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1. Salivary gland diseases
MADE BY : DR SHARIQUE NAZIR
FCPS OMFS

2. Category =Difficult
You were a part of a team that operated on a 43 year old man who was a diagnosed case
of adenoid cystic carcinoma. 2 weeks post op the patient presented to you with a
complaint of sweating over the chin and submental region on the operated site. What will
you suspect?
a) Trotter's Syndrome
b) Frey's Syndrome
c) Pickwian Syndrome
d) Chorda tympani syndrome
e) Gustatory lacrimation syndrome or “crocodile tears”

3. Answer = D
Related syndromes
1) Chorda tympani syndrome
◦ May accompany an operation or injury to the submandibular gland (chorda tympani syndrome)
◦ The chin and submental skin demonstrate sweating and flushing
2) Gustatory lacrimation syndrome or “crocodile tears”
◦ May accompany by facial nerve injury proximal to the geniculate ganglion
◦ Chewing food produces abundant tear formation particularly hot or spicy foods.
◦ It generally follows facial paralysis, either of Bell’s palsy type or the result of herpes zoster, head injury
or intracranial operative trauma.
Sympathetic = Sympathetic innervation is derived from the superior cervical ganglion nerve supply to the salivary glands via the vast arterial plexus of the face
Parasympathetic
• Parotid gland = Parotid gland receives innervation from the ninth cranial (glossopharyngeal) nerve via the auriculotemporal nerve from the otic ganglion i.e
The parasympathetic innervation to the parotid gland originates from the tympanic branch of the glossopharyngeal nerve (IX), which then travels via the
lesser petrosal nerve to the otic ganglion. Postganglionic parasympathetic nerves then travel via the auriculotemporal nerve to the parotid gland.
• Submandibular Parasympathetic control originates in the superior salivatory nucleus, which travels via the facial nerve (chorda tympani branch) to the
submandibular ganglion. Postganglionic parasympathetic nerves then travel directly to the submandibular gland
• Sublingual = Parasympathetic control originates in the superior salivatory nucleus, which travels via the facial nerve (chorda tympani branch) to the
submandibular ganglion. Postganglionic parasympathetic nerves then travel with lingual nerve to the sublingual gland

4. Category = Easy
A 35 years patient reported to opd with complaint of pain and sudden
swelling in floor of mouth especially at meal times. Medical history was
not significant. Diagnostic or Gold standartest for sialolith is
a) Occlusal view
b) Sialography
c) MRI
d) CT scan
e) OPG

5. Answer =B
Radiographs
1) Mandibular occlusal film
• Sublingual calculi in the anterior floor of the
mouth
• Submandibular gland calculi in the anterior floor of
the mouth (distal duct calculi)
2) Panoramic radiographs
• Stones in the parotid gland
• Posteriorly located submandibular stones
(proximal duct calculi)
3) Lateral oblique views of the mandible
• Calcification in the duct and gland parenchyma,
but in practice they are rarely used.
• Tongue depression on the symptomatic side can
be used to displace the submandibular gland
inferiorly and avoid superimposition of the
calculus on the mandible.
• Parotid duct calculi may be detected using a
lateral projection with an intraoral film placed in
the buccal sulcus
4) Periapical radiographs
• Calculi in each salivary gland or duct, including
minor salivary glands, depending on film
placement.
Sialography
 The gold standard in diagnostic salivary gland radiology is the sialogram.
◦ Delineate or evaluate the ductal system
◦ At one time considered the gold standard in the diagnosis of salivary gland
dysfunction secondary obstructive salivary disease
◦ Demonstrate the extent of salivary involvement in Sjögren syndrome.
◦ Provides the preliminary step in outlining the ductal morphology and
localizing an obstruction, if present, thus providing a route map for
therapeutic intervention.
◦ Important information that can be obtained during the sialogram study
includes the size, number, position, and mobility of the stone(s), as well as
the diameter of the distal duct and presence of stenosis within the ductal
system.
◦ Provide superior images of the ductal system, particularly images of the area
where the path of the duct overlies, or is obstructed by, bony structures or
the dentition
 Because of the risk in the use of contrast medium, this technique is no longer
favored and is contraindicated in acute conditions of salivary gland
Indications
 Detection of radiopaque and radiolucent (15%–20%) stones, as well as mucous
plugs.
 Assessment of the extent of destruction of the salivary duct or gland parenchyma
or both as a result of obstructive, inflammatory, traumatic, and neoplastic
diseases.
 Used as a therapeutic maneuver because the ductal system is dilated during the
study, and small mucous plugs or necrotic debris may be cleared during injection
of contrast medium into the ductal system

