Category: Quiz

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

 



Laryngo-tracheo-bronchial foreign bodies

Laryngo-tracheo-bronchial foreign bodies

Q. 1

For foreign body causing sudden choking, most appropriate first line of management is?

 A Tracheostomy
 B

Heimlich maneuver

 C Airway insertion
 D

Laryngoscopy

Q. 1

For foreign body causing sudden choking, most appropriate first line of management is?

 A Tracheostomy
 B

Heimlich maneuver

 C Airway insertion
 D

Laryngoscopy

Ans. B

Explanation:

Heimlich maneuver REF: Dhingra’s 4th ed p. 257

Management of Laryngeal foreign body:

A large bolus of food/ foreign body obstructed above the cords may make the patient totally aphonic, unable to cry for help. He may die of asphyxia unless immediate first aid measures are taken.

  1. Heimlich’s maneuvers: Sudden thrust directed upwards and backwards, below the epigastrium, squeezes the air from the lungs, sufficient to dislodge a foreign body.
  2. Cricothyrotomy or emergency tracheostomy should be done if Heimlich’s maneuvers fails.
  3. Once acute respiratory emergency is over, foreign body can be removed by direct laryngoscopyor  by laryngofissure, if found impacted

Management of Tracheal and bronchial foreign bodies:

Bronchoscopy under general anesthesia. Emergency removal of these foreign bodies is not indicated unless there is airway obstruction or they are of the vegetable nature (e.g. seeds) and likely to swell up. Methods to remove tracheobronchial foreign body:

  1. Conventional rigid bronchoscopy.
  2. Rigid bronchoscopy with telescopic aid.
  3. Bronchoscopy with C-arm fluoroscopy.
  4. Use of Dormia basket or Fogarty’s balloon for rounded objects.
  5. Tracheostomy first and then bronchoscopy through the tracheostome.
  6. Thoracotomy and bronchotomy for peripheral foreign bodies.
  7. Flexible fiber optic bronchoscopy in selected adult patients.

Q. 2

For Foreign bodies are retained in the larynx causing choking, first line of management is

 A Airway insertion
 B

Hemilich manouvere

 C Hemilich valve
 D Tracheostomy
Q. 2

For Foreign bodies are retained in the larynx causing choking, first line of management is

 A Airway insertion
 B

Hemilich manouvere

 C Hemilich valve
 D Tracheostomy
Ans. B

Explanation:

Hemilich manouvere


Q. 3

A 2-year-old child is brought by his parents to emergency with acute onset of respiratory distress and stridor. Most probable diagnosis is:

 A

Foreign body in airway

 B

Laryngomalacia

 C

Laryngotracheobronchitis

 D

Laryngeal papillomatosis

Q. 3

A 2-year-old child is brought by his parents to emergency with acute onset of respiratory distress and stridor. Most probable diagnosis is:

 A

Foreign body in airway

 B

Laryngomalacia

 C

Laryngotracheobronchitis

 D

Laryngeal papillomatosis

Ans. A

Explanation:

Q. 4

Heimlich manoeuver is done to:

 A

Remove foreign body

 B

Cardiac function without pacemaker

 C

Pulmonary function without heart lung machine

 D

Peripheral circulation

Q. 4

Heimlich manoeuver is done to:

 A

Remove foreign body

 B

Cardiac function without pacemaker

 C

Pulmonary function without heart lung machine

 D

Peripheral circulation

Ans. A

Explanation:

Q. 5

A 2 yrs old boy, is brought with sudden onset of stridor and respiratory difficulty. The chest examination reveals decreased breath sounds and wheeze in the right side. The chest X-Ray showed an opaque right hemithorax. Which of the following is the most likely diagnosis:

 A

Pneumothorax

 B

Acute epiglottitis

 C

Massive pleural effusion

 D

Foreign body aspiration

Q. 5

A 2 yrs old boy, is brought with sudden onset of stridor and respiratory difficulty. The chest examination reveals decreased breath sounds and wheeze in the right side. The chest X-Ray showed an opaque right hemithorax. Which of the following is the most likely diagnosis:

 A

Pneumothorax

 B

Acute epiglottitis

 C

Massive pleural effusion

 D

Foreign body aspiration

Ans. D

Explanation:

Foreign body inhalation is most common cause of acute collapse with peak age incedence in 1-2 years.

Ref: Textbook of Pediatrics By K.N Agarwal, 2010, Page 235


Q. 6

A child with acute respiratory distress shows hyperinflation of unilateral lung in chest X-ray. Most likely cause for above presentation is:

 A

Staphylococcal bronchopneumonia

 B

Aspiration pneumonia

 C

Congenital lobar emphysema

 D

Foreign body aspiration

Q. 6

A child with acute respiratory distress shows hyperinflation of unilateral lung in chest X-ray. Most likely cause for above presentation is:

 A

Staphylococcal bronchopneumonia

 B

Aspiration pneumonia

 C

Congenital lobar emphysema

 D

Foreign body aspiration

Ans. D

Explanation:

Foreign body aspiration is the commonest cause of acute lung collapse in a child.

Ref: Chest Radiology: The Essentials By Jannette Collins, Eric J. Stern, 2007, Page 196


Q. 7

Advantage of fibreoptic bronchoscopy over rigid bronchoscopy is :

 A

Foreign body removal

 B

Good view

 C

Bener airway control

 D

In a sick child it can be passed through endotracheal tube

Q. 7

Advantage of fibreoptic bronchoscopy over rigid bronchoscopy is :

 A

Foreign body removal

 B

Good view

 C

Bener airway control

 D

In a sick child it can be passed through endotracheal tube

Ans. B

Explanation:

Fibreoptic bronchoscopy can be easily performed and is rarely associated with complications.It has surpassed rigid bronchoscopy as the instrument of choice for evaluvating the tracheocbronchial tree.Further ,as compared to rigid bronchoscopy,flexibile bronchoscope allows for more complete exploration of the airway.It has a good view.

 
Ref: Knowles J., Rains A. (2011). Chapter 10. Compromised Airway. In R.L. Humphries, C. Stone (Eds), CURRENT Diagnosis & Treatment Emergency Medicine, 7e.

Q. 8

A five year old boy develops sudden aphonia and respiratory distress while having dinner. Which of the following is the next recommended step in the management of this patient?

 A

Heimlich’s manoeuvre

 B

Chest thrust manoeuvre

 C

Finger Sweep manoeuvre

 D

Cricothyroidotomy or Tracheostomy

Q. 8

A five year old boy develops sudden aphonia and respiratory distress while having dinner. Which of the following is the next recommended step in the management of this patient?

 A

Heimlich’s manoeuvre

 B

Chest thrust manoeuvre

 C

Finger Sweep manoeuvre

 D

Cricothyroidotomy or Tracheostomy

Ans. A

Explanation:

A large bolus of food obstructed above the cords may make the patient totally aphonic, unable to cry for help. He may die of asphyxia unless immediate first aid measures are taken. The measures consist of pounding on the back, turning the patient upside down & following Heimlich’s manoeuvre. These measures should not be done if patient is only partially obstructed, for fear of causing total obstruction.


Q. 9

The incidence of a foreign body being aspirated into the right lung is higher than into the left lung. All of the following statements support this, EXCEPT?

 A

Right inferior lobar bronchus is in continuation with the right principal bronchus

 B

Right principal bronchus is more vertical than the left bronchus

 C

Tracheal bifurcation directs the foreign body to the right lung

 D

Right lung is shorter and wider than left lung

Q. 9

The incidence of a foreign body being aspirated into the right lung is higher than into the left lung. All of the following statements support this, EXCEPT?

 A

Right inferior lobar bronchus is in continuation with the right principal bronchus

 B

Right principal bronchus is more vertical than the left bronchus

 C

Tracheal bifurcation directs the foreign body to the right lung

 D

Right lung is shorter and wider than left lung

Ans. D

Explanation:

A foreign body is more likely to get aspirated into the right lung as the right bronchus is wider, shorter and more vertical than the left principal bronchus. The greater width and the more vertical angulation of the right principal bronchus explain why foreign bodies enter it more commonly that the left.


Q. 10

An inhaled foreign body is likely to lodge in the right lung due to all of the following features except:

 A

Right lung is shorter & wider than left lung

 B

Right principal bronchus is more vertical than the left bronchus

 C

Tracheal bifurcation directs the foreign body to the right lung

 D

Right inferior lobar bronchus is in continuation with the principal bronchus

Q. 10

An inhaled foreign body is likely to lodge in the right lung due to all of the following features except:

 A

Right lung is shorter & wider than left lung

 B

Right principal bronchus is more vertical than the left bronchus

 C

Tracheal bifurcation directs the foreign body to the right lung

 D

Right inferior lobar bronchus is in continuation with the principal bronchus

Ans. A

Explanation:

A. i.e. Right lung is shorter and wider than left lung


Q. 11

Wheeze in children caused by –

 A

Foreign body

 B

Gastro-esophageal reflux disease

 C

Bronchial asthma

 D

a and c

Q. 11

Wheeze in children caused by –

 A

Foreign body

 B

Gastro-esophageal reflux disease

 C

Bronchial asthma

 D

a and c

Ans. D

Explanation:

Ans. is ‘a’ i.e., Foreign body; ‘c’ i.e., Bronchial asthma

Wheezing

o Wheezing referes to high pitch whistling sounds audible without auscultation by the stethoscope.

o It is produced by lower airway (bronchi and bronchioles) partial obstruction —) Sufficient air must flow through the narrowed airway to produce the wheezing.

o Common causes of wheezing in children :

  • Lower respiratory tract infections         
  • Bronchiolitis & Bronchial asthma      
  • Tropical eosinophilia
  • Loeffler’s syndrome                               
  • Hypersensitivity pneumonitis                     
  • Inhaled foreign bodies
  • Cystic fibrosis.        
  • External compression from enlarged mediastinal lymph nodes, cysts or tumor.

Q. 12

Acute onset of cough, stridor and dysponea in a child is mostly due to –

 A

Foreign body

 B

Acute Asthma

 C

Aspiration pneumonitis

 D

Primary complex

Q. 12

Acute onset of cough, stridor and dysponea in a child is mostly due to –

 A

Foreign body

 B

Acute Asthma

 C

Aspiration pneumonitis

 D

Primary complex

Ans. A

Explanation:

Ans. is ‘a’ i.e., Foreign body

“Choking and coughing episodes accompnied by wheezing are highly suggestive of airway foreign body” – Nelson

“Foreign body aspiration should always be considered as a potential cause of stridor and airway obstruction in children”.                                                                                                                           — O.P. Ghai

Foreign body aspiration

o Infants and toddlers use their mouths to explore their surroundings.

  • So, they are very prone to aspirate a foreign body.

o The most common age group is 6 months to 4 years.

o Most common foreign body aspirated is nuts (peanuts).

o Most airway foreign bodies lodge in a bronchus (right more than left).

Clinical manifestions

Three stages of symptoms may results : –

1. Stage I – Initial event —> Violent paroxysm of coughing (most common symptom), choking, gagging and wheeze immediately after aspiration. If obstruction is complete, child may be unable to vocalize (aphonia) and there may be cyanosis. If obstruction is incomplete drooling and stridor may occur.

2.  Stage H Asmptomatic —> The foreign body becomes lodged, reflex fatigue and immediate irritating symptoms subside. This stage is most tracherous and account for a large percentage of delayed diagnosis and overlooked foreign bodies.

3. Stage III – Complications —> Obstruction, erosions or infection can cause fever, hemoptysis, pneumonia and atelectasis. The most serious complication offoreign body aspiration is complete airway obstruction.


Q. 13

Immediate management of a child with foreign body inhalation is –

 A

IPPV

 B

Bronchoscopy

 C

Tracheostomy

 D

Exploratory Thoracotomy

Q. 13

Immediate management of a child with foreign body inhalation is –

 A

IPPV

 B

Bronchoscopy

 C

Tracheostomy

 D

Exploratory Thoracotomy

Ans. B

Explanation:

Ans. is ‘b’ i.e., Bronchoscopy

Treatment of aspirated foreign body

A)   Treatment of foreign body in upper respiratory tract.

o If obstruction is complete —> Immediate intervention.

o If obstruction is partial —> Patients should allow to use their own cough reflex to extrude the foreign body –> If it fails than intervention should be done.

o Method of removal of foreign body : –

1)If child is younger than 1 year —> Child should be placed face down over the rescuir’s arm with head positioned below trunk. Five measured back blows are delivered rapidly between the scapula. If obstruction persists, the infant should be rolled over and five rapid chest compressions should be performed. This sequence is repeated until the obstruction is relieved.

2) If child is elder than 1 year —> Abdominal thursts (Heimlich maneuver) should be performed.

B)   Treatment of foreign body in lower respiratory tract.

o The treatment of choice is prompt endoscopic (bronchoscopic) removal of foreign body.


Q. 14

In child, foreign body in lung –

 A

Rigid bronchoscopy

 B

Chest x-ray

 C

Flexible endoscopy

 D

Direct laryngoscopy

Q. 14

In child, foreign body in lung –

 A

Rigid bronchoscopy

 B

Chest x-ray

 C

Flexible endoscopy

 D

Direct laryngoscopy

Ans. A

Explanation:

Ans. is ‘a’ i.e., Rigid bronchoscopy

o Treatment of choice is removal of foreign body by rigid bronchoscope with appropriate antibiotics.


