Ranula — MCQs
Plunging ranula refers to a mucocoele that has penetrated which muscle?
What is the most likely diagnosis for the swelling in the floor of the mouth shown in the image?
Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
What is the likely diagnosis of the image given below?
Saroj, a 32-year-old female from a rural background, has a history of chronic tobacco chewing since 14 years of age. She now presents with difficulty in opening her mouth. On oral examination, no ulcers are seen. What is the most probable diagnosis?
What is the most common site of ectopic salivary gland?
All of the following statements regarding stones in the submandibular gland are true except?
Tumors of the minor salivary glands are most frequently found where?
Which tumor is seen exclusively in the parotid gland?
Hairy leukoplakia is characterized by?
Ranula Indian Medical PG Practice Questions and MCQs
Question 1: Plunging ranula refers to a mucocoele that has penetrated which muscle?
- A. Mylohyoid (Correct Answer)
- B. Digastric
- C. Geniohyoid
- D. Sternocleidomastoid
Explanation: ***Mylohyoid*** - A **plunging ranula**, also known as a **diving ranula**, occurs when a mucocoele from the sublingual gland ruptures through the **mylohyoid muscle**. - This allows the mucous collection to extend into the **submandibular space** or even the neck, presenting as a mass below the mylohyoid diaphragm. *Digastric* - The **digastric muscle** forms part of the floor of the mouth and neck, but a ranula does not penetrate this muscle. - Its role is primarily in elevating the hyoid bone and depressing the mandible. *Geniohyoid* - The **geniohyoid muscle** is located superior to the mylohyoid and plays a role in moving the hyoid bone, but it is not typically penetrated by a plunging ranula. - It lies above the anatomical plane commonly breached by plunging ranulas. *Sternocleidomastoid* - The **sternocleidomastoid muscle** is a large, superficial neck muscle, far from the anatomical location of a sublingual gland ranula. - Penetration of this muscle by a ranula is anatomically impossible.
Question 2: What is the most likely diagnosis for the swelling in the floor of the mouth shown in the image?
- A. Dermoid
- B. Ranula (Correct Answer)
- C. Branchial cyst
- D. Cystic hygroma
Explanation: ***Ranula*** - The image shows a **translucent, bluish, dome-shaped swelling** in the **floor of the mouth**, consistent with a ranula. - A ranula is a **mucus extravasation cyst** caused by trauma or obstruction of the **sublingual salivary gland** duct, leading to mucus accumulation. *Dermoid* - A **dermoid cyst** in the floor of the mouth typically presents as a **firm, doughy, non-translucent swelling**, often located in the midline. - Unlike a ranula, dermoid cysts are usually **not bluish** and contain **ectodermal elements** like hair and sebaceous material. *Branchial cyst* - **Branchial cysts** are congenital abnormalities typically found in the **lateral neck**, anterior to the sternocleidomastoid muscle. - They are generally **not found in the floor of the mouth** and arise from remnants of the branchial arches. *Cystic hygroma* - A **cystic hygroma** is a **lymphatic malformation**, commonly appearing as a soft, compressible, transilluminable mass, predominantly in the **neck** and axilla. - While it can be large and cystic, its typical location and presentation are **different from a floor of mouth swelling** like a ranula.
Question 3: Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
- A. Statements 1 & 2 are correct, 2 is not explaining 1 (Correct Answer)
- B. Statements 1 and 2 are correct and 2 is the correct explanation for 1
- C. Statements 1 and 2 are incorrect
- D. Statement 1 is incorrect
Explanation: ***Correct: Statements 1 & 2 are correct, 2 is not explaining 1*** **Analysis of Statement 1:** - A 59-year-old patient with **flaccid bullae** and **suprabasal acantholytic split** on histopathology is the classic presentation of **Pemphigus vulgaris** - The flaccid (easily ruptured) nature of bullae distinguishes it from tense bullae seen in bullous pemphigoid - The suprabasal location of the split (just above the basal layer) with acantholysis (loss of cell-to-cell adhesion) is pathognomonic - **Statement 1 is CORRECT** ✓ **Analysis of Statement 2:** - The **"row of tombstones" or "tombstone appearance"** is indeed a diagnostic histopathological feature of Pemphigus vulgaris - This appearance results from basal keratinocytes remaining attached to the basement membrane while suprabasal cells separate due to acantholysis - The intact basal cells standing upright resemble a row of tombstones - **Statement 2 is CORRECT** ✓ **Does Statement 2 explain Statement 1?** - Statement 2 describes a **histopathological appearance** (tombstone pattern) that is a **consequence** of the suprabasal split - However, it does NOT explain the **underlying cause** of the flaccid bullae or the suprabasal split - The true explanation involves **IgG autoantibodies against desmoglein 3 (and desmoglein 1)**, which attack intercellular adhesion structures (desmosomes), causing **acantholysis** - Therefore, **Statement 2 does NOT explain Statement 1** ✗ *Incorrect: Statement 2 is the correct explanation for Statement 1* - While both statements describe features of Pemphigus vulgaris, the tombstone appearance is a descriptive finding, not an explanatory mechanism *Incorrect: Statements 1 and 2 are incorrect* - Both statements are medically accurate descriptions of Pemphigus vulgaris features *Incorrect: Statement 1 is incorrect* - Statement 1 correctly describes the cardinal clinical and histopathological features of Pemphigus vulgaris
Question 4: What is the likely diagnosis of the image given below?