6. Category = Easy
In schrimer test diagnosis of sjogren syndrome is confirmed in the filter
paper by
a) >5mm of wetting in 10 minutes
b) >7mm of wetting in 15 minutes
c) >10mm of wetting in 10 min
d) <5mm of wetting in 5minute
e) 5mm of wetting in 20 minutes

7. Answer = D
Schirmer test for lacrimal flow
 A simple means to quantify or confirm the decreased tear secretion/lacrimal flow reduction
 A 35mm standardized strip of sterile filter paper is placed over the margin of the lower eyelid, so that the tabbed end rests just inside the lower lid.
 By measuring the length of wetting of the filter paper, tear production can be assessed. Values less than 5 mm (after a 5-minute period) are
considered abnormal
 The results of the Schirmer test are as follows
◦ Normal: 15 mm or greater wetting of the paper after 5 minutes
◦ Mild: 14 to 9 mm wetting of the paper after 5 minutes
◦ Moderate: 8 to 4 mm wetting of the paper after 5 minutes
◦ Severe: less than 4 mm wetting of the paper after 5 minutes.
 Usually, patients with Sjögren syndrome who have keratoconjunctivitis sicca are in the severe category, with less than 4 mm of wetting of the
paper strip after 5 minutes.

8. Category = Easy
Which of the following is the reason regarding the higher incidence rate of
sialolith formation in submandibular gland?
a) Acidic PH of submandibular saliva
b) Punctum of the duct is large
c) Higher calcium and phosphate levels.
d) No sharp curves in the sunbmadibular duct
e) No tortous course of the duct

9. Answer = C
Factors contribute to the higher incidence of submandibular calculi
 Highest concentration of calcium and phosphate
 Alkaline pH of submandibular saliva
 Anatomic factors of the submandibular gland and duct
The Wharton duct is the longest salivary duct; therefore, saliva has a greater
distance to travel before being emptied into the oral cavity.
Thicker, mucoid secretions
Tortous course of duct i.e duct of the submandibular gland has two sharp curves in
its course: (1) one at the posterior border of the mylohyoid muscle, and (2) one near
the ductal opening in the anterior floor of the mouth.
Punctum of the submandibular duct is smaller than the opening of the Stensen duct
Dependent position = Punctum or orifice is its most elevated location and upward
path of the submandibular (Wharton) duct lead to its flow occurs against the force
of gravity

10. Category = Difficult (FCPS PART 2 MCQ PAST
PAPERS)
A patient came with complaint that he is unable to protrude his tongue and
smile. He has the recent history of surgery in submandibular area. The
reason you think is
a) Damage to lingual buccal nerve
b) Damage to hypoglossal nerve and MMN
c) Damage to IAN AND MMN
d) Damage to facial nerve
e) Damage to facial nerve and lingual nerve

11. Answer = B
Tongue
Muscles of the tongue
 The tongue is entirely a muscular structure composed of the extrinsic
muscles (genioglossus, hyoglossus, styloglossus, and palatoglossus) as
well as the intrinsic muscles (longitudinal, vertical and transverse)
Innervation
 Motor innervation to muscles of the tongue is via the hypoglossal nerve,
except palatoglossus which is supplied by the vagus nerve.
 General sensory innervation of anterior two third via lingual nerve and
special sensory i.e taste via chorda tympani , posterior third both taste and
general sensory via glossopharyngeal and most posteriror via vagus nerve