Q. 15

Commonest sign of intrabronchial foreign body in children is –

 A

Cough

 B

Wheeze

 C

Dyspnoea

 D

Stridor

Q. 15

Commonest sign of intrabronchial foreign body in children is –

 A

Cough

 B

Wheeze

 C

Dyspnoea

 D

Stridor

Ans. A

Explanation:

Ans. is ‘a’ i.e., Cough


Q. 16

If a 5-year-old child suddenly develops stridor, which one of the following would be the most likely diagnosis‑

 A

Laryngomalacia

 B

Acute laryngo-tracheobronchitis

 C

Foreign body aspiration

 D

Acute epiglottitis

Q. 16

If a 5-year-old child suddenly develops stridor, which one of the following would be the most likely diagnosis‑

 A

Laryngomalacia

 B

Acute laryngo-tracheobronchitis

 C

Foreign body aspiration

 D

Acute epiglottitis

Ans. C

Explanation:

Ans. is ‘c’ i.e., Foreign body aspiration


Q. 17

A 4-year child presents with a history of hoarseness, croupy cough and aphonia, the child has dyspnoea with wheezing. The most probable diagnosis is ‑

 A

Asthmatic bronchitis

 B

Laryngeal foreign body

 C

Bronchopneumonia

 D

Retropharyngeal abscess

Q. 17

A 4-year child presents with a history of hoarseness, croupy cough and aphonia, the child has dyspnoea with wheezing. The most probable diagnosis is ‑

 A

Asthmatic bronchitis

 B

Laryngeal foreign body

 C

Bronchopneumonia

 D

Retropharyngeal abscess

Ans. B

Explanation:

Ans. is ‘b’ i.e., Laryngeal foreign body


Q. 18

Pappu 2 yrs old boy presents in the causality with 11/0 sudden onset of respiratory difficulty & strider on ausculation .i,ed breath sound & wheeze on the RT side. The X-Ray shows RT opaque hamithorex what will be diagnosis-

 A

Pnumothorax

 B

Acute epiglottitis

 C

Massive plural effusion

 D

Foreign body aspiration

Q. 18

Pappu 2 yrs old boy presents in the causality with 11/0 sudden onset of respiratory difficulty & strider on ausculation .i,ed breath sound & wheeze on the RT side. The X-Ray shows RT opaque hamithorex what will be diagnosis-

 A

Pnumothorax

 B

Acute epiglottitis

 C

Massive plural effusion

 D

Foreign body aspiration

Ans. D

Explanation:

D i.e. Foreign body aspiration


Q. 19

In erect posture commonest site of foreign body in bronchus –

 A

Right posterior basal

 B

Right anterior basal

 C

Lateral basal

 D

Medial basal

Q. 19

In erect posture commonest site of foreign body in bronchus –

 A

Right posterior basal

 B

Right anterior basal

 C

Lateral basal

 D

Medial basal

Ans. A

Explanation:

Ans is ‘a’ ie. Rt. posterior basal

  • Till now we have got only the below quoted text for aspiration and foreign body in lung.
  • From Schwart, 7/e        “The most common anatomic location for a foreign body is the right main stem bronchus or the rt. lower lobe.”
  • From Pretest (Pretest has quoted Harrison, I4/e, p 994)

” The right main stem bronchus is wider, shorter and vertically placed, and therefore the posterior segments of the right upper lobe (if the pt. aspirated while supine) are anatomically susceptible to aspiration puenmonia. The superior segments of the right lower lobe and left lower lobe (if the pt. supine) are also susceptible to aspiration pneumonia. These three segments are often referred to as the aspiration segments of the lung. The basilar segments of both lungs are susceptible to aspiration if the pts. aspirates while erect or sitting up.”

  • Inference : Segments involved
  • Aspiration in Supine Position :                                            
  • Aspiration in sitting or erection position
  • Rt. upper lobe – posterior segment*                          
  • Rt. basilar segments (of lower lobe)*.
  • Rt. lower lobe – superior segment*
  • Lt. lower lobe – superior segment*
  • This is the maximum we have got.

 


Q. 20

Foreign body aspiration in supine position causes which of the following parts of the lung commonly to be affected –

 A

Apical left lobe

 B

Apical lobe of right lung

 C

Apical part of the lower lobe

 D

Posterobasal segment of left lung

Q. 20

Foreign body aspiration in supine position causes which of the following parts of the lung commonly to be affected –

 A

Apical left lobe

 B

Apical lobe of right lung

 C

Apical part of the lower lobe

 D

Posterobasal segment of left lung

Ans. C

Explanation:

Ans. is ‘c’ i.e. Apical part of right lower lobe 


Q. 21

A foreign body completely obstructing the right main bronchus causes –

 A

Decreased ventilation perfusion ratio

 B

Increased ventilation in left lung

 C

Perfusion doubles in right lung

 D

Increased VF ratio in right lung

Q. 21

A foreign body completely obstructing the right main bronchus causes –

 A

Decreased ventilation perfusion ratio

 B

Increased ventilation in left lung

 C

Perfusion doubles in right lung

 D

Increased VF ratio in right lung

Ans. A

Explanation:

Answer is ‘a’ i.e. Decreased ventilation perfusion ratio


Q. 22

A 2-year-old boy presenting with sudden severe dyspnea, most common cause is:

 A

Foreign body

 B

Bronchiolitis

 C

Asthmatic attack

 D

None

Q. 22

A 2-year-old boy presenting with sudden severe dyspnea, most common cause is:

 A

Foreign body

 B

Bronchiolitis

 C

Asthmatic attack

 D

None

Ans. A

Explanation:

 

In case of stridor with acute airway obstruction (i.e. dyspnea) always history of any foreign body ingestion should be taken.


Q. 23

Palpatory thud audible slap is seen in:

 A

Tracheal foreign body

 B

Bronchial foregion body

 C

Laryngeal foreign body

 D

None

Q. 23

Palpatory thud audible slap is seen in:

 A

Tracheal foreign body

 B

Bronchial foregion body

 C

Laryngeal foreign body

 D

None

Ans. A

Explanation:

A foreign body in trachea may move up and down the trachea between the carnia and the undersurface of vocal cords causing “audible slap” and “palpatory thud.”


Q. 24

The commonest site of aspiration of a foreign body in the supine position is into the: 

 A

Right upper lobe apical 

 B

Right lower lobe apical

 C

Left basal

 D

Right medial

Q. 24

The commonest site of aspiration of a foreign body in the supine position is into the: 

 A

Right upper lobe apical 

 B

Right lower lobe apical

 C

Left basal

 D

Right medial

Ans. B

Explanation:

Q. 25

Best management for inhaled foreign body in an infant is: 

 A

Bronchoscopy

 B

IPPV and intubation

 C

Steroid

 D

Tracheostomy

Q. 25

Best management for inhaled foreign body in an infant is: 

 A

Bronchoscopy

 B

IPPV and intubation

 C

Steroid

 D

Tracheostomy

Ans. A

Explanation:

  • The peak incidence of inhaled foreign bodies is between the ages of one and three years with a male to female ratio of 2:1
  • Only 12% of the inhaled bodies impact in the larynx while most pass through the cords into the tracheobronchial tree.
  • In contrast to adults, where objects tend to lodge in the distal bronchi or right main bronchus, in children they tend to lie more centrally within the trachea (53%) or just distal to the carina (47%)
  • The treatment of choice for airway foreign bodies is prompt endoscopic removal with a Bronchoscope.

Q. 26

A 2 year old child with intercostal retraction and increas­ing cyanosis was brought with a history of foreign body aspiration. which might be lifesaving in this situation?

 A

Oxygen through face mask

 B

Heimlich’s manoeuvre

 C

Extra cardiac massage

 D

Intracaridiac adrenaline

Q. 26

A 2 year old child with intercostal retraction and increas­ing cyanosis was brought with a history of foreign body aspiration. which might be lifesaving in this situation?

 A

Oxygen through face mask

 B

Heimlich’s manoeuvre

 C

Extra cardiac massage

 D

Intracaridiac adrenaline

Ans. B

Explanation:

 

  • The child is presenting with cyanosis and intercostal retraction which indicates that the foreign body is lodged in the larynx.
  • Initial management for a foreign body lodged in trachea/larynx is Heimlich’s maneuver where a person stands behind the child and places his arms around his lower chest and gives four abdominal thrust.
  • In infants, lying the child on its back on the adults knee and pressing firmly on the upper abdomen is the preferred maneuver.
  • If Heimlich’s maneuvre fails, cricothyrotomy or emergency tracheostomy should be done.
  • Once acute respiratory emergency is over foreign body can be removed by direct laryngoscopy or by laryngofissure, if it is impacted.
  • Tracheal and bronchial foreign bodies are removed by bronchoscopy with full preparation and under GA.

 



Q. 27

A 2-year-old child develops acute respiratory distress. 0/E breath sounds are decreased with wheeze on right side. Chest X-ray shows diffuse opacity on right side—Most probable diagnosis:

 A

Pneumothorax

 B

Foreign body aspiration

 C

Pleural effusion

 D

U/L emphysema

Q. 27

A 2-year-old child develops acute respiratory distress. 0/E breath sounds are decreased with wheeze on right side. Chest X-ray shows diffuse opacity on right side—Most probable diagnosis:

 A

Pneumothorax

 B

Foreign body aspiration

 C

Pleural effusion

 D

U/L emphysema

Ans. B

Explanation:

 

Foreign body aspiration is a very common problem in pediatric age group (< 4 years). In the question, child is presenting with sudden onset respiratory distress and there is U/L decreased breath sounds + U/L wheezing and on chest X-ray a diffuse opacity is seen on right side i.e. there is clinical and radiological evidence of bronchospasm and collapse suggestive of a foreign body in bronchus


Q. 28

A 5-year-old boy having dinner suddenly becomes a phonic and is brought to casuality for the complaint of respiratory difficulty. What is the most appropriate management?

 A

Cricothyroidotomy

 B

Tracheostomy

 C

Humdifier

 D

Heimlich maneuver

Q. 28

A 5-year-old boy having dinner suddenly becomes a phonic and is brought to casuality for the complaint of respiratory difficulty. What is the most appropriate management?

 A

Cricothyroidotomy

 B

Tracheostomy

 C

Humdifier

 D

Heimlich maneuver

Ans. D

Explanation:

 

Emergency Physicians- 6th/ed pp 68,69

  • Aphonia (inability to speak) and sudden respiratory distress in a young boy while having food, suggests obstruction of the airway with a large bolus of food. Heimlich’s maneuver is the recommended, initial procedure of choice for relieving airway obstruction due to solid objects.
  • Cricothyroidotomy or tracheostomy should be performed if the Heimlich’s maneuver fails



Q. 29

A child develops acute respiratory distress, stridor, hyperinflation on one side of chest with decreased breath sound on that side. Most likely cause is :

 A

Asthma

 B

Aspiration pneumonia

 C

Foreign body aspiration

 D

Pleural effusion

Q. 29

A child develops acute respiratory distress, stridor, hyperinflation on one side of chest with decreased breath sound on that side. Most likely cause is :

 A

Asthma

 B

Aspiration pneumonia

 C

Foreign body aspiration

 D

Pleural effusion

Ans. C

Explanation:

Answer is C (Foreign Body Aspiration):

Foreign Body Aspiration is an important cause of stridor in. children. Obstruction leads to hyperinflation, chest wall hyperresonance and decreased breath sounds.

All the other choices mentioned in the question do not cause stridor.


Q. 30

During autopsy, foreign body is found in respiratory tract; manner of death is:

MP 07

 A

Homicide

 B

Suicide

 C

Accident

 D

Natural

Q. 30

During autopsy, foreign body is found in respiratory tract; manner of death is:

MP 07

 A

Homicide

 B

Suicide

 C

Accident

 D

Natural

Ans. C

Explanation:

Ans. Accident


Q. 31

A 5-year old boy while having dinner suddenly becomes aphonic and is brought to the casualty with the complaint of respiratory distress. Immediate management should be:   

AI 11

 A

Cricothyroidotomy

 B

Emergency tracheostomy

 C

Humidified oxygen

 D

Heimlich maneuver

Q. 31

A 5-year old boy while having dinner suddenly becomes aphonic and is brought to the casualty with the complaint of respiratory distress. Immediate management should be:   

AI 11

 A

Cricothyroidotomy

 B

Emergency tracheostomy

 C

Humidified oxygen

 D

Heimlich maneuver

Ans. D

Explanation:

Ans. Heimlich maneuver


Q. 32

Foreign body from trachea most common goes to right bronchus due to ‑

 A

Right bronchus shallow

 B

Wider & in continuous line with trachea

 C

Right bronchus is longer

 D

Right bronchus is horizontal

Q. 32

Foreign body from trachea most common goes to right bronchus due to ‑

 A

Right bronchus shallow

 B

Wider & in continuous line with trachea

 C

Right bronchus is longer

 D

Right bronchus is horizontal

Ans. B

Explanation:

Trachea bifurcates at Carina (at lower border of T4 vertebra at T4-T5 disc space) into right and left principal (primary) bronchi.

Right principal bronchus is wider, shorter (2.5 cm long), and more vertical in the line of trachea (25° with median plane).

Therefore a foreign body is most likely to lodge in the right bronchus.


Q. 33

Hemlichs maneuver is used for ‑

 A

Upper airway obstruction by foreign body

 B

BPPV

 C

Eustachian tube patency test

 D

Tympanic membrane integrity test

Q. 33

Hemlichs maneuver is used for ‑

 A

Upper airway obstruction by foreign body

 B

BPPV

 C

Eustachian tube patency test

 D

Tympanic membrane integrity test

Ans. A

Explanation:

Ans. is ‘a’ i.e., Upper airway obstruction by foreign body

Heimlich manoeuvre

Abdominal thrusts, also called the Heimlich manoeuvre or Heimlich maneuver, is a first aid procedure used to treat upper airway obstructions (or choking) by foreign objects. The term Heimlich maneuver is named after Dr. Henry Heimlich, who first described it in 1974.


Q. 34

A foreign body completely obstructing this structure (marked with arrow) causes?

 A

Decreased ventilation perfusion ratio

 B

Increased ventilation in left lung

 C

Perfusion doubles in right lung

 D

Increased VF ratio in right lung

Q. 34

A foreign body completely obstructing this structure (marked with arrow) causes?

 A

Decreased ventilation perfusion ratio

 B

Increased ventilation in left lung

 C

Perfusion doubles in right lung

 D

Increased VF ratio in right lung

Ans. A

Explanation:

Arrow representing Right bronchus

. Decreased ventilation perfusion ratio

Trachea bifurcates at Carina (at lower border of T4 vertebra at T4-T5 disc space) into right and left principal (primary) bronchi.



Tracheostomy

Tracheostomy

Q. 1

A double lumen tracheostomy tube all are true EXCEPT:

 A

Easy to remove inner cannula

 B

Easy to clean inner cannula

 C

Easy to replace inner cannula

 D

No inner cannula

Q. 1

A double lumen tracheostomy tube all are true EXCEPT:

 A

Easy to remove inner cannula

 B

Easy to clean inner cannula

 C

Easy to replace inner cannula

 D

No inner cannula

Ans. D

Explanation:

Q. 2

In emergency tracheostomy the following structures are damaged except?

 A

Isthmus of the thyroid

 B

Inferior thyroid artery

 C

Thyroid ima

 D

Inferior thyroid vein

Q. 2

In emergency tracheostomy the following structures are damaged except?

