Sialolithiasis — MCQs
Which of these is the best for management of a 3 cm stone in renal pelvis without evidence of hydronephrosis?
A 45-year-old patient complained of pain on one side of the neck. She is afraid of eating food as it worsens the pain. An ultrasound of the salivary glands is shown below. What is the most likely diagnosis?
All of the following are contrast radiographs except:
What does sialosis refer to?
Treatment of choice for SIADH is:
An otherwise healthy male presents with a creamy curd like white patch on the tongue. The probable diagnosis is
Best investigation to detect rupture of silicone breast implants is-
Genitourinary complication of ulcerative colitis
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?
Sialolithiasis Indian Medical PG Practice Questions and MCQs
Question 1: Which of these is the best for management of a 3 cm stone in renal pelvis without evidence of hydronephrosis?
- A. Retrograde pyeloplasty
- B. ESWL
- C. PCNL (Correct Answer)
- D. Antegrade pyeloplasty
Explanation: ***PCNL*** - **Percutaneous nephrolithotomy (PCNL)** is the gold standard treatment for large renal stones (>2 cm) due to its high stone-free rates in a single procedure. - For a 3 cm renal pelvis stone, PCNL provides the best clearance rate (~95%) with minimal need for repeat procedures. - It involves direct percutaneous access to the kidney, allowing fragmentation and removal of large stone burden efficiently. *ESWL* - **Extracorporeal shock wave lithotripsy (ESWL)** has limited efficacy for stones >2 cm, with stone-free rates dropping to 50-60% for 3 cm stones. - Multiple sessions are typically required, with increased risk of steinstrasse (stone street) formation and residual fragments. - While non-invasive, ESWL is not the optimal choice for this stone size. *Retrograde pyeloplasty* - This option appears to reference **retrograde endoscopic approaches** (such as retrograde intrarenal surgery - RIRS or ureteroscopy). - While retrograde ureteroscopy can treat renal stones, it is generally reserved for stones <2 cm due to longer operative time and lower stone-free rates for larger stones. - True "pyeloplasty" is a reconstructive procedure for ureteropelvic junction obstruction, not a stone removal technique. *Antegrade pyeloplasty* - This option likely refers to **antegrade endoscopic access** to the renal pelvis. - While antegrade access is used in PCNL, "pyeloplasty" specifically means surgical reconstruction of the UPJ for obstruction, not stone treatment. - Antegrade ureteroscopy alone (without nephroscopy) would be less effective than PCNL for a 3 cm stone.
Question 2: A 45-year-old patient complained of pain on one side of the neck. She is afraid of eating food as it worsens the pain. An ultrasound of the salivary glands is shown below. What is the most likely diagnosis?
- A. Sialolithiasis (Correct Answer)
- B. Salivary gland foreign body
- C. Cervical lymphadenopathy
- D. Osteoma of the floor of the mouth
Explanation: ***Sialolithiasis*** - The ultrasound image shows an **echogenic focus** with clear **posterior acoustic shadowing** within the salivary gland, which is characteristic of a salivary gland stone. - The patient's symptoms of **pain on one side of the neck** and **worsening pain with eating** (likely due to salivary stimulation) are classic for **sialolithiasis**, as the stone obstructs salivary flow. *Salivary gland foreign body* - While a foreign body could present with similar pain, it would typically appear as a distinct object on ultrasound, but its echogenicity and shading characteristics might differ depending on the material. - The history of a foreign body ingestion or insertion would be crucial, which is not mentioned here. *Cervical lymphadenopathy* - **Lymph nodes** on ultrasound typically appear as oval-shaped structures with a **hypoechoic cortex** and an **echogenic hilum**; they do not usually show significant acoustic shadowing unless calcified. - While cervical lymphadenopathy can cause neck pain, it is not typically exacerbated by eating in the same way an obstructed salivary gland would be. *Osteoma of the floor of the mouth* - An **osteoma** is a **benign bone tumor** that would present as a very **dense, highly echogenic mass** with severe posterior acoustic shadowing on ultrasound, originating from bony structures. - While an osteoma could cause pain, its location (floor of the mouth) and nature would not typically explain pain worsening specifically with eating due to salivary gland obstruction.
