Stroboscopy and High-speed Imaging — MCQs
A man takes peanut and develops tongue swelling, neck swelling, stridor, hoarseness of voice. What is the probable diagnosis?
Which imaging and Doppler techniques are combined in duplex ultrasonography?
A 50-year-old smoker presents with hoarseness, dysphagia, and weight loss. Flexible laryngoscopy shows a mass on the vocal cords. What is the next best step?
Identify the investigation being carried out in the image.
What are the characteristics of reversible pulpitis?
A singer presents with difficulty singing at a high pitch. On examination, bowing of the vocal cord is observed on the right side. Which of the following muscles has likely been compromised?
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.
In an infant brought with stridor, diagnosed with laryngomalacia, which of the following is NOT typically observed?
The voice is not affected in which of the following conditions?
A patient complains of sharp shooting pain in the pharynx and tonsil. On examination, a trigger zone is found in the tonsillar area. What is the diagnosis?
Stroboscopy and High-speed Imaging 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: Which imaging and Doppler techniques are combined in duplex ultrasonography?
- A. B-mode imaging and pulse-wave Doppler examination (Correct Answer)
- B. M-mode imaging and power Doppler examination
- C. M-mode imaging and waveform analysis
- D. A-mode imaging and pulse-wave Doppler examination
Explanation: ***B-mode imaging and pulse-wave Doppler examination*** - **B-mode imaging** provides a real-time, two-dimensional grayscale image of the vessel structure. - **Pulse-wave Doppler** assesses blood flow direction, velocity, and characteristics within the visualized vessel. *M-mode imaging and power Doppler examination* - **M-mode imaging** is primarily used for visualizing moving structures over time (e.g., cardiac valves), not for detailed vessel anatomy. - **Power Doppler** is sensitive to the presence of blood flow but does not provide information on flow direction or velocity, which is crucial for full duplex ultrasound. *M-mode imaging and waveform analysis* - **M-mode imaging** is not the primary imaging modality for evaluating vascular structures in duplex ultrasonography. - While waveform analysis is part of Doppler interpretation, combining it with M-mode imaging does not constitute duplex ultrasonography. *A-mode imaging and pulse-wave Doppler examination* - **A-mode imaging** represents echoes as spikes on a single line, providing limited anatomical information and is not used for vascular assessment. - Although pulse-wave Doppler is a component, the primary imaging mode is incorrect for duplex ultrasonography.
Question 3: A 50-year-old smoker presents with hoarseness, dysphagia, and weight loss. Flexible laryngoscopy shows a mass on the vocal cords. What is the next best step?
- A. Direct laryngoscopy with biopsy (Correct Answer)
- B. MRI of neck
- C. CT scan of neck
- D. Radiotherapy
Explanation: ***Direct laryngoscopy with biopsy*** - A definitive diagnosis of a vocal cord mass requires **histological examination** to rule out malignancy, especially given the patient's risk factors (age, smoking) and symptoms (hoarseness, dysphagia, weight loss). - **Direct laryngoscopy** allows for a thorough, magnified view of the mass and precise biopsy collection, which is superior to flexible laryngoscopy alone for definitive diagnosis and staging. *MRI of neck* - While MRI can provide excellent soft tissue detail for **staging** a known malignancy, it cannot provide a **histological diagnosis**. - It would typically be performed after a biopsy confirms malignancy to assess the extent of the tumor and potential spread. *CT scan of neck* - A CT scan is useful for evaluating **bony involvement**, lymph node status, and tumor extension for **staging purposes**, but it is not a diagnostic tool for identifying the specific type of tissue or cell pathology. - Like MRI, a CT scan would generally follow a biopsy confirming malignancy. *Radiotherapy* - **Radiotherapy** is a treatment modality for laryngeal cancer, not a diagnostic step. - Initiating treatment without a definitive histological diagnosis of malignancy would be inappropriate and potentially harmful.
Question 4: Identify the investigation being carried out in the image.
- A. Fluoroscopy
- B. X-ray after alkali ingestion
- C. X-ray after acid ingestion
- D. Barium Swallow (Correct Answer)
Explanation: ***Barium Swallow*** - The image shows a contrast material, characteristic of **barium**, flowing through the esophagus, captured as a sequence of X-ray images, which is the definition of a barium swallow study. - This **dynamic imaging** allows for evaluation of swallowing function and esophageal motility. *Fluoroscopy* - While a barium swallow uses **fluoroscopy** to visualize the movement of barium, fluoroscopy itself is the technique, not the specific investigation being performed. The image depicts the result of a specific type of fluoroscopic examination. - Fluoroscopy is a general term for real-time X-ray imaging, whereas "Barium Swallow" specifies the type of study being done on the upper GI tract. *X-ray after alkali ingestion* - This scenario would typically involve viewing the effects of **corrosive injury** to the esophagus, which would appear as mucosal damage, narrowing, or perforation. The image does not show these features; instead, it shows smooth passage of contrast. - There is no visible evidence of an acute or chronic injury pattern consistent with **alkali ingestion**, which often leads to severe burns or strictures. *X-ray after acid ingestion* - Similar to alkali ingestion, acid ingestion also causes **corrosive injury**, typically affecting the stomach more severely than the esophagus. The image does not demonstrate these pathological changes. - The smooth, unobstructed flow of contrast in multiple frames is indicative of normal esophageal function rather than the sequelae of corrosive ingestion.
