Diseases of the Oral Cavity and Salivary Glands Practice Questions

Q: A 16-year-old patient complains of difficulty in swallowing, difficulty in talking and sometimes difficulty in breathing. On physical examination the presentation is similar to that shown in the picture. What would be the probable diagnosis?

Lingual thyroid. ***Lingual thyroid*** - The image shows a **mass at the base of the tongue**, which is typical of a lingual thyroid, an ectopic thyroid tissue. - Symptoms like **difficulty swallowing (dysphagia)**, **difficulty talking (dysphonia)**, and **difficulty breathing (dyspnea)** are common with a lingual thyroid due to its obstructive nature. - Lingual thyroid results from **failure of thyroid descent** during embryological development and is the most common ectopic thyroid location. *Ranula* - A ranula is a **mucus extravasation cyst** found on the **floor of the mouth**, usually unilateral and bluish. - While it can cause speech or swallowing difficulties, its location is distinct from the mass seen at the tongue base. *Vallecular cyst* - A vallecular cyst is a **mucus retention cyst** located in the **vallecula** (between the base of tongue and epiglottis). - Can present with dysphagia and respiratory symptoms, but typically appears more **cystic and translucent** rather than solid tissue mass. - Less common in adolescents compared to lingual thyroid. *Enlarged adenoids* - Enlarged adenoids are located in the **nasopharynx** and typically cause nasal obstruction, mouth breathing, and recurrent ear infections. - They would not present as a visible mass at the base of the tongue nor cause dysphagia or dysphonia to this extent.

Q: A male patient complains of trismus, dysphagia and respiratory distress. On examination, he has a submental swelling with fever, tachycardia and tachypnea. What is the most likely diagnosis?

Ludwig's angina. ***Ludwig's angina*** - The patient's symptoms of **trismus, dysphagia, respiratory distress**, and a **submental swelling** with systemic signs like fever, tachycardia, and tachypnea are classic for Ludwig's angina. - This is a rapidly progressive and potentially life-threatening **cellulitis of the submandibular and sublingual spaces**, often originating from dental infections, that can compromise the airway. *Erysipelas* - Erysipelas is a superficial skin infection characterized by a **well-demarcated, raised, red rash**, often with a "peau d'orange" appearance, typically affecting the face or lower extremities. - While it causes fever and can be painful, it does not typically present with trismus, dysphagia, significant submental swelling, or rapid airway compromise as seen in the patient. *Pyogenic abscess* - A pyogenic abscess is a localized collection of **pus** surrounded by inflamed tissue, which can occur anywhere in the body. - While an abscess in the head and neck region could cause swelling, fever, and potentially dysphagia or trismus, the diffuse, brawny, non-fluctuant swelling and characteristic "woody" induration of the submental and sublingual spaces, along with rapid airway compromise, are more indicative of Ludwig's angina. *Orbital cellulitis* - Orbital cellulitis is an infection of the **orbital tissues posterior to the orbital septum**, commonly presenting with **proptosis, ophthalmoplegia, pain with eye movement**, and vision changes. - It does not typically cause submental swelling, trismus, or dysphagia, and while serious, its location and primary symptoms differ significantly from the presented case.

Q: A 22 year old male addicted to alcohol and abused with pan-masala-arecanut comes to the clinic with limited mouth opening and restricted tongue movement. The clinical suspicion will be of:

Sub-mucous fibrosis. ***Sub-mucous fibrosis*** - The combination of **pan-masala-arecanut** use and clinical symptoms like **limited mouth opening (trismus)** and **restricted tongue movement** are classic signs of **oral submucous fibrosis (OSMF)**, a precancerous condition. - OSMF is characterized by **progressive fibrosis** of the oral submucosa, leading to rigidity and loss of tissue elasticity, which impairs normal oral functions. *Leukoplakia* - **Leukoplakia** appears as a **white patch or plaque** that cannot be wiped away and is not attributable to any other known disease, often associated with tobacco use. - While it is also a **precancerous lesion**, it typically does not present with the severe **limited mouth opening** and **restricted tongue movement** seen in this patient. *Sideropenic dysphagia* - **Sideropenic dysphagia**, also known as **Plummer-Vinson syndrome**, is characterized by **iron deficiency anemia**, **dysphagia (difficulty swallowing)**, and esophageal webs. - It does not involve **limited mouth opening** or effects of betel nut chewing on oral mucosa. *Chronic hyperplastic candidiasis* - **Chronic hyperplastic candidiasis** (CHC) is a persistent white lesion caused by **Candida albicans**, often found in smokers and presenting as a non-scrapable white patch. - Although it can be chronic, CHC is a fungal infection that does not cause the **fibrotic changes** that lead to the severe **mouth opening restriction** observed here.