Question 3: All of the following are contrast radiographs except:
- A. Arthrography
- B. Tomography (Correct Answer)
- C. Arthrotomography
- D. Sialography
Explanation: ***Tomography*** - **Tomography** (e.g., CT scan) involves imaging structures in "slices" using X-rays but does not inherently require contrast medium for basic imaging. - While contrast material can be used in tomography to enhance specific structures, the technique itself is not exclusively a **contrast radiograph**. *Arthrography* - **Arthrography** is a type of contrast radiograph where a contrast medium is injected directly into a joint space to visualize soft tissue structures like ligaments, menisci, and articular cartilage. - The use of contrast is fundamental to distinguish these structures, which are not visible on plain X-rays. *Arthrotomography* - **Arthrotomography** combines arthrography with tomography, meaning a contrast agent is injected into a joint, and then tomographic slices are obtained. - This technique provides detailed cross-sectional images of the joint with enhanced contrast from the injected medium. *Sialography* - **Sialography** is a contrast radiograph procedure used to visualize the salivary ducts and glands. - A contrast medium is injected into the ductal system to identify obstructions, strictures, or inflammation within the salivary glands.
Question 4: What does sialosis refer to?
- A. Inflammatory parotid enlargement due to infection
- B. Autoimmune parotid gland dysfunction
- C. Ductal obstruction leading to salivary retention
- D. Non-inflammatory parotid enlargement due to metabolic conditions (Correct Answer)
Explanation: ***Non-inflammatory parotid enlargement due to metabolic conditions*** - **Sialosis** specifically denotes **non-inflammatory, non-neoplastic** enlargement of the parotid glands, often linked to systemic conditions. - It is frequently associated with **metabolic disorders** like diabetes mellitus, alcoholism, malnutrition, and certain drug therapies. *Inflammatory parotid enlargement due to infection* - This description refers to **sialadenitis**, which is an **inflammation** of the salivary glands, usually bacterial or viral (e.g., mumps). - It presents with acute pain, swelling, and sometimes pus discharge, differentiating it from the chronic, non-tender enlargement of sialosis. *Autoimmune parotid gland dysfunction* - This typically describes conditions like **Sjögren's syndrome**, an **autoimmune exocrinopathy** causing sicca symptoms (dry eyes and mouth) due to lymphocytic infiltration of the salivary glands. - While it involves parotid enlargement, the underlying mechanism is autoimmune inflammation, not metabolic. *Ductal obstruction leading to salivary retention* - This scenario points to **sialolithiasis** (salivary stones) or ductal strictures, causing symptoms of painful swelling, especially during eating, due to **salivary back-up**. - This is a mechanical obstruction leading to retention, distinct from the parenchymal hypertrophy seen in sialosis.
Question 5: Treatment of choice for SIADH is:
- A. Hypotonic Saline
- B. Demeclocycline (Correct Answer)
- C. Lithium carbonate
- D. Vasopressin
Explanation: ***Demeclocycline*** - **Demeclocycline** is a tetracycline antibiotic that acts as an **ADH antagonist**, inhibiting its effect on the renal tubules. [1] - This leads to increased free water excretion and a reduction in **hyponatremia** associated with SIADH, making it a treatment of choice, especially for chronic cases. [1] *Hypotonic Saline* - Administering **hypotonic saline** to a patient with SIADH would further dilute serum sodium levels and worsen the **hyponatremia**, which is the opposite of the desired effect. - SIADH is characterized by **excess free water** retention, and adding more free water would exacerbate the underlying pathology. *Lithium carbonate* - While **lithium** can cause nephrogenic diabetes insipidus (a condition of impaired ADH action), it is not the primary or preferred treatment for SIADH. - Its mechanism of action is different, and **demeclocycline** is more specifically targeted at blocking ADH effects in the kidney. *Vasopressin* - **Vasopressin** (ADH) is the hormone that is already in excess or acting excessively in **SIADH**. - Administering more vasopressin would worsen the condition by increasing water reabsorption and further decreasing serum sodium.