 A

Isthmus of the thyroid

 B

Inferior thyroid artery

 C

Thyroid ima

 D

Inferior thyroid vein

Ans. B

Explanation:

Isthmus, thyroid ima artery and inferior thyroid veins are midline structures and thus can be injured during tracheostomy, more so during emergency tracheostomy. Inferior thyroid artery, a branch of the thyrocervical trunk of the subclavian artery lies laterally away from midline, thus can escape injury.

In emergency tracheostomy following structures can be damaged:

– Isthmus

–  Inferior thyroid veins

– Thyroid ima artery

–  Left brachio-cephalic vein, jugular venous arch

–  Pleura (especially infants)

– Thymus

–  Esophagus (the trachea is small, mobile, and soft in infants damage the esophagus)


Q. 3

High tracheostomy is indicated in:

 A

Carcinoma

 B

TB

 C

Diphtheria

 D

All of the above

Q. 3

High tracheostomy is indicated in:

 A

Carcinoma

 B

TB

 C

Diphtheria

 D

All of the above

Ans. A

Explanation:

Q. 4

Indication for tracheostomy are all, EXCEPT:

 A

Flail chest

 B

Head injury

 C

Cardiac Tamponade

 D

Foreign body

Q. 4

Indication for tracheostomy are all, EXCEPT:

 A

Flail chest

 B

Head injury

 C

Cardiac Tamponade

 D

Foreign body

Ans. C

Explanation:

Indications for tracheostomy are Flail chest, Head injury, Foreign body, Tetanus etc.

Cardiac tamponade is not an indication for tracheostomy.


Q. 5

Mid tracheostomy is done over which of the following anatomical landmarks?

 A

1st and 2nd tracheal rings

 B

3rd and 4th tracheal rings

 C

5th and 6th tracheal rings

 D

7th and 8th tracheal rings

Q. 5

Mid tracheostomy is done over which of the following anatomical landmarks?

 A

1st and 2nd tracheal rings

 B

3rd and 4th tracheal rings

 C

5th and 6th tracheal rings

 D

7th and 8th tracheal rings

Ans. B

Explanation:

Tracheostomy has also been divided into:

A) High tracheostomy: Done above level of thyroid isthmus. Indication is ca larynx.

B) Mid tracheostomy: It is the preferred one and done through II and III rings, division of isthmus.

C) Low tracheostomy: Done below level of isthmus. Trachea is deep at this level and close to several large vessels.

 
A mid tracheostomy is done through the II or III rings and would entail division of the thyroid isthmus (isthmus lies against II, III and IV tracheal rings) or its retraction upwards or downwards to expose this part of trachea.

Q. 6

Which of the following could be the indication for a middle aged man posted for a high tracheostomy?

 A

Carcinoma

 B

TB

 C

Tetanus

 D

Diphtheria

Q. 6

Which of the following could be the indication for a middle aged man posted for a high tracheostomy?

 A

Carcinoma

 B

TB

 C

Tetanus

 D

Diphtheria

Ans. A

Explanation:

A high tracheostomy is done above the level of thyroid isthmus. It violates the 1st ring of trachea.
Tracheostomy at this site can cause perichondritis of the cricoid cartilage and subglottic stenosis and is always avoided.
Only indication for high tracheostomy is carcinoma of larynx because in such cases, total larynx would ultimately be removed and a fresh tracheostome made in a clean area lower down.
 

Q. 7

In emergency tracheostomy all of the following structures are damaged, EXCEPT?

 A

Isthmus of the thyroid

 B

Inferior thyroid artery

 C

Thyroid ima artery

 D

Inferior thyroid vein

Q. 7

In emergency tracheostomy all of the following structures are damaged, EXCEPT?

 A

Isthmus of the thyroid

 B

Inferior thyroid artery

 C

Thyroid ima artery

 D

Inferior thyroid vein

Ans. B

Explanation:

Bleeding can occur immediately after a tracheostomy and in the late postoperative period. Sources of hemorrhage include granulation tissue in the stoma or trachea, and erosion of thyroid vessels or the thyroid itself, the tracheal wall (frequently from suction trauma), or the innominate artery. Inferior thyroid artery, a branch of the thyrocervical trunk of the subclavian artery lies laterally away from midline, thus can escape injury.

Q. 8

True about pediatric tracheostomy –

 A

Most common early complication is subcutaneous emphysema

 B

3rd & 4th tracheal rings are incised

 C

Easy to remove the tracheostomy tube

 D

a and b

Q. 8

True about pediatric tracheostomy –

 A

Most common early complication is subcutaneous emphysema

 B

3rd & 4th tracheal rings are incised

 C

Easy to remove the tracheostomy tube

 D

a and b

Ans. D

Explanation:

Ans. is ‘a’ i.e., Most common early complication is subcutaneous emphysema; b i.e., 3rd & 4th tracheal ring are incised

o In most of the cases tracheostomy is performed with general anaesthesia and the patient intubated and paralyzed. o Neck is extended.

o A horizontal incision is made halfway between the cricoid cartilage and the sternal notch.

  • Subcutaneous fat and tissues are reflected, and deep cervical facia, is cut to expose thyroid isthmus.
  • A vertical cut is given in 2-3 or 3-4 rings in midline and no part of the tracheal wall is removed.
  • The endotracheal tube is withdrawn and a suitable size tracheostomy tube is simultaneously inserted.
  • Post-operatively neck & chest radiograph are obtained to evaluate the position of the tube and to identify the subcutaneous emphysema & pneumothorax that could have developed as complication.

o Tube must be cleaned at frequent intervals.

o Patient should be nursed in and atmosphere of moist air.


Q. 9

Indications of tracheostomy are

 A

Flail chest

 B

Head injury

 C

Tetanus

 D

All

Q. 9

Indications of tracheostomy are

 A

Flail chest

 B

Head injury

 C

Tetanus

 D

All

Ans. D

Explanation:

A i.e. Flail chest; B i.e. Head injury; C i.e. Tetanus


Q. 10

A new born with a goiter large enough to cause dyspnoea is best treated with –

 A

Sulfonamieds

 B

Tracheostomy

 C

T3

 D

Iodides

Q. 10

A new born with a goiter large enough to cause dyspnoea is best treated with –

 A

Sulfonamieds

 B

Tracheostomy

 C

T3

 D

Iodides

Ans. B

Explanation:

Ans. is ‘b’ i.e. Tracheostomy 

Partial thyroidectomy is preferred over tracheostomy.


Q. 11

Interstitial Emphysema may be found in the following conditions –

 A

Chest injury

 B

Tracheostomy

 C

Surgical wound

 D

All

Q. 11

Interstitial Emphysema may be found in the following conditions –

 A

Chest injury

 B

Tracheostomy

 C

Surgical wound

 D

All

Ans. D

Explanation:

Ans. is ‘d’ i.e., All 


Q. 12

A cricoid hook is used particularly –

 A

In thyroidectomy

 B

In block dissection of the neck

 C

For retracting the superior laryngeal nerve

 D

In tracheostomyMiscellaneous / 817

Q. 12

A cricoid hook is used particularly –

 A

In thyroidectomy

 B

In block dissection of the neck

 C

For retracting the superior laryngeal nerve

 D

In tracheostomyMiscellaneous / 817

Ans. D

Explanation:

Ans. is ‘d’ i.e., In tracheostomy 


Q. 13

A patient of carcinoma larynx with stridor presents in casualty, immediate management is:

 A

Planned tracheostomy

 B

Immediate tracheostomy

 C

High dose steroid

 D

Intubate, give bronchodilator and wait for 12 hours, if no response, proceed to tracheostomy

Q. 13

A patient of carcinoma larynx with stridor presents in casualty, immediate management is:

 A

Planned tracheostomy

 B

Immediate tracheostomy

 C

High dose steroid

 D

Intubate, give bronchodilator and wait for 12 hours, if no response, proceed to tracheostomy

Ans. B

Explanation:

 

Carcinoma larynx presenting with stridor means it is subglottic laryngeal carcinoma .Ideally in such cases emergency laryngectomy should be performed.

 

But not done in cases if

  • Intubation can not be done as growth is seen in subglottic area, therefore tube can not be put.
  • Planned tracheostomy can not be done as patient is suffering from stridor, which is an emergency. Therefore we will have to do emergency tracheostomy. With the precaution that the area of cancer should be removed within 72 hours.



Q. 14

Maintenance of airway during laryngectomy in a patient with carcinoma of larynx is best done by

 A

Tracheostomy

 B

Laryngeal mask airway

 C

Laryngeal tube

 D

Combi tube

Q. 14

Maintenance of airway during laryngectomy in a patient with carcinoma of larynx is best done by

 A

Tracheostomy

 B

Laryngeal mask airway

 C

Laryngeal tube

 D

Combi tube

Ans. A

Explanation:

Q. 15

Tracheostomy is indicated in all except:

 A

Tracheal stenosis

 B

Bilateral vocal cord palsy

 C

Foreign body larynx

 D

Uncomplicated bronchial asthma

Q. 15

Tracheostomy is indicated in all except:

 A

Tracheal stenosis

 B

Bilateral vocal cord palsy

 C

Foreign body larynx

 D

Uncomplicated bronchial asthma

Ans. D

Explanation:

Q. 16

The most common indication for tracheostomy is: 

 A

Laryngeal diphtheria

 B

Foreign body aspiration

 C

Carcinoma

 D

Asthma

Q. 16

The most common indication for tracheostomy is: 

 A

Laryngeal diphtheria

 B

Foreign body aspiration

 C

Carcinoma

 D

Asthma

Ans. B

Explanation:

Historically, the main indication for a tracheostomy was to bypass upper airway obstruction caused by a foreign body or infection, particularly diphtheria.

Nowadays upper airway obstruction is the least common indicator for tracheostomy. Almost two thirds of tracheostomies are currently performed on intubated intensive care patients, mainly to aid removal of secretions from the distal tracheobronchial tree and to facilitate weaning from distal tracheobronchial tree in acute respiratory failure and prolonged ventilation

 


Q. 17

Tracheostomy is not indicated in: 

 A

Emphysema

 B

Bronchiectosis

 C

Atelectasis

 D

Pneumothorax

Q. 17

Tracheostomy is not indicated in: 

 A

Emphysema

 B

Bronchiectosis

 C

Atelectasis

 D

Pneumothorax

Ans. D

Explanation:

 

 



Q. 18

A high tracheostomy may be indicated in:

 A

Scleroma of the larynx

 B

Multiple papilliomatosis of larynx

 C

Bilateral vocal cord paralysis

 D

Carcinoma of larynx

Q. 18

A high tracheostomy may be indicated in:

 A

Scleroma of the larynx

 B

Multiple papilliomatosis of larynx

 C

Bilateral vocal cord paralysis

 D

Carcinoma of larynx

Ans. D

Explanation:

 

 It is important (in tracheostomy) to refrain from causing any damage in the region of cricoid cartilage.

An exception to this rule is when a patient has laryngeal malignancy and under these circumstances tracheostomy should be placed high so as to allow resection of tracheostomy site at the time of laryngectomy – Scott Brown 7th/ed vol 2 pg. 2295

The high tracheostomy is generally avoided because of the postoperative risk of peri-chondritis of the cricoid cartilage and subglottic stenosis. In cases of carcinoma larynx with stridor when total laryngectomy would be done, high tracheostomy is indicated.



Q. 19

True about tracheostomy tube are all except:

 A

Double tube

 B

Made of titanium silver alloy

 C

Cuffed tube for IPPV

 D

Has to be changed ideally in every 2 to 3 days

Q. 19

True about tracheostomy tube are all except:

 A

Double tube

 B

Made of titanium silver alloy

 C

Cuffed tube for IPPV

 D

Has to be changed ideally in every 2 to 3 days

Ans. D

Explanation:

Q. 20

All are true about tracheostomy tube except: 

 A

Jackson’s tube has 2 lumens

 B

Removal of metallic tube in every 2-3 days

 C

Cuffed tube is used to prevent aspiration of pharyngeal secretion

 D

Made up of titanium-silver alloy

Q. 20

All are true about tracheostomy tube except: 

 A

Jackson’s tube has 2 lumens

 B

Removal of metallic tube in every 2-3 days

 C

Cuffed tube is used to prevent aspiration of pharyngeal secretion

 D

Made up of titanium-silver alloy

Ans. B

Explanation:

 

A tracheostomy tube may be metallic or nonmetallic

  • Metallic Tracheostomy Tube

Metallic tubes are formed from the alloy of silver, copper and phosphorus

Has an inner and an outer tube.The inner tube is longer than the outer one so that secretions and crusts formed in it can be removed and the tube reinserted after cleaning without difficulty. However, they do not have a cuff and cannot produce an airtight seal.

  • Nonmetallic Tracheostomy Tube

Can be of cuffed or noncuffed variety, e.g. rubber and PVC tubes. 

Cuffed Tracheostomy Tubes

  • A cuff is a balloon-like device around the distal end of the tracheostomy tube. Most cuffed tubes now available have low pressure cuffs with a high volume. This significantly reduces the possibility of pressure necrosis and potential stenosis formation. Pediatric tubes do not have a cufr. Cuffed tubes are used in situation where positive pressure ventilation is required, or when the airway is at risk from aspiration. (In unconscious patient or when patient is on respiration).

The cuff should be deflated every 2 hours for 5 mins to present pressure damage to the trachea.

Uncuffed Tracheostomy Tubes

This tube does not have a cuff that can be inflated inside the trachea.

It is suitable for a patient who has returned to the ward from a prolonged stay in intensive care and requires physiotherapy and suction via trachea.

This type of tube is not suitable for patients who are unable to swallow due to incompetent laryngeal reflexes, and aspiration of oral or gastric con­tents is likely to occur.

An uncuffed tube is advantageous in that it allows the patient to breathe around it in the event of the tube becoming blocked. Patients can also speak with an uncuffed tube.

 


Q. 21

In emergency tracheostomy following structures are damaged except:

 A

Isthmus of thyroid

 B

Inferior thyoid vein

 C

Inferior thyroid artery

 D

Thyroid ima

Q. 21

In emergency tracheostomy following structures are damaged except:

 A

Isthmus of thyroid

 B

Inferior thyoid vein

 C

Inferior thyroid artery

 D

Thyroid ima

Ans. C

Explanation:

 

Structures which lie below the midline viz. isthmus of thyroid and thyroid ima artery can be damaged in emergency tracheostomy.

