Category: Quiz

Heart-arterial supply, nerve supply, veins of heart

HEART-ARTERIAL SUPPLY, NERVE SUPPLY, VEINS OF HEART

Q. 1

Anterior cardiac veins open into:

 A

Right atrium

 B

Great cardiac vein

 C

Coronary sinus

 D

Marginal vein

Q. 1

Anterior cardiac veins open into:

 A

Right atrium

 B

Great cardiac vein

 C

Coronary sinus

 D

Marginal vein

Ans. A

Explanation:

Right atrium


Q. 2

In which of the following cardiac structure is middle cardiac vein located?

 A

Anterior AV groove

 B

Posterior AV groove

 C

Anterior interventricular sulcus

 D

Posterior interventricular sulcus

Q. 2

In which of the following cardiac structure is middle cardiac vein located?

 A

Anterior AV groove

 B

Posterior AV groove

 C

Anterior interventricular sulcus

 D

Posterior interventricular sulcus

Ans. D

Explanation:

Posterior interventricular vein or middle cardiac vein runs in the posterior interventricular sulcus and may drain into the right atrium or into the coronary sinus.

Q. 3

The middle cardiac vein is located in the?

 A

Anterior interventricular sulcus.

 B

Posterior interventricular sulcus.

 C

Posterior AV groove.

 D

Anterior AV groove.

Q. 3

The middle cardiac vein is located in the?

 A

Anterior interventricular sulcus.

 B

Posterior interventricular sulcus.

 C

Posterior AV groove.

 D

Anterior AV groove.

Ans. B

Explanation:

The middle cardiac vein commences at the apex of the heart; ascends in the posterior longitudinal sulcus, and ends in the coronary sinus near its right extremity.


Q. 4

Anterior cardiac vein open into ?

 A

Right atrium

 B

Great cardiac vein

 C

Coronary sinus

 D

Marginal vein

Q. 4

Anterior cardiac vein open into ?

 A

Right atrium

 B

Great cardiac vein

 C

Coronary sinus

 D

Marginal vein

Ans. A

Explanation:

The anterior cardiac veins drain the anterior portion of the right ventricle, cross the coronary groove, and empty directly into the right atrium. Anterior cardiac veins do not drain into the coronary sinus.
 Also Know:

The coronary sinus is the largest vein draining the heart muscle and lies in the coronary sulcus. The coronary sinus collects most of the venous return from the great, middle, and small cardiac veins and returns the venous blood to the right atrium. The coronary sinus opening in the right atrium is superior to the septal leaflet of the tricuspid valve.


Q. 5

Branches of R.C.A. (Rt. Coronary artery):

 A

Obtuse marginal

 B

Acute marginal

 C

Diagonal

 D

All

Q. 5

Branches of R.C.A. (Rt. Coronary artery):

 A

Obtuse marginal

 B

Acute marginal

 C

Diagonal

 D

All

Ans. B

Explanation:

B. i.e. Acute marginal


Q. 6

The right coronary artery supplies all of the following parts of the conducting system in the heart except: 

 A

SA Node

 B

AV Node

 C

AV Bundle

 D

Right Bundle branch

Q. 6

The right coronary artery supplies all of the following parts of the conducting system in the heart except: 

 A

SA Node

 B

AV Node

 C

AV Bundle

 D

Right Bundle branch

Ans. D

Explanation:

D i.e. Right bundle branch 

Right coronary artery supply SA node (in 65% cases), AV node, AV bundle or Bundle of His and part of LBB (left bundle branch Q); where as Left coronary artery supply SA node (in 35% cases), RBB (right bundle branch) & part of LBB Q


Q. 7

The middle cardiac vein is located at the:

 A

Anterior interventricular sulcus

 B

Posterior interventricular sulcus

 C

Posterior AV groove

 D

Anterior AV groove

Q. 7

The middle cardiac vein is located at the:

 A

Anterior interventricular sulcus

 B

Posterior interventricular sulcus

 C

Posterior AV groove

 D

Anterior AV groove

Ans. B

Explanation:

B i.e. Posterior interventricular sulcus 

  • vein & posterior interventricular br. of right coronary artery is located in poster inter ventricular sulcus Q

Q. 8

True statement about Rt coronary artery (RCA)

 A

Diameter less than LCA

 B

RCA arises from anterior aortic sinus

 C

RCA supplies major part of right atrium and right ventricle

 D

All

Q. 8

True statement about Rt coronary artery (RCA)

 A

Diameter less than LCA

 B

RCA arises from anterior aortic sinus

 C

RCA supplies major part of right atrium and right ventricle

 D

All

Ans. A

Explanation:

A i.e. Diameter less than LCA; B i.e. RCA arises from anterior aortic sinus


Q. 9

Branch of Rt. Coronary artery:

 A

Obtuse marginal

 B

Acute marginal

 C

Posterior interventricular

 D

b & c

Q. 9

Branch of Rt. Coronary artery:

 A

Obtuse marginal

 B

Acute marginal

 C

Posterior interventricular

 D

b & c

Ans. D

Explanation:

B. i.e. Acute marginal; C. i.e. Posterior interventricular


Q. 10

The right coronary artery supplies all of the following parts of the conducting system in the heart except:

 A

SA Node

 B

AV Node

 C

AV Bundle

 D

Right Bundle branch

Q. 10

The right coronary artery supplies all of the following parts of the conducting system in the heart except:

 A

SA Node

 B

AV Node

 C

AV Bundle

 D

Right Bundle branch

Ans. D

Explanation:

Answer is D (Right bundle branch)

Right bundle is supplied by the Left coronary artery.

Right coronary artery supplies the SA node (in 65% cases), AV node, AV bundle or Bundle of His and part of left bundle branch(LBB)

Left cronoary artery supplies the right bundle branch (RBB, part of LBB and sometimes the SA node (in 35% cases),


Q. 11

Branches of left coronary artery are all of the following except:   

 A

Anterior interventricular branch

 B

Left diagonal artery

 C

Left atrial artery

 D

Posterior interventricular branch

 

Q. 11

Branches of left coronary artery are all of the following except:   

 A

Anterior interventricular branch

 B

Left diagonal artery

 C

Left atrial artery

 D

Posterior interventricular branch

 

Ans. D

Explanation:

The left coronary artery, which is usually larger than the right coronary artery, supplies the major part of the heart, including the greater part of the left atrium, left ventricle, and ventricular septum.

  • It arises from the left posterior aortic sinus of the ascending aorta.
  • It then enters the atrioventricular groove and divides into an anterior interventricular branch and a circumflex branch. Branches
  • The anterior interventricular (descending) branch /left anterior descending (LAD) runs downward in the anterior interventricular groove to the apex of the heart.
  • The anterior interventricular branch supplies the right and left ventricles with numerous branches that also supply the anterior part of the ventricular septum. One of these ventricular branches (left diagonal artery) may arise directly from the trunk of the left coronary artery.
  • The left circumflex artery (LCX) is the same size as the anterior interventricular artery. It winds around the left margin of the heart in the atrioventricular groove. A left marginal artery is a large branch that supplies the left margin of the left ventricle down to the apex. Anterior ventricular and posterior ventricular branches supply the left ventricle. Atrial branches supply the left atrium.

Posterior interventricular branch: It is typically a branch of the right coronary artery (80%, known as right dominance). Alternately, the Posterior interventricular branch can be a branch of the left circumflex coronary artery (20%, known as left dominance) which itself is a branch of the left coronary artery


Q. 12

Arterial supply to SA node is by:       

 A

Left anterior descending coronary artery

 B

Posterior interventricular (descending) artery

 C

Left coronary artery

 D

Right coronary artery

Q. 12

Arterial supply to SA node is by:       

 A

Left anterior descending coronary artery

 B

Posterior interventricular (descending) artery

 C

Left coronary artery

 D

Right coronary artery

Ans. D

Explanation:

The right coronary artery arises from the anterior aortic sinus of the ascending aorta and runs forward between the pulmonary trunk and the right auricle.

The artery of the sinuatrial node (branch of right coronary artery) supplies the SA node and the right and left atria; in 40% of individuals it arises from the left coronary artery.


Q. 13

Cardiac dominance is determined by coronary artery:

 A

Supplying circulation to the SA node

 B

Supplying circulation to the inferior portion of the interventricular septum

 C

Supplying circulation to the interatrial septum

 D

Supplying circulation to the anterior portion of the interventricular septum

Q. 13

Cardiac dominance is determined by coronary artery:

 A

Supplying circulation to the SA node

 B

Supplying circulation to the inferior portion of the interventricular septum

 C

Supplying circulation to the interatrial septum

 D

Supplying circulation to the anterior portion of the interventricular septum

Ans. B

Explanation:

In 85% of patients the right coronary artery (RCA) is said to be “dominant” because it supplies circulation to the inferior portion of the interventricular septum via the right posterior descending coronary artery/posterior interventricular artery.

In these cases the RCA travels to the cross-section of the AV groove and the posterior interventricular (IV groove). Here, it gives rise to the right posterior descending coronary artery (PDA) branch which travels in the posterior IV groove and gives off several septal perforator branches (SP). The SP supply blood to the lower portion of the IV septum. Generally, the dominant RCA also gives rise to the AV nodal branch which supplies blood to the AV node

The dominant RCA also provides the right postero-lateral (PLA) branch to the lower postero-lateral portion of the left ventricle.

The sinus or sino-atrial (SA) node branch originates in the proximal portion of the RCA in 60% of cases and as a left atrial branch of the Cx in the remaining 40% of cases. This is unrelated to whether the artery is “dominant” or not.


Q. 14

The Diagram repersents the blood supply of Heart. Identify the Vessel Marked B in the Diagram ?

 A

Left Coronary Artery

 B

Left Circumplex Artery

 C

Left Anterior Descending Branch  (LAD)

 D

Right Cornorary Artery

Q. 14

The Diagram repersents the blood supply of Heart. Identify the Vessel Marked B in the Diagram ?

 A

Left Coronary Artery

 B

Left Circumplex Artery

 C

Left Anterior Descending Branch  (LAD)

 D

Right Cornorary Artery

Ans. B

Explanation:


Q. 15

Right coronary artery supplies all, except‑

 A

Anterior 2/3 of ventricular septum

 B

SA node

 C

AV node

 D

LBB

Q. 15

Right coronary artery supplies all, except‑

 A

Anterior 2/3 of ventricular septum

 B

SA node

 C

AV node

 D

LBB

Ans. A

Explanation:

Right coronary artery supplies

(i) SA node (in 65%),

(ii) whole conducting system (AV bundle, bundle of his, part of left bundle branch) except RBB and part of left branch of AV bundle,

(iii) posterior part of ventricular septum,

(iv) most of right ventricle except small part adjoining anterior interventricular groove and small part of left ventricle adjoining posterior interventricular groove.

Left coronary artery supplies

(i) most of the left atrium,

(ii) most of the left ventricle including apex,

(iii) small part of right ventricle odjoining anterior interventricular septum,

(iv) anterior 2/3 of ventricular septum,

(v) RBB, LBB 

(vi) SA node in 35% of cases.


Q. 16

True about SA node are all except ‑

 A

Supplied by nodal artery

 B

Primary pacemaker

 C

Supplied by left vagus nerve

 D

Made up of nodal cells and connective tissue

Q. 16

True about SA node are all except ‑

 A

Supplied by nodal artery

 B

Primary pacemaker

 C

Supplied by left vagus nerve

 D

Made up of nodal cells and connective tissue

Ans. C

Explanation:

 

  • SA node is located in the upper part of crista terminalis at the junction of SVC and the right atrium.
  • It is the pacemaker of the heart and generates impulse at a rate of 70-100/min.
  • SA node is suplied by nodal artery, a branch of RCA in 65% cases and a branch of circumflex branch of LCA in 35% cases.
  • SA node is supplied by right vagus/parasympathetic (inhibitory) and right Sympathetic (excitatory) system as it develops from structures on the right side of embryo.
  • The SA node consists of connective tissue stroma containing an irregular whorled network of cardiac nodal cells, the SA nodal artery and numerous nerve endings (postganglionic parasympathetic and postganglionic sympathetic).

Q. 17

The artery represented below supplies all of the following parts of the conducting system in the heart except?

 A

SA Node

 B

AV Node

 C

AV Bundle

 D

Right Bundle branch

Q. 17

The artery represented below supplies all of the following parts of the conducting system in the heart except?

 A

SA Node

 B

AV Node

 C

AV Bundle

 D

Right Bundle branch

Ans. D

Explanation:

 

The arrow represents Right coronary artery.

D i.e. Right bundle branch 

Right coronary artery supply SA node (in 65% cases), AV node, AV bundle or Bundle of His and part of LBB (left bundle branch ); where as Left coronary artery supply SA node (in 35% cases), RBB (right bundle branch) & part of LBB.



Quinsy

Quinsy

Q. 1 In which of  the following locations there is collection of pus in the quinsy:
 A Peritonsillar space
 B Parapharyngeal space
 C Retropharyngeal space
 D Within the tonsil
Q. 1 In which of  the following locations there is collection of pus in the quinsy:
 A Peritonsillar space
 B Parapharyngeal space
 C Retropharyngeal space
 D Within the tonsil
Ans. A

Explanation:

Peritonsillar space

Quinsy (Peritonsillar abscess) usually unilateral and most commonly affected adult males

i) This consists of suppuration outside the tonsillar capsule, and the swelling can extends to the soft palate and the tonsil may also be pushed medially.

ii) It is a complication of acute or chronic tonsillitis, There occurs accumulation of pus between the tonsil capsule and tonsil bed. In most cases pus collection occurs antero-superior to tonsil, but may sometimes occur lateral or superior to tonsil

iii) Quinsy is the collection of pus in the peritonsillar space which lies between the capsule of tonsil and the superior constrictor muscle

Para-pharyngeal labscess-infection from tonsil or peritonsillar tissue may involve parapharyngeal space with

abscess formation.

The tonsil should be removed 6-8 weeks following a quinsy

Complication of peritonsillar abscess

Aspiration and asphyxia

Para pharyngeal abscess

Thrombosis of internal jugular vein or even a carotid artery rupture can occurs because of extension of this abscess to para pharyngeal space   Laryngeal oedema with resultant asphyxia

Septicaemia and multiple abscesses mayo cure


Q. 2

Quinsy is also known as

 A

Peritosillar abscess

 B

Retropharyngeal abscess

 C

Parapharyngeal abscess

 D

Paraepiglottic abscess

Q. 2

Quinsy is also known as

 A

Peritosillar abscess

 B

Retropharyngeal abscess

 C

Parapharyngeal abscess

 D

Paraepiglottic abscess

Ans. A

Explanation:

Q. 3

Swelling between tonsillar area and superior constrictor muscle is known as:

 A

Quinsy

 B

Dental abscess

 C

Par apharyngeal abscess

 D

Retroparyngeal abscess

Q. 3

Swelling between tonsillar area and superior constrictor muscle is known as:

 A

Quinsy

 B

Dental abscess

 C

Par apharyngeal abscess

 D

Retroparyngeal abscess

Ans. A

Explanation:

Q. 4

Quinsy is also known as:

 A

Peritosillar abscess

 B

Retropharyngeal abscess

 C

Parapharyngeal abscess

 D

Paraepiglottic abscess

Q. 4

Quinsy is also known as:

 A

Peritosillar abscess

 B

Retropharyngeal abscess

 C

Parapharyngeal abscess

 D

Paraepiglottic abscess

Ans. A

Explanation:

Quinsy is also known as peritonsillar abcess, it is a collection of pus in the peritonsillar space which lies between the capsule of palatine tonsil and pharyngeal muscle.

Peritonsillar abcess is the most common deep space infection of head and neck in the adult.

It is characterized by pain, difficulty swallowing, trismus, hot potato voice, fever, malaise, dehydration and rancid breath.

Examination shows erythematous oropharyngeal mucosa, purulent tonsillar exudates, inferomedial displacement of tonsil on the involved side with contralateral deviation of the uvula.


Q. 5

A child with high fever, severe sore throat presented with painful swallowing. Her voice was abnormal. Quinsy was diagnosed. What is referred to as Quinsy?

