Nodules, Polyps, and Cysts — MCQs
A man takes peanut and develops tongue swelling, neck swelling, stridor, hoarseness of voice. What is the probable diagnosis?
What condition is suggested by eyelid papules and a hoarse cry in a child?
What is the most likely diagnosis for the swelling in the floor of the mouth shown in the image?
Which of the following is a precancerous lesion?
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 patient presents with hoarseness of voice and a clinical condition as shown in the image. Identify the lesion:
Which of the following is true regarding Singer's nodule?
Hyponasal voice is seen in all except?
A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?
All of the following are risk factors for carcinoma of the gallbladder, EXCEPT -
Nodules, Polyps, and Cysts Indian Medical PG Practice Questions and MCQs
Question 1: A man takes peanut and develops tongue swelling, neck swelling, stridor, hoarseness of voice. What is the probable diagnosis?
- A. FB in larynx
- B. Angioneurotic edema (Correct Answer)
- C. Parapharyngeal abscess
- D. FB bronchus
Explanation: Andioneurotic edema - The combination of **tongue swelling**, **neck swelling**, **stridor**, and **hoarseness of voice** following peanut ingestion is highly suggestive of **angioneurotic edema**, a severe allergic reaction that can lead to airway obstruction [1]. - This is a life-threatening condition requiring immediate medical intervention, often associated with generalized **anaphylaxis** when triggered by allergens [2]. *FB in larynx* - While a **foreign body (FB) in the larynx** can cause stridor and hoarseness, the widespread swelling of the tongue and neck points away from a localized laryngeal obstruction [3]. - A laryngeal FB would typically be associated with a more sudden onset of choking and coughing, not diffuse edema [3]. *Parapharyngeal abscess* - A **parapharyngeal abscess** would typically present with **fever**, **severe throat pain**, and **trismus** (difficulty opening the mouth), which are not mentioned in this scenario. - The acute, rapid onset of symptoms after peanut consumption is inconsistent with the slower progression of an abscess. *FB bronchus* - A **foreign body in the bronchus** would primarily cause **coughing**, **wheezing**, and possibly **respiratory distress**, often unilateral, rather than severe global swelling of the tongue and neck. - Inspiratory stridor and hoarseness are more indicative of upper airway involvement than bronchial obstruction.
Question 2: What condition is suggested by eyelid papules and a hoarse cry in a child?
- A. Croup
- B. Lipoid proteinosis (Correct Answer)
- C. Acrodermatitis enteropathica
- D. Congenital syphilis
Explanation: ***Lipoid proteinosis*** - This condition is characterized by **hoarseness from infancy** due to deposition in the vocal cords and characteristic **beaded papules on the eyelids** (moniliform blepharosis). - Also known as **Urbach-Wiethe disease**, it is a rare autosomal recessive disorder resulting from mutations in the **ECM1 gene**, leading to abnormal deposition of hyaline material in various tissues. *Croup* - Croup typically presents with a **barking cough** and **stridor**, often following a viral upper respiratory infection. - It does not cause eyelid papules or chronic hoarseness from infancy, but rather acute respiratory distress. *Acrodermatitis enteropathica* - This is a rare autosomal recessive disorder of **zinc malabsorption**, leading to a classic triad of **dermatitis**, **diarrhea**, and **alopecia**. - It does not involve eyelid papules or hoarseness as primary features. *Congenital syphilis* - Congenital syphilis can cause a wide range of manifestations, including skin rashes, bone abnormalities, and rhinitis ("snuffles"), but eyelid papules and chronic hoarseness are not typical presenting features. - Diagnosis is usually confirmed by serological tests for syphilis.
Question 3: 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 4: Which of the following is a precancerous lesion?