Inferior thyroid veins emerge at the lower border of the isthmus form a plexus in front of the trachea and drains into brachioce­phalic vein can be damaged during tracheostomy but inferior thyroid artery, a branch of thyrocervical trunk of subclavian artery lies laterally away from midline and can thus escape injury.


Q. 22

Most common complication of tracheostomy is: 

 A

Tracheoesophageal fistula

 B

Tracheocutaenous fistula

 C

Surgical emphysema

 D

All

Q. 22

Most common complication of tracheostomy is: 

 A

Tracheoesophageal fistula

 B

Tracheocutaenous fistula

 C

Surgical emphysema

 D

All

Ans. D

Explanation:

 

 Complications of Tracheostomy

IMMEDIATE

Most common complication of tracheostomy is hemorrhage. The commonest cause of bleeding during tracheostomy is Anterior jugular vein.

Other Immediate Complication of tracheostomy

  • Air embolism                                                                    • Apnea (due to sudden release of retained CO2)
  • Cardiac arrest                                                                   • Local damage to structures
  • Pneumothorax (d/t injury to apical pleura)

INTERMEDIATE

During first few hours or days

  • Dislodgement/Displacement of the tube
  • Surgical emphysema :May occur as the air may leak into the cervical tissues.

This is occasionally found in the immediate postoperative period.

Presents as a swollen area around the root of the neck and upper chest, which displays crepitus on palpation. It is due to overtight suturing of the wound and is not dangerous unless it leads to mediastinal emyphysema and cardiac tamponade.

  • Pneumothorax/pneumomediastinum
  • Tubal obstruction by Scabs/crusts
  • Infection (tracheitis and tracheobronchitis, local wound infection).
  • Dysphagia :

– This is fairly common in the first few days after tracheostomy.

– In normal swallowing a positive subglottic pressure is created by the closing of the vocal cords – which is why one cannot speak during swallowing.This is not possible with a tracheostomy tube in place, and thus swallowing is incoordinate. – Another reason for dysphagia is that if an inflatable cuff is blown up it will press on and obstruct the oesophagus.

  • Tracheal necrosis
  • Tracheo arterial (Tracheal innominate artery fistula) /Tracheoeshophageal fistula
  • Recurrent laryngeal nerve injury.

LATE

  • Hemorrhage due to erosion of major vessels
  • Stenosis of the trachea (at the level of stoma)
  • Laryngeal stenosis due to perichondritis of cricoid cartilage.
  • Difficulty with decannulation
  • Tracheocutaneous fistula/scars.

According to Scott-Brown’s 7th vol 2 p. 2301 – Tracheoarterial fistula / Tracheoesophageal fistula are intermediate complications and not late complications like tracheocutaneous fistula.


Q. 23

“Gold standard” surgical procedure for prevention of aspiration is:

 A

Thyroplasty

 B

Tracheostomy

 C

Tracheal division and permanent tracheostome

 D

Feeding gastrostomy/jejunostomy

Q. 23

“Gold standard” surgical procedure for prevention of aspiration is:

 A

Thyroplasty

 B

Tracheostomy

 C

Tracheal division and permanent tracheostome

 D

Feeding gastrostomy/jejunostomy

Ans. C

Explanation:

 

Aspiration is the passage of foreign material beyond the vocal cords:

  • The larynx has 3 distinct functions – respiration, phonation and airway protection. Dysfunction of larynx can lead to aspiration.
  • The primary goal of treatment of aspiration is to separate the upper digestive tract from the upper respiratory tract for a short period of time or in some cases, permanently.
  • There are 3 broad categories of treatment.

Temporary/Adjunct Treatments

  • Medical Therapy – in the form of antibiotics is important to prevent aspiration pneumonia.
  • It is important to make the patient NPO, to avoid further aspiration and to find an alternate feeding route to maintain the patients nutritional status. A nasogastric tube (feeding gastostomy/jejunostomy) is commonly placed, but this may actually increase the aspiration reflux by making the lower esophageal and upper esophageal sphincters incompetent.

  

Vocal cord medialization (by injecting Gel foam) is useful in unilateral paralysis.This is helpful but is rarely curative, if there is a serious aspiration problem.

Tracheostomy will often make aspiration worse by preventing laryngeal elevation on swallowing. It does however, allow easy access to the chest for suctioning. Even a cuffed tube doesn’t prevent aspiration as secretions pool above the cuff and the seal is never perfect”- Scotts Brown 7th/ed vol 1 pg. 1278

Definite – Reversible Procedures

  • Endolaryngeal stents: They function like a cork in the bottle. There job is to seal the glottis and therefore thay need to be used in conjunction with a tracheostomy tube. But they are not often used as they are effective only as a short term solution, plus there is risk of glottic stenosis.
  • Laryngotracheal separation: The procedure involves transecting the cervical trachea and bringing out the lower end as a permanent end stoma
  • But it has disadvantage of sacrificing voice.
  • Alternative procedure is Tracheoesophageal diversion but has higher complication rates.

Definite – Irreversible Procedure

It includes: Narrow field laryngectomy: it was considered as a gold standard prior to 1970s, when the irreversible procedures like laryngo tracheal separation were not done.

Also Know

  • Investigation of choice for diagnosing aspiration = Fibreoptic endoscopic evaluation of swallow (FESS)
  • Videofluoroscopic modified Barium swallow (often called as ideofluoroscopy)



Q. 24

All are true statement about tracheostomy and larynx in children except:

 A

Omega shaped epiglottis

 B

Laryngeal cartilages are soft and collapsable

 C

Larynx is high in children

 D

Trachea can be easily palpated

Q. 24

All are true statement about tracheostomy and larynx in children except:

 A

Omega shaped epiglottis

 B

Laryngeal cartilages are soft and collapsable

 C

Larynx is high in children

 D

Trachea can be easily palpated

Ans. D

Explanation:

 

Infant’s larynx differs from adult in:

  • It is situated high up (C2 – C4).Q (in adults = C3 – C6)
  • Of equal size in both sixes (in adults it is larger in males)
  • Larynx is funnel shaped
  • The narrowest part of the infantile larynx is the junction of subglottic larynx with trachea and this is because cricoid cartilage is very small
  • Epiglottis is omega shaped, soft, large and patulous.
  • Laryngeal cartilages are soft and collapse easily
  • Short trachea and short neck.
  • Vocal cords are angled and lie at level of C4
  • Trachea bifurcates at level of T2
  • Thyroid cartilage is flat. The cricothyroid and thyrohyoid spaces are narrow.

Tracheostomy in Infants and Children                                                                                                              

Trachea of infants and children is soft and compressible and its identification may become difficult and the surgeon may easily displace it and go deep or lateral to it injuring recurrent laryngeal nerve or even the carotid.

During positioning, do not extend too much as this pulls structures from chest into the neck and thus injury may occur to pleura, innominate vessels and thymus or the tracheostomy opening may be made twoo low near suprasternal notch

Tracheostomy in Infants and Children                                                                                               

The incision is a short transverse one, midway between lower border of thyroid cartilage and the suprasternal notch. The neck must be well extended.

A incision is made through two tracheal rings, preferably the third or fourth.



Q. 25

Complication commonly occurring in tracheostomy in children is:       

March 2004

 A

Stenosis

 B

Difficult decanulation

 C

Difficult weaning

 D

Infection

Q. 25

Complication commonly occurring in tracheostomy in children is:       

March 2004

 A

Stenosis

 B

Difficult decanulation

 C

Difficult weaning

 D

Infection

Ans. B

Explanation:

Ans. B i.e. Difficult decanulation


Q. 26

All of the following are true regarding tracheostomy tube except:               

September 2008

 A

Double lumen tube

 B

Made of titanium silver alloy

 C

Cuffed tube prevents aspiration of pharyngeal secretions

 D

Ideally should be changed every 3rd day

Q. 26

All of the following are true regarding tracheostomy tube except:               

September 2008

 A

Double lumen tube

 B

Made of titanium silver alloy

 C

Cuffed tube prevents aspiration of pharyngeal secretions

 D

Ideally should be changed every 3rd day

Ans. D

Explanation:

Ans. D: Ideally should be changed every 3rd day

Care of the tracheostomy tube:

Inner cannula should be removed and cleaned as and when indicated for the first 3 days. Outer tube, unless blocked or displaced, should not be removed for 3-4 days to allow a track to be formed when tube placement will be easy.


Q. 27

One of the most important complication of tracheostomy is:              

September 2008

 A

Surgical emphysema

 B

Hemorrhage

 C

Recurrent laryngeal nerve palsy

 D

Displacement of tube

Q. 27

One of the most important complication of tracheostomy is:              

September 2008

 A

Surgical emphysema

 B

Hemorrhage

 C

Recurrent laryngeal nerve palsy

 D

Displacement of tube

Ans. B

Explanation:

Ans. B: Hemorrhage

Indications for tracheostomy

To relieve upper airway obstruction

  • Foreign body
  • Trauma
  • Acute infection – acute epiglottitis, diphtheria
  • Glottic oedema
  • Bilateral abductor paralysis of the vocal cords
  • Tumours of the larynx
  • Congenital web or atresia

– To improve respiratory function

  • Fulminating bronchopneumonia
  • Chronic bronchitis and emphysema
  • Chest injury and flail chest
  • Respiratory paralysis
  • Unconscious head injury
  • Bulbar poliomyelitis
  • Tetanus
  • Advantages of tracheostomy over endotracheal intubation
  • Reduces patient discomfort
  • Reduces need for sedation
  • Improves ability to maintain oral and bronchial hygiene
  • Reduces risk of glottic trauma
  • Reduces dead space and reduces work of breathing
  • Augments process of weaning from ventilatory support
  • Complications of tracheostomy

– Immediate

  • Haemorrhage
  • Surgical trauma – oesophagus, recurrent laryngeal nerve
  • Pneumothorax

– Intermediate

  • Tracheal erosion
  • Tube displacement
  • Tube obstruction
  • Subcutaneous emphysema
  • Aspiration and lung abscess Late
  • Persistent tracheo-cutaneous fistula
  • Laryngeal and tracheal stenosis
  • Tracheomalacia
  • Tracheo-oesophageal fistula
  • Post-operative tracheostomy care
  • Maintain patent airway
  • Frequent atraumatic suction
  • Humidification of inspired air and oxygen
  • Mucolytic agents
  • Coughing and physiotherapy
  • Occasional bronchial lavage
  • Prevent infection and complications
  • Aseptic tube suction, handling and tube changing
  • Prophylactic antibiotics
  • Deflate cuff for 5 minutes every hours
  • Avoid tube impinging on posterior tracheal wall
  • Percutaneous tracheostomy
  • Indicated in patients likely to require ventilatory support for more than 2 weeks
  • Usually performed at the bedside in an ITU
  • Has significant cost benefits compared to open procedure

Q. 28

Method to establish a safer airway in a patient with neck trauma, cricoid fracture with possibility of a difficult airway:                                     

March 2011

 A

Orotracheal intubation

 B

Cricothyroidotomy

 C

Emergency tracheostomy

 D

None of the above

Q. 28

Method to establish a safer airway in a patient with neck trauma, cricoid fracture with possibility of a difficult airway:                                     

March 2011

 A

Orotracheal intubation

 B

Cricothyroidotomy

 C

Emergency tracheostomy

 D

None of the above

Ans. C

Explanation:

Ans. C: Emergency tracheostomy

Tracheostomy is an alternative when intubation is not possible

Tracheostomy:

  • Double tube
  • Made of titanium silver alloy
  • In emergency trachesostomy, structure which can be injured are:

–        Inferior thyroid vein

–        Isthmus of thyroid

–        Thyroid imam artery

  • Common complication is tracheal stenosis
  • Mitomycin is used for tracheal stenosis

Q. 29

Mini tracheostomy is performed through ‑

 A

Cricothyroid membrane

 B

2nd and 3rd tracheal rings

 C

Any of the above

 D

None of the above

Q. 29

Mini tracheostomy is performed through ‑

 A

Cricothyroid membrane

 B

2nd and 3rd tracheal rings

 C

Any of the above

 D

None of the above

Ans. A

Explanation:

Ans. is ‘a’ i.e., Cricothyroid membrane

Cricothyrotomy or Laryngtomy or Minitracheostomy

  • It is the procedure to open the airway through the cricothyroid membrane.
  • Patient’s head and neck are extended, lower border of throid cartilage and cricoid ring is identified. Skin in this area is incised vertically and then cricothyroid membrane is opened with a transverse incision.
  • It is an emergency procedure to buy time for the patient to be shifted to the operation theatre.


Chambers of heart

CHAMBERS OF HEART

Q. 1

Which chamber’s anterior wall forms most of the sternocostal surface of the heart?

 A

Left atrium

 B

Left ventricle

 C

Right atrium

 D

Right ventricle

Q. 1

Which chamber’s anterior wall forms most of the sternocostal surface of the heart?

 A

Left atrium

 B

Left ventricle

 C

Right atrium

 D

Right ventricle

Ans. D

Explanation:

The heart has three important surfaces: an anterior surface, a diaphragmatic surface, and a pulmonary surface. The anterior surface, or sternocostal surface, is mostly made up of the right ventricle. The diaphragmatic surface is mostly the left ventricle, but a little bit of the right ventricle sits on the diaphragm as well. Finally, the pulmonary surface, which is on the left, is mostly made up of the left ventricle.


Q. 2

Torus aorticus is an impression in the cavity of?

 A

Right atrium

 B

Left atrium

 C

Right ventricle

 D

Left ventricle

Q. 2

Torus aorticus is an impression in the cavity of?

 A

Right atrium

 B

Left atrium

 C

Right ventricle

 D

Left ventricle

Ans. A

Explanation:

Torus aorticus is a bulge in the right atrial wall anterosuperiorly above the membranous septum. It is superior to the coronary sinus and anterior to the fossa ovalis. It represents the deeper and anterior surface of the posterior sinus and cusp of the aortic valve.


Q. 3

Which of the following cardiac chamber forms the base of the heart?

 A

Right atrium

 B

Right ventricle

 C

Left atrium

 D

Left ventricle

Q. 3

Which of the following cardiac chamber forms the base of the heart?