12. Category = Moderate
Leafless tree pattern on sialography is typical of
a) Sialosis or sialdenosis
b) Sjogren syndrome
c) Sialodochitis
d) Sialolithisasis
e) Intraglandular tumor

13. Answer = A

14. Category = Easy
Most common systemic disease associated with sjogrens syndrome is
a) Systemic lupus erythematosus (SLE)
b) Rheumatoid arthritis
c) Osteoarthritis
d) Scleroderma
e) Arthritis

15. Answer = B
Sjogren syndrome
 A multisystem or systemic, immune mediated (autoimmune), chronic
inflammatory disease process involving mostly the exocrine glands (principally
the salivary i.e major and minor and lacrimal glands) with a variable
presentation that, resulting in xerostomia (dry mouth) and xerophthalmia or
keratoconjunctivitis sicca (dry eyes) = sicca means “dry”
 The two types of Sjögren syndrome
1) Primary Sjögren syndrome, or sicca syndrome, characterized by xerostomia
(dry mouth) and keratoconjunctivitis sicca/xerophthalmia (dry eyes)
2) Secondary Sjögren syndrome, which is composed of primary Sjögren
syndrome and an associated automimmune multisystem connective tissue
disorder, most commonly rheumatoid arthritis (others include systemic
lupus erythematosus (SLE), or scleroderma).
• Sicca complex describes the triad of dry eyes, dry mouth, and lymphocytic
infiltration of the exocrine glands.

16. Category = Easy
One year H/o dryness of eyes and mouth. Definitive diagnose of sjogren
syndrome is made by
a) Anti SSA , anti SSB
b) Rose bengal, schirmers test
c) Lower lip Labial gland biopsy
d) Schintigraphy
e) Salivary flow rate studies

17. Answer = C

18. Category = Easy
Which one of the following is the malignant tumor of salivary gland
a) Oncocytoma
b) Polymorphous low grade adenocarcinoma
c) Monomorphic adenoma
d) Basal cell adenoma
e) Canalicular adenoma

19. Answer = B

20. Category = Easy
A 40-year-old woman develops Frey syndrome after undergoing parotidectomyor parotid
swelling surgery. The most likely cause is injury to branches of which of the following
nerves?
a) Facial nerve
b) Great auricular
c) Auriculotemporal nerve
d) Posterior auricular
e) Mandibular nerve

21. Answer = C
Mechanism or Pathogenesis
 Auriculotemporal nerve (branch of the mandibular (V3)
division of the Trigeminal nerve)
Sensory fibers to the preauricular and temporal regions,
Carries parasympathetic fibers to the parotid gland i.e The
parasympathetic innervation which stimulates the saliva
production is carried from the tympanic branch of the
glossopharyngeal nerve to the otic ganglion via the lesser
petrosal nerve. From there the parasympathetic postganglionic
neurons reach the gland via the auriculotemporal nerve.
Sympathetic vasomotor and sudomotor (sweat stimulating)
fibers to the cutaneous sweat glands of preauricular skin.
▪ Aberrant neuronal regeneration or misdirect of the postganglionic
secretomotor parasympathetic nerve fibers, which are carried in
the auriculotemporal nerve from the otic ganglion to the parotid
with the Sympathetic vasomotor and sudomotor (sweat
stimulating) fibers to the cutaneous sweat glands of preauricular
skin after 2- months. As a result, sweating, dermal flush/redness,
or both occur in the distribution of the auriculotemporal nerve
during salivary, gustatory or psychic stimulation due to stimulation
of local sweat glands

22. Category = Easy
Most common gland of stone formation is
a) Parotid gland (stensen duct)
b) Sublingual gland
c) Submandibular gland (wharton duct)
d) Carmalt gland
e) Exocrine glands

23. Answer = C
Incidence of Sialolithiasis (by Gland)
 Submandibular gland 85%
 Parotid gland 10%
 Sublingual gland 5%
 Minor glands Rare (most often within the glands of the upper lip
or buccal mucosa)