- A. Dermoid cyst
- B. Ranula (Correct Answer)
- C. Mucocele
- D. Ludwig angina
Explanation: ***Ranula*** - The image exhibits a characteristic **translucent, bluish, dome-shaped swelling** on the floor of the mouth, which is highly suggestive of a ranula. - A ranula is a type of **mucocele specifically involving the sublingual gland** or minor salivary glands in the floor of the mouth, often due to obstruction or trauma to the salivary duct. *Dermoid cyst* - While dermoid cysts can appear on the floor of the mouth, they typically present as a **firmer, doughy consistency** and are often **yellowish or skin-colored**, due to their epithelial and adnexal contents. - They are usually located in the midline and are **congenital lesions**, which differ in appearance from the fluid-filled, translucent nature of a ranula. *Mucocele* - A mucocele is a general term for a mucus retention cyst, but they typically present as **smaller, painless, bluish, benign lesions** found on the **lips** (especially the lower lip) or buccal mucosa, resulting from trauma to minor salivary glands. - The size and specific location (floor of the mouth associated with sublingual gland) in the image point more specifically to a ranula rather than a general mucocele. *Ludwig angina* - Ludwig angina is a **severe, rapidly spreading cellulitis of the submandibular and sublingual spaces**, usually stemming from an odontogenic infection. - It presents with **firm, brawny swelling of the submandibular region** and floor of the mouth, often accompanied by fever, dysphagia, and airway compromise, which are not depicted in the image.
Question 5: Saroj, a 32-year-old female from a rural background, has a history of chronic tobacco chewing since 14 years of age. She now presents with difficulty in opening her mouth. On oral examination, no ulcers are seen. What is the most probable diagnosis?
- A. Submucous oral fibrosis (Correct Answer)
- B. Carcinoma of buccal mucosa
- C. TM joint arthritis
- D. Trigeminal nerve paralysis
Explanation: **Explanation:** The clinical presentation of a young patient with a long-standing history of tobacco/areca nut chewing presenting with progressive difficulty in opening the mouth (trismus) is a classic description of **Oral Submucous Fibrosis (OSMF)**. **1. Why the correct answer is right:** OSMF is a chronic, insidious, premalignant condition characterized by juxta-epithelial inflammatory reaction followed by **progressive fibrosis of the lamina propria and deeper connective tissues**. The alkaloids in areca nut (e.g., arecoline) stimulate fibroblasts to produce excessive collagen, while flavonoids inhibit collagenase. This leads to the formation of palpable vertical fibrous bands, particularly in the buccal mucosa, resulting in restricted mouth opening (trismus) and a "burning sensation" when eating spicy food. The absence of ulcers in this case further supports a fibrotic rather than an ulcerative/malignant process. **2. Why the incorrect options are wrong:** * **Carcinoma of buccal mucosa:** While tobacco is a risk factor, malignancy typically presents with a non-healing ulcer, proliferative growth, or induration, rather than isolated trismus without a visible lesion. * **TM joint arthritis:** This would present with joint pain, clicking sounds, and tenderness over the pre-auricular area, usually unrelated to tobacco chewing. * **Trigeminal nerve paralysis:** This would result in sensory loss or weakness of the muscles of mastication (motor V3), but not mechanical restriction due to fibrosis. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Areca nut (betel nut) is the primary causative agent. * **Clinical Sign:** "Hockey-stick" appearance of the uvula and restricted tongue protrusion due to fibrosis. * **Pre-malignant potential:** OSMF has a high malignant transformation rate (approx. 7–13%). * **Management:** Cessation of habit, intralesional steroids (to reduce inflammation), and hyaluronidase (to break down collagen). Surgical release is reserved for severe cases.