 A

Right atrium

 B

Right ventricle

 C

Left atrium

 D

Left ventricle

Ans. C

Explanation:

Posterior surface or base of the heart is entirely formed by the left atrium which receives the 4 pulmonary veins. 
  • The anterior or sternocostal surface consist of the right atrium, vertical atrioventricular groove, and the right ventricle with a narrow strip of left ventricle appearing on the horizon of the left border.
  • The inferior or diaphragmatic surface consist of the right atrium receiving the inferior vena cava, the anteroposterior atrioventricular groove and to the left this the ventricular surface is made up of one third right ventricle and two third left ventricle separated by posterior interventricular branch of right coronary artery.

Q. 4

The membranous part of the interventricular septum is situated in between:

 A

Right ventricle and right atrium

 B

Right ventricle and left atrium

 C

Left ventricle and left atrium

 D

Left ventricle and right atrium

Q. 4

The membranous part of the interventricular septum is situated in between:

 A

Right ventricle and right atrium

 B

Right ventricle and left atrium

 C

Left ventricle and left atrium

 D

Left ventricle and right atrium

Ans. D

Explanation:

Membranous part of ventricular system is a small portion of the ventricular and atrioventricular septum located at the base of the heart adjacent to the anteroseptal tricuspid commissure , the right aortic posterior valve commissure and the anterior mitral valve leaflet. Because of the apical displacement of the tricuspid valve compared to mitral valve, a portion of the membranous septum  separates the left ventricle from the right atrium.

 
The remaining three regions of the ventricular septum are inlet, outlet and trabecula. They are all muscular and and they radiate out from the membranous septum.
 

Q. 5

In humans, where does depolarisation of cardiac ventricular muscle starts from?

 A

Posterobasal part of ventricle

 B

Left side of inter ventricular septum

 C

Uppermost part of interventricular septum

 D

Basal portion of ventricle

Q. 5

In humans, where does depolarisation of cardiac ventricular muscle starts from?

 A

Posterobasal part of ventricle

 B

Left side of inter ventricular septum

 C

Uppermost part of interventricular septum

 D

Basal portion of ventricle

Ans. B

Explanation:

In humans, depolarization of the ventricular muscle starts at the left side of the interventricular septum and moves first to the right across the mid portion of the septum.
 
The wave of depolarization then spreads down the septum to the apex of the heart. It then returns along the ventricular walls to the AV groove, proceeding from the endocardial to the epicardial surface. The last parts of the heart to be depolarized are the posterobasal portion of the left ventricle, the pulmonary conus, and the uppermost portion of the septum.

Q. 6

True about anatomy of right ventricle:

 A

TV & PV Share fibrous continuity

 B

More prominent trabeculation

 C

Crista supraventricularis Separate Tricuspid valve & Pulmonary valve and Apex trabeculated both

 D

All

Q. 6

True about anatomy of right ventricle:

 A

TV & PV Share fibrous continuity

 B

More prominent trabeculation

 C

Crista supraventricularis Separate Tricuspid valve & Pulmonary valve and Apex trabeculated both

 D

All

Ans. D

Explanation:

All Correct

Right ventricle is situated anteriorlyQ. As the anterior (sternocostal) surface of heart consists mainly of right ventricleQ with right atrium on its right and a narrow strip of left ventricle left border. The tip of left auricular appendage peeps over the to of this border.


Q. 7

Base of heart is formed by

 A

Rt. ventricle

 B

LV

 C

LV + RV

 D

RA + LA

Q. 7

Base of heart is formed by

 A

Rt. ventricle

 B

LV

 C

LV + RV

 D

RA + LA

Ans. D

Explanation:

D i.e. RA + LA 

The base of heart forms its posterior surface. It is formed mainly by the left atriumQ and by small part of right atriumQ.


Q. 8

Base of the heart is formed mainly by:

 A

Right atrium

 B

Left atrium

 C

Right ventricle

 D

Left ventricle

Q. 8

Base of the heart is formed mainly by:

 A

Right atrium

 B

Left atrium

 C

Right ventricle

 D

Left ventricle

Ans. B

Explanation:

The heart has three surfaces: sternocostal (anterior), diaphragmatic (inferior), and a base (posterior).

It also has an apex, which is directed downward, forward, and to the left.

The sternocostal surface is formed mainly by the right atrium and the right ventricle.

The right border is formed by the right atrium; the left border, by the left ventricle and part of the left auricle.

The diaphragmatic surface of the heart is formed mainly by the right and left ventricles. The inferior surface of the right atrium, into which the inferior vena cava opens, also forms part of this surface.

The base of the heart, or the posterior surface, is formed mainly by the left atrium, into which open the four pulmonary veins.


Q. 9

In PA view of X-ray chest, right border of the heart is formed by all except:

 A

Superior venacava

 B

Inferior venacava

 C

Right atrium

 D

Left atrial appendage

Q. 9

In PA view of X-ray chest, right border of the heart is formed by all except:

 A

Superior venacava

 B

Inferior venacava

 C

Right atrium

 D

Left atrial appendage

Ans. D

Explanation:

Ans. Left atrial appendage


Q. 10

Right border of heart is formed by ‑

 A

Right ventricle

 B

Right atrium

 C

SVC

 D

IVC

Q. 10

Right border of heart is formed by ‑

 A

Right ventricle

 B

Right atrium

 C

SVC

 D

IVC

Ans. B

Explanation:

External features of heart

The heart has following borders and surfaces :- 

A) Borders

i) Right border :- Formed by right atrium.

ii)  Left border (obtuse margin):- Formed mainly by left ventricle and partly by left auricle (in its upper most part).

iii) Inferior border (acute margin):- Formed mainly by right ventricle and partly by left ventricle near apex.

iv) Upper border :- Mainly by left atrium and partly by right atrium where SVC enters.

v) Apex :- Formed by left ventricle.

B) Surfaces

i) Anterior (sternocostal) surface :- Formed mostly by right ventricle (major) and right auricle and partly by left ventricle and left auricle.

ii) Inferior (diaphragmatic) surface :- It is formed by left ventricle (left 2/3) and right ventricle (right 1/3). It is traversed by posterior interventricular groove (PIV) containing PIV branch of RCA.


Q. 11

Crista terminalis is present in ‑

 A

Left atrium

 B

Left ventricle

 C

Right atrium

 D

Right ventricle

Q. 11

Crista terminalis is present in ‑

 A

Left atrium

 B

Left ventricle

 C

Right atrium

 D

Right ventricle

Ans. C

Explanation:

Crista terminalis (divides the right atrium into anterior and posterior part) is a ridge of smooth muscle fibers extending from the SVC to valve of IVC.

It is developed from embryonic right venous valve and is represented on the surface by sulcus terminalis.


Q. 12

Where is torus aorticus located 

 A

Left atrium

 B

Right atrium

 C

Aorta

 D

Left ventricle

Q. 12

Where is torus aorticus located 

 A

Left atrium

 B

Right atrium

 C

Aorta

 D

Left ventricle

Ans. B

Explanation:

Torus aorticus is a buldge in the right atrial septum sited superiorly and anteriorly.

It is produced due to adjacent nonocoronary aortic sinus at the base of ascending aorta.

It is superior to coronary sinus and anterior to fossa ovalis.


Q. 13

Not true about superior vena cava 

 A

Opens into right ventricle

 B

Enters the heart at level of 3rd costal

 C

Pierces paricardium at 2nd costal cartilage

 D

Receives azygos vein behind sternal angle

Q. 13

Not true about superior vena cava 

 A

Opens into right ventricle

 B

Enters the heart at level of 3rd costal

 C

Pierces paricardium at 2nd costal cartilage

 D

Receives azygos vein behind sternal angle

Ans. A

Explanation:

SVC opens in to right atrium (not right ventricle).

Superior vena-cava

  • SVC collects blood from the upper half of the body and drains into the right atrium. It is formed by the union of two brachiocephalic veins at the level of lower border of 1″ right costal cartilage. It passes vertically downwards behind the right border of sternum and piercing the pericardium at the level of the second costal cartilage, enters the upper border of the right atrium to end in the upper and posterior part of sinus venorum at the lower border of third right costal cartilage (opposite Ts vertebra).
  • Behind the sternal angle (T4 vertebral level), SVC receives the azygos vein.
  • SVC is divided into two parts –

i) Upper half (extrapericardial) 

ii) Lower half (intrapericardial)


Q. 14

Not true about right atrium ‑

 A

Posterior part is smooth

 B

Anterior part is derived from absorption of right horn of sinus venosus

 C

Fossa oval i s repressent remnant of foramen ovale

 D

Anterior and posterior parts are divided by Crista terminalis

Q. 14

Not true about right atrium ‑

 A

Posterior part is smooth

 B

Anterior part is derived from absorption of right horn of sinus venosus

 C

Fossa oval i s repressent remnant of foramen ovale

 D

Anterior and posterior parts are divided by Crista terminalis

Ans. B

Explanation:

Ans. is ‘b’ i.e., Antirior part is derived from absorption of right horn of sinus venosus

Sinus venarum (posterior part of right atrium) is derived from absorption of right horn of sinus venosus (not anterirpart).

Right atrium

It has thinnest walls of the four chambers. It is divided by crista terminalis into two parts :-

i) Rough anterior part or atrium proper (pectinate part), including auricle.

It is derived from right half of primitive atrial chamber. There is a series of transverse muscular ridges called musculi pectinate which are attached to crista terminalis and gives appearance like “teeth of a comb”. SA node is situated in the upper part of crista terminates. Auricle lies in the superomedial portion.

ii) Posterior smooth part or sinus venorum.

It is derived from absorption of right horn of sinus venosus. It has openings of :‑

I) Superior vena cava :- Has no valve.

2)   Inferior vena cava :- Orifice is guarded by a rudimentary valve of IVC (Eustachian valve) derived from embryonic right venous valve, which directs the blood from IVC towards foramen ovale in fetal live. This valve is nonfunctional in adults.

3) Coronary sinus :- Orifice lies between tricuspid orifice and IVC orifice. It is guarded by a functional semilunar valve (thebesian valve). Thebesian valve develops from right venous valve.

4) Venae cardis minimae (thebesian veins):- Open through foramina venorum minimarum.

5) Anterior cardiac vein

6) Right marginal vein :- Sometimes it may open into coronary sinus (not in right atrium).

iii) Interatrial septal region

Interatrial septum develops from approximation of embryonic septum primum and septum secundum. Feauters on right atrial side are :

1) Fossa ovalis :- Oval shaped depression lying above the level of IVC opening in the interatrial septum. It is the embryologic remnant of foramen ovale, which connects right atrium to left atrium in embryonic life. Floor of the fossa ovalis is formed by septum primum.

2) Limbus fossa ovalis (Annulus ovalis) :- It is thickened rim present above the fossa ovalis. It represents the lower free margin of septum secundum.

3) Triangle of Koch :- It is a triangular region in the lower part of interatrial septum which contains AV node. It is bounded above by tendon of Todaro below by base of septal leaflet of tricuspid valve and anteriorly (base) by orifices of coronary sinus.

Immediately above the membranous septum, the septal region shows a slight bulge known as torus aorticus, produced by right posterior (non-coronary) aortic sinus (of valsalva).


Q. 15

Not true about the structure marked with red arrow:

 A

Opens into right ventricle

 B

Enters the heart at level of 3rdcostal

 C

Pierces paricardium at 2nd costal cartilage

 D

Receives azygos vein behind sternal angle

Q. 15

Not true about the structure marked with red arrow:

 A

Opens into right ventricle

 B

Enters the heart at level of 3rdcostal

 C

Pierces paricardium at 2nd costal cartilage

 D

Receives azygos vein behind sternal angle

Ans. A

Explanation:

 Ans;A).Opens into right ventricle

This structure is superior venacava

SVC opens in to right atrium (not right ventricle).

Superior vena-cava

  • SVC collects blood from the upper half of the body and drains into the right atrium. 
  • It is formed by the union of two brachiocephalic veins at the level of lower border of 1″ right costal cartilage. 
  • It passes vertically downwards behind the right border of sternum and piercing the pericardium at the level of the second costal cartilage, enters the upper border of the right atrium to end in the upper and posterior part of sinus venorum at the lower border of third right costal cartilage.

Structure and Course of superior vena cava

  • It is formed by the left and right brachiocephalic veins (also referred to as the innominate veins), which also receive blood from the upper limbs, eyes and neck, behind the lower border of the first right costal cartilage.
  • It passes vertically downwards behind first intercostal space and receives azygos vein just before it pierces the fibrous pericardium opposite right second costal cartilage and its lower part is intrapericardial.
  • And then, it ends in the upper and posterior part of the sinus venarum of the right atrium, at the upper right front portion of the heart.
  • No valve divides the superior vena cava from the right atrium. As a result, the (right) atrial and (right) ventricular contractions are conducted up into the internal jugular vein and, through the sternocleidomastoid muscle, can be seen as the jugular venous pressure.


Epistaxis

Epistaxis

Q. 1

A 55 year old man presented with epistaxis. On investigation, nasopharyngeal cancer was diagnosed. Regarding nasopharyngeal carcinoma,

Assertion: This patient may have ulcerative form of nasopharyngeal cancer

Reason: Because epistaxis is the common symptom of ulcerative type
 

 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. 1

A 55 year old man presented with epistaxis. On investigation, nasopharyngeal cancer was diagnosed. Regarding nasopharyngeal carcinoma,

Assertion: This patient may have ulcerative form of nasopharyngeal cancer

Reason: Because epistaxis is the common symptom of ulcerative type
 

 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:

In ulcerative form of nasopharyngeal carcinoma, epistaxis is the common symptom. Proliferative type causes obstructive nasal symptoms. Growth infiltrates submucosally in infiltrative type of carcinoma.

Ref: Diseases of Ear, Nose and Throat By PL Dhingra, 4th Edition, Page 232, 233.


Q. 2

Which artery is responsible for epistaxis after ligation of external carotid artery?

 A

Ethmoidal artery

 B

Greater palatine artery

 C

Ascending pharyngeal artery

 D

Superior labial artery

Q. 2

Which artery is responsible for epistaxis after ligation of external carotid artery?

 A

Ethmoidal artery

 B

Greater palatine artery

 C

Ascending pharyngeal artery

 D

Superior labial artery

Ans. A

Explanation:

Ethmoidal artery is a branch of internal carotid artery while rest of the arteries provided in the options are branches of external carotid arteries, thereby after ligation of external carotid artery, ethmoidal artery is the only artery which can cause epistaxis.