Q: Cause of Ludwig angina is:

Tooth infection. ***Tooth infection*** - **Odontogenic infections**, particularly from the mandibular molars (especially 2nd and 3rd molars), are the most common cause of Ludwig's angina, accounting for **70-90% of cases**. - These infections spread contiguously from the **apex of the tooth** through the thin lingual cortex into the submandibular and sublingual spaces. - The infection causes **bilateral cellulitis** of the floor of the mouth with characteristic "bull neck" appearance. *Retropharyngeal abscess* - A retropharyngeal abscess forms in the **potential space between the pharynx and prevertebral fascia**. - While it can cause airway compromise and neck swelling, it's anatomically distinct from Ludwig's angina, which involves the **submandibular, sublingual, and submental spaces**. - Retropharyngeal abscess typically presents with dysphagia, neck stiffness, and fever. *Parotid abscess* - A parotid abscess is an infection of the **parotid gland**, located superficially in the preauricular region. - It causes swelling anterior to the ear and along the **mandibular angle**, not the floor of the mouth. - It does not involve the submandibular/sublingual spaces and does not cause the bilateral "board-like" induration characteristic of Ludwig's angina. *Tonsillitis* - While tonsillar infections can occasionally spread to deep neck spaces, they typically cause **peritonsillar abscess** (quinsy). - Tonsillitis rarely causes Ludwig's angina unless there is direct extension through the pharyngeal wall, which is uncommon. - The anatomical distance between the tonsillar fossa and the submandibular space makes this an unlikely cause.

Q: Commonest cause of Ludwig's Angina is

Dental infection of 2nd molar teeth. ***Dental infection of 2nd molar teeth*** - Infections of the **mandibular second and third molars** are the most common source of **Ludwig's angina** due to their proximity. - The roots of these teeth extend below the level of the mylohyoid muscle, allowing infection to spread directly into the **submylohyoid space**. *Dental infection of 2nd premolar teeth* - While dental infections can cause **Ludwig's angina**, second premolar infections are less commonly implicated than molar infections. - The roots of premolars are typically positioned above the **mylohyoid muscle**, making direct spread to the submandibular and sublingual spaces less likely. *Dental infection of canine tooth* - Canine tooth infections are more likely to cause localized abscesses or cellulitis rather than the widespread infection characteristic of **Ludwig's angina**. - The anatomical location of canine roots generally directs infection into the **buccal or labial spaces**. *Dental infection of Incisor teeth* - Infections of incisor teeth are rare causes of **Ludwig's angina** as their roots are located superior to the mylohyoid line. - These infections typically spread *anteriorly* or *labially*, rather than into the deep fascial spaces of the neck.

Q: Symmetrical persistent enlargement of the parotid gland is seen in:

Mikulicz disease.. ***Mikulicz disease*** - This condition is characterized by **chronic, symmetrical enlargement of the lacrimal and salivary glands**, predominantly the parotid glands [1]. - It is often considered a benign lymphoepithelial lesion, now frequently reclassified as an **IgG4-related disease** or a manifestation of **Sjögren syndrome**. *Sjögren syndrome* - While **parotid gland enlargement can occur** in Sjögren syndrome [1], it is not always "symmetrical and persistent" in the same distinct pattern as described for Mikulicz disease. - Sjögren syndrome is primarily an **autoimmune disorder** leading to xerostomia and xerophthalmia, with glandular enlargement being a possible, but not always defining, feature in all cases. *Cylindroma* - A cylindroma (**adenoid cystic carcinoma**) is a **malignant tumor** of salivary glands [1], and it typically presents as a **solitary, unilateral mass**, not a symmetrical, persistent enlargement. - This type of tumor is characterized by its **infiltrative growth pattern** and perineural invasion, which are distinct from the diffuse glandular enlargement seen in Mikulicz disease. *All of the options* - This option is incorrect because **Cylindroma does not present with symmetrical persistent parotid enlargement**, making an "all of the above" answer inappropriate. - While Sjögren syndrome can involve parotid enlargement, the specific presentation of "symmetrical persistent enlargement" is more definitively associated with Mikulicz disease or its contemporary understanding within IgG4-related diseases.

Q: Sialolithiasis is most commonly seen in which gland?

Submandibular. ***Submandibular*** - The **submandibular gland** is the most common site for **sialolithiasis** due to several factors. - Its **Wharton's duct** is long, tortuous, and travels against gravity, and the saliva from the submandibular gland is more alkaline and contains a higher concentration of mucin and calcium, all contributing to stone formation. *Parotid* - While sialolithiasis can occur in the **parotid gland**, it is much less common than in the submandibular gland. - The saliva from the parotid gland is more serous, making stone formation less likely. *Sublingual* - **Sialolithiasis** in the **sublingual gland** is exceedingly rare. - The numerous small ducts and serous nature of its secretions make stone formation highly unlikely. *Minor salivary gland* - **Minor salivary glands** are rarely affected by **sialolithiasis**. - While they can develop other pathologies like mucoceles, stone formation is not a common presentation.