 A

Peritonsillar abscess

 B

Retropharyngeal abscess

 C

Parapharyngeal abscess

 D

Any of the above

Q. 5

A child with high fever, severe sore throat presented with painful swallowing. Her voice was abnormal. Quinsy was diagnosed. What is referred to as Quinsy?

 A

Peritonsillar abscess

 B

Retropharyngeal abscess

 C

Parapharyngeal abscess

 D

Any of the above

Ans. A

Explanation:

  • When infection penetrates the tonsillar capsule and involves the surrounding tissues, peritonsillar cellulitis results.
  • Peritonsillar abscess otherwise known as ‘quinsy’ and cellulitis present with severe sore throat, odynophagia, trismus, medial deviation of the soft palate and peritonsillar fold, and an abnormal muffled (“hot potato”) voice.
 

Q. 6

Pus collection in “quinsy” usually gets collected in which location?

 A

Peritonsillar space

 B

Within the tonsil

 C

Parapharyngeal space

 D

Retropharyngeal space

Q. 6

Pus collection in “quinsy” usually gets collected in which location?

 A

Peritonsillar space

 B

Within the tonsil

 C

Parapharyngeal space

 D

Retropharyngeal space

Ans. A

Explanation:

Quinsy usually follows an episode of acute tonsillitis.

Parapharyngeal abscess is a complication of quinsy.


Q. 7

Quincy tonsillectomy is done in:

 A

Tonsilolith

 B

Tonsillar malignancy

 C

Tonsillitis

 D

None of the above

Q. 7

Quincy tonsillectomy is done in:

 A

Tonsilolith

 B

Tonsillar malignancy

 C

Tonsillitis

 D

None of the above

Ans. C

Explanation:

Q. 8

Tonsillectomy following peritonsillar abscess is done after weeks:

 A

1-3 weeks

 B

6-8 weeks

 C

4-6 weeks

 D

8-12 weeks

Q. 8

Tonsillectomy following peritonsillar abscess is done after weeks:

 A

1-3 weeks

 B

6-8 weeks

 C

4-6 weeks

 D

8-12 weeks

Ans. B

Explanation:

 

 

The tonsils should be removed 6-8 weeks following a Quinsy. – Turner 10th/ed p 86

Tonsils are removed 4-6 weeks following an attack of Quinsy. – Dhingra 6th/ed 

Most people would practise interval tonsillectomy for these patients, deferring surgery for 6 weeks following resolution of an attack. – Head and Neck Surgery by Chris de Souza  


Q. 9

Contraindication of adenotonsillectomy:

 A

Age < 4 yr

 B

Poliomyelitis

 C

Haemophilus infection

 D

b and c

Q. 9

Contraindication of adenotonsillectomy:

 A

Age < 4 yr

 B

Poliomyelitis

 C

Haemophilus infection

 D

b and c

Ans. D

Explanation:

 

Tonsillectomy should not be performed during epidemics of poliomyelitis.This is because there are evidences that the virus may gain access to the exposed nerve sheaths and give rise to the fatal bulbar form of the disease.

It should not be undertaken in the presence of respiratory tract infections or during the period of incubation of after contact with one of the infectious disease (i.e. Haemophilus) or if there is tonsillar inflammation.

It is safer to wait for 3 weeks after an acute inflammatory disease, before performing tonsillectomy

According of Turner – Tonsillectomy can be performed at any age, if there are sufficient indications for their removal.

According to Dhingra –  Children < 3 years (Not < 4 years as given in the options) are poor candidates for surgery. So tonsillectomy should not be done in them.

According to Head and Neck Surgery de Souza ‑ As tonsillar tissue has a role in the development of the immune system, it is advisable that surgery should be delayed until the age of 3 whenever possible.


Q. 10

In which of the following locations, there is collection of pus in the quinsy:

 A

Peritonsillar space

 B

Parapharyngeal space

 C

Retropharyngeal space

 D

Within the tonsil

Q. 10

In which of the following locations, there is collection of pus in the quinsy:

 A

Peritonsillar space

 B

Parapharyngeal space

 C

Retropharyngeal space

 D

Within the tonsil

Ans. A

Explanation:

 

Quinsy is collection of pus in the peritonsillar space which lies between the capsule of tonsil and superior constrictor muscle i.e. peritonsillar abscess.


Q. 11

True about quinsy is:

 A

Penicillin is used in treatment

 B

Abscess is located in capsule

 C

Commonly occurs bilaterally

 D

Immediate tonsillectomy should be done

Q. 11

True about quinsy is:

 A

Penicillin is used in treatment

 B

Abscess is located in capsule

 C

Commonly occurs bilaterally

 D

Immediate tonsillectomy should be done

Ans. A

Explanation:

 

  • Quinsy is collection of pus outside the capsule (not in capsule) in peritonsillar area
  • It is usually unilateral
  • Patient presents with toxic symptoms due to septicemia as well as local symptoms (e.g. dribbling of saliva from mouth)
  • Antibiotics: High-dose penicillin. (IV benzipenicillin) is the DOC. In patients allergic to penicillin, erythromycin is the DOC. If antibiotics fail to relieve the condition within 48 hours, then the abscess must be opened and drained.



Q. 12

7-year-old child has peritonsillar abscess and presents with trismus, the best treatment is:

 A

Immediate abscess drainage orally

 B

Drainage externally

 C

Systemic antibiotics up to 48 hours then drainage

 D

Tracheostomy

Q. 12

7-year-old child has peritonsillar abscess and presents with trismus, the best treatment is:

 A

Immediate abscess drainage orally

 B

Drainage externally

 C

Systemic antibiotics up to 48 hours then drainage

 D

Tracheostomy

Ans. C

Explanation:

Q. 13

Quinsy refers to ‑

 A

Intra-tonsillar abscess

 B

Peritonsillar abscess

 C

Submandibular abscess

 D

Retropharyngeal abscess

Q. 13

Quinsy refers to ‑

 A

Intra-tonsillar abscess

 B

Peritonsillar abscess

 C

Submandibular abscess

 D

Retropharyngeal abscess

Ans. B

Explanation:

Ans. is ‘b’ i.e., Peritonsillar abscess

Ouinsv (Peritonsillar abscess)

Quinsy consists of suppuration outside the capsule in the area around the capsule. There is collection of pus between the capsule of tonsil and the superior constrictor muscle, i.e. in the peritonsillar area. Peritonsillar abscess is a complication of tonsillitis and is most commonly caused by group A beta – hemolytic streptococcus. Clinical features of Quinsy

Clinical features are divided into :‑

1) General : They are due to septicaemia and resemble any acute infection. They include fever (up to 104°F), chills and rigors, general malaise, body aches, headache, nausea and constipation.

2) Local :

  1. Severe pain in throat. Usually unilateral.
  2. Odynophagia. It is so marked that the patient cannot even swallow his own saliva which dribbles from the angle of his mouth. Patient is usually dehydrated.
  3. Muffled and thick speech, often called “Hot potato voice”.
  4. Foul breath due to sepsis in the oral cavity and poor hygiene.
  5. Ipsilateral earache. This is referred pain via CN IX which supplies both the tonsil and the ear.
  6. Trismus due to spasm of pterygoid muscles which are in close proximity to the superior constrictor.

Examination findings

  1. The tonsil, pillars and soft palate on the involved side are congested and swollen. Tonsil itself may not appear enlarged as it gets buried in the oedematous pillars.
  2. Uvula is swollen and oedematous and pushed to the opposite side.
  3. Bulging of the soft palate and anterior pillar above the tonsil.
  4. Mucopus may be seen covering the tonsillar region.
  5. Cervical lymphadenopathy is commonly seen. This involves jugulodigastric lymph nodes.
  6. Torticollis : Patient keeps the neck tilted to the side of abscess.

Treatment of peritonsillar abscess

  • IV fluids
  • Antibiotics : High dose penicllin. (iv benzipenicillin) is the DOC. In patients allergic to penicillin erythromycin is the DOC.
  • Incision and drainage per orally, if the abscess does not resolve depite high dose of iv antibiotics.
  • Tonsillectomy is done 6 weeks following an attack of quinsy (interval tonsillectomy).


Tonsillectomy

Tonsillectomy

Q. 1 Which of  the  following is  most  accurate in describing coblation intracapsular tonsillectomy?
 A Electric energy is transferred to vibration energy
 B lt can only cut, and not coagulate
 C . lt creates significant thermal injury to tissues
 D lt utilizes a thin layer of ionized sodium to ablate tissues
Q. 1 Which of  the  following is  most  accurate in describing coblation intracapsular tonsillectomy?
 A Electric energy is transferred to vibration energy
 B lt can only cut, and not coagulate
 C . lt creates significant thermal injury to tissues
 D lt utilizes a thin layer of ionized sodium to ablate tissues
Ans. B

Explanation:

It utilizes a thin layer of ionized sodium to ablate tissues

The newer methods of tonsillectomy include:

a. Coblation         b. Harmonic scapel            c.Ligasure (Thermal Welding)

d. Laser               e. Intra-capsular methods

Coblation

Uses radiofrequency (RF) energy to ionize NaCI in a saline medium, then the energy of these ions (plasma) is used to break molecular tissue bonds

•    May also be used for direct hemostasis

•    RF energy is supposed to stay in the irrigation to minimize collateral heating

•    Temperatue is not supposed to exceed 70 C (cautery is routinely 200-400 C)

•    Most studies indicate less pain than electrocautery, some cite equivalent pain to cold knife

•    Intraoperative blood loss comparable to electrocautery

•    No electrical connection to patient

•    Very high cost compared to electrocautery or cold knife ($150-200/piece)

•    Operative times up to twice as long than electrocautery

•    Aggressive marketing campaign targeted to lay public


Q. 2

Tonsillectomy is contraindicated in:

 A

Small atrophic tonsils

 B

Quinsy

 C

Poliomyelitis epidemic

 D

Tonsillolith

Q. 2

Tonsillectomy is contraindicated in:

 A

Small atrophic tonsils

 B

Quinsy

 C

Poliomyelitis epidemic

 D

Tonsillolith

Ans. C

Explanation:

Q. 3

Bilateral tonsillectomy is performed on an otherwise healthy 11-year-old female with recurrent upper respiratory tract infections. On pathologcal examination of the tonsils, numerous small, yellow granules are noted. A granule crushed between two slides have a dense, gram-positive center and numerous branching filaments at the periphery. The granules are most likely composed of which of the following organisms?

 A

Actinomyces israelii

 B

Aspergillus fumigatus

 C

Blastomyces dermatitidis

 D

Candida albicans

Q. 3

Bilateral tonsillectomy is performed on an otherwise healthy 11-year-old female with recurrent upper respiratory tract infections. On pathologcal examination of the tonsils, numerous small, yellow granules are noted. A granule crushed between two slides have a dense, gram-positive center and numerous branching filaments at the periphery. The granules are most likely composed of which of the following organisms?

 A

Actinomyces israelii

 B

Aspergillus fumigatus

 C

Blastomyces dermatitidis

 D

Candida albicans

Ans. A

Explanation:

Actinomyces are normal inhabitants of the gastrointestinal tract that grow under anaerobic and microaerophilic conditions.

Although they are gram-positive rods, they grow as branching filaments and have been confused with fungi.

The yellow colonies (sulfur granules) are found in low-oxygen niches like the tonsils and in actinomycotic abscesses.

Aspergillus fumigatus may be present in the respiratory tract as an opportunistic pathogen; however, fungus balls are generally seen only in pre-existing cavities (e.g., bronchiectasis, TB), not in the tonsils.

Blastomyces dermatitidis is a respiratory pathogen that is seen as thick-walled yeasts within granulomas.

Candida albicans, also a normal inhabitant of the oral cavity, would present as whitish plaques and would appear microscopically as budding yeasts.


Q. 4

Tonsillectomy is recommended if number of acute infections in a year exceed:

 A

3

 B

4

 C

5

 D

6

Q. 4

Tonsillectomy is recommended if number of acute infections in a year exceed:

 A

3

 B

4

 C

5

 D

6

Ans. A

Explanation:

Tonsillectomy and adenoidectomy are indicated for chronic or recurrent acute infection and for obstructive hypertrophy.

The American Academy of Otolaryngology–Head and Neck Surgery Clinical Indicators Compendium suggests tonsillectomy after three or more infections per year despite adequate medical therapy.

Some feel that tonsillectomy is indicated in children who miss 2 or more weeks of school annually secondary to tonsil infections. 
 
Ref: Schwartz’s principle of surgery 9th edition, chapter 18.

Q. 5

All of the following are absolute indications for tonsillectomy, except

 A

Recurrent attacks

 B

Peritonsillar abscess

 C

Suspected malignancy

 D

Acute tonsillitis

Q. 5

All of the following are absolute indications for tonsillectomy, except

 A

Recurrent attacks

 B

Peritonsillar abscess

 C

Suspected malignancy

 D

Acute tonsillitis

Ans. D

Explanation:

Recurrent throat infections, peritonsillar abcess, tonsillitis causing febrile seizures, hypertrophy of tonsils causing sleep apnoea or speech interference and any suspicion of malignancy are absolute indications for tonsillectomy.


Q. 6

Secondary Haemorrhage after tonsillectomy usually presents at:

 A

12 hours

 B

24 hours

 C

6 days

 D

12 days

Q. 6

Secondary Haemorrhage after tonsillectomy usually presents at:

 A

12 hours

 B

24 hours

 C

6 days

 D

12 days

Ans. C

Explanation:

Secondary haemorrhage usually seen between the 5th to 10th postoperative day.
It is the result of sepsis & premature separation of the membrane.

Usually, it is heralded by bloodstained sputum but may be profuse. Simple measures like removal of clot, topical application of dilute adrenaline or hydrogen peroxide with pressure usually suffice.
For profuse bleeding, general anaesthesia is given & bleeding vessel is electrocoagulated or ligated. Sometimes, approximation of pillars with mattress sutures may be requered.
Sometimes, external carotid ligation may also be required.

Systemic antibiotics are given for control of infection.


Q. 7

A 5-year-old patient is scheduled for tonsillectomy. On the day of surgery he had running nose, temperature 37.5°C and dry cough. Which of the following should be the most appropriate decision for surgery?

 A

Surgery should be cancelled

 B

Should get X-ray chest before proceeding for surgery

 C

Cancel surgery for 3 weeks and patient to be on antibiotic

 D

Can proceed for surgery if chest is clear and there is no history at asthma

Q. 7

A 5-year-old patient is scheduled for tonsillectomy. On the day of surgery he had running nose, temperature 37.5°C and dry cough. Which of the following should be the most appropriate decision for surgery?

 A

Surgery should be cancelled

 B

Should get X-ray chest before proceeding for surgery

 C

Cancel surgery for 3 weeks and patient to be on antibiotic

 D

Can proceed for surgery if chest is clear and there is no history at asthma

Ans. C

Explanation:

Several studies have shown that children undergoing an elective surgical procedure with an acute upper respiratory tract infection has an increased incidence of laryngospasm, bronchospasm or oxygen desaturation.


Q. 8

Quincy tonsillectomy is done in:

 A

Tonsilolith

 B

Tonsillar malignancy

 C

Tonsillitis

 D

None of the above

Q. 8

Quincy tonsillectomy is done in:

 A

Tonsilolith

 B

Tonsillar malignancy

 C

Tonsillitis

 D

None of the above

Ans. C

Explanation:

Q. 9

Tonsillectomy is contraindicated in which of the following condition?

 A

Small atrophic tonsils

 B

Quinsy

 C

Poliomyelitis epidemic

 D

Tonsillolith

Q. 9

Tonsillectomy is contraindicated in which of the following condition?

 A

Small atrophic tonsils

 B

Quinsy

 C

Poliomyelitis epidemic

 D

Tonsillolith

Ans. C

Explanation:

Performing tonsillectomy during poliomyelitis epidemic is an absolute contraindication.

Unimmunised children may develop polio following tonsillectomy.

A tonsillectomy may be performed long after the epidemic has passed and the child is immunised against polio.