Question 6: What is the most common site of ectopic salivary gland?
- A. Cheek
- B. Palate
- C. Angle of mandible (Correct Answer)
- D. Tongue
Explanation: **Explanation:** The correct answer is **Angle of mandible (Option C)**. This refers to a specific clinical entity known as a **Stafne’s Bone Cavity** (or Static Bone Cyst). **Why it is correct:** Ectopic salivary gland tissue (also called salivary gland choristoma) refers to normal salivary tissue found in an abnormal anatomical location. The most frequent site is the **mandible**, specifically near the angle, below the inferior alveolar canal. This occurs when a portion of the submandibular gland becomes entrapped during the ossification of the mandible. On a radiograph, this appears as a well-defined, asymptomatic radiolucency near the angle of the jaw. **Analysis of incorrect options:** * **A. Cheek:** While ectopic tissue can occur in the buccal mucosa, it is significantly less common than the mandibular site. * **B. Palate:** The palate is the most common site for **minor salivary gland tumors** (specifically Pleomorphic Adenoma), but it is not the most common site for *ectopic* (choristomatous) tissue. * **D. Tongue:** Ectopic salivary tissue can be found at the base of the tongue (near the lingual tonsils), but this is a rare occurrence compared to the mandibular angle. **High-Yield Clinical Pearls for NEET-PG:** * **Stafne’s Cyst:** It is not a true cyst (no epithelial lining); it is a developmental depression containing ectopic submandibular gland tissue. * **Most common site for Minor Salivary Glands:** Palate. * **Most common site for Sialolithiasis (Stones):** Submandibular gland (Wharton’s duct) due to alkaline pH and high calcium/mucin content. * **Most common Salivary Gland Tumor:** Pleomorphic Adenoma (most common site: Parotid).
Question 7: All of the following statements regarding stones in the submandibular gland are true except?
- A. 80% of stones occur in the submandibular gland
- B. Majority of submandibular stones are radiolucent (Correct Answer)
- C. Stones are the most common cause of obstruction within the submandibular gland
- D. Patient presents with acute swelling in the region of the submandibular gland
Explanation: ### Explanation **1. Why the correct answer is right:** The statement "Majority of submandibular stones are radiolucent" is **false**, making it the correct choice for an "except" question. In reality, **80% of submandibular gland stones are radiopaque** (visible on X-ray). This is because submandibular saliva is highly alkaline and has a high concentration of calcium and phosphate salts, leading to dense calcification of the stones. In contrast, parotid stones are more likely to be radiolucent (only 20% are radiopaque). **2. Analysis of incorrect options:** * **Option A:** True. Approximately 80% of all salivary calculi (sialolithiasis) occur in the submandibular gland [1]. This is due to the long, upward course of Wharton’s duct and the viscous, mucin-rich nature of the saliva. * **Option C:** True. Sialolithiasis is the most common cause of salivary gland obstruction, leading to stasis and potential secondary infection (sialadenitis) [1]. * **Option D:** True. Patients typically present with "mealtime syndrome"—acute, painful swelling of the gland triggered by eating, as saliva production increases against an obstructed duct. **3. Clinical Pearls for NEET-PG:** * **Wharton’s Duct:** The most common site for stone formation. * **Composition:** Submandibular stones have higher calcium content than parotid stones. * **Imaging:** The best initial radiograph for a submandibular stone is an **Intraoral Periapical (IOPA) view** or a **Mandibular Occlusal view**. * **Management:** Small distal stones can be removed via duct incision (sialolithotomy); proximal or intraglandular stones may require gland excision [1]. * **Sialendoscopy:** The modern "gold standard" for both diagnosis and minimally invasive removal of salivary stones [1].
Question 8: Tumors of the minor salivary glands are most frequently found where?