24. Category = Moderate
Which of the following condition exhibits both inflammatory and neoplastic
characteristics?
a) Pleomorphic adenoma
b) Mucocele
c) Mikulicz’s disease
d) Sialolithiasis
e) Rheumatoid arthritis

25. Answer = C
 An autoimmune also called benign lymphoepithelial
lesion which is closely related to sjogren syndrome
and exhibits both inflammatory and neoplastic
characteristics

26. Category = Easy
Xerostoma and xerophthalmia is seen in
a) BMS
b) Sicca syndrome
c) Mikulik syndrome
d) Radiation of gland
e) Sjogren syndrome

27. Answer = B

28. Category = Easy
Dry eyes and dry mouth and joint pain occurs in
a) BMS
b) Sicca syndrome
c) Mikulik syndrome
d) Radiation of gland
e) Sjogren syndrome

29. Answer = E

30. Category = Moderate
Multiple small and 1 large ( more than 7mm) submandibular stone located
near hilum of submandibular gland, best treatment option
a) Lithotomy
b) Removal of salivary gland
c) Lithotripsy
d) Sialodochoplasty
e) Lacrimal probe removal

31. Answer = B

32. Category = Difficult
Over the past 8 months, the patient had noticed a progressively enlarging mass anterior
and inferior to her right ear. The patient explained that the mass has slowly enlarged,
prompting her to bring it to her dentist’s attention. There is no associated pain,
paraesthesias, or motor deficits. She denies any constitutional symptoms, including
fever, chills, night sweats, appetite changes, and weight loss. The probable diagnosis
would be
a) Monomorphic adenoma.
b) Warthin tumor
c) Pleomorphic adenoma
d) Malignant salivary gland neoplasms.
e) Mucoepidermoid carcinoma

33. Answer = C

34. Category = Easy
What percentage of the sialoliths present in parotid gland are
poorly calcified?
a) 5 %
b) 10 %
c) 20 %
d) 40 %
e) 50 %

35. Answer = E

36. Category = Easy
The patient was recently evaluated by her general dentist and was subsequently referred
for evaluation and treatment of a persistent mass in her lower lip. The lesion was noticed 1
month earlier and has gradually increased to its current size. The mass developed after
trauma to the lower lip during function and has proved to be a site of continued trauma
due to its persistence. The provisional prognosis would be
a) Fibroma
b) Mucocele
c) Hemangioma
d) Lipoma
e) Ranula

37. Answer = B

38. Category = Difficult (FCPS PART 2 MCQ PAST
PAPERS)
A patient came with diagnosed case of adenoid cystic carcinoma. After
excision what do you suggest
a) Neck dissection
b) Radiotherapy
c) Chemotherapy
d) Radio plus chemo
e) No need of any further therapy

39. Answer = B

40. Category = Moderate
7mm stone in the hilum is treated by
a) Sialolithetomy
b) Submandibular gland excision
c) Siolodochotomy
d) Sialodochoplasty
e) Lacrimal probe removal

41. Answer = B
The management of submandibular gland calculi depends on the
Location of the stone (most important)
They can be present in the anterior or posterior portions of submandibular duct and also in the intraglandular portion of the duct. The most frequent location of
submandibular gland calculi is extraglandular.
Anterior stones are generally well visualized on a mandibular occlusal radiograph and may be amenable to intraoral removal.
Posterior stones occur in up to 50% of cases and may be located at the hilum of the gland or within the substance of the gland itself, making intraoral removal
difficult because of limited access. A routine mandibular occlusal film will likely not demonstrate the stone because of its posterior position, and a panoramic
radiograph or a CT scan may be necessary to localize the stone.
Duration of symptoms
Number of repeated episodes
Size of the stone
If small and anteriorly
placed
Attempt to dilate the
Wharton duct or orifice
with lacrimal probes and
retrieve the stone by
passing suture (Be careful
not to displace stone
posteriorly)
Sialodochoplasty (i.e.,
revision of the salivary
duct)
Posteriorly located stones
Shock wave lithotripsy
(Extracorporeal)
Presence of calculus in the
intraglandular portion of the duct or
posterior stone that can not be
palpated intraorally with normal
function of the gland sialographically
and no infection/inflammatory
changes
Perihilar or intraparenchymal stones
measuring less than 7 mm
Repeated chronic stone formation
Repeated signs and symptoms
Extraoral gland removal and the
associated stones (sialadenectomy)
Presence of calculus in the
intraglandular portion of the duct or
posterior stone that can not be
palpated intraorally with abnormal
function of the gland sialographically
or infection/inflammatory changes
Perihilar or intraparenchymal stones
measuring more than 7 mm
Repeated chronic stone formation
Repeated signs and symptoms