 
Indications for Tonsillectomy:
  • Recurrent episodes of acute tonsillitis that is more than four attacks a year 
  • Patients with recurrent sore throats and rheumatic fever and when tonsils cause repeated attacks of otitis media.
  • Presence or history of a peritonsillar abscess or of diphtheria carriers.
  • Massive tonsillar hypertrophy causing respiratory obstruction in children
  • Sleep apnea
  • Glossopharyngeal neuralgia

Q. 10

Which of the following is an indiction for tonsillectomy-

 A

Rheumatic fever

 B

Glomerulonephritis

 C

Recurrent upper respiratory infection

 D

All

Q. 10

Which of the following is an indiction for tonsillectomy-

 A

Rheumatic fever

 B

Glomerulonephritis

 C

Recurrent upper respiratory infection

 D

All

Ans. C

Explanation:

Ans. is ‘c’ i.e., Recurrent upper respiratory infection

Indications of tonsillectomy

If more than six attacks of tonsillitis in a year for two consecutive years.

o Recurrent sore throat     

o Tonsillar or pentonsillar abscess                 

o Retention cyst of tonsil                  

o Diphtheria carriers

o Tonsillolith        

o Suspicious malignancy  

o Obustructive sleep apnea


Q. 11

A 5-year old patient is schedules for tonsillectomy. On the day of surgery he had running nose, temperature 37.5°C and dry cough. Which of the following should be the most appropriate decision for surgery.

 A

Surgery should be cancelled

 B

Can proceed for surgery if chest is clear and there is no history of asthma

 C

Should get X-ray chest before proceeding for surgery

 D

Cancel surgery for 3 weeks and patient to be on antibiotic

Q. 11

A 5-year old patient is schedules for tonsillectomy. On the day of surgery he had running nose, temperature 37.5°C and dry cough. Which of the following should be the most appropriate decision for surgery.

 A

Surgery should be cancelled

 B

Can proceed for surgery if chest is clear and there is no history of asthma

 C

Should get X-ray chest before proceeding for surgery

 D

Cancel surgery for 3 weeks and patient to be on antibiotic

Ans. D

Explanation:

D i.e. Cancel surgery for 3 weeks and patient to be on antibiotic 

Surgery should be postponed if there is evidence of acute infection or suspicion of a clotting dysfunction (eg. recent aspirin ingestion)Q.

Child with an upper respiratory tract infection (URI) has an irritable airway and is at increased risk for laryngospasm, bronchospasm, post intubation croup, atelectasis, pneumonia & episodes of desaturation.

Because bronchial hyper reactivity may last for upto 6 weeks after a URI, cancellation will make a difference only if surgery is delayed for this amount of time or longerQ.


Q. 12

Tonsillectomy is indicated in:

 A

Acute tonsillitis

 B

Aphthous ulcers in the pharynx

 C

Rheumatic tonsillitis

 D

Physiological enlargement

Q. 12

Tonsillectomy is indicated in:

 A

Acute tonsillitis

 B

Aphthous ulcers in the pharynx

 C

Rheumatic tonsillitis

 D

Physiological enlargement

Ans. C

Explanation:

Q. 13

A 5-year-old patient is scheduled of for tonsillectomy. On the day of surgery, he had running nose, temperature, 37.5°C and dry cough. Which of the following should be the most appropriate decision for surgery?

 A

Surgery should be canceled

 B

Can proceed for surgery if chest is clear and there is no history of asthma

 C

Should get X-ray chest before proceeding for surgery

 D

Cancel surgery for 3 weeks and patient to be on antibiotic

Q. 13

A 5-year-old patient is scheduled of for tonsillectomy. On the day of surgery, he had running nose, temperature, 37.5°C and dry cough. Which of the following should be the most appropriate decision for surgery?

 A

Surgery should be canceled

 B

Can proceed for surgery if chest is clear and there is no history of asthma

 C

Should get X-ray chest before proceeding for surgery

 D

Cancel surgery for 3 weeks and patient to be on antibiotic

Ans. D

Explanation:

 

There are no absolute contraindications to tonsillectomy. As such tonsillectomy is an elective operation and should not be undertaken in presence of respiratory tract infections or during the period of incubation of after contact with one of the infectious disease, if there is tonsillar inflammations.

It is much safer to wait some 3 weeks after an acute inflammatory before operating, because of the greatly increased risk of postoperative haemorrhage.

Also, these patients may develop a laryngospasm with airway manipulation. This complication carries the potential for significant morbidity and even mortality.

 

 

 


Q. 14

Tonsillectomy following peritonsillar abscess is done after weeks:

 A

1-3 weeks

 B

6-8 weeks

 C

4-6 weeks

 D

8-12 weeks

Q. 14

Tonsillectomy following peritonsillar abscess is done after weeks:

 A

1-3 weeks

 B

6-8 weeks

 C

4-6 weeks

 D

8-12 weeks

Ans. B

Explanation:

 

 

The tonsils should be removed 6-8 weeks following a Quinsy. – Turner 10th/ed p 86

Tonsils are removed 4-6 weeks following an attack of Quinsy. – Dhingra 6th/ed 

Most people would practise interval tonsillectomy for these patients, deferring surgery for 6 weeks following resolution of an attack. – Head and Neck Surgery by Chris de Souza  


Q. 15

Most common postoperative complication of tonsillectomy is:

 A

Palatal palsy

 B

Hemorrhage

 C

Injury to uvula

 D

Infection

Q. 15

Most common postoperative complication of tonsillectomy is:

 A

Palatal palsy

 B

Hemorrhage

 C

Injury to uvula

 D

Infection

Ans. B

Explanation:

Q. 16

Secondary hemorrhage after tonsillectomy develops:

 A

Within 12 hrs

 B

Within 24 hrs

 C

Within 6 days

 D

Within 1 months

Q. 16

Secondary hemorrhage after tonsillectomy develops:

 A

Within 12 hrs

 B

Within 24 hrs

 C

Within 6 days

 D

Within 1 months

Ans. C

Explanation:

The main complication is hemorrhage which occurs in 3-5% patients


Q. 17

A male 15 years of age presents with hemorrhage, 5 hours after tonsillectomy. Treatment of choice is:

 A

External gauze packing

 B

Antibiotics and mouth wash

 C

Irrigation with saline

 D

Reopen immediately

Q. 17

A male 15 years of age presents with hemorrhage, 5 hours after tonsillectomy. Treatment of choice is:

 A

External gauze packing

 B

Antibiotics and mouth wash

 C

Irrigation with saline

 D

Reopen immediately

Ans. D

Explanation:

 

Reactionary hemorrhage occurs within a few hours of the operation and may be severe.

It may occur after operation and is treated by a return to the theater when the vessel is ligated under anesthesia.

  • Reactionary haemorrhage mostly occurs due to dislodgement of any clot or because BP of patient comes back to normal after hypotensive anaesthesia.
  • Secondary haemorrhage mainly occurs due to infection.

Indications for blood transfusion in a case of Tonsillectomy

–          End-stage renal disease

–          Hypertension                                                  

–          Reduced hemoglobin and hematocrit               

 

 


Q. 18

After tonsillectomy, secondary haemorrhage occurs:

 A

Within 24 hours

 B

After 2 weeks

 C

5-10 post operative days

 D

After 1 month

Q. 18

After tonsillectomy, secondary haemorrhage occurs:

 A

Within 24 hours

 B

After 2 weeks

 C

5-10 post operative days

 D

After 1 month

Ans. C

Explanation:

Q. 19

Torrential bleed during tonsillectomy is due to:

 A

Facial artery

 B

Tonsillar artery

 C

Paratonsillar vein

 D

None

Q. 19

Torrential bleed during tonsillectomy is due to:

 A

Facial artery

 B

Tonsillar artery

 C

Paratonsillar vein

 D

None

Ans. B

Explanation:

Q. 20

M/C cause of haemorrhage during tonsillectomy is

 A

Paratonsillar vein

 B

Maxillary A

 C

Lingual A

 D

Middle meningeal A

Q. 20

M/C cause of haemorrhage during tonsillectomy is

 A

Paratonsillar vein

 B

Maxillary A

 C

Lingual A

 D

Middle meningeal A

Ans. A

Explanation:

Q. 21

Tonsillectomy is contraindicated in:

 A

Small atrophic tonsils

 B

Quinsy

 C

Poliomyelitis epidemic

 D

Tonsillolith

Q. 21

Tonsillectomy is contraindicated in:

 A

Small atrophic tonsils

 B

Quinsy

 C

Poliomyelitis epidemic

 D

Tonsillolith

Ans. C

Explanation:

Q. 22

Torrential bleed during tonsillectomy is due to ‑

 A

Facial artery

 B

Tonsilar artery

 C

Paratonsillar vein

 D

None

Q. 22

Torrential bleed during tonsillectomy is due to ‑

 A

Facial artery

 B

Tonsilar artery

 C

Paratonsillar vein

 D

None

Ans. C

Explanation:

Ans. is ‘c’ i.e., Paratonsillar vein

“Excessive bleeding at the time of operation usually arises because of trauma to an aberrant vessel or paratonsillar vein”.

Complications of tonsillectomy

Complications of tonsillectomy may be :-

i)  Immediate

ii) Delayed

Immediate complications

1) Primary haemorrhage Occurs at the time of operation. It can be controlled by pressure, ligation or electrocoagulation of the bleeding vessels.

2) Reactionary haemorrhage : Occurs within a period of 24 hours.

3) Injury to tonsillar pillars, uvula, soft palate, tongue or superior constrictor muscle due to bad surgical technique.

4) Injury to teeth.

5) Aspiration of blood.

6) Facial oedema : Some patients get oedema of the face particularly of the eyelids.

7) Surgical emphysema

Dalaved complications

1) Seconclaty haemorrhage : Usually seen between the 5th to 10th post-operative day. It is the result of sepsis and premature separation of the membrane. Usually, it is heralded by bloodstained sputum but may be profuse.

2) Infection : Infection of tonsillar fossa may lead to parapharyngeal abscess or otitis media.

3) Lung complications : Aspiration of blood, mucus or tissue fragments may cause atelectasis or lung abscess.

4) Scarring in soft palate and pillars.

5) Tonsillar remnants : Tonsil tags or tissue, left due to inadequate surgery, may get repeatedly infected.

6) Hypertrophy of lingual tonsil : This is a late complication and is compensatory to loss of palatine tonsils.



Acute Tonsilitis

Acute Tonsilitis

Q. 1

During Tonsillitis, pain in the ear is due to involvement of?

 A

Vagus Nerve

 B

Chorda tympani Nerve

 C

Glossopharyngeal Nerve

 D

Hypoglossal Nerve

Q. 1

During Tonsillitis, pain in the ear is due to involvement of?

 A

Vagus Nerve

 B

Chorda tympani Nerve

 C

Glossopharyngeal Nerve

 D

Hypoglossal Nerve

Ans. C

Explanation:

Q. 2 A  6  years  old  female  child  presents  with severe pain in throat and odynophagia, since one week General examination revealed, cervical lymphadenopathy, but no signs or symptoms of upper airway obstruction. Intra-oral examination revealed swelling, redness and protrusion of both tonsils,    Most    common    causathe    agent    is: 
 A Haemolytic streptococcus
 B Non-haemolytic streptococcus
 C H. influenza
 D Staphylococci
Q. 2 A  6  years  old  female  child  presents  with severe pain in throat and odynophagia, since one week General examination revealed, cervical lymphadenopathy, but no signs or symptoms of upper airway obstruction. Intra-oral examination revealed swelling, redness and protrusion of both tonsils,    Most    common    causathe    agent    is: 
 A Haemolytic streptococcus
 B Non-haemolytic streptococcus
 C H. influenza
 D Staphylococci
Ans. A

Explanation:

Haemolytic streptococcus

BACTERIAL PHARYNGOTONSILLITIS

Etiology

Group A beta-haemolytic streptococcus is the most common and important pathogen causing acute bacterial pharyngotonsillitis. This infection most commonly presents in children aged 5-6 yrs.

SYMPTOMS

It is characterized by fever, dry sore throat, cervical adenopathy, dysphagia and odynophagia. The tonsils and

pharyngeal mucosa are erythematous and may be covered with purulent exudate; the tongue may also become red

(strawberry tongue).

DIAGNOSIS

In cases of strongly suspected pharyngitis caused by group A beta hemolytic streptococcus the combination of rapid

strep tests based on ELISA (enzyme-linked immunosorbent assay) or latex agglutination, with a throat culture if negative, increases the sensitivity and specificity of either test alone.

TREATMENT

The primary antibiotic treatment for streptococcal pharyngotonsillitis consists of penicillin.


Q. 3

A child presents with a white patch over the tonsils; diagnosis is best made by culture in:

 A

Loeffler medium

 B

LJ medium

 C

Blood agar

 D

Tellurite medium

Q. 3

A child presents with a white patch over the tonsils; diagnosis is best made by culture in:

 A

Loeffler medium

 B

LJ medium

 C

Blood agar

 D

Tellurite medium

Ans. A

Explanation:

In the child presenting with a white patch over the tonsil, we suspect a diagnosis of ‘diphtheria’. Usual media used for cultivation of Diphtheria are Loeffler’s serum slope & tellurite blood agar.
 
Ref: Text Book of Microbilogy By Ananthanarayan, 6th Edition, Page 215 and 8th Edition, Page 233

Q. 4

A febrile 23-year-old college student presents with fatigue and difficulty swallowing. Physical exam reveals exudative tonsillitis, palatal petechiae, cervical lymphadenopathy, and tender hepatosplenomegaly. A complete blood count reveals mild anemia, lymphocytosis with about 30% of the lymphocytes exhibiting atypical features, and a mild thrombocytopenia. Coombs’ test is positive. Which of the following is the most likely complication of this syndrome?

 A

Acute cholecystitis

 B

Ascending cholangitis

 C

Diarrhea

 D

Splenic rupture

Q. 4

A febrile 23-year-old college student presents with fatigue and difficulty swallowing. Physical exam reveals exudative tonsillitis, palatal petechiae, cervical lymphadenopathy, and tender hepatosplenomegaly. A complete blood count reveals mild anemia, lymphocytosis with about 30% of the lymphocytes exhibiting atypical features, and a mild thrombocytopenia. Coombs’ test is positive. Which of the following is the most likely complication of this syndrome?

 A

Acute cholecystitis

 B

Ascending cholangitis

 C

Diarrhea

 D

Splenic rupture

Ans. D

Explanation:

The syndrome represented by the clinical vignette is infectious mononucleosis.

Epstein-Barr virus (EBV) is the usual cause of heterophile-positive infectious mononucleosis; cytomegalovirus is responsible for a minority of cases.

Rarely, splenic rupture requiring splenectomy can result from splenomegaly and capsular swelling, usually occurring during the 2nd and 3rd weeks of the illness.

Acute cholecystitis is not associated with infectious mononucleosis.
The most frequently isolated pathogens are E. coli, Klebsiella spp., group D Streptococcus, Staphylococcus spp., and Clostridium spp.
Ascending cholangitis is not associated with infectious mononucleosis.
Cholangitis usually presents with biliary colic, jaundice, and spiking fever with chills (Charcot’s triad).
Blood cultures are usually positive (E. coli is a common isolate), with an accompanying leukocytosis.

AIDS-related cholangitis has been reported, presenting with abdominal pain and obstructive liver symptoms. Potential etiologic agents include Cytomegalovirus, Cryptosporidium parvum, and Microsporidia, including Enterocytozoon cuniculi.

Diarrhea is not usually produced by infectious mononucleosis.

Q. 5

An 8 year old child is referred to you with history of Mononeuritis multiplex. On examination you find that there is hepatosplenomegaly. Examination of the oral cavity and pharynx revealed enlarged orange coloured tonsils. Which of the following statement regarding the above condition is false?

 A

It is a case of Tangier diaese

 B

The plasma LDL – c levels will be low

 C

It is an autosomal recessive condition

 D

It is caused by ABCA1 deficiency

Q. 5

An 8 year old child is referred to you with history of Mononeuritis multiplex. On examination you find that there is hepatosplenomegaly. Examination of the oral cavity and pharynx revealed enlarged orange coloured tonsils. Which of the following statement regarding the above condition is false?