- A. Keratosis of larynx (Correct Answer)
- B. Laryngitis sicca
- C. Scleroma larynx
- D. Pachydermia of larynx
Explanation: ***Keratosis of larynx*** - **Keratosis of the larynx**, particularly with **dysplasia**, is considered a **precancerous lesion** due to the potential for malignant transformation into squamous cell carcinoma [1]. - It involves abnormal thickening and keratinization of the laryngeal mucosa, often linked to irritants like **smoking** and **alcohol** [1]. *Laryngitis sicca* - This condition involves **dryness and crusting of the laryngeal mucosa**, typically due to environmental factors or systemic drying conditions. - While uncomfortable, it is generally an **inflammatory** condition and not considered precancerous. *Scleroma larynx* - **Laryngeal scleroma** is a chronic inflammatory condition caused by infection with **Klebsiella rhinoscleromatis**, leading to granulomatous changes and fibrosis. - It results in progressive airway obstruction but is a bacterial infection and **not a precancerous lesion**. *Pachydermia of larynx* - **Pachydermia of the larynx** refers to a benign thickening of the laryngeal mucosa, often in the interarytenoid region, typically due to **chronic irritation** or reflux. - Although it indicates chronic inflammation and hyperkeratosis, it is generally considered a **benign reactive change** rather than a true precancerous condition, unless significant dysplasia is also present (which would classify it under keratosis). **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Head and Neck, pp. 746-747.
Question 5: 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 6: A patient presents with hoarseness of voice and a clinical condition as shown in the image. Identify the lesion:
- A. Diphtheria (Correct Answer)
- B. Follicular tonsillitis
- C. Aphthous ulcer
- D. Membranous tonsillitis
Explanation: ***Diphtheria*** - The image shows a **thick, grayish-white pseudomembrane** covering the tonsils and likely extending to other parts of the pharynx, which is a classic sign of diphtheria. - **Hoarseness** indicates laryngeal involvement, a severe complication of diphtheria due to pseudomembrane formation extending to the larynx, potentially causing airway obstruction. *Follicular tonsillitis* - This condition presents with **pus-filled follicles** or spots on the tonsils, which are typically yellow or white, rather than a confluent membrane. - While it causes throat pain and fever, it generally does not lead to the formation of a **firm, adherent pseudomembrane** or significant hoarseness from laryngeal obstruction as seen in diphtheria. *Aphthous ulcer* - An aphthous ulcer is a **small, painful, shallow sore** with a white or yellowish center and a red border, typically found on the non-keratinized oral mucosa. - It does not present as a widespread, thick membranous lesion covering the tonsils and causing hoarseness. *Membranous tonsillitis* - While "membranous tonsillitis" describes the presence of a membrane on the tonsils, this term is often used generally. However, the specific characteristics in the image (thick, grayish, adherent membrane with severe symptoms like hoarseness) are pathognomonic for **diphtheria**. - Other causes of membranous tonsillitis, such as infectious mononucleosis, typically present with a less adherent membrane and often lack the severe systemic toxicity and potential for rapid airway compromise seen in diphtheria.
Question 7: Which of the following is true regarding Singer's nodule?
- A. Laser therapy is treatment of choice
- B. It occurs at junction of anterior 1/3rd and posterior 2/3rd (Correct Answer)
- C. Requires excision as its potentially malignant
- D. Most common symptom is pain
Explanation: ***Correct: It occurs at junction of anterior 1/3rd and posterior 2/3rd*** **Singer's nodules**, also known as **vocal cord nodules**, are typically found at the junction of the **anterior one-third and posterior two-thirds** of the true vocal cords. This area experiences the most vibratory stress and contact during phonation, making it prone to trauma from vocal abuse, leading to the formation of bilateral benign lesions. *Incorrect: Laser therapy is treatment of choice* **Voice therapy** is the **first-line treatment** for Singer's nodules, aiming to modify vocal behaviors and reduce vocal strain. **Surgery**, including laser therapy or microlaryngeal excision, is reserved for cases that do not respond to conservative voice therapy and when nodules significantly impair vocal function. *Incorrect: Requires excision as its potentially malignant* Singer's nodules are **benign lesions** with no malignant potential. They are not considered premalignant and do not undergo malignant transformation. Surgical excision is considered only if voice therapy fails after adequate trial and the nodules continue to cause significant dysphonia. *Incorrect: Most common symptom is pain* The most common symptom associated with Singer's nodules is **hoarseness** or **dysphonia** (altered voice quality). The voice may sound breathy, rough, or strained. **Pain is generally not a prominent symptom** of vocal cord nodules, which helps differentiate them from other laryngeal pathologies like laryngitis or vocal cord polyps with inflammation.