42. Category = Difficult (FCPS PART 2 MCQ PAST
PAPER)
Diagnostic criteria for Sicca syndrome
a) Xerostomia and xerophthalmia persist more than 3 month
b) Xerostomia and xerophthalmia persist more than 6 month
c) Xerostomia, xerophthalmia plus SLE
d) Xerostomia, Xerophthalmia plus Arthralgia
e) Symptoms persist more than 6 months

43. Answer =A

44. Category = Difficult (FCPS PART 2 MCQ PAST
PAPERS)
A 75 years old patient, diagnosed case of sjogren syndrome. She has
parotid gland swelling. Choice of investigation for this patient is
a) Schimmer test
b) Labial gland biopsy
c) CT scan
d) FNAC cytology
e) Schintigraphy

45. Answer = D

46. Category = Moderate
Most concerning complication associated with Sjogren syndrome
a) Acute and chronic sialadenitis (which may be infective)
b) Sialolithiasis
c) Dental caries due to xerostomia
d) Corneal ulceration due to xerophthalmia.
e) Parotid lymphoma

47. Answer = E
1) Acute and chronic sialadenitis (which may be infective)
2) Sialolithiasis
3) Dental caries due to xerostomia
4) Corneal ulceration due to xerophthalmia.
5) Parotid lymphoma
 Probably the most concerning complication associated with SS
 The overall prevalence is estimated to be 4%.
 Usually, these are mucosal associated lymphoid tissue (MALT) lymphomas, which are low-grade
non-Hodgkin’s type with good prognosis. If high-grade lymphomas occur, the life expectancy is
affected
 In addition, the risk of parotid lymphoma is increased 44-fold.
 When an involved gland contains nodules or masses, FNA of the dominant mass should be
performed to exclude lymphoma.

48. Category = Moderate
A 18-year-female patient presents to you with bilateral, painless
enlargement of her parotid glands. She has a history of anorexia nervosa.
Which one of the following is the most likely diagnosis?
a) Sialadenitis
b) Sialolithiasis
c) Sialosis
d) Sialorrhoea
e) Sialometaplasia

49. Answer = C
 Sialosis presents as a bilateral non-inflammatory, painless enlargement
of parotid glands and may be associated with eating disorders.
 Sialorrhoea refers to increased salivary flow.
 Sialadentis and sialolithiasis are unlikely to involve parotid glands
bilaterally.

50. Category = Moderate
A 45-year-old patient presents with a 2 × 2 cm well-demarcated firm mass
in his right parotid region. A fine-needle aspiration cytology report shows
evidence of a mixture of glandular epithelium and myoepithelial cells
within a mesenchymal background. What is the most likely diagnosis ?
a) Acinic cell carcinoma
b) Adenoid cystic carcinoma
c) Adenolymphoma
d) Pleomorphic adenoma
e) Squamous cell carcinoma

