of the trigeminal nerve.

  • The inferior alveolar nerve which give rise to the mylohyoid nerve innervates the mylohyoid muscle. 

Q. 3

Second branchial arch give rise to all of the following muscles, EXCEPT:

 A

Stapedius

 B

Stylohyoid

 C

Stylopharyngeus

 D

Posterior belly of digastric

Q. 3

Second branchial arch give rise to all of the following muscles, EXCEPT:

 A

Stapedius

 B

Stylohyoid

 C

Stylopharyngeus

 D

Posterior belly of digastric

Ans. C

Explanation:

Second branchial arch give rise to muscles of facial expression, stylohyoid, posterior belly of digastric and stapedius. Third branchial arch give rise to stylopharyngeus muscle.
 
Muscles derived from first branchial are:
  • Masseter
  • Temporalis
  • Mylohyoid
  • Anterior belly of digastric
  • Tensor tympani
  • Tensor veli palatini
  • Lateral and medial pterygoid
Muscles derived from 4th branchial arch:
  • Inferior constrictor of pharynx
  • Cricothyroid
Muscles derived from 6th branchial arch:
  • All the intrinsic muscles of the larynx except cricothyroid
  • All the muscles of the pharynx except stylopharyngeus
  • All the muscles of palate except tensor palati

Q. 4

All of the following are Digastric muscles, Except:

 A

Muscle fibers in the ligament of Treitz

 B

Omohyoid

 C

Occipitofrontalis

 D

Sternocleidomastoid

Q. 4

All of the following are Digastric muscles, Except:

 A

Muscle fibers in the ligament of Treitz

 B

Omohyoid

 C

Occipitofrontalis

 D

Sternocleidomastoid

Ans. D

Explanation:

D i.e. Sternocleidomastoid

–   Diagastric, Omohyoid, Occipitofrontalis, Gastroenemius, and Suspensory muscle of duodenum (i.e., muscle in Ligament of Treitz)Q are all digastric muscles i.e, muscles with two muscle bellies. Mn- “DOGS”

Sternocleidomastoid muscle has two heads not two belliesQ


Q. 5

Posterior belly of digastric is supplied by‑

 A

Mandibular nerve

 B

Hypoglosal nerve

 C

Accessory nerve

 D

Facial nerve

Q. 5

Posterior belly of digastric is supplied by‑

 A

Mandibular nerve

 B

Hypoglosal nerve

 C

Accessory nerve

 D

Facial nerve

Ans. D

Explanation:

D i.e. Facial nerve


Q. 6

All are elevators of larynx except:

 A

Thyrohyoid

 B

Digastric

 C

Stylohyoid

 D

mylohyoid

Q. 6

All are elevators of larynx except:

 A

Thyrohyoid

 B

Digastric

 C

Stylohyoid

 D

mylohyoid

Ans. A

Explanation:

 

 The main laryngeal elevators are: Digastric anterior and posterior, the stylohyoid, mylohyoid, geniohyoid, genioglossus, hyoglossus, and thyropharyngeus muscles


Q. 7

Submandibular gland is divided into superficial and deep parts by ‑

 A

Digastric

 B

Geniohyoid

 C

Mylohyoid

 D

Stylohyoid

Q. 7

Submandibular gland is divided into superficial and deep parts by ‑

 A

Digastric

 B

Geniohyoid

 C

Mylohyoid

 D

Stylohyoid

Ans. C

Explanation:

Submandibular gland

  • This walnut sized gland lies below the mandible in the anterior part of digastric triangle. It is .1-shaped and consists of a large superficial and a small deep parts, separated by mylohyoid muscle and continuous with each other around the posterior border of mylohyoid muscle.

Superficial part

  • It is situated in the anterior part of digastric triangle. The gland is partially closed in a capsule formed by two layers of deep cervical fascia. It has three surfaces : (i) inferior, (ii) lateral, and (iii) medial.

i)    Inferior surface is covered by skin, platysma, cervical branch of facial nerve, deep fascia, facial vein and submandibular lymph nodes.

ii)   Lateral surface is related to submandibular fossa (on mandible), medial pterygoid (insertion) and facial artery.

iii)  Medial surface is related to mylohyoid, hyoglossus and styloglossus muscles.

Deep part

  • It lies on the hyoglossus muscle deep to mylohoid. It is related above to lingual nerve and submandibular ganglion; and below to hypoglossal nerve.

Q. 8

Posterior belly of digastric is supplied by

 A

Facial nerve

 B

Mandibular nerve

 C

Glossopharyndeal nerve

 D

Trochlear nerve

Q. 8

Posterior belly of digastric is supplied by

 A

Facial nerve

 B

Mandibular nerve

 C

Glossopharyndeal nerve

 D

Trochlear nerve

Ans. A

Explanation:

Ans. is `a’ i.e., Facial nerve


Q. 9

Which of the suprahyoid muscle is supplied muscle by both facial nerve & mandibular nerve?

 A

Stylohyoid

 B

Mylohyoid

 C

Digastric

 D

Hyoglossus

Q. 9

Which of the suprahyoid muscle is supplied muscle by both facial nerve & mandibular nerve?

 A

Stylohyoid

 B

Mylohyoid

 C

Digastric

 D

Hyoglossus

Ans. C

Explanation:

Anterior belly of digastric is supplied by nerve to mylohyoid (a branch of mandibular nerve) & posterior belly is supplied by facial nerve.


Q. 10

Muscle of neck with dual neerve supply?

 A

Sternohyoid

 B

Thyrohyoid

 C

Digastric

 D

Stylohyoid

Q. 10

Muscle of neck with dual neerve supply?

 A

Sternohyoid

 B

Thyrohyoid

 C

Digastric

 D

Stylohyoid

Ans. C

Explanation:

Anterior belly of digastric is supplied by nerve to mylohyoid (a branch of mandibular nerve) & posterior belly is supplied by facial nerve.


Q. 11

Oral diaphragm is formed by:

 A

Mylohyoid

 B

Geniohyoid

 C

Omohyoid

 D

Digastric

Q. 11

Oral diaphragm is formed by:

 A

Mylohyoid

 B

Geniohyoid

 C

Omohyoid

 D

Digastric

Ans. A

Explanation:

Mylohyoid muscle of each side unite to make a thin sheet of muscular floor (oral diaphragm) of oral cavity.


Q. 12

Structures lying deep to posterior belly of digastric are all except?

 A

Retromandibular vein

 B

Hypoglossal nerve

 C

Hyoglossus muscle

 D

Occipital artery

Q. 12

Structures lying deep to posterior belly of digastric are all except?

 A

Retromandibular vein

 B

Hypoglossal nerve

 C

Hyoglossus muscle

 D

Occipital artery

Ans. A

Explanation:

Relations of Digastric triangle

Superficial

Deep (medial)

  • Platysma
  • Mastoid process & sternocleidomastoid
  • Stykohyoid muscle
  • Retromandibular vein & parotid gland
  • Submandibular salivary gland
  • Angle of mandible with medial pterygoid

For anterior belly

  • Mylohyoid

For posterior belly

  • Transverse process of atlas with superior oblique & rectus capitis lateralis muscle.
  • Hyoglossus muscle
  • Hypoglossal & spinal accessory nerves
  • Occipital, internal & external carotid, facial & lingual arteries
  • Internal jugular vein

 



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