Question 5: What are the characteristics of reversible pulpitis?
- A. Aggravated by heat and may be relieved by cold
- B. Aggravated by cold and may be relieved by heat
- C. No reaction to hot and cold, indicating necrosis
- D. Reacts to electric pulp tester (Correct Answer)
Explanation: ***Reacts to electric pulp tester*** - In **reversible pulpitis**, the pulp is still vital and responsive, thus it will react to an **electric pulp tester** (EPT) with a sharp, transient pain at a lower current. - The sensation elicited by EPT indicates the presence of nerve fibers and a viable pulp, consistent with a reversible condition. *Aggravated by heat and may be relieved by cold* - This symptom profile, where pain is **aggravated by heat** and **relieved by cold**, is characteristic of **irreversible pulpitis**, not reversible pulpitis. - The relief with cold often indicates a build-up of pressure within the pulp that is temporarily alleviated by the vasoconstrictive effect of cold. *Aggravated by cold and may be relieved by heat* - While some mild, transient cold sensitivity can occur in **reversible pulpitis**, severe or prolonged cold sensitivity is more indicative of irreversible pulpitis. Relief with heat is not a typical characteristic of reversible pulpitis and would be very unusual for any pulpitis. - This pattern of discomfort is not a direct characteristic of reversible pulpitis; reversible pulpitis typically presents with **sharp, transient pain to cold** that resolves quickly. *No reaction to hot and cold, indicating necrosis* - A lack of reaction to thermal stimuli (hot and cold) is indicative of a **necrotic pulp**, meaning the pulp tissue has died. - In **reversible pulpitis**, the pulp is inflamed but still vital, and therefore will react to thermal stimuli, usually with a sharp, transient pain to cold.
Question 6: A singer presents with difficulty singing at a high pitch. On examination, bowing of the vocal cord is observed on the right side. Which of the following muscles has likely been compromised?
- A. Posterior cricoarytenoid
- B. Lateral cricoarytenoid
- C. Cricothyroid (Correct Answer)
- D. Thyroarytenoid
Explanation: ***Cricothyroid*** - The **cricothyroid muscle** is primarily responsible for **tensioning and elongating the vocal cords**, which is crucial for increasing vocal pitch. - Damage to this muscle or its innervation (superior laryngeal nerve) results in an inability to reach higher pitches and can cause **vocal cord bowing** due to reduced tension. *Posterior cricoarytenoid* - This muscle is the **primary abductor** of the vocal cords, meaning it opens the vocal cords for breathing. - Compromise would lead to difficulty breathing or a paralyzed vocal cord in the adducted position, not bowing with difficulty singing high notes. *Lateral cricoarytenoid* - The **lateral cricoarytenoid muscle** is a **vocal cord adductor** and rotator, bringing the vocal cords together to regulate voice intensity. - Dysfunction typically results in a weak and breathy voice, or difficulty bringing the cords together, not specifically difficulty with high pitch. *Thyroarytenoid* - The **thyroarytenoid muscle** (which includes the vocalis muscle) acts to **relax and shorten the vocal cords**, lowering pitch and modulating vocal cord tension. - Dysfunction would primarily lead to difficulty with lower pitches or a hoarse voice, as it prevents proper relaxation of the vocal cords.
Question 7: 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 8: In an infant brought with stridor, diagnosed with laryngomalacia, which of the following is NOT typically observed?
- A. Stridor will be inspiratory
- B. Hoarseness (Correct Answer)
- C. Prominent arytenoids
- D. Floppy aryepiglottic folds
Explanation: ***Correct: Hoarseness*** - **Laryngomalacia** primarily involves the collapse of supraglottic structures during inspiration, leading to inspiratory stridor - Hoarseness is NOT typically observed because laryngomalacia does **not directly affect the vocal cords** - Hoarseness indicates pathology at the level of the **vocal cords** themselves (such as vocal cord paralysis or inflammation), which is a different entity - The supraglottic collapse in laryngomalacia occurs above the vocal cords, leaving vocal cord function intact *Incorrect: Stridor will be inspiratory* - **Inspiratory stridor** is the hallmark feature of laryngomalacia - The collapse of supraglottic structures during inspiration creates a narrow airway, producing the characteristic high-pitched sound on inhalation - This is the most common presenting symptom in affected infants *Incorrect: Prominent arytenoids* - Laryngoscopy in laryngomalacia often reveals **prominent or redundant arytenoid mucosa** - The collapse of redundant tissue over the arytenoids makes them appear more prominent due to inward movement during inspiration - This contributes to the airway obstruction seen in the condition *Incorrect: Floppy aryepiglottic folds* - **Floppy, shortened aryepiglottic folds** are a hallmark anatomical feature of laryngomalacia - These folds collapse inward during inspiration, obstructing the laryngeal inlet - This collapse is the primary mechanism causing the inspiratory stridor in laryngomalacia
Question 9: The voice is not affected in which of the following conditions?