51. Answer = D
According to multicellular theory, the tumor is derived from intercalated ductal cells and myoepithelial cells of salivary
gland
Epithelial component
May form various patterns like ducts, acini, tubules, sheets and strands or
islands of ductal or myoepithelial origin
The epithelium often forms cystic structures
Keratinizing squamous cells and mucus-producing cells also can be seen.
Intercalated
Ductal or
glandular
epithelial cells
Ductal cells are
cuboidal or
columnar
Non ductal cells (myoepithelial cells)
Myoepithelial cells often make up a large
percentage of the tumor cells and have a variable
morphology, sometimes appearing angular or
polygonal or spindled.
Modified myoepithelial cell, which may differentiate
along a variety of cell lines (pleomorphic means
many forms)
Some myoepithelial cells are rounded and
demonstrate an eccentric nucleus and eosinophilic
hyalinized cytoplasm, thus resembling plasma
cells. These characteristic plasmacytoid
myoepithelial cells are more prominent in tumors
arising in the minor glands
Mesenchymal component or stroma (The highly characteristic
“stromal” changes are believed to be produced by the myoepithelial cells)
Myxoid
Osseous or osteoid
Mucoid
Fibroid
Vascular
Fibro collagenous
Myxochondroid (Extensive accumulation of mucoid material may
occur between the tumor cells, resulting in a myxomatous
background)
Chondroid appearance (Vacuolar degeneration of cells produce a
chondroid appearance or background)

52. Category = Moderate
A 45-year-old male patient presents with a painful lump in his right parotid region. On
clinical examination there is evidence of a mild weakness of his right facial nerve. Which
one of the following is the most likely diagnosis ?
a) Adenoid cystic carcinoma
b) Adenolymphoma
c) Basal cell adenoma
d) Monomporphic adenoma
e) Pleomorphic adenoma

53. Answer = A

54. Category = Moderate
Which of the following is not seen in Sjogren’s Syndrome?
a) Xerostomia
b) Lung disease
c) Cataract
d) Sialolith
e) Joint pain

55. Answer = C

56. Category = Easy
Best way to palpate submandibular gland is:
a) Bimanual extraoral palpation with the patient head tipped forward and
towards the same side
b) Monomanual extraoral palpation with patient's head tipped forward and
toward the same side
c) Bimanual, simultaneous intraoral and extraoral palpation
d) Intraoral palpation with the patient head tipped forward
e) Extraoral palpation

57. Answer = C

58. Category = Easy
What is the approximate unstimulated salivary flow rate
a) 2 ml/min
b) 0.2 ml/min
c) 0.02 ml/min
d) 20 ml/min
e) 3 ml/min

59. Answer = B

60. Category = Easy
25 years old patient presented to you with a history of bluish lesion on the inside of lower
lip. The patient states that it ruptures and reoccurs after some time. He had not sought
any medical help previously for the condition. What is the preferred treatment of recurrent
mucocele?
a) Marsupilization of the mucocele
b) Enucleating the mucocele only
c) Enucleating the mucocele along with salivary gland tissue and surrounding tissue
d) Enucleating the mucocele with salivary gland tissue only
e) Enucleation/excision of salivary gland

61. Answer = C
 Salivary ducts, especially those of the minor salivary glands, are occasionally traumatized, commonly by
lip biting, and are severed or disrupted beneath the surface mucosa. Subsequent saliva production may
then extravasate beneath the surface mucosa into soft tissue. Over time, secretions accumulate within
the tissue and may produce a pseudocyst (without a true epithelial lining) that contains thick, viscous
saliva. These lesions are most common in the mucosa of the lower lip and are known as mucoceles. The
second most common site of mucocele formation is the buccal mucosa.
 Mucocele formation results in an elevated, thinned, and stretched overlying mucosa that appears as a
vesicle filled with a clear or blue gray mucus.
 The patient frequently relates a history of the lesion filling with fluid, rupture of the fluid collection, and
refilling of the lesion.
 Some instances of mucocele formation regress spontaneously without surgery.
 For persistent or recurrent lesions, the preferred treatment consists of excision of the mucocele and the
associated minor salivary glands that contributed to its formation to prevent recurrence in that same
location
 For lower lip mucoceles, regional local anesthesia is administered via a mental nerve block, and an
incision is made through the mucosa. Careful dissection around the mucocele may permit its complete
removal; however, in many cases, the thin lining ruptures and decompresses the mucocele before
removal. The regional associated minor salivary glands are removed as well and sent for histopathologic
evaluation.
 The recurrence rates of mucoceles may be as high as 15% to 30% after surgical removal, possibly
caused by incomplete removal or repeat trauma to the minor salivary glands.