Q. 3

A child was brought to the emergency department with recurrent epistaxis. A detailed history revealed that he had a fall two days before, but he neglected because it didn’t hurt him. Examination shows septal hematoma. Management of septal hematoma is:

 A

Incision and drainage

 B

Wait and watch

 C

Only pressure bandage

 D

All of the above

Q. 3

A child was brought to the emergency department with recurrent epistaxis. A detailed history revealed that he had a fall two days before, but he neglected because it didn’t hurt him. Examination shows septal hematoma. Management of septal hematoma is:

 A

Incision and drainage

 B

Wait and watch

 C

Only pressure bandage

 D

All of the above

Ans. A

Explanation:

Septal hematoma is a complication of direct nasal trauma, often associated with fracture of the nasal septum with or without concomitant nasal bone fracture.

  • Bleeding from submucosal blood vessels leads to an accumulation of blood between the mucoperichondrium and the septal cartilage, which may lead to ischemic avascular necrosis of the underlying cartilage, destruction of the cartilage and saddle deformity of the distal nose. 
  • Prompt incision of the hematoma and drainage through the mucosal surface is necessary.
 

Q. 4

An 70 yrs aged patient with epistaxis , patient is hypertensive with B.P = 200/110 mmHg. On examination no active bleeding noted, next step of management is:

 A

Observation with hypertension control

 B

Internal maxillary artery ligation

 C

Anterior and posterior nasal pack

 D

Anterior nasal pack

Q. 4

An 70 yrs aged patient with epistaxis , patient is hypertensive with B.P = 200/110 mmHg. On examination no active bleeding noted, next step of management is:

 A

Observation with hypertension control

 B

Internal maxillary artery ligation

 C

Anterior and posterior nasal pack

 D

Anterior nasal pack

Ans. A

Explanation:

Q. 5

A middle aged man presented with epistaxis, serous otitis media with hearing loss, and otalgia. He had a history of infectious mononucleosis few weeks earlier. Malignancy was suspected. Which of the following is the commonest nasopharyngeal malignancy?

 A

Adenocarcinoma

 B

Sq.cell tumour

 C

Squamous cell carcinoma

 D

Transitional cell carcinoma

Q. 5

A middle aged man presented with epistaxis, serous otitis media with hearing loss, and otalgia. He had a history of infectious mononucleosis few weeks earlier. Malignancy was suspected. Which of the following is the commonest nasopharyngeal malignancy?

 A

Adenocarcinoma

 B

Sq.cell tumour

 C

Squamous cell carcinoma

 D

Transitional cell carcinoma

Ans. C

Explanation:

Q. 6

Manifestations of vitamin C deficiency are ‑

 A

Pseudoparalysis

 B

Sabre tibia

 C

Epistaxis

 D

a and c

Q. 6

Manifestations of vitamin C deficiency are ‑

 A

Pseudoparalysis

 B

Sabre tibia

 C

Epistaxis

 D

a and c

Ans. D

Explanation:

Ans. is ‘a’ i.e., Pseudoparalysis; ‘c’ i.e., Epistaxis


Q. 7

Which of the following is/are not the features of henoch-Schonlein purpura (HSP) –

 A

Abdominal pain

 B

Splinter hemorrhage

 C

Thrombocytopenia

 D

Epistaxis

Q. 7

Which of the following is/are not the features of henoch-Schonlein purpura (HSP) –

 A

Abdominal pain

 B

Splinter hemorrhage

 C

Thrombocytopenia

 D

Epistaxis

Ans. C

Explanation:

Ans. is ‘c’ i.e., Thrombocytopenia

o HSP is characterized by tetrad of palpable purpura, arthritis, glomerulonephritis and abdominal pain.

o Less common skin lesions are : nonpalpable macules & patches, urticaria, bullous lesions, vesicles, splinter hemorrhage and ulcerations.

o Rarely epistaxis may occur.


Q. 8

A 15-year-old female presented to the emergency department with history of recurrent epistaxis, hematuria and hematochezia. There was a history of profuse bleeding from the umbilicus stump at birth. Previous investigations revealed normal prothrombin time, activated partial thromboplastin time, thrombin time and fibrinogen levels. Her platelet counts as well as platelet function tests were normal but urea clot lysis test was positive. Which one of the following clotting factor is most likely to be deficient

 A

Factor X

 B

Factor XI

 C

Factor XII

 D

Factor XIII

Q. 8

A 15-year-old female presented to the emergency department with history of recurrent epistaxis, hematuria and hematochezia. There was a history of profuse bleeding from the umbilicus stump at birth. Previous investigations revealed normal prothrombin time, activated partial thromboplastin time, thrombin time and fibrinogen levels. Her platelet counts as well as platelet function tests were normal but urea clot lysis test was positive. Which one of the following clotting factor is most likely to be deficient

 A

Factor X

 B

Factor XI

 C

Factor XII

 D

Factor XIII

Ans. D

Explanation:

Ans. is ‘d’ i.e. Factor XIII

o Individuals with a positive bleeding history, particularly with features such as delayed bleeding, umbilical stump bleeding or miscarriages and in whom the initial panel of screening test is negative, should be tested for Factor XIII deficiency.


Q. 9

Aminocaproic acid would be recommended for a hemophilic child with –

 A

Epistaxis

 B

Haematuria

 C

Oral bleeding

 D

a and c

Q. 9

Aminocaproic acid would be recommended for a hemophilic child with –

 A

Epistaxis

 B

Haematuria

 C

Oral bleeding

 D

a and c

Ans. D

Explanation:

Ans. is ‘a’ i.e., Epitaxis; ‘c’ i.e., Oral bleeding

  • Epsilon aminocaproic acid (EACA) and tranexamic acid, inhibitors of fibrinolytic enzyme, inhibit clot lysis and promote the hemostasis in oral bleeds, and other sites e.g., epistaxis.

o In hematuria it is contraindicated. Factor VIII is given, if not controlled prednisolone is given.

o In hemarthrosis, Factor VIII is given.


Q. 10

M/C cause of epistaxis in 3 years old child:

 A

Nasal polyp

 B

Foreign body

 C

Upper respiratory catarrh

 D

Atrophic rhinitis

Q. 10

M/C cause of epistaxis in 3 years old child:

 A

Nasal polyp

 B

Foreign body

 C

Upper respiratory catarrh

 D

Atrophic rhinitis

Ans. C

Explanation:

Q. 11

In a 5-year-old child, most common cause of unilateral epistaxis is:

 A

Foreign body

 B

Polyp

 C

Atrophic rhinitis

 D

Maggot’s

Q. 11

In a 5-year-old child, most common cause of unilateral epistaxis is:

 A

Foreign body

 B

Polyp

 C

Atrophic rhinitis

 D

Maggot’s

Ans. A

Explanation:

Q. 12

Recurrent epistaxis in a 15-year-old female, the most common cause is:

 A

Juvenile nasopharyngeal fibroma

 B

Rhinosporiodiosis

 C

Foreign body

 D

Hematopoietic disorder

Q. 12

Recurrent epistaxis in a 15-year-old female, the most common cause is:

 A

Juvenile nasopharyngeal fibroma

 B

Rhinosporiodiosis

 C

Foreign body

 D

Hematopoietic disorder

Ans. D

Explanation:

Q. 13

Epistaxis in elderly person is common in:

 A

Foreign body

 B

Allergic rhinitis

 C

Hypertension

 D

Nasopharyngeal carcinoma

Q. 13

Epistaxis in elderly person is common in:

 A

Foreign body

 B

Allergic rhinitis

 C

Hypertension

 D

Nasopharyngeal carcinoma

Ans. C

Explanation:

 



Q. 14

Systemic causes of epistaxis are all except:

 A

Hypertension

 B

Anticoagulant treatment

 C

Hereditary telangiectasia

 D

Hemophilia

Q. 14

Systemic causes of epistaxis are all except:

 A

Hypertension

 B

Anticoagulant treatment

 C

Hereditary telangiectasia

 D

Hemophilia

Ans. D

Explanation:

Q. 15

A 70 years aged patient with epistaxis, patient is hyper­tensive with BP = 200/100 mm Hg. On examination no active bleeding noted, next step of management is:

 A

Observation

 B

Internal maxillary artery ligation

 C

Anterior and posterior nasal pack

 D

Anterior nasal pack

Q. 15

A 70 years aged patient with epistaxis, patient is hyper­tensive with BP = 200/100 mm Hg. On examination no active bleeding noted, next step of management is:

 A

Observation

 B

Internal maxillary artery ligation

 C

Anterior and posterior nasal pack

 D

Anterior nasal pack

Ans. A

Explanation:

Q. 16

Source of epistaxis after ligation of external carotid artery is:

 A

Maxillary artery

 B

Greater palatine artery

 C

Superior labial artery

 D

Ethmoidal artery

Q. 16

Source of epistaxis after ligation of external carotid artery is:

 A

Maxillary artery

 B

Greater palatine artery

 C

Superior labial artery

 D

Ethmoidal artery

Ans. D

Explanation:

Q. 17

If posterior epistaxis cannot be controlled, which artery is ligated: 

 A

Posterior ethmoidal artery

 B

Maxillary artery

 C

Sphenopalatine artery

 D

External carotid artery

Q. 17

If posterior epistaxis cannot be controlled, which artery is ligated: 

 A

Posterior ethmoidal artery

 B

Maxillary artery

 C

Sphenopalatine artery

 D

External carotid artery

Ans. C

Explanation:

 

Ligation technique is reserved for intractable bleeding where the source cannot be located or controlled by other techniques.

The hierarchy of arteries used for ligation is:

  • Sphenopalatine artery
  • Internal maxillary artery
  • External carotid Artery
  • Anterior/posterior ethmoidal artery

Earlier the most common artery ligated was maxillary artery but now endonasal sphenopalatine artery ligation (ESPAL) is the ligation of choice



Q. 18

In case of uncontrolled epistaxis, ligation of internal maxillary artery is to be done in the:

 A

Maxillary antrum

 B

Pterygopalatine fossa

 C

At the neck

 D

Medial wall of orbit

Q. 18

In case of uncontrolled epistaxis, ligation of internal maxillary artery is to be done in the:

 A

Maxillary antrum

 B

Pterygopalatine fossa

 C

At the neck

 D

Medial wall of orbit

Ans. B

Explanation:

Q. 19

Treatment of choice in recurrent epistaxis in a patient with hereditary hemotelangiectasis:

 A

Anterior ethmoidal artery ligation

 B

Septal dermatoplasty

 C

External carotid artery ligation

 D

Internal carotid artery ligation

Q. 19

Treatment of choice in recurrent epistaxis in a patient with hereditary hemotelangiectasis:

 A

Anterior ethmoidal artery ligation

 B

Septal dermatoplasty

 C

External carotid artery ligation

 D

Internal carotid artery ligation

Ans. B

Explanation:

 

Hereditary hemotelangiectasia (HHT) or Osler-Weber-Rendu disease is an autosomal dominant condition affecting blood vessels in the skin, mucous membranes and viscera

The genetic abnormality is located to chromosome 9 and 12

Classical features:

  • Telangiectasia
  • AN malformations
  • Aneurysms
  • Recurrent epistaxis (seen in 93% cases)



Q. 20

Causes of epistaxis are all except:

 A

Allergic rhinitis

 B

Foreign body

 C

Tumor

 D

Hypertension

Q. 20

Causes of epistaxis are all except:

 A

Allergic rhinitis

 B

Foreign body

 C

Tumor

 D

Hypertension

Ans. A

Explanation:

 

 Many nasal problems can lead to epistaxis viz nasal trauma, viral rhinitis, chronic infections of nose (which lead to crust formation like atrophic rhinitis, rhinits sicca, TB of nose), foreign bodies in nose (maggots and non living), DNS, neoplasms (hemangioma, papilloma, carcinoma or sarcoma).

Two nasal conditions which donot lead to epistaxis:

  • Nasal polyps
  • Allergic rhinitis

Pharyngeal conditions which lead to epistaxis:

  • Adenoiditis
  • Juvenile angiofibroma
  • Malignant tumors

Q. 21

Posterior epistaxis is commonly seen in: 

 A

Children with ethmoidal polyps

 B

Foreign bodies of the nose

 C

Hypertension

 D

Nose picking

Q. 21

Posterior epistaxis is commonly seen in: 

 A

Children with ethmoidal polyps

 B

Foreign bodies of the nose

 C

Hypertension

 D

Nose picking

Ans. C

Explanation:

 

M/c cause of epistaxis in adults is hypertension

  • M/c site – Woodruff area
  • Causes posterior epistaxis

Q. 22

Posterior epistaxis occurs from:

 A

Woodruffs plexus

 B

Kiesselbach’s plexus

 C

Atherosclerosis

 D

Littles area

Q. 22

Posterior epistaxis occurs from:

 A

Woodruffs plexus

 B

Kiesselbach’s plexus

 C

Atherosclerosis

 D

Littles area

Ans. A

Explanation:

Q. 23

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. 23

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. 24

Which is known as artery of epistaxis?

 A

Anterior ethmoidal A

 B

Sphenopalatine A

 C

Greater palatine A

 D

Septal branch of superior labial A

Q. 24

Which is known as artery of epistaxis?

 A

Anterior ethmoidal A

 B

Sphenopalatine A

 C

Greater palatine A

 D

Septal branch of superior labial A

Ans. B

Explanation:

Q. 25

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. 25

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. 26

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. 26

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. 27

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. 27

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. 28

A 25 years old female develops serous otitis media of left ear with cough and occasional hemoptysis and . hematuria and epistaxis for one and half months her. Hemoglobin is 7 gm. B.P. > 170/100, ptoreinuria +++, RA positive (+ve) and ANCA positive (+ve), the likely cause is-

 A

Wegener’s granulo matosis

 B

Rheumiatoid arthritis

 C

Rapidly proliferative glomerulonephritis

 D

Good pasteur’s syndrome

Q. 28

A 25 years old female develops serous otitis media of left ear with cough and occasional hemoptysis and . hematuria and epistaxis for one and half months her. Hemoglobin is 7 gm. B.P. > 170/100, ptoreinuria +++, RA positive (+ve) and ANCA positive (+ve), the likely cause is-

 A

Wegener’s granulo matosis

 B

Rheumiatoid arthritis

 C

Rapidly proliferative glomerulonephritis

 D

Good pasteur’s syndrome

Ans. A

Explanation:

Answer is A (Wegener’s granulomatosis):

The patient in question is presenting with the charachteristic triad of Wegener’s granutomatosis namely, vasculitis of the upper respiratory tract (serious otitis media and epistaxis), vasculitis of the lower respiratory tract (hemoptysis) and vasculitis of the kidney (proteinuria)

Presence of ANCA and Rheumatoid factor further support the diagnosis of Wegener’s granulomatosis which is the single best answer of choice.