 A

It is a case of Tangier diaese

 B

The plasma LDL – c levels will be low

 C

It is an autosomal recessive condition

 D

It is caused by ABCA1 deficiency

Ans. C

Explanation:

Tangier disease is an autosomal co dominant condition caused by mutation in the gene coding for ABCA 1.

These patients have low levels of HDL-C, ApoA – I and LDL-C. There may be a slightly elevated triglyceride levels.

The accumulation of cholesterol in the reticulo endothelial system is responsible for the findings described in the question.

Ref: Harrison, Edition 17, Page – 2423 ; Essential revision notes for MRCP by Philip A Kalra, Edition 3, Page – 333


Q. 6

Commonest causative organism for acute tonsillitis is which of the following?

 A

B streptococci

 B

Parainfluenza virus

 C

H influenza

 D

Corynebacterium

Q. 6

Commonest causative organism for acute tonsillitis is which of the following?

 A

B streptococci

 B

Parainfluenza virus

 C

H influenza

 D

Corynebacterium

Ans. A

Explanation:

Parainfluenza virus causes tracheobronchitis and H influenza cause acute epiglottitis.


Q. 7

A 12-year-old child presents with fever and cervical lymphadenopathy. Oral examination shows a grey membrane on the right tonsil extending to the anterior pillar. Which of the following medium will be ideal for the culture of the throat swab for a rapid identification of the pathogen –

 A

Nutrient agar

 B

Bloodagar

 C

Loffler’s serum slope

 D

Lowenstein Jensen medium

Q. 7

A 12-year-old child presents with fever and cervical lymphadenopathy. Oral examination shows a grey membrane on the right tonsil extending to the anterior pillar. Which of the following medium will be ideal for the culture of the throat swab for a rapid identification of the pathogen –

 A

Nutrient agar

 B

Bloodagar

 C

Loffler’s serum slope

 D

Lowenstein Jensen medium

Ans. C

Explanation:

Ans. is ‘c’ i.e., Loeffler’s serum slope 

.   Fever, cervical lymphadenopathy and grey membrane on the tonsil extending to anterior pillar is suggestive of diphtherial infection. For rapid growth the specimen is inoculated on Loeffler’s serum slope which shows the growth in 4-8 hrs.


Q. 8

A child presents with a white patch over the tonsils, diagnosis is best made by culture in –

 A

Loeffler medium

 B

LJ medium

 C

Blood agar

 D

Tellurite medium

Q. 8

A child presents with a white patch over the tonsils, diagnosis is best made by culture in –

 A

Loeffler medium

 B

LJ medium

 C

Blood agar

 D

Tellurite medium

Ans. D

Explanation:

Ans. is ‘d’ i.e., Tellurite medium 

– Best diagnosis of any bacteria is made by culture of specimen in the “selective media” and the selective medium for

C. diphtheriae is tellurite agar. Loeffler’s medium shows early growth (in 4-8 hrs), but it is not a selective medium for

C. diphtheriae.

Note :

  • Most of the guides have given Loeffler’s medium as correct answer. According to them diphtheria is an emergency, so we should make early diagnosis.

Read text below :

  • Green wood has not mentioned Loeffler’s medium at all :

“The recommended media include blood agar and a selective medium containing tellurite”.

  • Jawetz writes

“Specific treatment must never be delayed for laboratory reports if the clinical picture is suggestive of diphtheria” – 

  • Although growth on Loeffler’s medium helps in making an earlier diagnosis, as we have started treatment on clinical ground, waiting for the growth on tellurite media would be the best option to diagnose the diphtheria as it acts as a selective media.

So

–         For earliest diagnosis of diphtheria – Loeffler’s serum slope

–         For best diagnosis of diphtheria       – Tellurite medium



Q. 9

A child has respiratory infection with membrane over Peritonsillar area. Swab was taken from the local area. The appropriate media for culture is –

 A

L.J. media

 B

Blood tellurite media

 C

Cary media

 D

Loeffler serum slope

Q. 9

A child has respiratory infection with membrane over Peritonsillar area. Swab was taken from the local area. The appropriate media for culture is –

 A

L.J. media

 B

Blood tellurite media

 C

Cary media

 D

Loeffler serum slope

Ans. B

Explanation:

Ans. is ‘b’ i.e., Blood tellurite media 


Q. 10

A child come with fever, cold, cough, membrane over tonsils; nasal swab is taken, culture should be done on which medium for earliest diagnosis ‑

 A

Loffelers serum slop

 B

L. J. media

 C

MC Conkey’s Agar

 D

Citrate media

Q. 10

A child come with fever, cold, cough, membrane over tonsils; nasal swab is taken, culture should be done on which medium for earliest diagnosis ‑

 A

Loffelers serum slop

 B

L. J. media

 C

MC Conkey’s Agar

 D

Citrate media

Ans. A

Explanation:

Ans. is ‘a’ i.e., Loffelers serum slop 

Diphtheria bacilli grow on Loeffler’s serum slope very rapidly and colonies can be seen in 6-8 hours, long before other bacteria grow.


Q. 11

All of the following cause a gray-white membrane on the tonsils, except:

 A

Infectious mononucleosis

 B

Ludwig’s angina

 C

Streptococcal tonsillitis

 D

Diphtheria

Q. 11

All of the following cause a gray-white membrane on the tonsils, except:

 A

Infectious mononucleosis

 B

Ludwig’s angina

 C

Streptococcal tonsillitis

 D

Diphtheria

Ans. B

Explanation:

 

Ludwigs angina is cellulitis of submandibular space. It does not lead to membrane formation over tonsils.

 



Fungal Sinusits

Fungal Sinusits

Q. 1

 True about mucormycosis is?

 A Nose is a common site
 B Diabetics is not a predisposing factor
 C Common in India
 D

All of the above

Q. 1

 True about mucormycosis is?

 A Nose is a common site
 B Diabetics is not a predisposing factor
 C Common in India
 D

All of the above

Ans. D

Explanation:

All of the above

REF: Harrison 17th ed p 1261, International Journal of Infectious Diseases Volume 15, Issue 8, Pages e533-e540, August 2011

Mucormycosis

  • Caused by — rhizopus , rhizomucor , cunninghamella
  • Moulds with non septate hyphae
  • The higher prevalence of mucormycosis in India turned out to be statistically significant (p < 0.0001) in comparison with all other countries
  • Predisposing factors

–          Organ transplant recipients

–          Long term desferroxamine therapy

–          Immunosuppression due to steroids or cytotoxic drugs

–          Hematological malignancy

–          Diabetics

–          Chronic renal failure

  • Five forms
  1. Rhinocerebral (most common site)
  2. Pulmonary mucormycosis (2nd most common)
  3. Cutaneous
  4. Gastrointestinal
  5. Disseminated

Diagnosis:

Microscopy and biopsy show organisms that appears as broad ribbon like usually non septate hyphae which branch at right angles


Q. 2

Mucormycosis of paranasal sinus is most common in

 A

HIV

 B

Diabetes

 C

Those on immuno suppressants

 D

Post surgical

Q. 2

Mucormycosis of paranasal sinus is most common in

 A

HIV

 B

Diabetes

 C

Those on immuno suppressants

 D

Post surgical

Ans. B

Explanation:

 

MUCORMYCOSIS:

  • Caused by – rhizopus , rhizomucor , cunninghamella
  • Moulds with non septate hyphae
  • The higher prevalence of mucormycosis in India turned out to be statistically significant (p < 0.0001) in comparison with all other countries
  • Predisposing factors

            – Organ transplant recipients

            – Long term desferroxamine therapy

            – Immunosuppression due to steroids or cytotoxic drugs Hematological malignancy

            – Diabetics

            – Chronic renal failure

  • Five forms
  1. Rhinocerebral (most common site)
  2. Pulmonary mucormycosis (2′ most common)
  3. Cutaneous
  4. Gastrointestinal
  5. Disseminated

Diagnosis:

Microscopy and biopsy show organisms that appears as broad ribbon like usually non septate hyphae which branch at right angles


Q. 3 True about Mucormycosis is:
 A Nose is a common site
 B Diabetes mellitus is predisposing
 C Vascular invasion seen
 D All of the above
Q. 3 True about Mucormycosis is:
 A Nose is a common site
 B Diabetes mellitus is predisposing
 C Vascular invasion seen
 D All of the above
Ans. D

Explanation:

All of the above


Q. 4

Choose the TRUE statement/s about mucormycosis:

 A

Nose is a common site

 B

Diabetics is a predisposing factor

 C

Common in India

 D

All of the above

Q. 4

Choose the TRUE statement/s about mucormycosis:

 A

Nose is a common site

 B

Diabetics is a predisposing factor

 C

Common in India

 D

All of the above

Ans. D

Explanation:

Mucormycosis

Caused by – rhizopus, rhizomucor, cunninghamella. The higher prevalence of mucormycosis in India turned out to be statistically significant (p < ? 0001. in comparison with all other countries Predisposing factors:

  • Organ transplant recipients
  • Long term desferroxamine therapy
  • Immunosuppression due to steroids or cytotoxic drugs
  • Hematological malignancy
  • Diabetis Mellitus
  • Chronic renal failure
Five forms of mucormycosis are:
  • Rhinocerebral (most common site)
  • Pulmonary mucormycosis (2nd most common)
  • Cutaneous
  • Gastrointestinal
  • Disseminated
  • Miscellaneous
Diagnosis: Biopsy with histopathologic examination is the most sensitive and specific modality for definitive diagnosis. Biopsy shows wide, thick walled, ribbon like, aseptate hyphal elements that branch at acute angles.

Q. 5

TRUE about mucormycosis is:

 A

Not seen in India

 B

Nose is a common site

 C

Diabetes is not a predisposing factor

 D

Metachromatic bodies are seen

Q. 5

TRUE about mucormycosis is:

 A

Not seen in India

 B

Nose is a common site

 C

Diabetes is not a predisposing factor

 D

Metachromatic bodies are seen

Ans. B

Explanation:

Mucormycosis: is an opportunistic mycosis caused by fungi of class zygomycetes.

Mucor and rhizopus species are the most common agents to cause Zygomycoses.

These fungi are ubiquitious worldwide in soil, manure and decaying organic matter.

Mucoracae are commonly cultured from the nose, throat, mouth and feces of many healthy individuals.

The most common clinical presentation is induration of the skin with surrounding erythema with rapidly progressing to necrosis.

Conditions that predispose:

  • Acidosis associated with diabetes mellitus
  • Organ transplant recipients
  • Long term desferroxamine therapy
  • Immunosuppression due to steroids or cytoxic drugs
  • Hematological malignancy leukaemia, lymphoma
  • Chronic renal failure
  • Severe burn

Good to know:

Rhinocerebral mucormycosis is a rare opportunistic infection of the sinuses, nasal passages, oral cavity, and brain caused by saprophytic fungi (rhizopus, mucor). Most commonly seen in immunocompromised individual.

Ref: Jawetz, ‘Medical microbiology’, 23rd Edition, Page 650; Textbook of Microbiology,By R. Ananthanarayan, C.K. Jayaram Paniker, 7th Edition, Page 625.


Q. 6

All of the following are diagnostic criteria of Allergic Fungal Sinusitis (AFS), EXCEPT:

 A

Areas of High Attenuation on CT scan

 B

Orbital invasion

 C

Allergic Eosinophilic mucin

 D

Type I Hypersensitivity

Q. 6

All of the following are diagnostic criteria of Allergic Fungal Sinusitis (AFS), EXCEPT:

 A

Areas of High Attenuation on CT scan

 B

Orbital invasion

 C

Allergic Eosinophilic mucin

 D

Type I Hypersensitivity

Ans. B

Explanation:

The diagnostic criteria for allergic fungal sinusitis (AFS) are the presence of characteristic allergic mucin, type I hypersensitivity (eosinophilic-lymphocytic inflammation), absence of fungal invasion, immuno-compromised individuals and radiological confirmation (areas of high attenuation on CT scan).


Q. 7

Which type of Allergic reaction is seen in patients with Allergic fungal sinusitis?

 A

Type 1 and Type 2

 B

Type 2 and Type 3

 C

Type 1 and Type 3

 D

Type 4 and Type 1

Q. 7

Which type of Allergic reaction is seen in patients with Allergic fungal sinusitis?

 A

Type 1 and Type 2

 B

Type 2 and Type 3

 C

Type 1 and Type 3

 D

Type 4 and Type 1

Ans. C

Explanation:

A combination of type 1 and 3 hypersensitivity reaction is thought to be involved in the pathogenesis of Allergic fungal sinusitis. 
 
It  is thought to involve direct stimulation of eosinophils by a subset of helper T cells (TH2) primed by fungal antigens.
It results in vigorous inflammation and polyp formation.
Causative organisms includes  usually those of the Dematiaceae family, but Aspergillus species are also seen.
Patients usually presents with features of chronic sinusitis.
Patients are treated with systemic steroids, surgery, and nasal irrigations.
 


Q. 8

An elderly diabetic has left sided orbital cellulites, CT scan of paranasal sinuses shows evidence of left maxillae sinusitis. Gram stained smear of the orbital exudates shows irregularly branching septate hyphae. The following is the most likely aetiological agent –

 A

Aspergillus

 B

Rhizopus

 C

Mucor

 D

Candida

Q. 8

An elderly diabetic has left sided orbital cellulites, CT scan of paranasal sinuses shows evidence of left maxillae sinusitis. Gram stained smear of the orbital exudates shows irregularly branching septate hyphae. The following is the most likely aetiological agent –

 A

Aspergillus

 B

Rhizopus

 C

Mucor

 D

Candida

Ans. A

Explanation:

Ans. is `a’ i.e., Aspergillus

  • Septate hyphae and involvement of sinuses suggets the diagnosis of Aspergillus infection.
  • Aspergillus can cause sinusitis and the hyphae of Aspergillus are septate and branched.

Q. 9

Mucormycosis-

 A

Angio-invasion

 B

Lymph invasion

 C

Septate hyphae

 D

All

Q. 9

Mucormycosis-

 A

Angio-invasion

 B

Lymph invasion

 C

Septate hyphae

 D

All

Ans. A

Explanation:

Ans. is ‘a’ i.e., Angio-invasion

MUCORMYCOSIS

  • Mucormycosis is most commonly caused by species ofRhizopus, Rhizomucor and Cunninghamella, but species of Apophysomyces, saksenaea, mucor and Absidia also are occasionally responsible.
  • They appear as nonseptate hyphae in tissues.
  • In all forms of mucormycosis, vascular invasion (angio-invasion) is a prominant feature.

.   Ischemic or hemorrhagic necrosis is the foremost histological finding.

.  Predisposing factors:

a) For paranasal sinus

  1. Diabetes                                                1. Hematological malignancies
  2. Organ transplantation                          2. Long term deferoxamine therapy b)For Gastrointestinal mucormycosis
  3. Uremia                                                   3. Diarrhea] disease
  4. Severe malnutrition

– Primary cutaneous inoculation is uncommon but occurs in burn eschars, underneath occlusive dressings, and sites of minor trauma in immunocompromized adults and low-birth-weight neonates.

Treatment

Debridement plus amphotericin B.


Q. 10

Orbital mucormycosis is a complication of

 A

AIDS

 B

Steroid therapy

 C

Cushing’s disease

 D

Diabetic ketoacidosis

Q. 10

Orbital mucormycosis is a complication of

 A

AIDS

 B

Steroid therapy

 C

Cushing’s disease

 D

Diabetic ketoacidosis

Ans. D

Explanation:

Ans. is ‘d’ i.e., Diabetic ketoacidosis

Note – Orbital mucormycosis occurs secondary to paranasal sinus mucormycosis.