62. Category = Difficult (FCPS PART 2 MCQ PAST
PAPERS)
The swelling of pleomorphic adenoma is
a) Board like hard
b) Cartilage hard
c) Stony hard
d) Soft and fluctuant
e) Bony hard

63. Answer = B

64. Category = Moderate
A 58 year old female presented with dryness of eyes and mouth, she was a
diagnosed case of Sjogrens syndrome and was on medication since last 3
years; she now came to resolve the issue of dryness of mouth. Oral
medicine that can be prescribed to the patient is.
a) Atropine
b) Pilocarpine 5mg orally
c) Cevimeline 5mg orally
d) Anti-inflammatory drugs
e) Steroids

65. Answer = B

66. Category = Easy
A patient presented with redness and sweating on cheek area adjacent to
ear, while eating or thinking about certain foods. This condition can occur
following.
a) Enucleation
b) Parotidectomy
c) Marsupialization.
d) Chemotherapy.
e) Radiotherapy

67. Answer = B

68. Category = Difficult (FCPS MCQ PAST PAPER)
You are doing a parotid surgery. Most reliable point to locate facial nerve
a) ABD
b) SCM, PBD
c) Anterior belly of digastric and SCM
d) Mastoid tip and anterior belly of digastric
e) Tragal pointer, PBD, mastoid tip

69. Answer = E

70. Category =Moderate
50 years old female presented to the OPD with complaint of dry mouth. On
inquiring about her medical history she added that she had joint pains and
a gritty feeling in her eyes. She had also been seeing a rheumatologist.
Labial gland biopsy showed lymphocytic infiltration >50, probable
diagnosis is
a) Sjogren Syndrome
b) Sicca syndrome
c) Burkitt's Lymphoma
d) Tmj Arthritis
e) Mumps

71. Answer = A
 Biopsy of the minor salivary glands of the lower lip is considered highly accurate and widely used diagnostic
test in establishing the diagnosis of Sjögren syndrome, since the histopathologic changes seen in the minor
glands are similar to those in the major glands (parotid).
 The basic microscopic finding in Sjogren syndrome is a lymphocytic infiltration of the salivary glands, which
leads to destruction of the acinar units i.e glandular parenchyma is infiltrated and eventually destroyed by
lymphoplasmacytic infiltration and replacement
 The involvement of the salivary and lacrimal glands results from a lymphocytic replacement of the normal
glandular elements
Technique
 A 1.5- to 2.0-cm incision is made on clinically normal lower labial mucosa, parallel to the vermilion border and
lateral to the midline, allowing the harvest of five or more accessory glands. These glands then can be
examined histopathologically for the presence of focal chronic inflammatory aggregates composed of 50 or
more lymphocytes and plasma cells.
 The aggregates should be adjacent to normal-appearing acini and should be found consistently in most of the
glands in the specimen. The following formula has been suggested:
◦ Focus score = Number of inflammatory aggregates X 4 / Number of mm2 of salivary gland parenchyma or
number of inflammatory aggregates per 4-mm2 area of salivary gland tissue.
◦ A focus score ≥ 1 (i.e., one or more foci of 50 or more cells per 4-mm2 area of glandular tissue) is
considered supportive of the diagnosis of Sjogren syndrome
◦ The greater the number of foci (up to 12 or confluent foci) is, the greater is the correlation with this
diagnosis.

72. Category = Easy
Bilateral swelling of the parotid gland with fever is seen resolve
in a week
a) Measles
b) Mumps
c) Sjogren syndrome
d) Bacterial infection
e) Dehydration

73. Answer =B
Viral parotitis (Mumps)
 Acute, Non suppurative and communicable disease
 Caused by paramyxovirus
 Begins 2 to 3 weeks after exposure of virus (incubation period)
 Painful, non erythematous bilateral preauricular or parotid swelling along with fever, chills
and headache
Treatment
 Usually resolve in 5 to 12 days
 Supportive and symptomatic care for fever, head ache and malaise with antipyretics,
analgesics and adequate hydration
Complications
 Meningitis
 Pancreatitis
 Nephritis
 Orchitis
 Testicular atrophy and sterility in 20% of young adults