Q. 29

A 25 years old female develops serous otitis media of left ear with cough and occasional hemoptysis and hematuria and epistaxis for one and half months her hemoglobin is 7 gm. B.P is > 170/100, proteinuria +++, RA – ve and ANCA – ve, the likely cause is‑

 A

Wegener’s granulomatosis

 B

Rheumiatoid arthritis

 C

Rapidly proliferative glomerulonephritis

 D

Goodpasteur’s syndrome

Q. 29

A 25 years old female develops serous otitis media of left ear with cough and occasional hemoptysis and hematuria and epistaxis for one and half months her hemoglobin is 7 gm. B.P is > 170/100, proteinuria +++, RA – ve and ANCA – ve, the likely cause is‑

 A

Wegener’s granulomatosis

 B

Rheumiatoid arthritis

 C

Rapidly proliferative glomerulonephritis

 D

Goodpasteur’s syndrome

Ans. A

Explanation:

Answer is A>D (Wegener’s granulumatosis > Goodpasture’s Syndrome);

The patient in question is presenting with characteristic clinical triad of Wegener’s granulomatosis, namely, Vasculitis of upper respiratory tract (serous otitis media, epistaxis), Vasculitis of lower respiratory tract (cough and hemoptysis) and vasculitis of the kidney (proteinuria)

Although positive ANCA assays are often instrumental in suggesting the diagnosis of WG, Negative ANCA assays do not preclude the diagnosis, 10% of patients with disseminated WG and upto 30% of patients with limited WG may be negative for ANCA

The clinical picture is classical of Wegner’s Granulomatosis. However, the absence of ANCA confuses the diagnosis. Nevertheless the presence or absence of ANCA should be adjunctive and in the presence of a classical clinical picture of WG, tissue diagnosis (biopsy) should be performed to confirm the diagnosis.

Definitive diagnosis of WG is established by tissue biopsy and not by presence or absence of ANCA

Pulmonary + Renal Syndrome
Pulmonary (Hemoptysis) + Renal (Proteinuria) manifestations

Wegener’s granulomatosis

Classical Clinical presentation is one of a young Male/Female (male: female=1:1) presenting with upper respiratory tract features (Otitis media, Epistaxis) along with hemoptysis and acute glomerulonephritis+

ANCA is usually positive and suggests the diagnosis

Negative ANCA does not preclude the diagnosis. In the presence of classical clinical picture a provisional diagnosis of WG should be made on clinical ground and confirmed/ excluded by tissue biopsy

The patient in question is presenting with classical clinical triad of Wegener’s granulomatosis. Although ANCA is negative a negative ANCA does not preclude the diagnosis of WG. Based on the strong clinical suspicion, WG should the single best initial provisional diagnosis and tissue biopsy should be performed.

Goodpasture’s syndrome

 

Classical clinical presentation is one of a young male smoker (male female=3-4:1) presenting with hemoptysis and signs of acute glomerulonephritis

 

Although disease may be preceeded by an upper respiratory tract infection, upper respiratory tract involvement features like otitis media and epistaxis are not characterstic of good pasture’s syndrome

 

ANCA is usually negative

 

Diagnosis is made by detecting serum levels of Anti GBM antibodies

 

The patient in question is not presenting with classical clinical features of good pasture’s syndrome and serum levels of Anti GBM antibodies have not been provided in the question. These make a diagnosis of Good pasture’s syndrome less likely.




Q. 30

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. 30

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. 31

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. 31

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.


Q. 32

Rhinolith can cause 

 A

Nasal obstruction

 B

Epistaxis

 C

Epiphora

 D

All of the above

Q. 32

Rhinolith can cause 

 A

Nasal obstruction

 B

Epistaxis

 C

Epiphora

 D

All of the above

Ans. D

Explanation:

A rhinolith is a calculus present in the nasal cavity.

The word is derived from the roots rhino- and -lith, literally meaning “nose stone”. 

A rhinolith usually forms around the nucleus of a small exogenous foreign body, blood clot or secretion by slow deposition of calcium and magnesium salts.

Over a period of time, they grow into large irregular masses that fill the nasal cavity.

They may cause pressure necrosis of the nasal septum or lateral wall of nose leading to nasal obstruction, epistaxis, headache, sinusitis and epiphora.



Ludwig’s Angina

Ludwig’s Angina

Q. 1

Ludwig’s angina is:

 A

Membrane over tonsil

 B

Infection of submandibular space

 C

Peritonsillar abscess

 D

Chest pain

Q. 1

Ludwig’s angina is:

 A

Membrane over tonsil

 B

Infection of submandibular space

 C

Peritonsillar abscess

 D

Chest pain

Ans. B

Explanation:

Q. 2

All of the following statements regarding Ludwigs angia are true except

 A

Cellulitis of floor of mouth

 B

Infection can spread to retropharyngeal space

 C

It is usually caused by both aerobic and anaerobic organisms

 D

Can cause aphthous ulcer in the pharynx

Q. 2

All of the following statements regarding Ludwigs angia are true except

 A

Cellulitis of floor of mouth

 B

Infection can spread to retropharyngeal space

 C

It is usually caused by both aerobic and anaerobic organisms

 D

Can cause aphthous ulcer in the pharynx

Ans. D

Explanation:

Apthous ulcers are idiopathic in origin, it is not related to ludwig’s angina.

Ludwigs angina is a rapidly progressing cellulitis of submandibular space often resulting from an underlying dental infection.

Infection is caused by both aerobic and anaerobic organisms, and can spread to involve the entire submandibular space.


Q. 3

Which of the following statements best represent Ludwig’s angina?

 A

A type of coronary artery spasm

 B

An infection of the cellular tissues around submandibular salivary gland

 C

Oesophageal spasm

 D

Retropharyngeal infection

Q. 3

Which of the following statements best represent Ludwig’s angina?

 A

A type of coronary artery spasm

 B

An infection of the cellular tissues around submandibular salivary gland

 C

Oesophageal spasm

 D

Retropharyngeal infection

Ans. B

Explanation:

Answer is ‘b’ ie an infection of the cellular tissues around submandibular salivary gland

  • Ludwig’s angina is a rapidly progressive cellulitis of the submandibular space that can cause airway obstruction and death.
  • The submandibular space lies between.

– Mucous membrane of the floor of mouth and tongue on one side and.

– Superficial layer of deep cervical fascia extending between the hyoid bone and mandible on the other.

  • The submandibular space is divided into 2 compartments by the mylohyoid muscle.

a. Sublingual compartment (above the mylohyoid).

b. Submaxillary and submental (below the mylohyoid)

The two compartments are continuous around the posterior border of mylohyoid muscle.

  • Aetiology – Dental infections are the most common cause.
  • The infection is most often caused by a virulent streptococcus (Group A streptococcus are most common) along with anaerobes.
  • Clinical Features

– Odynophagia (painful swallowing).

– Trismus (difficulty in opening mouth).

When infection is localized to sublingual space, structures in the floor of month are swollen and tongue seems to be pushed up and back.

– When infection spreads to submaxillary space, the submental and submandibular regions become swollen and tender with woody hard feeling.

  • Complications

– Airway obstruction due to laryngeal oedema, or swelling and push back of the tongue.

Spread of infection to parapharyngeal, retropharyngeal spaces and thence to the mediastinurri. Aspiration pneumonia.

Septicemia.

  • Treatment

– Consists of giving high doses of broad-spectrum antibiotics, combined with metronidazole to combat the anaerobes immediately until the results of cultures and sensitivity tests are available.

In advanced cases when the swelling does not subside rapidly with antibiotics, incision and drainage is advised.


Q. 4

True about Ludwig’s angina:

 A

Involves both submandibular and sublingual spaces

 B

Most common cause is dental infection

 C

Bilateral

 D

a and b

Q. 4

True about Ludwig’s angina:

 A

Involves both submandibular and sublingual spaces

 B

Most common cause is dental infection

 C

Bilateral

 D

a and b

Ans. D

Explanation:

Q. 5

Ludwig’s angina is characterized by all the following except:

 A

Cellulitis of the floor of the mouth

 B

Caused by anaerobic organisms

 C

Aphthous ulcers in the pharynx

 D

Infection spreads to retropharyngeal space

Q. 5

Ludwig’s angina is characterized by all the following except:

 A

Cellulitis of the floor of the mouth

 B

Caused by anaerobic organisms

 C

Aphthous ulcers in the pharynx

 D

Infection spreads to retropharyngeal space

Ans. C

Explanation:

 

  • Ludwig’s Angina is a rapidly spreading cellulitis of the floor of the mouth which involves submandibular space secondary to dental infection.
  • Submandibular space is divided into sublingual space (above the mylohyoid) and submaxillary space (below the mylohyoid muscle) 

Bacteriology: Mixed infections involving both aerobes and anaerobes are common like, alpha haemolytic streptococci, staphylococci bacteriodes and E. coll. H. influenzae is a rare cause.

 

Clinical features: In Ludwig’s angina, there is usually cellulitis of the tissue rather than frank abscess.

  • Marked difficulty in swallowing (odynophagia).
  • Varying degrees of trisumus.
  • On involvement of sublingual space, floor of the mouth is swollen, edematous and tongue seems to be pushed up and back.
  • On involvement of the submaxillary space, the submental and submandibular regions become swollen and tender and impart woody-hard feel.Tongue is progressively pushed upward and backward threatening the airway.
  • Laryngeal edema may appear, if it spreads to parapharyngeal or retropharyngeal space.

Treatment: Systemic antibiotics

  • I and D should be postponed as long as possible because pus is seldom found.
  • Tracheostomy is required if airway is endangered.
  • If incision and drainage for Ludwig’s angina is done under GA-there are increased chances of aspiration and shock as tongue is pushed up and back in Ludwig angina.

Q. 6

Infection of submandibular space is seen in:

 A

Ludwig’s angina

 B

Vincent angina

 C

Prinzmetal angina

 D

Unstable angina

Q. 6

Infection of submandibular space is seen in:

 A

Ludwig’s angina

 B

Vincent angina

 C

Prinzmetal angina

 D

Unstable angina

Ans. A

Explanation:

Q. 7

Ludwigs angina usually begins in ‑

 A

Submandibular space

 B

Sublingual space

 C

Parotid space

 D

Retropharyngeal space

Q. 7

Ludwigs angina usually begins in ‑

 A

Submandibular space

 B

Sublingual space

 C

Parotid space

 D

Retropharyngeal space

Ans. A

Explanation:

Ans. is ‘a’ i.e., Submandibular space

Ludwig’s angina is a rapidly spreading bilateral cellulitis that involves the floor of mouth, under the tongue.

Floor of mouth is comprised of sublingual space, submandibular space and submental space.

Ludwig’s angina usually begins in the submandibular space, and then rapidly spreads to involve the subligual space, usually on a bilateral basis.

Most common cause is infection of the root of the teeth (Dental infection), especially 2nd and 3nd mandibular molar.

Other causes are mouth injury, mandibular fracture, and submandibular sialadenitis.



Adenoid

Adenoid

Q. 1

Adenoidectomy with grommet insertion is treatment of choice for

 A

Serous otitis media in children

 B

Serous otitis media in adults

 C

Adenoiditis in children

 D

All of the above

Q. 1

Adenoidectomy with grommet insertion is treatment of choice for

 A

Serous otitis media in children

 B

Serous otitis media in adults

 C

Adenoiditis in children

 D

All of the above

Ans. A

Explanation:

 

  • Common cause of serous otitis media in children is growth of adenoid; hence treatment aims at removal of cause (adenoidectomy) and drainage of middle ear by grommet.
  • Serous otitis media in adults should arouse suspicion of nasopharyngeal carcinoma and hence the treatment aims at removal of carcinoma
  • Adenoiditis is an acute condition and requires treatment conservatively.

Q. 2

6 year old child with recurrent URTI with mouth breathing and failure to grow with high arched palate and impaired hearing is :

 A

Tonsillectomy

 B

Grommet insertion

 C

Myringotomy with grommet insertion

 D

Adenoidectomy with grommet insertion

Q. 2

6 year old child with recurrent URTI with mouth breathing and failure to grow with high arched palate and impaired hearing is :

 A

Tonsillectomy

 B

Grommet insertion

 C

Myringotomy with grommet insertion

 D

Adenoidectomy with grommet insertion

Ans. D

Explanation:

Q. 3

What is the treatment of choice in a 6 year old child with recurrent URTI with mouth breathing having high arched palate, impaired hearing and growth failure?

 A

Tonsillectomy

 B

Grommet insertion

 C

Myringotomy with grommet insertion

 D

Adenoidectomy with grommet insertion

Q. 3

What is the treatment of choice in a 6 year old child with recurrent URTI with mouth breathing having high arched palate, impaired hearing and growth failure?

 A

Tonsillectomy

 B

Grommet insertion

 C

Myringotomy with grommet insertion

 D

Adenoidectomy with grommet insertion

Ans. D

Explanation:

Hypertrophic adenoid tissue causes nasal obstruction, mouth-breathing, and similarly, obstruction of the Eustachian tube orifices.

Removing large adenoids enhances the patency of the nasopharyngeal airway, relieving the overall pressure in the nasopharynx, in turn allowing improved aeration of the middle ear cleft.  

The goal of placement of tympanostomy tubes is to aerate the middle ear space and prevent accumulation of middle ear inflammation and effusion.

In effect, ventilation of the middle ear enhances hearing thresholds. 
 

Q. 4

A 6 year old child presented with recurrent URTI, mouth breathing and failure to grow. On examination he has high arched palate and impaired hearing. What is the management of choice in this child?

 A

Myringotomy

 B

Myringotomy with grommet insertion

 C

Adenoidectomy with grommet insertion

 D

Tonsillectomy

Q. 4

A 6 year old child presented with recurrent URTI, mouth breathing and failure to grow. On examination he has high arched palate and impaired hearing. What is the management of choice in this child?