Question 8: Hyponasal voice is seen in all except?
- A. Adenoids
- B. Nasal polyp
- C. Deviated nasal septum
- D. Cleft lip (Correct Answer)
Explanation: ***Cleft lip*** - A **cleft lip** primarily affects the appearance of the lip and a portion of the nose but doesn't typically obstruct the nasal passages to cause a hyponasal voice. - The voice quality in individuals with a cleft lip, without an associated cleft palate, is usually normal. *Adenoids* - **Enlarged adenoids** can obstruct the nasopharyngeal airway, leading to reduced nasal resonance and a **hyponasal (rhinolalia clausa)** voice. - This obstruction prevents air from exiting through the nose during speech, making sounds like 'm' and 'n' sound like 'b' and 'd'. *Nasal polyp* - **Nasal polyps** can physically block the nasal passages, impairing airflow through the nose during speech. - This blockage leads to a reduction in nasal resonance, resulting in a **hyponasal voice**. *Deviated nasal septum* - A **deviated nasal septum** can significantly narrow one or both nasal passages, restricting airflow. - This structural obstruction can cause a **hyponasal voice** due to reduced nasal resonance.
Question 9: A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?
- A. 48%
- B. 12%
- C. 24%
- D. 3% (Correct Answer)
Explanation: ***3%*** - **Purely cystic thyroid nodules** (as described in this case with "isolated cystic swelling") have a **very low risk of malignancy**, typically **2-3%** or less. - According to **ATA guidelines** and **TIRADS classification**, purely cystic nodules are considered **low suspicion** lesions. - The cystic nature suggests a **benign process** such as a degenerated adenoma, colloid cyst, or simple cyst. - **Fine needle aspiration (FNA)** may still be considered if the nodule is >2 cm or has any suspicious solid components, but is often not required for purely cystic lesions. *48%* - This percentage is **significantly higher** than the actual malignancy risk for a purely cystic thyroid swelling. - Such a **high risk** would typically be associated with **solid nodules** exhibiting highly suspicious ultrasound features such as: - Microcalcifications - Irregular or spiculated margins - Taller-than-wide shape - Marked hypoechogenicity - Extrathyroidal extension *24%* - This percentage represents a **moderate to high risk** of malignancy, which is **not characteristic** of an isolated purely cystic thyroid swelling. - A risk in this range might be seen with: - **Mixed solid-cystic nodules** with predominantly solid components - Solid nodules with **intermediate suspicious features** on ultrasound *12%* - While lower than 24% or 48%, 12% is still **considerably higher** than the generally accepted malignancy risk for purely cystic thyroid nodules. - This risk level could be plausible for: - **Predominantly cystic nodules** with some eccentric solid components - Solid nodules with **mildly suspicious** features on ultrasound
Question 10: All of the following are risk factors for carcinoma of the gallbladder, EXCEPT -
- A. Adenomatous gall bladder polyps
- B. Choledochal cysts
- C. Oral contraceptives (Correct Answer)
- D. Typhoid carriers
Explanation: ***Oral contraceptives*** - While **oral contraceptives** can increase the risk of **gallstones**, they are not directly recognized as a specific risk factor for **gallbladder carcinoma**. - The impact of oral contraceptives on gallbladder cancer risk is generally considered to be minor or non-existent compared to established risk factors. *Typhoid carriers* - **Chronic asymptomatic carriers of Salmonella Typhi** have a significantly increased risk of developing **gallbladder carcinoma**, likely due to chronic inflammation and cellular damage. - The bacteria can reside in the gallbladder for years, leading to a persistent inflammatory state and genetic mutations. *Adenomatous gall bladder polyps* - **Adenomatous polyps** in the gallbladder are considered **premalignant lesions**, especially if they are larger than 10 mm, and are associated with an increased risk of progression to adenocarcinoma. - Their presence indicates a need for careful monitoring and often surgical removal due to their malignant potential. *Choledochal cysts* - **Choledochal cysts**, congenital dilations of the bile ducts, are well-established risk factors for **cholangiocarcinoma** (bile duct cancer) and, less commonly, **gallbladder carcinoma**. - The stasis and reflux of bile within these cysts lead to chronic irritation and inflammation, increasing the risk of malignant transformation.
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