  • Predisposing factors for paranasal sinus mucormycosis

Diabetes mellitus                                                           – Long term deferoxamine therapy

–  Hematological malignancies                                      – Organ transplantation

.  Predisposing factors for G.I. mucormycosis

– Uremia                                                                           – Diarrheal diseases

–   Severe malnutrition


Q. 11

Which among the following is true regarding fungal sinusitis:

 A

Surgery is required for treatment

 B

Most common organism is Aspergillus niger

 C

Amphoterecin B IV is used for invasive fungal sinusitis

 D

a and c

Q. 11

Which among the following is true regarding fungal sinusitis:

 A

Surgery is required for treatment

 B

Most common organism is Aspergillus niger

 C

Amphoterecin B IV is used for invasive fungal sinusitis

 D

a and c

Ans. D

Explanation:

Q. 12

All of the following are diagnostic criteria of allergic Fungal sinusitis (AFS) except:

 A

Areas of High attuenuation on CT scan

 B

Orbital invasion

 C

Allergic eosinophilic mucin

 D

Type 1 Hypersensitivity

Q. 12

All of the following are diagnostic criteria of allergic Fungal sinusitis (AFS) except:

 A

Areas of High attuenuation on CT scan

 B

Orbital invasion

 C

Allergic eosinophilic mucin

 D

Type 1 Hypersensitivity

Ans. B

Explanation:

 

Allergic fungal sinusitis is a noninvasive form of fungal sinusitis as such orbital invasion is not its feature.


Q. 13

All are true about mucormycosis, except:

 A

Lymph invasion

 B

Angio invasion

 C

Long term deferoxanine therepy

 D

b and c

Q. 13

All are true about mucormycosis, except:

 A

Lymph invasion

 B

Angio invasion

 C

Long term deferoxanine therepy

 D

b and c

Ans. D

Explanation:

 

  • Mucormycosis is caused by Rhizopus species, Rhizomucus and Absidia species.
  • Intitially, the disease runs a subtle course with only fever and rhinorrhea. Later on, it invades the orbit and intracranial cavity with rapid loss of vision, meningitis, cavernous sinus thrombosis and multiple cranial nerve palsies.
  • It has marked predilection for vascular invasion leading to widespread thrombosis, tissue necrosis, and gangrene.
  • Characteristic nasal finding is a dark necrotic turbinate surrounded by pale mucosa blackish discharge and crusts.
  • M/C site is middle turbinate followed by middle meatus and septum.
  • Investigation of choice is MRI, while biopsy is confirmatory.

Treatment: Includes amphotericin-B, heparin, hyperbaric oxygen, and debridement.



Q. 14

Topical steroids are not recommended post-surgery for:

 A

Allergic fungal sinusitis

 B

Chronic rhinosinusitis

 C

Antrochoanal polyp

 D

Ethmoidal polyps

Q. 14

Topical steroids are not recommended post-surgery for:

 A

Allergic fungal sinusitis

 B

Chronic rhinosinusitis

 C

Antrochoanal polyp

 D

Ethmoidal polyps

Ans. C

Explanation:

 

Topical steroids are not recommended in post surgery for antrochoanal polyps.

For antrochoanal polyps, cause is infection and not the allergy.

Antrochoanal polyps are single, unilateral and rarely recur.

Topical steroids are rarely recommended.


Q. 15

A diabetic with orbital cellulitis and maxillary sinusitis shows hyaline, narrow, septate and ranching hyphae with invasion of the blood vessels fungus on microscopy. Which is the causative fungus ?

 A

Candida

 B

Rhizospora

 C

Aspergillus

 D

Histoplasma

Q. 15

A diabetic with orbital cellulitis and maxillary sinusitis shows hyaline, narrow, septate and ranching hyphae with invasion of the blood vessels fungus on microscopy. Which is the causative fungus ?

 A

Candida

 B

Rhizospora

 C

Aspergillus

 D

Histoplasma

Ans. C

Explanation:

Ans. is ‘c’ i.e., Aspergillus

Diagnosis of Aspergillus infection:

Histologic examination of affected tissue reveals either infarction, with invasion of blood vessels by many fungal hyphae, or acute necrosis, with limited inflammation and hyphae.

Aspergillus hyphae are hyaline, narrow, and septate, with branching at 45°; no yeast forms are present in infected tissue.

Hyphae can be seen in cytology or microscopy preparations, which therefore provide a rapid means of presumptive diagnosis.



Complications of Sinusitis

Complications of Sinusitis

Q. 1

A 19 year old young girl with previous history of repeated pain over medial canthus and chronic use of nasal decongestants, presented with abrupt onset of fever with chills & rigor, diplopia on lateral gaze, moderate proptosis & chemosis. On examination optic disc is congested. Most likely diagnosis is

 A

Cavernous sinus thrombosis

 B

Orbital cell ulitis

 C

Acute Ethmoidal sinusitis

 D

Orbital apex syndrome

Q. 1

A 19 year old young girl with previous history of repeated pain over medial canthus and chronic use of nasal decongestants, presented with abrupt onset of fever with chills & rigor, diplopia on lateral gaze, moderate proptosis & chemosis. On examination optic disc is congested. Most likely diagnosis is

 A

Cavernous sinus thrombosis

 B

Orbital cell ulitis

 C

Acute Ethmoidal sinusitis

 D

Orbital apex syndrome

Ans. A

Explanation:

Cavernous sinus thrombosis [Ref:Khurana 4/e, p 384-389; Parsons’ 20/e, p 456-459; Dhingra ENT 5/e, p 213-214; Yonoff & Duker Ophthalmology 1076-1077, 1460-1461; http://en.wikipedia.org/wiki/cavernous_sinus_thrombosis, http://emedicine.medscape.com/article/791704-overview, www.sepeap.org/archivos/pdf/10126.pdf]

  • Repeated pain over medial canthus and chronic use of nasal decongestants suggest chronic ethmoidal sinusitis.
  • Patient’s other symptoms suggest that she has landed up in complicated sinusitis
  • Now lets see the symptoms one by one ?

There is sudden onset of ?

– Chills & rigor Systemic symptoms

– Diplopia on lateral gaze –> s/o VI C.N. (abducent) involvement leading to lateral rectus palsy

– Proptosis & chemosis

b/o venous congestion

– Optic disc congestion

  • So, among the given options ?
  • Orbital apex syndrome (OAS) can be ruled out as visual loss is often the initial manifestations of an OAS (not seen in this patient).

Orbital apex syndrome

Orbital apex syndrome is caused by any etiology (infective, neoplastic,granulomatous inflammation or traumatic)

that involves the structures in the orbital apex (posterior orbit).

Orbital apex consists of the superior orbital fissure + optic canal.

Thus so:

Orbital apex syndrome Superior orbital fissure syndrome + optic nerve signs

Superior orbital fissure syndrome is caused by involvement of all extraocular peripheral nerves passing through the

superior orbital fissure i.e. III, IV, VI, & VI.

Orbital apex syndrome is characterized by:

– Ophthalmoplegia (due to paresis of III, IV, VI, & VI cranial nerves),

– Ptosis,

– Anaesthesia in the region supplied by ophthalmic division of Vth nerve (decreased corneal

sensation and -Early visual loss and afferent papillary defect (caused by optic nerve involvement).

  • The remaining two options; cavernous sinus thrombosis & orbital cellulitis can impose adignostic difficulty. Both of these have almost similar presentation with some differences.
  • Abrupt onset of chills & rigor, mod. proptosis and lateral gaze palsy favour cavernous sinus thrombosis (CST). In orbital cellulitis onset is slow & systemic features are mild & there is restricted ocular movement in all directions from the beginning.
  • Optic disc congestion & vision loss in late stages are found both in CST & orbital cellulitis.
Differences in CST, Orbital cellulitis & OAS

Clinical

features

CST

Orbital

Cellulitis

OAS

Onset

Abrupt

Slow

Slow

Systemic

features

Marked

Mild

Mild

Laterality

Initially unilateral, but can

become bilateral in more

than 50% cases

Unilateral

Unilateral

Proptosis

Moderate

Marked

Mild to

moderate

Chemosis

Moderate

Marked

Mild

Vision

Not affected in early

stages

Not affected in

early stages

Lost in early

stages

Ophthalmo-

plegia

Sequential & complete -4

lateral gaze palsy to start

with ,as 6th C.N. is

involved first*

Concurrent &

complete

Concurrent &

complete

Edema in

mastoid

region

Present (Diagnostic sign)

Absent

Absent

*6th cranial nerve passes through the cavernous sinus (separated only by endothelial lining), so is involved first in CST.


Q. 2

Scenario: A 35 year old female presented with acute sinusitis to the ENT specialist. On examination she noticed a swelling over the frontal sinus which is soft doughy in nature and extremely tender.
 
Assertion: Pott’s puffy tumor is a complication of frontal sinusitis.
 
Reason: The presentation is due to osteomyelitis of frontal bone.
 
 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. 2

Scenario: A 35 year old female presented with acute sinusitis to the ENT specialist. On examination she noticed a swelling over the frontal sinus which is soft doughy in nature and extremely tender.
 
Assertion: Pott’s puffy tumor is a complication of frontal sinusitis.
 
Reason: The presentation is due to osteomyelitis of frontal bone.
 
 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:

Osteomyelitis of frontal bone results from acute infection of frontal sinus either directly or through the venous spread.

 

Q. 3

Pott puffy tumour occurs as complication of which sinusitis:

 A

Frontal

 B

Sphenoid

 C

Ethmoid

 D

None of the above

Q. 3

Pott puffy tumour occurs as complication of which sinusitis:

 A

Frontal

 B

Sphenoid

 C

Ethmoid

 D

None of the above

Ans. A

Explanation:

If infection in the frontal sinus spreads to the marrow of the frontal bone, localized osteomyelitis with bone destruction can result in a doughy swelling of the forehead classically described as Pott puffy tumour.
 

Q. 4

A patient with history of running nose and pain over medial aspect of the eye presents with sudden onset of high grade fever, prostration, chemosis, proptosis and diplopia on lateral gaze with congestion of the optic disc. Which of the following is the most likely diagnosis?

 A

Acute ethmoidal sinusitis

 B

Orbital Cellulitis

 C

Cavernous Sinus Thrombosis

 D

Orbital Apex Syndrome

Q. 4

A patient with history of running nose and pain over medial aspect of the eye presents with sudden onset of high grade fever, prostration, chemosis, proptosis and diplopia on lateral gaze with congestion of the optic disc. Which of the following is the most likely diagnosis?

 A

Acute ethmoidal sinusitis

 B

Orbital Cellulitis

 C

Cavernous Sinus Thrombosis

 D

Orbital Apex Syndrome

Ans. C

Explanation:

Patients with CST appear quite ill with abrupt onset of fever, headache, nuchal rigidity, nausea, vomiting & eye pain. Testing of cranial nerves reveal unilateral or bilateral palsies of CN III, IV & VI as well as sensory deficits in the ophthalmic branch of trigeminal nerve. Eye findings may include orbital edema & tenderness, retinal haemorrhages, papilledema, proptosis & dilated or sluggish pupils.

It is difficult to differentiate CST from other options based on clinical features. The presence of lateral gaze palsy is typically seen in CST and not in others.

Ref: Greenberg’s text-atlas of emergency medicine – Page 49.


Q. 5

A 19 year old young girl with previous history of repeated pain over medial canthus and chronic use of nasal decongestants, presented with abrupt onset of fever with chills & rigor, diplopia on lateral gaze, moderate proptosis & chemosis. On examination optic disc is congested. Most likely diagnosis is:

 A

Cavernous sinus thrombosis

 B

Orbital cellulitis

 C

Acute Ethmoidal sinusitis

 D

Orbital apex syndrome

Q. 5

A 19 year old young girl with previous history of repeated pain over medial canthus and chronic use of nasal decongestants, presented with abrupt onset of fever with chills & rigor, diplopia on lateral gaze, moderate proptosis & chemosis. On examination optic disc is congested. Most likely diagnosis is:

 A

Cavernous sinus thrombosis

 B

Orbital cellulitis

 C

Acute Ethmoidal sinusitis

 D

Orbital apex syndrome

Ans. A

Explanation:

Patient is suffering from cavernous venous thrombosis, as a complication of chronic ethmoidal sinusitis. The facial veins make clinically important connections with the cavernous sinus through the superior ophthalmic veins. Cavernous sinus thrombosis usually results from infections in the orbit, nasal sinuses, and superior part of the face.

Think Detail:
Cavernous sinus: is located on the side of the body of sphenoid. The cavernous sinuses consist of extradural venous plexuses surrounded by a dural fold.

 

Structures 

Within its cavity

Internal carotid artery

Abducent nerve
Carotid sympathetic plexus

Lateral wall

Oculomotor nerve

Trochlear nerve
Opthalmic division of trigeminal nerve
Maxillary division of trigeminal nerve

 

Tributaries:

Anteriorly

Opthalmic veins (connects with the facial vein)

Posteriorly

 

Superior petrosal sinus (connects with transverse sinus)
Inferior petrosal sinus (conncets with internal juglar vein)

Medially

Anterior and posterior intercavernos sinuses (connects the two cavernous sinuses)

Superiorly

Superficial middle cerebral vein (from latwral surface of the brain)

Cerebrsl veins from inferior surface of brain

Cavernous sinus thrombosis (CST) is a late complication of facial or paranasal sinus infection, resulting in thrombosis of the cavernous sinus and inflammation of its surrounding anatomic structures, including cranial nerves.

Clinical features:
Infection of the cavernous sinus is characterized by sepsis, orbital pain, chemosis, proptosis, and ophthalmoplegia. Cavernous sinus thrombosis results in paresis of cranial nerves III, IV, and VI and the opthalmic and maxillary divisions of the cranial nerve V. 
The diagnosis is based primarily on clinical data. CT and MR imaging can provide diagnostic information.Treatment is with broad spectrum antibiotics and should be started early .This has high mortality.
 
Cavernous sinus syndrome: is characterized by multiple cranial neuropathies. The clinical presentation includes impairment of ocular motor nerves, Horner’s syndrome, and sensory loss of the first or second divisions of the trigeminal nerve in various combinations. The pupil may be involved or spared or may appear spared with concomitant oculosympathetic and parasympathetic involvement.
 
Ref: 1) Comprehensive opthalmology,by AK Khurana,4th Edition, Page 384-389; 
2) Parsons ‘ Diseases of the Eye, 20th Edition, Page 456-459;

Q. 6

A Young girl with previous history of repeated pain over medial canthus and chronic use of decongestants now presents with intense chills, rigors, and diplopia on lateral gaze. Examination shows optic disc congested.

Most likely diagnosis would be:

 A

Ethmoidal Sinusitis

 B

Orbital Cellulitis

 C

Cavernous Sinus Thrombosis

 D

Orbital Apex syndrome

Q. 6

A Young girl with previous history of repeated pain over medial canthus and chronic use of decongestants now presents with intense chills, rigors, and diplopia on lateral gaze. Examination shows optic disc congested.

Most likely diagnosis would be:

 A

Ethmoidal Sinusitis

 B

Orbital Cellulitis

 C

Cavernous Sinus Thrombosis

 D

Orbital Apex syndrome

Ans. C

Explanation:

C i.e. Cavernous Sinus Thrombosis 

Periostitis

  • It is rare inflammation of periosteum mostly affecting orbital margin.
  • Mostly d/t trauma, TB, syphilis or extension of inflammation from neightbouring tissue.
  • Deep orbit involvement causes less definite signs.
  • There may be pain of deep seated nature, proptosis with deviation of direction of eye
  • If apex of orbit is involved (orbital apex syndrome) various ocular motor palsies may develop with trigeminal anaesthesia & neuralgia and occasionly amaurosis d/t involvement of optic nerveQ.

Orbital Cellulitis (OC)

It is a purulent inflammation of cellular tissue of orbit. It is most common d/t extension of inflammation from neighbouring tissue esp nasal sinuses (mc. ethmoid). Other less common causes are penetrating injuries (esp with retained foreign

body with in 72 hours), septic operations, posterior extension of suppurative infections of eyelids or eyeball eg panopthalmitis, facial erysipelas, or dacrocystitis, metastases in pyaemia

Preseptal orbital cellulites involves structures anterior to orbital septum i.e. largely lids and presents as a swelling of lids, with erythema, chemosis and conjunctival discharge. But there is no proptosis, or restriction of ocular movements or visual function.