 A

Myringotomy

 B

Myringotomy with grommet insertion

 C

Adenoidectomy with grommet insertion

 D

Tonsillectomy

Ans. C

Explanation:

Child in the question is showing features of adenoid hyperplasia as indicated by mouth breathing, nasal obstruction and recurrent URTI. He has impaired hearing as a result of serous otitis media which occur as a complication of adenoid hyperplasia. So the treatment of choice is adenoidectomy with grommet insertion which will take care of both the adenoid as well as serous otitis media.


Q. 5

Rhinolalia clausa is associated with all of the following, EXCEPT:

 A

Allergic rhinitis

 B

Palatal paralysis

 C

Adenoids

 D

Nasal polyps

Q. 5

Rhinolalia clausa is associated with all of the following, EXCEPT:

 A

Allergic rhinitis

 B

Palatal paralysis

 C

Adenoids

 D

Nasal polyps

Ans. B

Explanation:

Palatal paralysis is a cause of Rhinolalia Aperta (Hypernasality) and not Rhinolilia Clausa (Hyponasality).
 
Rhinolalia Aperta (Hypernasality or hyperrhinolalia or open nasality) is defined as excess resonance of vowels and voiced consonants within the nasal cavities. The anatomic-physiologic basis is open coupling between the oral and nasal cavities due to incomplete closure of the hard palate and/or velopharyngeal sphincter.
 

Q. 6

Common cause of eustachian diseases is due:

 A

Adenoids

 B

Siegle’s

 C

Otitis media

 D

Pharyngitis

Q. 6

Common cause of eustachian diseases is due:

 A

Adenoids

 B

Siegle’s

 C

Otitis media

 D

Pharyngitis

Ans. A

Explanation:

Q. 7

6 year old child with recurrent URTI with mouth breathing and failure to grow with high arched palate and impaired hearing is:

 A

Tonsillectomy

 B

Grommet insertion

 C

Myringotomy with grommet insertion

 D

Adenoidectomy with grommet insertion

Q. 7

6 year old child with recurrent URTI with mouth breathing and failure to grow with high arched palate and impaired hearing is:

 A

Tonsillectomy

 B

Grommet insertion

 C

Myringotomy with grommet insertion

 D

Adenoidectomy with grommet insertion

Ans. D

Explanation:

Q. 8

A child presents with recurrent respiratory tract infec­tion, mouth breathing and decreased hearing. Treatment is:

 A

Tonsillectomy

 B

Adenoidectomy

 C

Grommet insertion

 D

All

Q. 8

A child presents with recurrent respiratory tract infec­tion, mouth breathing and decreased hearing. Treatment is:

 A

Tonsillectomy

 B

Adenoidectomy

 C

Grommet insertion

 D

All

Ans. D

Explanation:

 

Child is presenting with mouth breathing. Palate is high arched.There is nasal obstruction and recurrent respiratory tract infections along with hearing impairment. All these features are suggestive of adenoid hyperplasia. In case of adenoid hyperplasia, impairment of hearing is due to secretory otitis.

Thus the logical step in the management would be myringotomy with grommet insertion (to treat SOM) and adenoidectomy or tonsilectomy (to remove the causative factor). 



Q. 9

A child has Adenoidectomy done but he has effusion in middle ear. What is the next step in management?

 A

Grommet insertion

 B

Mastoidectomy

 C

Tympanoplasty

 D

None

Q. 9

A child has Adenoidectomy done but he has effusion in middle ear. What is the next step in management?

 A

Grommet insertion

 B

Mastoidectomy

 C

Tympanoplasty

 D

None

Ans. A

Explanation:

Q. 10

6-year-old child with recurrent URTI with mouth breath­ing and failure to grow with high arched palate and impaired hearing is:

 A

Tonsillectomy

 B

Grommet insertion

 C

Myringotomy with grommet insertion

 D

Adenoidectomy with grommet insertion

Q. 10

6-year-old child with recurrent URTI with mouth breath­ing and failure to grow with high arched palate and impaired hearing is:

 A

Tonsillectomy

 B

Grommet insertion

 C

Myringotomy with grommet insertion

 D

Adenoidectomy with grommet insertion

Ans. D

Explanation:

Q. 11

Regarding adenoids true is/are:

 A

There is failure to thrive

 B

Mouth breathing is seen

 C

CT scan should be done to assess size

 D

a and b

Q. 11

Regarding adenoids true is/are:

 A

There is failure to thrive

 B

Mouth breathing is seen

 C

CT scan should be done to assess size

 D

a and b

Ans. D

Explanation:

 

  • High arched palate and mouth breathing are features of hypertrophied adenoids which leads to adenoid facies
  • In adenoids as a consequence of recurrent nasal obstruction and URTI, child develops failure to thrive
  • Size of adenoids may well be assessed using lateral radiograph of nasopharynx, and CT scan is not necessary

Q. 12

Indication for Adenoidectomy in children include all except:

 A

Recurrent respiratory tract infections

 B

Recurrent Middle ear infection with deafness

 C

Chronic serous otitis media

 D

Multiple adenoids

Q. 12

Indication for Adenoidectomy in children include all except:

 A

Recurrent respiratory tract infections

 B

Recurrent Middle ear infection with deafness

 C

Chronic serous otitis media

 D

Multiple adenoids

Ans. B

Explanation:

Q. 13

The inner Waldeyer’s group of lymph nodes does not include:

 A

Submandibular lymph node

 B

Tonsils

 C

Lingual tonsils

 D

Adenoids

Q. 13

The inner Waldeyer’s group of lymph nodes does not include:

 A

Submandibular lymph node

 B

Tonsils

 C

Lingual tonsils

 D

Adenoids

Ans. A

Explanation:

 

Submandibular nodes do not form part of Waldeyer’s lymphatic ring.

They form part of the outer group of lymph nodes into which efferents from the constituents of the Waldeyer’s lymphatic ring may drain.


Q. 14

A 6-year-old boy presented to ENT OPD with recurrent URTI, mouth breathing and impaired hearing. The boy was diagnosed as having adenoid hypertrophy for which adenoidectomy was done and grommet inserted; 1 week after surgery,the boy was again brought to the OPD with torticollis. Which of the following are true about above clinical scenario.

 A

Antlantoaxial subluxation is the cause for his torticollis

 B

The condition is M/C in children with Down’s syndrome

 C

Torticollis is not a complication after adenoid surgery and it is a sheer coincidence

 D

a and b

Q. 14

A 6-year-old boy presented to ENT OPD with recurrent URTI, mouth breathing and impaired hearing. The boy was diagnosed as having adenoid hypertrophy for which adenoidectomy was done and grommet inserted; 1 week after surgery,the boy was again brought to the OPD with torticollis. Which of the following are true about above clinical scenario.

 A

Antlantoaxial subluxation is the cause for his torticollis

 B

The condition is M/C in children with Down’s syndrome

 C

Torticollis is not a complication after adenoid surgery and it is a sheer coincidence

 D

a and b

Ans. D

Explanation:

 

Torticollis can occur as a complication of adenoidectomy due to ligamentous laxity secondary to inflammatory process following adenoidectomy. It is called as Grisel syndrome.

This is M/C in patients of Down syndrome as children with Down’s already have asymptomatic atlantoaxial instability which mani­fests after surgery.


Q. 15

Rhinolalia clausa is associated with all of the following except:

 A

Allergic rhinitis

 B

Palatal paralysis

 C

Adenoids

 D

Nasal polyps

Q. 15

Rhinolalia clausa is associated with all of the following except:

 A

Allergic rhinitis

 B

Palatal paralysis

 C

Adenoids

 D

Nasal polyps

Ans. B

Explanation:

Q. 16

In a patient with hypertrophied adenoids, the voice abnormality that is seen is:

 A

Rhinolalia clausa

 B

Rhinolalia aperta

 C

Hot potato voice

 D

Staccato voice

Q. 16

In a patient with hypertrophied adenoids, the voice abnormality that is seen is:

 A

Rhinolalia clausa

 B

Rhinolalia aperta

 C

Hot potato voice

 D

Staccato voice

Ans. A

Explanation:

 

  • Rhinolalia clausa is lack of nasal resonance (hyponasality).
  • It is seen in conditions which block the nose or nasopharynx as in case of allergic rhinitis, adenoids and nasal polpys.
  • Palatal paralysis will lead to hypernasality and not hyponasality.



Q. 17

Which of the following is not a complication of adenoid­ectomy?

 A

Hyponasality of speech

 B

Retro pharyngeal abscess

 C

Velopharyngeal insufficiency

 D

Grisel syndrome

Q. 17

Which of the following is not a complication of adenoid­ectomy?

 A

Hyponasality of speech

 B

Retro pharyngeal abscess

 C

Velopharyngeal insufficiency

 D

Grisel syndrome

Ans. A

Explanation:

 

 Hyponasality of speech is not a complication of adenoidectomy. Adenoidectomy results in hypernasality.


Q. 18

NOT true for adenoid hypertrophy:

 A

Mouth breathing is seen

 B

High arched palate present

 C

There is failure to thrive

 D

CT scan should be done to assess size

Q. 18

NOT true for adenoid hypertrophy:

 A

Mouth breathing is seen

 B

High arched palate present

 C

There is failure to thrive

 D

CT scan should be done to assess size

Ans. D

Explanation:

 

Adenoid hypertrophy/ Enlarged adenoids

  • It is the unusual growth (“hypertrophy”) of the adenoid tonsil.
  • Firstly described and adenoidectomy performed by the Danish physician Wilhelm Meyer (1824-1895) in Copenhagen in 1868.
  • He described that a long term adenoid hypertrophy will cause an obstruction of the nasal airways.
  • These will lead to a dentofacial growth anomaly that was defined as adenoid facies.
  • There is very little lymphoid tissue in the nasopharynx of young babies; humans are born without substantial adenoids.

Q. 19

Patient presents with mouth breathing, recurrent serous otitis media and adenoid facies. What is the best line of management ?

 A

Adenoidectomy

 B

Tonsillectomy

 C

Antibiotics

 D

Supportive therapy

Q. 19

Patient presents with mouth breathing, recurrent serous otitis media and adenoid facies. What is the best line of management ?

 A

Adenoidectomy

 B

Tonsillectomy

 C

Antibiotics

 D

Supportive therapy

Ans. A

Explanation:

Ans. is ‘a’ i.e., Adenoidectomy

The triad of nasal and aural symptoms with adenoid facies points to the diagnosis of enlarged adenoids.

For the treatment of enlarged adenoids when symptoms are not marked breathing excercise, decongenstant nasal drops and antihistaminics are used and when symptoms are marked, adenoidectomy is done.

We have a patient with marked and recurrent symptoms thus adenoidectomy is the treatment of choice.



Liver

LIVER

Q. 1

The right lobe of the liver consists which of the following segments?

 A

V, VI, VII and VIII

 B

IV, V, VI, VII and VIII

 C

I, V, VI, VII and VIII

 D

I, IV, V, VI, VII and VIII

Q. 1

The right lobe of the liver consists which of the following segments?

 A

V, VI, VII and VIII

 B

IV, V, VI, VII and VIII

 C

I, V, VI, VII and VIII

 D

I, IV, V, VI, VII and VIII

Ans. A

Explanation:

Ans. V, VI, VII and VIII


Q. 2

The following diagram shows the various lobes of Liver. Identify Structure Marked A in the diagram 

 A

Caudate Lobe

 B

Quadrate Lobe

 C

Medial Lobe

 D

None of the Above 

Q. 2

The following diagram shows the various lobes of Liver. Identify Structure Marked A in the diagram 

 A

Caudate Lobe

 B

Quadrate Lobe

 C

Medial Lobe

 D

None of the Above 

Ans. B

Explanation:


Q. 3

Bare area of liver is related to –

 A

Aorta

 B

Hepatic vein

 C

Portal vein

 D

Gall bladder

Q. 3

Bare area of liver is related to –

 A

Aorta

 B

Hepatic vein

 C

Portal vein

 D

Gall bladder

Ans. B

Explanation:

 Hepatic vein

  • Between two layers of coronary ligaments, there is a large triangular area in diaphragmatic surface of liver which is not covered by peritoneum.
  • It is called ‘bare area of liver’.
  • It is related to inferior vena cava (IVC).
  • The hepatic veins (usually three) leave the liver in bare area.
  • This area is clinically important as it is a site where infection can spread from abdominal cavity to thoracic cavity.

Q. 4

Liver segment which is physiologically independent‑

 A

Segment I

 B

Segment II

 C

Segment III

 D

Segment IV

Q. 4

Liver segment which is physiologically independent‑

 A

Segment I

 B

Segment II

 C

Segment III

 D

Segment IV

Ans. A

Explanation:

 Caudate lobe (segment I) is a physiological independent part of liver, supplied by both right and left hepatic arteries; right and left branches of portal vein and drains bile into both right and left hepatic duct.


Q. 5

Weight of liver ‑

 A

600-800 gm

 B

1000-1200gm

 C

1400-1600gm

 D

1800-2000gm

Q. 5

Weight of liver ‑

 A

600-800 gm

 B

1000-1200gm

 C

1400-1600gm

 D

1800-2000gm

Ans. C

Explanation:

Ans. is ‘c’ i.e., 1400-1600 gm

  • Liver is the largest gland of body situated in right upper quadrant of abdominal cavity and occupies whole of the right hypochondrium, greater part of epigastrium with extension into left hypochondrium.
  • It weighs about 1500-1600 gm in males and 1200-1300 gm in females.
  • Liver has five surfaces : anterior, posterior, superior, inferior and right.
  • It has only one prominent border, inferior border.
  • Liver is covered by Glisson’s capsule.
  • Interior of liver is divided into hexagonal lobules.
  • Lobule contains sinusoids which have fenesterated endothelium covering the subendothelial space of Disse.
  • Two important cells in liver are hepatocytes (Parenchymal cells) and kupffer cells (monocytic-mocrophages).

Q. 6

Caudate lobe of liver is ‑

 A

I

 B

III

 C

IV

 D

VI

Q. 6

Caudate lobe of liver is ‑

 A

I

 B

III

 C

IV

 D

VI

Ans. B

Explanation:

Ans. is ‘a’ i.e., I


Q. 7

Type of collagen found in space of Disse in liver is –

 A

Collagen I & II

 B

Collagen III & IV

 C

Collagen II &

 D

Collagen II & V

Q. 7

Type of collagen found in space of Disse in liver is –

 A

Collagen I & II

 B

Collagen III & IV

 C

Collagen II &

 D

Collagen II & V

Ans. B

Explanation:

Ans. is ‘b’ i.e., Collagen III & IV 



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