Q: 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?

Sialolithiasis. ***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.

Q: Not typically associated with Ludwig's angina is

Aphthous ulcer in pharynx. ***Aphthous ulcer in pharynx*** - **Aphthous ulcers** are discrete, painful oral lesions typically associated with trauma, stress, or certain systemic conditions, and are **not a feature** of the infection and inflammation seen in Ludwig's angina [1]. - Ludwig's angina is a severe **bacterial infection** of the submandibular, sublingual, and submental spaces, characterized by aggressive cellulitis rather than ulcerative lesions. *It is caused by anaerobic organisms* - **Mixed flora**, including **anaerobic bacteria** (e.g., Peptostreptococcus, Bacteroides, Fusobacterium), are commonly implicated in Ludwig's angina, often originating from odontogenic infections [2]. - The presence of anaerobes contributes to the rapid progression and extensive tissue destruction characteristic of this severe infection [2]. *Cellulitis in the floor of mouth* - Ludwig's angina is specifically defined as a **rapidly spreading cellulitis** that involves the **submandibular, sublingual, and submental spaces** of the floor of the mouth. - This cellulitis is non-suppurative but causes significant edema and induration, which can displace the tongue superiorly and posteriorly. *Glottal edema, may require tracheostomy* - The extensive edema in the floor of the mouth can extend rapidly to the **larynx**, leading to **glottal edema** and **airway obstruction**. - Due to the critical risk of airway compromise, an emergency **tracheostomy** or **cricothyrotomy** may be necessary to secure the airway in advanced cases.

Question 1

A 16-year-old patient complains of difficulty in swallowing, difficulty in talking and sometimes difficulty in breathing. On physical examination the presentation is similar to that shown in the picture. What would be the probable diagnosis?

Accepted Answer

Lingual thyroid

Answer

Ranula

Answer

Enlarged adenoids

Answer

Vallecular cyst

Question 2

A male patient complains of trismus, dysphagia and respiratory distress. On examination, he has a submental swelling with fever, tachycardia and tachypnea. What is the most likely diagnosis?

Accepted Answer

Ludwig's angina

Answer

Erysipelas

Answer

Pyogenic abscess

Answer

Orbital cellulitis

Question 3

A 6-year-old boy has recurrent history of pain and swelling below his left ear, which generally lasts for 3–7 days and improves mildly after a course of antibiotics. Sialography shows punctate sialectasis. He should be treated by

Accepted Answer

endoscopic washouts and antibiotics

Answer

radiotherapy

Answer

prolonged low-dose antibiotics

Answer

total conservative parotidectomy

Question 4

A 22 year old male addicted to alcohol and abused with pan-masala-arecanut comes to the clinic with limited mouth opening and restricted tongue movement. The clinical suspicion will be of:

Accepted Answer

Sub-mucous fibrosis

Answer

Leukoplakia

Answer

Sideropenic dysphagia

Answer

Chronic hyperplastic candidiasis

Question 5

Cause of Ludwig angina is:

Accepted Answer

Tooth infection

Answer

Retropharyngeal abscess

Answer

Parotid abscess

Answer

Tonsillitis

Question 6

Commonest cause of Ludwig's Angina is

Accepted Answer

Dental infection of 2nd molar teeth

Answer

Dental infection of 2nd premolar teeth

Answer

Dental infection of canine tooth

Answer

Dental infection of Incisor teeth

Question 7

Symmetrical persistent enlargement of the parotid gland is seen in:

Accepted Answer

Mikulicz disease.

Answer

Sjögren syndrome.

Answer

Cylindroma.

Answer

All of the options.

Question 8

Sialolithiasis is most commonly seen in which gland?

Accepted Answer

Submandibular

Answer

Parotid

Answer

Sublingual

Answer

Minor salivary gland

Question 9

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?

Accepted Answer

Sialolithiasis

Answer

Salivary gland foreign body

Answer

Cervical lymphadenopathy

Answer

Osteoma of the floor of the mouth

Question 10

Not typically associated with Ludwig's angina is

Accepted Answer

Aphthous ulcer in pharynx

Answer

It is caused by anaerobic organisms

Answer

Cellulitis in the floor of mouth

Answer

Glottal edema, may require tracheostomy

Diseases of the Oral Cavity and Salivary Glands — MCQs

Diseases of the Oral Cavity and Salivary Glands — MCQs

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