Question 6: An otherwise healthy male presents with a creamy curd like white patch on the tongue. The probable diagnosis is
- A. Histoplasmosis
- B. Aspergillosis
- C. Lichen Planus
- D. Candidiasis (Correct Answer)
Explanation: ***Candidiasis*** - The classic presentation of **oral candidiasis** (thrush) is a **creamy, curd-like white patch** on the mucous membranes, including the tongue, which can often be scraped off. - This common fungal infection, caused by *Candida albicans*, can occur in otherwise healthy individuals, especially after antibiotic use, or with mild immunosuppression. *Histoplasmosis* - This fungal infection is typically associated with **pulmonary involvement** in endemic areas (e.g., Ohio and Mississippi River valleys). - Oral lesions, if present, are usually **firm, nodular, or ulcerative**, not creamy white patches, and often signify disseminated disease in immunocompromised individuals. *Aspergillosis* - Primarily a **pulmonary infection**, especially in immunocompromised patients, with symptoms like fever, cough, and dyspnea. [1] - Oral manifestations are rare and typically present as **necrotic ulcers** or plaques, not creamy white patches, and are usually seen in severely immunocompromised patients. [1] *Lichen Planus* - Oral lichen planus presents with **white reticular (lace-like) patterns** (Wickham's striae), plaques, or erosions on the buccal mucosa, tongue, or gingiva. - These lesions are typically **non-scrapable** and can be associated with pain or burning, differing significantly from the "creamy curd-like" description.
Question 7: Best investigation to detect rupture of silicone breast implants is-
- A. Mammography
- B. X-ray
- C. MRI (Correct Answer)
- D. USG
Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** is considered the **gold standard** for detecting silicone breast implant ruptures due to its superior soft tissue contrast and ability to differentiate silicone from other tissues. - It can accurately identify both **intracapsular** (linguine sign) and **extracapsular** ruptures, as well as associated silicone granulomas. *Mammography* - While useful for breast cancer screening, **mammography** has limited sensitivity for detecting silicone implant ruptures, especially subtle ones. - It can show indirect signs like implant contour abnormalities or increased implant density but is often inconclusive for rupture diagnosis. *X-ray* - **X-rays** provide very little information regarding the integrity of silicone breast implants because silicone is radiolucent and does not show up clearly on standard radiographs. - Its utility is primarily for detecting calcifications or foreign bodies, not implant rupture. *USG* - **Ultrasound (USG)** can be a useful initial screening tool for detecting implant ruptures, showing signs like the **"stepladder sign"** for intracapsular rupture or anechoic collections (silicone outside the capsule). - However, its accuracy is highly operator-dependent, and it may miss subtle ruptures or be limited by poor visualization due to scar tissue, making MRI a more definitive choice.
Question 8: Genitourinary complication of ulcerative colitis
- A. Urinary calculi (Correct Answer)
- B. Pyelonephritis
- C. Urethritis
- D. Cystitis
Explanation: ***Urinary calculi*** - Patients with ulcerative colitis are at an increased risk of developing **urinary calculi** due to several factors, including chronic dehydration, malabsorption of fats leading to increased oxalate absorption (enteric hyperoxaluria), and altered urine composition. - The inflammatory process and potential for surgical interventions (e.g., colectomy with ileostomy) can further predispose individuals to kidney stone formation. *Cystitis* - While cystitis (bladder inflammation) can occur in the general population, it is not considered a specific or significantly elevated genitourinary complication directly linked to the pathogenesis of ulcerative colitis itself. - It results primarily from bacterial infection, and there is no direct evidence suggesting UC patients have a higher intrinsic risk compared to the general population. *Pyelonephritis* - Pyelonephritis (kidney infection) is not a direct or common complication of ulcerative colitis. - It is typically caused by bacterial ascent from the lower urinary tract and is not specifically promoted by the inflammatory processes or metabolic changes associated with UC. *Urethritis* - Urethritis (inflammation of the urethra) is primarily associated with sexually transmitted infections or irritation and is not a recognized genitourinary complication directly caused by ulcerative colitis. - There is no increased incidence of urethritis in UC patients compared to the general population.
Question 9: 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 10: 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).
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