However, orbital cellulites term is reserved for infections behind the orbital septum which may or may not spill over to lids. Bacterial OC is more common in children and fulminant infection (& ischemic infarction) with Mucor or Aspergillus typically affects patients with diabetes (esp ketoacidosis) and immunosuppression. Presentation is Extensive swelling of lids with chemosis often obscure proptosis (i.e. most commonly lateral & downwards). Proptosis with impaired mobility resulting in diplopia Pain is severe, increased by movement of eye or pressure Unilateral, tender, warm & red periorbital edema. Painful opthalmoplegia

Rapid onset of severe malaise, fever, pain

Vision may be impaired owing to retrobulbar optic neuritis or compression of otic nerve or its blood supply at the apex of orbit

Fundus is difficult to examine; it may be normal or show engorgement of veins and optic neuritis developing later into optic atrophy.

Orbit abscess usually pointing, towards skin of lid near orbital margin or conjunctival fornix is rare in sinus related but common in post traumatic or post operative cases. Panopthalmitis may supervene & there is grave danger of Meningitis, cerebral symptoms and cavernous sinus thrombosis, (CST). CST should be suspected when there is evidence of bilateral involvement, rapidly progressive proptosis, and congestion of facial, conjunctival and retinal veins. Additional features include abrupt progression of clinical signs a/w prostration, severe headache, nausea and vomittingQ.

Cavernous Sinus Thrombosis

  • Infection may occur via obital veins, as in septic lesions of face, orbital cellulites, erysipelas, and infective conditions of mouth, pharynx, ear, nose and accessory sinuses, or as a metastasis in infectious diseases or septic condition.
  • The patient presents with almost same features as in orbital cellulites, but with systemic symptoms such as fever, rigors, vomiting, headache, altered sensorium and severe cerebral symptomsQ.
  • Another important diagnostic feature is transference of symptoms to the fellow eye 0, which occurs in 50% of cases where as bilateral orbital cellulitis is very rare. The first sign of other eye involvement is often paralysis of the opposite lateral rectus Q & this should be carefully watched for in any suspicious case of inflammatory unilateral proptosis.
  • These is severe supra orbital pain d/t involvement of ophthalmic division of trigeminal nerve, and paresis of ocular motor nerves.
  • In later stages pupil is dilated, eye immobilized and cornea anesthetic.
  • Proptosis occurs in almost all cases, but is of late onset in cases of otic origin.
  • Retinal veins may be greathy engorged and when this occurs it is usually accompanied by pronounced disc swelling (both indicating extensive implication of orbital veins)
  • Bilateral (but more pronounced on the side of aural lesion), typical papilledema is most common in otitic cases & indicate meningitis or cerebral abscess
  • Simultaneous bilateral CST, with proptosis and disc swelling, occurs in disease of sphenoid sinuses.
  • Edema in the mastoid region behind the ear (d/t thrombosis of emissary vein) confirms the diagnosis.

Feature

Cavernous sinus

thrombosis

Orbital cellulites

Panopthalmitis

Leteralality

Unilateral initially but

very soon becomes

bilateral

Unilateral

Unilateral

Proptosis

(degree)

Moderate

Marked

Moderate

Vison

Initially not affected

Initially not

affected

Complete loss from

beginning

Cornea & anterio

chamber

Initially clear

Initially clear

Hazy d/t corneal edem,

Pus in anterior chamber

Ocular

movements

Complete limitation to

palsy

Markedly limited

Painful & limites

Mastoid edema

Present

No

No

Systemic systems

eg fever etc.

Marked

Mild

Mild


Q. 7

A patient with history of running nose and pain over medial aspect of the eye presents with sudden onset of high grade fever, prostration, chemosis, proptosis and diplopia on lateral gaze with congestion of the optic disc. Which of the following is the most likely diagnosis:

 A

Acute ethmoidal sinusitis

 B

Orbital Cellulitis

 C

Cavernous Sinus Thrombosis

 D

Orbital Apex Sundrome

Q. 7

A patient with history of running nose and pain over medial aspect of the eye presents with sudden onset of high grade fever, prostration, chemosis, proptosis and diplopia on lateral gaze with congestion of the optic disc. Which of the following is the most likely diagnosis:

 A

Acute ethmoidal sinusitis

 B

Orbital Cellulitis

 C

Cavernous Sinus Thrombosis

 D

Orbital Apex Sundrome

Ans. C

Explanation:

C i.e. Cavernous Sinus Thrombosis


Q. 8

Complications of acute sinusitis:

 A

Orbital cellulitis

 B

Pott’s puffy tumor

 C

Conjunctival chemosis

 D

All

Q. 8

Complications of acute sinusitis:

 A

Orbital cellulitis

 B

Pott’s puffy tumor

 C

Conjunctival chemosis

 D

All

Ans. D

Explanation:



Q. 9

Orbital cellulitis is a complication of:

 A

Parasinusitis

 B

Faciomaxillary trauma

 C

Endoscopic sinus surgery

 D

All of these

Q. 9

Orbital cellulitis is a complication of:

 A

Parasinusitis

 B

Faciomaxillary trauma

 C

Endoscopic sinus surgery

 D

All of these

Ans. D

Explanation:

Q. 10

A 24-year-old female with long standing history of sinusitis present with fevers, headache (recent origin) and personality changes; Fundus examination revealed papilledema. Most likely diagnosis is:

 A

Frontal lobe abscess

 B

Meningitis

 C

Encephalitis

 D

Frontal bone osteomyelitis

Q. 10

A 24-year-old female with long standing history of sinusitis present with fevers, headache (recent origin) and personality changes; Fundus examination revealed papilledema. Most likely diagnosis is:

 A

Frontal lobe abscess

 B

Meningitis

 C

Encephalitis

 D

Frontal bone osteomyelitis

Ans. A

Explanation:

 

  • Patient is presenting with fever, headache and personality changes which is typical of frontal lobe abscess (which is a complication of chronics sinusitis). In meningitis and encephalitis although patient presents with fever and headache, but personality changes are not seen.
  • Frontal bone osteomyelitis (Pott’s puffy tumor) presents as doughy swelling on forehead.

Q. 11

Cavernous sinus thrombosis following sinusitis results in all of the following signs except:

 A

Constricted pupil in response to light

 B

Engorgement of retinal veins upon ophthalmoscopic examination

 C

Ptosis of eyelid

 D

Ophthalmoplegia

Q. 11

Cavernous sinus thrombosis following sinusitis results in all of the following signs except:

 A

Constricted pupil in response to light

 B

Engorgement of retinal veins upon ophthalmoscopic examination

 C

Ptosis of eyelid

 D

Ophthalmoplegia

Ans. A

Explanation:

 

Ptosis and ophthalmoplegia occur in cavernous sinus thrombosis due to involvement of III, IV and V cranial nerves.

Retinal vessels are also engorged but pupils are fixed and dilated (not constricted), due to involvement of III nerve and sympathetic plexus.


Q. 12

A young female patient with long history of sinusitis presented with frequent fever along with personality changes and headache of recent origin. The fundus examination revealed papilledema. The most likely diagnosis is :

 A

Frontal lobe abscess

 B

Meningitis

 C

Encephalitis

 D

Frontal bone osteomyelitis

Q. 12

A young female patient with long history of sinusitis presented with frequent fever along with personality changes and headache of recent origin. The fundus examination revealed papilledema. The most likely diagnosis is :

 A

Frontal lobe abscess

 B

Meningitis

 C

Encephalitis

 D

Frontal bone osteomyelitis

Ans. A

Explanation:

Answer is A (Frontal lobe abscess) :

Development of headache, fever and papilledema in the setting of sinusitis suggest an infective pathology causing raised introcranial tension. Further, presence of personality changes suggest a mass lesion affecting the frontal lobe. A brain abscess typically presents as an expanding intracranial mass lesion, and the presence of personality changes limits such a mass lesion to the frontal lobe. A frontal lobe abscess thus explains the presence of an infectious mass lesion causing personality changes.


Q. 13

A 19 years old young girl with previous history of repeated pain over medial canthus and chronic use of nasal decongestants, presented with abrupt onset of fever with chills and rigor, diplopia on lateral gaze, moderate proptosis and chemosis. On examination optic disc is congested. Most likely diagnosis is:

 A

Cavernous sinus thrombosis

 B

Orbital cellulitis

 C

Acute ethmoidal sinusitis

 D

Orbital apex syndrome

Q. 13

A 19 years old young girl with previous history of repeated pain over medial canthus and chronic use of nasal decongestants, presented with abrupt onset of fever with chills and rigor, diplopia on lateral gaze, moderate proptosis and chemosis. On examination optic disc is congested. Most likely diagnosis is:

 A

Cavernous sinus thrombosis

 B

Orbital cellulitis

 C

Acute ethmoidal sinusitis

 D

Orbital apex syndrome

Ans. A

Explanation:

Ans. Cavernous sinus thrombosis



Anatomy of heart

ANATOMY OF HEART

Q. 1

Which structure does NOT lie in the coronary sulcus?

 A

Circumflex artery

 B

Coronary sinus

 C

Right coronary artery

 D

Right marginal artery

Q. 1

Which structure does NOT lie in the coronary sulcus?

 A

Circumflex artery

 B

Coronary sinus

 C

Right coronary artery

 D

Right marginal artery

Ans. D

Explanation:

The coronary sulcus is the groove which separates the atria from the ventricles. The right and left coronary arteries, circumflex artery, and coronary sinus all lie in this groove. The right marginal artery is a branch of the right coronary artery which lies on the right ventricle and supplies that chamber of the heart.


Q. 2

Right border of the heart in CXR is formed by

 A

Pulmonary artery

 B

Superior vena cava

 C

Rt atrium

 D

b and c

Q. 2

Right border of the heart in CXR is formed by

 A

Pulmonary artery

 B

Superior vena cava

 C

Rt atrium

 D

b and c

Ans. D

Explanation:

B i.e., Superior vena cava; C i.e. Right atrium


Q. 3

Normal heart axis is:

 A

-90 to + 90°

 B

-90 to + 180°

 C

-30 to +90°

 D

-90 to 180°

Q. 3

Normal heart axis is:

 A

-90 to + 90°

 B

-90 to + 180°

 C

-30 to +90°

 D

-90 to 180°

Ans. C

Explanation:

Answer is C (-30 to +90°)


Q. 4

In the adult heart, floor of fossa ovalis represents:

 A

Septum intermedium

 B

Septum primum

 C

Septum spurium

 D

Septum secundum

Q. 4

In the adult heart, floor of fossa ovalis represents:

 A

Septum intermedium

 B

Septum primum

 C

Septum spurium

 D

Septum secundum

Ans. B

Explanation:

Ans. B: Septum primum

Fossa ovalis and anulus ovalis lie on the atrial septum, which separates the right atrium from the left atrium.

The fossa ovalis is a shallow depression, which is the site of the foramen ovale in the fetus.

The anulus ovalis forms the upper margin of the fossa.

The floor of the fossa represents the persistent septum primum of the heart of the embryo, and the anulus is formed from the lower edge of the septum secundum


Q. 5

NOT a content of middle mediastinum:

 A

Ascending aorta

 B

Oesophagus

 C

Pulmonary trunk

 D

Phrenic nerve

Q. 5

NOT a content of middle mediastinum:

 A

Ascending aorta

 B

Oesophagus

 C

Pulmonary trunk

 D

Phrenic nerve

Ans. B

Explanation:

The esophagus is considered to be located in the superior and posterior mediastinum.


Q. 6

Base of the heart is formed mainly by:

 A

Right atrium

 B

Left atrium

 C

Right ventricle

 D

Left ventricle

Q. 6

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. 7

Which of these does not form the right border of the heart on X-ray:       

 A

Right atrium

 B

Arch of aorta

 C

Superior vena cava

 D

Inferior vena cava

Q. 7

Which of these does not form the right border of the heart on X-ray:       

 A

Right atrium

 B

Arch of aorta

 C

Superior vena cava

 D

Inferior vena cava

Ans. B

Explanation:

 Right border of the mediastinal shadow (chiefly produced due to the heart and the vessels entering and leaving it) is formed from above downwards by the right brachiocephalic vein, superior vena cava, right atrium and the inferior vena cava

The Base of the Heart

  • The base is located posteriorly and is formed mainly by the left atrium.
  • It lies opposite T5 to TS (supine position) and T6 to T9 vertebrae (erect position) and faces superiorly, posteriorly and towards the right shoulder.
  • The base or posterior aspect of the heart is quadrilateral in shape and it is from its most superior part from which the ascending aorta and pulmonary trunk emerge, and into which the superior vena cava enters.
  • The base is separated from the diaphragmatic surface of the heart by the posterior part of the coronary groove (L. sulcus).

The Apex of the Heart

  • This blunt apex is formed from by the left ventricle, which points inferolaterally.
  • The apex is located posterior to the left 5th intercostal space in adults, 7 to 9 cm from the median plane, and just left of the midclavicular line.
  • The apex beat is an impulse imparted by the hear; it is its point of maximal pulsation or the lowest, most lateral point at which pulsation can be felt.

The Sternocostal (Anterior) Surface of the Heart

  • This surface of the heart is mainly formed by the right ventricle and is visible in PA radiographs of the thorax.

The Diaphragmatic (Inferior) Surface of the Heart

  • The surface of the heart is usually horizontal or slightly concave.
  • It is formed by both ventricles, mainly the left one.
  • The posterior interventricular sulcus divides this surface into a right 1/3 and a left 2/3.

The Pulmonary (Left) Surface of the Heart

  • This surface of the heart is mainly formed by the left ventricle and occupies the cardiac notch of the left lung.

Radiological Anatomy of the Heart

  • In PA radiographs of the thorax, the right border of the cardiovascular silhouette is formed by (superior to inferior): (1) the superior vena cava; (2) the right atrium; (3) the inferior vena cava.
  • The left border of the cardiovascular silhouette is formed by: (1) the arch of the aorta, which produces a characteristic aortic knob; (2) the pulmonary trunk; (3) the left auricle; (4) the left ventricle.

Q. 8

Right side of mediastinal shadow is NOT formed by:

September 2012

 A

Superior vena cava

 B

Right innominate

 C

Right atrium

 D

Right ventricle

Q. 8

Right side of mediastinal shadow is NOT formed by:

September 2012

 A

Superior vena cava

 B

Right innominate

 C

Right atrium

 D

Right ventricle

Ans. D

Explanation:

Ans. D i.e. Right ventricle

Radiology of heart

Right border of heart is formed by:

–  SVC/ Right brachiocephalic vessels,

– IVC and

– Right atrium

Left border of heart is formed by:

–  Left atrial appendage,

– Left ventricle,

– Aortic arch and

–  Pulmonary artery


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 the heart in a chest X-ray is not formed by:

 A

WC

 B

SVC

 C

Right atrium

 D

Aorta

Q. 10

Right border of the heart in a chest X-ray is not formed by:

 A

WC

 B

SVC

 C

Right atrium

 D

Aorta

Ans. D

Explanation:

Ans. Aorta


Q. 11

Prominent left border of heart is formed by all the following except:

 A

Azygous vein

 B

Pericardial cyst

 C

Coronary artery aneurysm

 D

Enlarged left auricular aneurysm

Q. 11

Prominent left border of heart is formed by all the following except:

 A

Azygous vein

 B

Pericardial cyst

 C

Coronary artery aneurysm

 D

Enlarged left auricular aneurysm

Ans. A

Explanation:

Ans. Azygous vein


Q. 12

The right side of mediastinum shadow is not formed by:

 A

Superior vena cava

 B

Right innominate vein

 C

Right atrium

 D

Right ventricle

Q. 12

The right side of mediastinum shadow is not formed by:

 A

Superior vena cava

 B

Right innominate vein

 C

Right atrium

 D

Right ventricle

Ans. D

Explanation:

Ans. Right ventricle


Q. 13

The Diagram shows the venous draingae of Heart. Identify the Structure marked B in the Diagram ?

 A

Great Cardiac Vein

 B

Coronary Sinus

 C

Middle Cardiac Vein

 D

Anterior Cardiac Vein

Q. 13

The Diagram shows the venous draingae of Heart. Identify the Structure marked B in the Diagram ?