- A. Unilateral abductor palsy (Correct Answer)
- B. Unilateral adductor palsy
- C. Partial abductor palsy
- D. Total adductor palsy
Explanation: In phoniatrics, the quality of voice depends on the ability of the vocal cords to meet in the midline (**adduction**) for vibration. ### **Explanation of the Correct Answer** **A. Unilateral abductor palsy:** In this condition, the affected vocal cord is paralyzed in the **median (midline) position** because it cannot move outward (abduct). Since the paralyzed cord is already at the midline, the healthy cord can easily meet it during phonation. As a result, the glottic gap is closed perfectly, and the **voice remains normal**. This condition is often asymptomatic and may only present with mild exertional dyspnea (stridor). ### **Why the Other Options are Incorrect** * **B. Unilateral adductor palsy:** The affected cord remains in the **paramedian or lateral position** and cannot move to the midline. This creates a large glottic gap during speech, leading to a **breathy, weak voice (hoarseness)**. * **C. Partial abductor palsy:** According to **Semon’s Law**, in progressive lesions of the recurrent laryngeal nerve, abductor fibers are injured first. This results in the cord being stuck in a position that interferes with the symmetry of vibration, leading to varying degrees of **hoarseness**. * **D. Total adductor palsy:** This involves a complete failure of the cords to approximate, leading to significant **aphonia** (loss of voice) or severe breathiness. ### **Clinical Pearls for NEET-PG** * **Semon’s Law:** In progressive recurrent laryngeal nerve (RLN) injury, abductors (Posterior Cricoarytenoid) are paralyzed before adductors. * **Wagner and Grossman Hypothesis:** If the Superior Laryngeal Nerve (SLN) is intact, the cricothyroid muscle keeps the paralyzed cord in the **paramedian** position. * **Position of Cords:** * Unilateral RLN palsy: Paramedian position. * Bilateral RLN palsy: Median/Paramedian (Airway emergency, but voice is often good). * Combined RLN + SLN palsy: **Cadaveric position** (Intermediate position).
Question 10: A patient complains of sharp shooting pain in the pharynx and tonsil. On examination, a trigger zone is found in the tonsillar area. What is the diagnosis?
- A. Sphenopalatine neuralgia
- B. Paratrigeminal neuralgia
- C. Glossopharyngeal neuralgia (Correct Answer)
- D. Trigeminal neuralgia
Explanation: **Explanation:** The clinical presentation of **sharp, shooting (paroxysmal) pain** localized to the **pharynx and tonsillar area**, initiated by a **trigger zone** in the tonsil, is the classic hallmark of **Glossopharyngeal Neuralgia**. **1. Why Glossopharyngeal Neuralgia is correct:** This condition involves the 9th cranial nerve. The pain is typically unilateral and occurs in the distribution of the glossopharyngeal nerve (posterior third of the tongue, tonsillar fossa, pharynx, and beneath the angle of the jaw). Common triggers include swallowing, talking, coughing, or touching the tonsillar area. **2. Why other options are incorrect:** * **Sphenopalatine neuralgia (Sluder’s Neuralgia):** Characterized by pain in the lower face, nose, and orbit, often associated with nasal congestion or rhinorrhea, rather than pharyngeal triggers. * **Paratrigeminal neuralgia (Raeder’s Syndrome):** Presents as trigeminal pain (usually V1/V2 distribution) accompanied by oculosympathetic palsy (Horner’s syndrome). * **Trigeminal neuralgia (Tic Douloureux):** The most common facial neuralgia, but the pain is located in the distribution of the 5th cranial nerve (usually maxillary or mandibular branches). Trigger zones are typically on the skin of the face or the gingiva, not the pharynx. **High-Yield Clinical Pearls for NEET-PG:** * **Eagle’s Syndrome:** A key differential diagnosis where an elongated styloid process irritates the glossopharyngeal nerve, causing similar pain. * **Treatment:** Medical management is the first line, primarily using **Carbamazepine**. * **Surgical Management:** If medical therapy fails, **Microvascular Decompression (MVD)** of the 9th nerve or rhizotomy is performed. * **Vagal Association:** In rare cases, glossopharyngeal neuralgia can trigger the carotid sinus reflex, leading to bradycardia or syncope.
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