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?
All of the following statements regarding stones in the submandibular gland are true except?
Hairy leukoplakia is characterized by?
Areas of carcinoma of the oral mucosa can be identified by staining with which of the following?
A patient presents with a history of recurrent episodes of pain and swelling in the mandibular posterior region and is diagnosed with pericoronitis. The partially erupted 3rd molar was vital. Radiographical examination revealed a well-defined radiolucency on the distal aspect of the affected tooth. What is the most likely diagnosis?
What is the recommended treatment for a mucocele on the lower lip?
A parulis is an inflammatory enlargement seen in which of the following locations?
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: 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 6: 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.
Question 7: Areas of carcinoma of the oral mucosa can be identified by staining with which of the following?
- A. 1% zinc chloride
- B. 2% silver nitrate
- C. Gentian violet
- D. 2% toluidine blue (Correct Answer)
Explanation: **Explanation:** **1. Why 2% Toluidine Blue is Correct:** Toluidine blue (also known as tolonium chloride) is a **vital acidophilic dye** that has a high affinity for nucleic acids. Malignant and dysplastic cells have a significantly higher DNA/RNA content and increased nuclear-to-cytoplasmic ratios compared to normal cells. When applied to the oral mucosa, the dye selectively stains these areas of high nucleic acid concentration, highlighting suspicious lesions (carcinoma in situ or invasive squamous cell carcinoma) as dark blue. This is a common chair-side screening tool used to demarcate biopsy sites. **2. Why the Other Options are Incorrect:** * **1% Zinc Chloride:** This is primarily used as an astringent or in certain chemical cautery pastes (like Mohs paste), but it has no diagnostic staining properties for malignancy. * **2% Silver Nitrate:** This is a caustic agent used for chemical cauterization of aphthous ulcers or to control minor bleeding (hemostasis). It stains tissues black but is not selective for cancer cells. * **Gentian Violet:** This is an antifungal and antiseptic dye used to treat oral candidiasis (thrush). While it stains the mucosa purple, it does not differentiate between normal and malignant cells. **3. High-Yield Clinical Pearls for NEET-PG:** * **False Positives:** Toluidine blue can also stain inflammatory lesions (like ulcers) because of the high cellular turnover; therefore, a "re-stain" after 10–14 days of anti-inflammatory treatment is often recommended. * **Lugol’s Iodine:** Another vital stain used in the oral cavity and esophagus. Normal squamous epithelium (rich in glycogen) stains brown, while **malignant cells (glycogen-poor) remain unstained.** * **Gold Standard:** Remember that while toluidine blue helps in identifying the site, the definitive diagnosis of oral cancer always requires a **histopathological examination (biopsy).**
Question 8: A patient presents with a history of recurrent episodes of pain and swelling in the mandibular posterior region and is diagnosed with pericoronitis. The partially erupted 3rd molar was vital. Radiographical examination revealed a well-defined radiolucency on the distal aspect of the affected tooth. What is the most likely diagnosis?
- A. Dentigerous cyst.
- B. Paradental cyst. (Correct Answer)
- C. Eruption cyst.
- D. Periapical cyst.
Explanation: ### Explanation The correct diagnosis is **Paradental Cyst** (also known as Craig’s cyst). **1. Why Paradental Cyst is correct:** A paradental cyst is an inflammatory odontogenic cyst that typically occurs on the **distal or buccal aspect** of a **partially erupted mandibular third molar** with a history of **pericoronitis**. * **Key Diagnostic Feature:** The tooth involved is **vital**. * **Pathogenesis:** Inflammation (pericoronitis) stimulates the epithelial rests of Malassez or the reduced enamel epithelium, leading to cyst formation. Radiographically, it appears as a well-defined radiolucency distal to the tooth. **2. Why other options are incorrect:** * **Dentigerous Cyst:** This is a developmental cyst that attaches to the **cemento-enamel junction (CEJ)** and encloses the crown of an **unerupted** tooth. In this case, the tooth is partially erupted and the radiolucency is specifically distal. * **Eruption Cyst:** This is essentially a soft-tissue analog of a dentigerous cyst. It presents as a bluish, fluctuant swelling on the alveolar ridge over an erupting tooth, rather than a deep distal radiolucency. * **Periapical (Radicular) Cyst:** This is the most common inflammatory cyst, but it occurs at the **apex** of a **non-vital** tooth due to pulp necrosis. The question specifies the tooth is vital. **Clinical Pearls for NEET-PG:** * **Location:** Most common in the mandibular 3rd molar (distal) or mandibular 1st/2nd molars (buccal—where it is called a **Buccal Bifurcation Cyst**). * **Vitality:** Always check tooth vitality; if the tooth is vital and there is a history of pericoronitis, think Paradental Cyst. * **Treatment:** Enucleation of the cyst; extraction of the involved third molar is usually necessary.