- A. Upper lip
- B. Lower lip
- C. Palate (Correct Answer)
- D. Tongue
Explanation: **Explanation:** **1. Why the Palate is Correct:** Minor salivary glands are distributed throughout the oral cavity, but they are found in the highest concentration in the **hard and soft palate** (specifically the posterolateral aspect of the hard palate). Because of this high density, the palate is the most common site for minor salivary gland tumors, accounting for approximately 50% of all cases. **2. Analysis of Incorrect Options:** * **Upper Lip (Option A):** While the upper lip is the second most common site for minor salivary gland tumors, it lags significantly behind the palate. Interestingly, a tumor in the upper lip is more likely to be benign (e.g., Canalicular adenoma) compared to the lower lip. * **Lower Lip (Option B):** Tumors of the lower lip are rare. Most swellings here are **Mucoceles** (extravasation cysts) rather than true neoplasms. If a neoplasm does occur in the lower lip, there is a much higher statistical probability of it being malignant. * **Tongue (Option C):** Tumors can occur in the base or mobile tongue (from glands of Von Ebner or Blandin-Nuhn), but this is a less frequent site compared to the palate. **3. NEET-PG High-Yield Pearls:** * **The "50% Rule":** Approximately 50% of all minor salivary gland tumors are **malignant**. This contrasts with the Parotid gland, where ~80% of tumors are benign. * **Most Common Malignancy:** The most common malignant tumor of the minor salivary glands is **Adenoid Cystic Carcinoma** (characterized by perineural invasion and a "Swiss-cheese" appearance on histology). * **Most Common Benign Tumor:** Pleomorphic Adenoma remains the most common benign tumor across both major and minor glands. * **Site Frequency:** Palate > Upper Lip > Cheek/Buccal Mucosa.
Question 9: Which tumor is seen exclusively in the parotid gland?
- A. Warthin tumor (Correct Answer)
- B. Pleomorphic adenoma
- C. Mucoepidermoid carcinoma
- D. Adenoid cystic carcinoma
Explanation: **Explanation:** The correct answer is **Warthin tumor (Papillary Cystadenoma Lymphomatosum)**. **Why Warthin Tumor is the correct answer:** Warthin tumor is unique because it arises from **salivary gland tissue entrapped within intra-parotid lymph nodes** during embryogenesis. Since lymph nodes are incorporated into the capsule of the parotid gland but not into other salivary glands (like the submandibular or sublingual glands), Warthin tumor occurs **exclusively in the parotid gland** (specifically the tail of the parotid). It is the most common benign tumor to present bilaterally and is strongly associated with smoking. **Why other options are incorrect:** * **Pleomorphic Adenoma:** While it is the most common tumor of the parotid, it can occur in any salivary gland, including the submandibular gland and minor salivary glands of the palate. * **Mucoepidermoid Carcinoma:** This is the most common malignant salivary gland tumor. It occurs frequently in the parotid but is also the most common malignancy in the minor salivary glands. * **Adenoid Cystic Carcinoma:** This tumor is notorious for perineural invasion. While it can occur in the parotid, it is the most common tumor found in the **submandibular and minor salivary glands**. **High-Yield Clinical Pearls for NEET-PG:** * **Hot Spot on Scan:** Warthin tumor shows increased uptake on **Technetium-99m pertechnetate** scans (Hot tumor). * **Epidemiology:** Most common in elderly males; strong association with **smoking**. * **Bilateralism:** It is the most common salivary tumor to be **bilateral** (10%) or multicentric. * **Histology:** Characterized by a double layer of oncocytic epithelium and a dense lymphoid stroma with germinal centers.
Question 10: Hairy leukoplakia is characterized by?
- A. Pain
- B. EBV infection (Correct Answer)
- C. No association with HIV
- D. Pre-cancerous
Explanation: **Explanation:** **Hairy Leukoplakia (HL)** is a distinctive white lesion of the oral mucosa, primarily affecting the lateral borders of the tongue. 1. **Why Option B is correct:** The condition is caused by the **Epstein-Barr Virus (EBV)**. In immunocompromised states, EBV undergoes productive replication in the squamous epithelium of the tongue, leading to the characteristic corrugated or "hairy" appearance. It is considered an opportunistic infection. 2. **Why other options are incorrect:** * **Option A:** HL is typically **asymptomatic (painless)**. Patients usually discover it incidentally or due to its texture. * **Option C:** There is a **strong association with HIV**. It is one of the most common oral manifestations of HIV/AIDS and often serves as an early clinical sign of progression to AIDS or a declining CD4 count. * **Option D:** Unlike "Oral Leukoplakia," Hairy Leukoplakia has **no malignant potential**. It is not a pre-cancerous lesion and does not require aggressive surgical excision. **High-Yield Clinical Pearls for NEET-PG:** * **Appearance:** White, non-scrapable, vertical ridges (corrugated) on the lateral margins of the tongue. * **Diagnosis:** Usually clinical; biopsy shows hyperkeratosis, acanthosis, and "balloon cells" in the upper stratum spinosum. * **Treatment:** Generally not required unless for cosmetic reasons (Acyclovir or Podophyllin can be used), but its presence mandates an immediate workup for HIV/immunodeficiency. * **Differentiating Feature:** Unlike Oral Candidiasis, Hairy Leukoplakia **cannot** be scraped off.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free