 A

Great Cardiac Vein

 B

Coronary Sinus

 C

Middle Cardiac Vein

 D

Anterior Cardiac Vein

Ans. B

Explanation:


Q. 14

Right border of heart is formed by ‑

 A

Right ventricle

 B

Right atrium

 C

SVC

 D

IVC

Q. 14

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. 15

Not a middle mediastinal structure ‑

 A

Pulmonary trunk

 B

Phrenic nerve

 C

Thymus

 D

Heart

Q. 15

Not a middle mediastinal structure ‑

 A

Pulmonary trunk

 B

Phrenic nerve

 C

Thymus

 D

Heart

Ans. C

Explanation:

 Thymus


Q. 16

Posterior surface of heart is formed by –

 A

RA

 B

LA

 C

LV

 D

RV

Q. 16

Posterior surface of heart is formed by –

 A

RA

 B

LA

 C

LV

 D

RV

Ans. B

Explanation:

Ans. is ‘b>a’ i.e., LA>RA

Surfaces of the heart

  1. Anterior (sternocostal) surface :- Formed mostly by right ventricle (major) and right auricle and partly by left ventricle and left auricle.
  2. 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.
  3. Base (posterior surface) :- Formed mainly by left atrium and partly by right atrium. It is separated from T5 to T, vertebrae by pericardium, oblique pericardial sinus, esophagus and descending thoracic aorta.
  4. Right surface :- Mainly by right atrium.
  5. Left surface :- Mainly by left ventricle and partly by left auricle.

Q. 17

Base of heart is at the level of which vertebrae ‑

 A

C4 – C7

 B

C7 – T2

 C

T5 – T8

 D

T9 – T12

Q. 17

Base of heart is at the level of which vertebrae ‑

 A

C4 – C7

 B

C7 – T2

 C

T5 – T8

 D

T9 – T12

Ans. C

Explanation:

Ans. is’c’ i.e., T5 – T8


Q. 18

Base of the heart is formed by ‑

 A

Right atrium

 B

Right ventricle

 C

Left atrium

 D

Left ventricle

Q. 18

Base of the heart is formed by ‑

 A

Right atrium

 B

Right ventricle

 C

Left atrium

 D

Left ventricle

Ans. C

Explanation:

Ans. is `c > a’ i.e., Left atrium > Right atrium 


Q. 19

Heart is fully developed at which age of intrauterine life ‑

 A

3rd month

 B

4th month

 C

5″ month

 D

6″ month

Q. 19

Heart is fully developed at which age of intrauterine life ‑

 A

3rd month

 B

4th month

 C

5″ month

 D

6″ month

Ans. A

Explanation:

Ans. is ‘a’ i.e., 3rd month 



Acute Sinusitis

Acute Sinusitis

Q. 1

A 30-year-old,lady, with a history of chronic otitis and sinusitis is found to have a low serum IgA level. All other immunoglobulin classes are found to be normal. Which of the following statements is correct?

 A

She may suffer an anaphylactic reaction following the administration of blood products

 B

Not associated with other autoimmune disorders

 C

Intravenous immunoglobulin (IVIG) is the treatment of choice

 D

All of the above

Q. 1

A 30-year-old,lady, with a history of chronic otitis and sinusitis is found to have a low serum IgA level. All other immunoglobulin classes are found to be normal. Which of the following statements is correct?

 A

She may suffer an anaphylactic reaction following the administration of blood products

 B

Not associated with other autoimmune disorders

 C

Intravenous immunoglobulin (IVIG) is the treatment of choice

 D

All of the above

Ans. A

Explanation:

The patient is suffering from isolated IgA deficiency.

 
IgA deficiency is the most common PID.
It is asymptomatic in most cases; however, individuals may present with increased numbers of acute and chronic respiratory infections that may lead to bronchiectasis.
In addition, over their lifetime, these patients experience an increased susceptibility to drug allergies, atopic disorders, and autoimmune diseases.
Serum antibodies to IgA are reported in as many as 44% of patients with selective IgA deficiency.
If these antibodies are of the IgE isotype, they can cause severe or fatal anaphylactic reactions after intravenous administration of blood products containing IgA.
 
Administration of intravenous immunoglobulin (IVIG), which is >99% IgG, is not indicated because most IgA-deficient patients make IgG antibodies normally. Many IVIG preparations contain sufficient IgA to cause anaphylactic reactions.

Q. 2

A couple presents to a clinic for the work-up of infertility after 5 years of unprotected intercourse. The wife denies any medical problems and notes regular menstrual cycles. The husband states that he has had chronic sinusitis and lower respiratory tract infections. Physical examination of the woman is unremarkable. Examination of the man is remarkable for dextrocardia. Further work-up of the husband will most likely reveal?

 A

Azoospermia

 B

Germinal cell aplasia

 C

Immotile sperm

 D

Isolated gonadotropin deficiency

Q. 2

A couple presents to a clinic for the work-up of infertility after 5 years of unprotected intercourse. The wife denies any medical problems and notes regular menstrual cycles. The husband states that he has had chronic sinusitis and lower respiratory tract infections. Physical examination of the woman is unremarkable. Examination of the man is remarkable for dextrocardia. Further work-up of the husband will most likely reveal?

 A

Azoospermia

 B

Germinal cell aplasia

 C

Immotile sperm

 D

Isolated gonadotropin deficiency

Ans. C

Explanation:

The husband is suffering from Kartagener’s syndrome, an autosomal recessive disorder characterized by infertility, situs inversus, chronic sinusitis, and bronchiectasis. The underlying cause of these varied manifestations are defects in the dynein arms, spokes of microtubule doublets of cilia in the airways and the reproductive tract. Since sperm motility is dependent on the functioning of cilia, infertility frequently accompanies this disorder.

Situs inversus occurs because ciliary function is necessary for cell migration during embryonic development.

Azoospermia is not a feature of Kartagener’s syndrome, as sperm production or survival is not affected in this disorder.

Germinal cell aplasia, also known as Sertoli only syndrome, is characterized by oligospermia or azoospermia.

Isolated gonadotropin deficiency is characterized by delayed or incomplete pubertal maturation.


Q. 3

A couple presents to a clinic for work-up of infertility after 5 years of unprotected intercourse. The wife denies any medical problems and notes regular menstrual cycles. The husband states that he has had chronic sinusitis and lower respiratory tract infections. Physical examination of the woman is unremarkable. Examination of the man is remarkable for dextrocardia. Further work-up of the husband will most likely reveal?

 A

Azoospermia

 B

Germinal cell aplasia

 C

Immotile sperm

 D

Isolated gonadotropin deficiency

Q. 3

A couple presents to a clinic for work-up of infertility after 5 years of unprotected intercourse. The wife denies any medical problems and notes regular menstrual cycles. The husband states that he has had chronic sinusitis and lower respiratory tract infections. Physical examination of the woman is unremarkable. Examination of the man is remarkable for dextrocardia. Further work-up of the husband will most likely reveal?

 A

Azoospermia

 B

Germinal cell aplasia

 C

Immotile sperm

 D

Isolated gonadotropin deficiency

Ans. C

Explanation:

The husband is suffering from Kartagener’s syndrome, an autosomal recessive disorder characterized by infertility, situs inversus, chronic sinusitis, and bronchiectasis.

The underlying cause of these varied manifestations are defects in the dynein arms, spokes of microtubule doublets of cilia in the airways and the reproductive tract.

Since sperm motility is dependent on the functioning of cilia, infertility frequently accompanies this disorder.

Situs inversus occurs because ciliary function is necessary for cell migration during embryonic development.

Azoospermia is not a feature of Kartagener’s syndrome, as sperm production or survival is not affected in this disorder.

Germinal cell aplasia, also known as Sertoli only syndrome, is characterized by oligospermia or azoospermia.

Isolated gonadotropin deficiency is characterized by delayed or incomplete pubertal maturation.

Ref: Federico M.J., Stillwell P., Deterding R.R., Baker C.D., Balasubramaniam V., Zemanick E.T., Sagel S.D., Halbower A., Burg C.J., Kerby G.S. (2012). Chapter 19. Respiratory Tract & Mediastinum. In W.W. Hay, Jr., M.J. Levin, R.R. Deterding, J.J. Ross, J.M. Sondheimer (Eds), CURRENT Diagnosis & Treatment: Pediatrics, 21e.


Q. 4

A patient presented with history of recurrent frontal sinusitis. Which of the following view of the X-ray is the best to show frontal sinus in this patient?

 A

Towne’s view

 B

Water’s view

 C

Caldwell’s view

 D

Schuller’s view

Q. 4

A patient presented with history of recurrent frontal sinusitis. Which of the following view of the X-ray is the best to show frontal sinus in this patient?

 A

Towne’s view

 B

Water’s view

 C

Caldwell’s view

 D

Schuller’s view

Ans. C

Explanation:

Caldwell view is also known as occipitofrontal view or nose-forehead position. Structures seen are:

  • Frontal sinuses (seen best)
  • Ethmoid sinuses
  • Maxillary sinuses
  • Frontal process of zygoma and zygomatic process of frontal bone
  • Superior margin of orbit and lamina papyracea
  • Superior orbital fissure
  • Foramen rotundum (inferolateral to superior orbital fissure)
 
Structures seen in Water’s view (occipitomental view or nose-chin position):
  • Maxillary sinuses (seen best)
  • Frontal sinuses
  • Sphenoid sinus (if the film is taken with open mouth)
  • Zygoma
  • Zygomatic arch
  • Nasal bone
  • Frontal process of maxilla
  • Superior orbital fissure
Structures seen in Towne’s view:
  • Arcuate eminence and superior semicircular canal
  • Mastoid antrum
  • Internal auditory canal
  • Tympanic cavity
  • Cochlea
  • External auditory canal
  • Both petrous pyramids
Structures seen in Schuller’s view:
  • External canal superimposed on internal canal
  • Mastoid air cells
  • Tegmen
  • Lateral sinus plate
  • Condyle of mandible
  • Sino-dural angle
  • Antrum and upper part of attic
 

Q. 5

Kartagener’s syndrome includes –

 A

Situs inversus

 B

Bronchiectasis Sinusitis

 C

Male infertility

 D

All

Q. 5

Kartagener’s syndrome includes –

 A

Situs inversus

 B

Bronchiectasis Sinusitis

 C

Male infertility

 D

All

Ans. D

Explanation:

Ans. is ‘a’ i.e., Situs inversus; ‘b’ Bronchiectasis, Sinusitis’ `c’ Male infertility

o Kartagener’s syndrome is a subgroup of primary ciliary dyskinesia. [Ref Bobbin’s r/e p. 692 & 71h/e p. 727] Primary ciliary dyskinesia ‑

o It is an antosomal recessive syndrome.

o It is characterized by poorly functioning cilia. There is absence or shortening of Dynein arms that are responsible for the coordinated bending of cilia.

o Approximately half of the patients with primary ciliary dyskinesia have kartagener’s syndrome.

Kartagener’s syndrome

Poor functioning of cilia contribute to retention of secretions and recurrent infections

Sinusitis              –>

Lack of ciliary activity interferes with bacterial clearance, predisposing sinuses to infection

 Situs inversus       —>       Due to ineffective cell motility during embryogenesis

Infertility                           Due to ineffective mobility of sperm


Q. 6

A child present with recurrent sinusitis and recurrent chest infections. Chest X-ray reveals dextrocardia and situs invertus. The diagnosis is ‑

 A

Kartagener’s syndrome

 B

Good-pasture’s syndrome

 C

Ehlers-Danlos syndrome

 D

William Campbell syndrome

Q. 6

A child present with recurrent sinusitis and recurrent chest infections. Chest X-ray reveals dextrocardia and situs invertus. The diagnosis is ‑

 A

Kartagener’s syndrome

 B

Good-pasture’s syndrome

 C

Ehlers-Danlos syndrome

 D

William Campbell syndrome

Ans. A

Explanation:

Ans is ‘a’ i.e., Kartagener’s syndrome

o Kartagener’s syndrome is a subgroup of primary ciliary dyskinesia.

Primary ciliary dyskinesia:

o It is an autosomal recessive syndrome.

o It is characterized by poorly functioning cilia. There is absence or shortening of Dynein arms that are responsible for the coordinated bending of cilia.

o Approximately half of the patients with primary ciliary dyskinesia have kartagener’s syndrome.


Q. 7

Features associated with DNS include all of the following except:

 A

Epistaxis

 B

Atrophy of turbinate

 C

Hypertrophy of turbinate

 D

Recurrent sinusitis

Q. 7

Features associated with DNS include all of the following except:

 A

Epistaxis

 B

Atrophy of turbinate

 C

Hypertrophy of turbinate

 D

Recurrent sinusitis

Ans. B

Explanation:

Q. 8

DNS may be associated with all the following except:

 A

Recurrent sphenoiditis

 B

Acute otitis media

 C

Hypertrophy of the inferior turbinate

 D

Recurrent maxillary sinusitis

Q. 8

DNS may be associated with all the following except:

 A

Recurrent sphenoiditis

 B

Acute otitis media

 C

Hypertrophy of the inferior turbinate

 D

Recurrent maxillary sinusitis

Ans. A

Explanation:

 

  • In deviated nasal septum, the nasal chamber on the concave side of the nasal septum is wide and shows compensatory hypertrophy of turbinates and not atrophy.
  • The sphenoid sinus opens in the sphenoethmoid recess near the roof of nasal cavity and this opening is not affected by DNS.



Q. 9

In acute sinusitis, the sinus most often involved in chil­dren is:

 A

Maxillary

 B

Sphenoid

 C

Ethmoid

 D

Frontal

Q. 9

In acute sinusitis, the sinus most often involved in chil­dren is:

 A

Maxillary

 B

Sphenoid

 C

Ethmoid

 D

Frontal

Ans. C

Explanation:

 

Most common sinusitis in children is Ethmoid. Most common sinusitis in adults is Maxillary.


Q. 10

Sinus least involved in sinusitis is:

 A

Maxillary

 B

Ethmoid

 C

Frontal

 D

Sphenoid

Q. 10

Sinus least involved in sinusitis is:

 A

Maxillary

 B

Ethmoid

 C

Frontal

 D

Sphenoid

Ans. D

Explanation:

 

Isolated involvement of sphenoid sinus is rare. It is often a part of pansinusitis or is associated with infection of posterior ethmoidal sinus.                                                                                                                                              

The sphenoid sinus is rarely affected on its own —Turner 10th/ed p 48

The reason for sphenoid sinus to be least affected is that it opens high up in the sphero ethmoid recess which is not affected by most of the conditions of nose


Q. 11

Common organisms causing sinusitis:

 A

Pseudomonas

 B

Moraxella catarrhalis

 C

Streptococcus pnenumoniae

 D

b and c

Q. 11

Common organisms causing sinusitis:

 A

Pseudomonas

 B

Moraxella catarrhalis

 C

Streptococcus pnenumoniae

 D

b and c

Ans. D

Explanation:

 

 

Among community-acquired cases, S. pneumoniae and nontypable Haemophilus influenzae are the most common pathogens, accounting for 50-60% of cases. Moraxella catarrhalis causes disease in a signigicant percentage (20%) of children but less often in adults. Other streptococcal species and Staphylococcus aureus cause only a small percentage of cases, although there . is increasing concern about community strains of methicillin – resistant S. aureus (MRSA) as an emerging cause. -Harrison 17th/ed

 

The bacterial pathogens causing acute bacterial sinusitis in children and adolescents include Streptococcus pneumoniae (= 30%), nontypable Haerrophilus influenzae (=20%). – Nelson 18th/ed

 

M/C Organism causing sinusitis in adults is also Streptococcus pneumoniae followed by H. influenza. – scotts Brown 7th/ed

In children:

M/C is Streptococcus pneumoniae (30-43%) followed by both H. influenza and Moraxella catarrhalis (20-28% each)


Q. 12

Sphenoid sinusitis pain is referred most commonly to:

 A

Occiput

 B

Cost of nose

 C

Frontal

 D

Temporal region

Q. 12

Sphenoid sinusitis pain is referred most commonly to:

 A

Occiput

 B

Cost of nose

 C

Frontal

 D

Temporal region

Ans. A

Explanation:

 

Acute sphenoditis: Headache – usually localized to the occiput or vertex. Pain may also be referred to the mastoid region.