Question 9: What is the recommended treatment for a mucocele on the lower lip?
- A. Incision
- B. Excision
- C. Excision with removal of adjacent salivary glands (Correct Answer)
- D. Biopsy
Explanation: ### Explanation **Correct Answer: C. Excision with removal of adjacent salivary glands** **1. Why Option C is Correct:** A mucocele (specifically the **extravasation type**, which is most common on the lower lip) occurs due to the traumatic rupture of a minor salivary gland duct, leading to the accumulation of mucus in the surrounding submucosal tissue. The definitive treatment is **surgical excision of the cyst**. However, to prevent **recurrence**, it is mandatory to remove the **offending minor salivary gland** and any adjacent minor glands involved in the field. If the gland is left behind, it will continue to secrete mucus, leading to the formation of a new mucocele. **2. Why Other Options are Incorrect:** * **Incision (A):** Simply incising the lesion (I&D) will lead to temporary decompression, but the lesion will almost certainly recur as soon as the wound heals because the underlying secretory gland remains functional. * **Excision (B):** While excision of the cyst wall is necessary, "excision" alone (without addressing the minor salivary glands) is incomplete and carries a high risk of recurrence. * **Biopsy (D):** While a biopsy can confirm the diagnosis, it is not a "treatment." Since mucoceles are usually diagnosed clinically based on their characteristic bluish, translucent appearance and history of trauma, the primary goal is therapeutic excision. **3. NEET-PG High-Yield Pearls:** * **Most common site:** Lower lip (due to frequent trauma/biting). * **Ranula:** A mucocele occurring in the floor of the mouth, usually arising from the **sublingual gland**. * **Plunging Ranula:** A clinical variant that extends below the mylohyoid muscle into the neck, presenting as a soft cervical swelling. * **Histology:** Extravasation mucoceles lack a true epithelial lining (they are "pseudocysts" lined by granulation tissue).
Question 10: A parulis is an inflammatory enlargement seen in which of the following locations?
- A. The end of a sinus tract (Correct Answer)
- B. An extraction socket
- C. Irritation from calculus or an overhanging restoration
- D. None of the above
Explanation: **Explanation:** A **parulis** (commonly known as a "gum boil") is a localized accumulation of inflammatory granulation tissue found at the **opening of a sinus tract** on the gingiva. It represents the oral terminus of a tract that drains a chronic apical periodontitis or a periapical abscess. When the inflammatory exudate from a non-vital tooth burrows through the alveolar bone and reaches the soft tissue, it creates a small, elevated, sessile mass. **Analysis of Options:** * **Option A (Correct):** A parulis marks the exit point of a sinus tract. It serves as a drainage portal for pus; if the tract becomes blocked, the lesion may swell and become painful, but it typically regresses once the underlying dental infection is treated. * **Option B (Incorrect):** An inflammatory enlargement in an extraction socket is usually associated with "Alveolar Osteitis" (Dry Socket) or "Epulis Granulomatosum" (granulation tissue growing out of a healing socket), not a parulis. * **Option C (Incorrect):** Enlargements caused by calculus or overhanging restorations are typically classified as **Pyogenic Granuloma** or **Peripheral Ossifying Fibroma**. These are reactive hyperplasias due to local irritation rather than the drainage of a deep-seated infection. **High-Yield Clinical Pearls for NEET-PG:** * **Pathophysiology:** Most parulides are associated with the buccal aspect of the ridge due to the thinner bone on the facial surface. * **Clinical Sign:** A "gutta-percha point" test is often used radiographically to trace the sinus tract from the parulis back to the offending tooth. * **Differential Diagnosis:** Must be distinguished from a periodontal abscess or a pyogenic granuloma. * **Treatment:** The parulis resolves spontaneously once the source of infection is eliminated via Root Canal Treatment (RCT) or extraction.
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