 

Maxillary sinus     Along the infraorbital margin and referred to upper teeth or gums on affected side (along the distribution of superior orbital nerve) Pain is aggravated on stooping or coughing.

Frontal sinus        Pain localized over forehead. It has a characteristic periodicity

Ethmoid sinus      Pain localized over the nasal bridge, inner canthus and behind the ear.



Q. 13

Most definitive diagnosis of sinusitis is:

 A

X-ray PNS

 B

Proof puncture

 C

Sinoscopy

 D

Transillumination test

Q. 13

Most definitive diagnosis of sinusitis is:

 A

X-ray PNS

 B

Proof puncture

 C

Sinoscopy

 D

Transillumination test

Ans. C

Explanation:

Q. 14

Pathognomonic feature of Maxillary sinusitis is:

 A

Mucopus in the middle meatus

 B

Inferior turbinate hypertrophy

 C

Purulent nasal discharge

 D

Atrophic sinusitis

Q. 14

Pathognomonic feature of Maxillary sinusitis is:

 A

Mucopus in the middle meatus

 B

Inferior turbinate hypertrophy

 C

Purulent nasal discharge

 D

Atrophic sinusitis

Ans. A

Explanation:

  • Characteristic finding of maxillary sinusitis on Rhinoscopy is pus or mucopus in in the middle meatus.
  • Mucosa and turbinates may appear red and swollen.

Q. 15

Kartagener’s syndrome includes all of the following, Except :

 A

Sites inversus

 B

Bronchiectasis

 C

Sinusitis

 D

Cystic fibrosis

Q. 15

Kartagener’s syndrome includes all of the following, Except :

 A

Sites inversus

 B

Bronchiectasis

 C

Sinusitis

 D

Cystic fibrosis

Ans. D

Explanation:

Answer is D (Cystic fibrosis):

Note : 

Situs inversus refers to perfect mirror image of normal physiologic position of visceral organs with preservation of their A-P relationship. Situs inversus is usually associated with dextrocardia (Heart on Right Side of chest).


Q. 16

Sinusitis in children is commoner in which sinus:

 A

Frontal

 B

Maxillary

 C

Ethmoid

 D

Sphenoid

Q. 16

Sinusitis in children is commoner in which sinus:

 A

Frontal

 B

Maxillary

 C

Ethmoid

 D

Sphenoid

Ans. C

Explanation:

Q. 17

Which of the following is false regarding frontal sinusitis ‑

 A

Pain shows periodicity

 B

Most common sinus involved in infants and children

 C

Pain is referred to as office headache

 D

Tenderness is present just above the medial canthus of eye

Q. 17

Which of the following is false regarding frontal sinusitis ‑

 A

Pain shows periodicity

 B

Most common sinus involved in infants and children

 C

Pain is referred to as office headache

 D

Tenderness is present just above the medial canthus of eye

Ans. B

Explanation:

Ans. is ‘b’ i.e., Most common sinus involved in infants and children

Most common sinus involved in infant and children is Ethmoid sinus.

Clinical features of acute sinusitis

Most common presenting patient’s compliant is persistent nasal discharge which can be of any quality (thin, thick, clear, or purulent). Nasal discharge from a sinus infection can be blood – tinged from excessive nose blowing and irritation. The clinical symptoms of acute sinusitis have been classified into major and minor.


Q. 18

A minor symptom of sinusitis is 

 A

Nasal blockage

 B

Facial congestion

 C

Nasal congestion

 D

Halitosis

Q. 18

A minor symptom of sinusitis is 

 A

Nasal blockage

 B

Facial congestion

 C

Nasal congestion

 D

Halitosis

Ans. D

Explanation:

 

The clinical symptoms of acute sinusitis have been classified into major and minor.

Major

  • Facial pain or pressure
  • Purulent nasal discharge
  • Fever
  • Nasal congestion
  • Nasal obstruction
  • Hyposmia or Anosmia
  • Facial congestion or fullness

Minor

  • Headache
  • Cough
  • Fatigue
  • Halitosis
  • Dental pain
  • Ear pain or pressure


Allergic Rhinitis

Allergic Rhinitis

Q. 1

Which test is most useful in diagnosis of allergic rhinitis?

 A

Radioallergosorbent test

 B

Serum IgE levels

 C

PBF

 D

Immediate hypersensitivity skin test

Q. 1

Which test is most useful in diagnosis of allergic rhinitis?

 A

Radioallergosorbent test

 B

Serum IgE levels

 C

PBF

 D

Immediate hypersensitivity skin test

Ans. D

Explanation:

An accurately ap­plied skin test is the most valuable tool for identifying the causative antigen in allergic rhi­nitis, yielding results in approximately 20-30 minutes.

The radioallergosorbent test (RAST), albeit accurate, is more expensive and less dis­criminative than skin testing.

Elevated immu­noglobulin E (IgE) levels are observed in only 30%-40% of patients with allergic rhinitis and may be secondary to other unrelated dis­orders.

Although eosinophils are usually iden­tified in nasal secretions from patients with al­lergic rhinitis, they are also detected in eosinophilic nonallergic rhinitis and hyperplas­tic sinusitis.

peripheral eosinophilia seen in a peripheral blood smear is an inconsistent finding.


Q. 2

A 45 year old lady presented with features suggestive of mononeuritis multiplex. She gives a h/o regular attacks of bronchial asthma preceded by allergic rhinitis. She also has cutaneous purpura. Blood routine examination revealed eosinophilia. The diagnosis to be considered in this clinical scenario is?

 A

Microscopic polyangiitis

 B

Endogenous bronchial asthma

 C

Churg strauss syndrome

 D

Wegeners vasculitis

Q. 2

A 45 year old lady presented with features suggestive of mononeuritis multiplex. She gives a h/o regular attacks of bronchial asthma preceded by allergic rhinitis. She also has cutaneous purpura. Blood routine examination revealed eosinophilia. The diagnosis to be considered in this clinical scenario is?

 A

Microscopic polyangiitis

 B

Endogenous bronchial asthma

 C

Churg strauss syndrome

 D

Wegeners vasculitis

Ans. C

Explanation:

When small-vessel vasculitis is associated with peripheral eosinophilia, cutaneous purpura, mononeuritis, asthma, and allergic rhinitis, a diagnosis of Churg-Strauss syndrome is considered.

Ref: Harrisons Principles of Internal Medicine, 18th Edition, Page 2344


Q. 3

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

 A

Allergic rhinitis

 B

Palatal paralysis

 C

Adenoids

 D

Nasal polyps

Q. 3

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. 4

Early mediators of allergic rhinitis are:

 A

Leukotriene

 B

IL-4

 C

IL-5

 D

All

Q. 4

Early mediators of allergic rhinitis are:

 A

Leukotriene

 B

IL-4

 C

IL-5

 D

All

Ans. D

Explanation:

Ans. is All


Q. 5

In Allergic rhinitis nasal mucosa is:

 A

Pale and swollen

 B

Pink and swollen

 C

Atrophied

 D

Bluish and atrophied

Q. 5

In Allergic rhinitis nasal mucosa is:

 A

Pale and swollen

 B

Pink and swollen

 C

Atrophied

 D

Bluish and atrophied

Ans. A

Explanation:

Ans. is a i.e Pale and swollen

  • Nasal mucosa pale, boggy, swollen and bluish
  • Nasal mucosa congested and swollen (Hypertrophic)
  • Mulberry appearance
  • Pale and atrophied nasal mucosa
  • Allergic rhinitis
  • Vasomotor rhinitis
  • Chronic hypertrophic rhinitis
  • Atrophic rhinitis



Q. 6

All of the following surgical procedures are used for allergic rhinitis except:

 A

Radiofrequency ablation of the inferior turbinate

 B

Laser ablation of the inferior turbinate

 C

Submucosal placement of silastic in inferior turbinate

 D

Inferior turbinectomy

Q. 6

All of the following surgical procedures are used for allergic rhinitis except:

 A

Radiofrequency ablation of the inferior turbinate

 B

Laser ablation of the inferior turbinate

 C

Submucosal placement of silastic in inferior turbinate

 D

Inferior turbinectomy

Ans. C

Explanation:

Ans. is c i.e. Submucosal placement of sialistic in inferior turbinate

  • Surgery is done in a case of allergic rhinitis when other methods have failed or when there is marked septal deviation or bony turbinate enlargement which makes topical nasal spray usage difficult
  • It should never be used as first line of treatment.

Q. 7

Allergic rhinitis treatment includes all except:

 A

Antibiotics

 B

Avoiding allergen

 C

Corticosteroids

 D

Surgery

Q. 7

Allergic rhinitis treatment includes all except:

 A

Antibiotics

 B

Avoiding allergen

 C

Corticosteroids

 D

Surgery

Ans. A

Explanation:

Q. 8

Causes of epistaxis are all except:

 A

Allergic rhinitis

 B

Foreign body

 C

Tumor

 D

Hypertension

Q. 8

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. 9

Rhinolalia clausa is associated with all of the following except:

 A

Allergic rhinitis

 B

Palatal paralysis

 C

Adenoids

 D

Nasal polyps

Q. 9

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. 10

All of the following statements about Churg Strauss Syndrome are true, except:

 A

Marked Eosinophilia

 B

Mononeuritis multiplex is common

 C

Renal failure is common

 D

Often associated with Allergic Rhinitis

Q. 10

All of the following statements about Churg Strauss Syndrome are true, except:

 A

Marked Eosinophilia

 B

Mononeuritis multiplex is common

 C

Renal failure is common

 D

Often associated with Allergic Rhinitis

Ans. C

Explanation:

Answer is C (Renal failure is common):

Churg Strauss Syndrome is not prominent and renal failure is rare.

The Renal disease in Churg Strauss Syndrome is less common and generally less severe than with granulomatosis with polyangitis (Wegener’s) and microscopic polyangitis ‘- Harrison’s 18th/2793

‘Renal failure is rare in Churg Strauss syndrome – Pulmonary Involvement in Systemic Autoimmune Disease


Q. 11

MC cause of discharge from the nose is

 A

CSF rhinorrhea

 B

Lupus erythematosus

 C

Trauma

 D

Allergic rhinitis

Q. 11

MC cause of discharge from the nose is

 A

CSF rhinorrhea

 B

Lupus erythematosus

 C

Trauma

 D

Allergic rhinitis

Ans. D

Explanation:

Q. 12

Which of the following is the preformed toxin involved in mechanism of allergic rhinitis ‑

 A

Histamine

 B

Leukotriene

 C

TXA2

 D

PGD2

Q. 12

Which of the following is the preformed toxin involved in mechanism of allergic rhinitis ‑

 A

Histamine

 B

Leukotriene

 C

TXA2

 D

PGD2

Ans. A

Explanation:

Ans. is ‘a’ i.e., Histamine


Q. 13

Allergic rhinitis is which type of hypersensitivity reaction?

 A

Type -1

 B

Type-2

 C

Type-3

 D

Type-4

Q. 13

Allergic rhinitis is which type of hypersensitivity reaction?

 A

Type -1

 B

Type-2

 C

Type-3

 D

Type-4

Ans. A

Explanation:

 

Pathogenesis of allergic rhinitis

Allergic rhinitis is a type I hypersensitivity. It occurs in two phases:‑

1) Initial response/Acute or early phase

After first antigen exposure, this antigen is presented to CD-4 helper T cells (TH2 type) by antigen presenting cells. These primed TH, cells release IL-4 that acts on B-cells to form Ig E specific for that particular antigen. The antigen specific Ig E antibodies then bind to the surface receptors of mast cells and basophils. The process from first antigen exposure to the coating of mast cells by Ig E acts as sensitization (prior sensitization) and first exposure is also called priming or sensitizing exposure (dose). Subsequent exposure (shocking dose) to same antigen then results in activation of mast cells and basophils with release of inflammatory mediators 

  1. Histamine (most important)
  2. PAF
  3. Heparin
  4. Cytokines (IL-1, 3, 4, 5, 6; INF)
  5. Leukotriens (B4, Ch D4)
  6. Eosinophil chemolactic factor (ECF)
  7. PGD2
  8. Neutrophil chemolactic factor (NCF)
  • The release of these mediators result in : –
  1. Increased vascular permeability and vasodilatation which result in tissue edema – Nasal blockage and sneezing.
  2. Smooth muscle spasm → Bronchoconstriction
  3. Hyperactivity of glands → Rhinorrhea
  4. Recruitment of inflammatory cells.

2) Late phase response

  • Recruited inflammatory cells of initial phase amplify and sustain the inflammatory response without additional exposure to the triggered antigen. PAF is the most important mediator in initiation of late phase response. Eosinophils are particularly important cells among the recruited cells which also include neutrophils, basophils, monocytes and T-cells. It causes symptoms like nasal congestion and post nasal drip.



Q. 14

Allergic salute is seen in

 A

Allergic rhinitis

 B

Chronic sinusitis

 C

Nasal Myiasis

 D

Chronic conjunctivitis

Q. 14

Allergic salute is seen in

 A

Allergic rhinitis

 B

Chronic sinusitis

 C

Nasal Myiasis

 D

Chronic conjunctivitis

Ans. A

Explanation:


Anterior triangle of neck

ANTERIOR TRIANGLE OF NECK

Q. 1

All of the following are in the anterior triangle of neck EXCEPT:

 A

Diagastric

 B

Subclavian

 C

Muscular

 D

Submental

Q. 1

All of the following are in the anterior triangle of neck EXCEPT:

 A

Diagastric

 B

Subclavian

 C

Muscular

 D

Submental

Ans. B

Explanation:

  • Posterior triangle of neck has 2 parts: Occipital & subclavian
  • Subclavian triangle is also c/d as supraclavicular or omoclavicular triangle.
  • Anterior triangles of neck are-Submental, Digastric, Carotid, Muscular.

Q. 2

Structure superficial to mylohyoid in anterior digastric triangle are all EXCEPT:

 A

Deep part of submandibular gland

 B

Hypoglossal nerve

 C

Part of parotid gland

 D

Mylohyoid artery & nerve

Q. 2

Structure superficial to mylohyoid in anterior digastric triangle are all EXCEPT:

 A

Deep part of submandibular gland

 B

Hypoglossal nerve

 C

Part of parotid gland

 D

Mylohyoid artery & nerve

Ans. D

Explanation:

  • Deep part of submandibular gland & hypoglossal neve are deep to mylohyoid muscle.
  • Structures passing superficial to mylohyoid in anterior part of digastric triangle are submandibular gland (superficial part), facial vein, facial artery, mylohyoid nerve & vessels, hypoglossal nerve & submandibular nodes.

Q. 3

All is true about digastric triangle EXCEPT:

 A

On either side is anterior belly of digastric muscle

 B

Floor is formed by mylohyoid muscle

 C

Floor is formed by hyoglossus muscle

 D

Contains mylohyoid nerve & vessels

Q. 3

All is true about digastric triangle EXCEPT:

 A

On either side is anterior belly of digastric muscle

 B

Floor is formed by mylohyoid muscle

 C

Floor is formed by hyoglossus muscle

 D

Contains mylohyoid nerve & vessels

Ans. A

Explanation:

  • Digastric triangle is bounded by anterior belly if digastric anteriorly & posterior belly posteriorly.
  • Mylohyoid & hyoglossus muscles are the floor.
  • Digastric triangle contains mylohyoid nerve & vessels, submandibular gland, facial artery & vein, hypoglossal nerve & submandibular lymph nodes.

Q. 4

On both sides submental triangle is bounded by:

 A

Hyoid bone

 B

Anterior digastric 

 C

Posterior digastric

 D

Mylohyoid

Q. 4

On both sides submental triangle is bounded by:

 A

Hyoid bone

 B

Anterior digastric 

 C

Posterior digastric

 D

Mylohyoid

Ans. B

Explanation:

  • Submental triangle is bounded by anterior belly of digastric (laterally), midline of the neck b/w the mandible & the hyoid bone (medially) & base of hyoid bone.
  • Mylohyoid muscle is at the floor & submental lymph nodes are the content.


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