74. Category = Easy
56 years old female patient presented with a lesion on the hard palate associated with
pain. Medical history was insignificant although she did mention a generalised feeling of
malaise and weakness. A biopsy was taken and sent for histopathology. H/P showed Swiss
cheese appearance (cribriform). What is your Diagnosis?
a) Pleomorphic adenoma
b) Adenoid cystic carcinoma
c) Acinic cell carcinoma
d) Low grade polymorphous adenoma
e) Mucoepidermoid carcinoma

75. Answer = B
Cribriform or glandular pattern = Most classic and best recognized appearance
• Characterized by islands or infiltrative proliferation of basaloid epithelial cells that contain multiple cylindrical,
cystlike spaces resembling Swiss cheese or cribiform pattern. These spaces often contain a mildly basophilic
mucoid material, a hyalinized eosinophilic product, or a combined mucoid-hyalinized appearance.
 Sometimes the hyalinized material also surrounds these cribriform islands, or small strands of tumor are found
embedded within this hyalinized “stroma.”
 The tumor cells are small and cuboidal, exhibiting deeply basophilic nuclei and little cytoplasm. These cells are
fairly uniform in appearance, and mitotic activity is rarely seen.
Tubular pattern
 The tumor cells are similar but occur as multiple small ducts or tubules within a hyalinized stroma. The tubular
lumina can be lined by one to several layers of cells, and sometimes both a layer of ductal cells and myoepithelial
cells can be discerned.
Solid pattern
 Consists of larger islands or sheets of tumor cells that demonstrate little tendency toward duct or cyst formation.
 Unlike the cribriform and tubular patterns, cellular pleomorphism and mitotic activity, as well as focal necrosis in
the center of the tumor islands, may be observed.
 Positive immunostaining reactions for CD43 and c-kit (CD117) in adenoid cystic carcinoma have been reported to
be useful diagnostic features that can help to distinguish this tumor from polymorphous low-grade
adenocarcinoma, basal cell adenoma, and canalicular adenoma.

76. Category = Difficult (FCPS PART 2 MCQ PAST PAPERS)
A patient reported with complaint of sweating over right auricle and temporal region
during eating. Patient reported that it developed after he underwent surgery for parotid
tumor. It is a complication which may result from injury to Auriculotemporal nerve during
removal of parotid tumor is. It is called Frey’s syndrome. How you can prevent Frey’s
syndrome during surgery
a) BTX
b) Fascia between skin flap and parotid
c) Ligation of capsule
d) Radiotherapy
e) Proper suturing

77. Answer = B
Prevention of initial risk or intraoperative surgical management (Aim =
Creation of a barrier at the time of surgery that hinders aberrant nerve
regeneration)
1) Increased skin flap thickness
2) Acellular dermal matrix (extracellular connective tissue graft generated via
decellularization process wherein cellular component of the dermis is removed)
3) Rotation of the sternocleidomastoid muscle flap over the parotid bed following
parotid surgery = not only prevent Frey’s syndrome but also fills in the cosmetic
deformity due to hollowing of the face in the parotid region.
4) Superficial temporal fascia
5) Free fat/abdominal fat
6) Fascia lata
7) Temporoparietal fascia
8) SMAS

78. Category = Easy
Most common complication of Mumps is
a) Myocarditis
b) Uveitis
c) Conjuctivitis
d) Orchitis
e) Pericarditis

79. Answer = D
Viral parotitis (Mumps)
 Acute, Non suppurative and communicable disease
 Caused by paramyxovirus
 Begins 2 to 3 weeks after exposure of virus (incubation period)
 Painful, non erythematous bilateral preauricular or parotid swelling along with fever, chills
and headache
Treatment
 Usually resolve in 5 to 12 days
 Supportive and symptomatic care for fever, head ache and malaise with antipyretics,
analgesics and adequate hydration
Complications
 Meningitis
 Pancreatitis
 Nephritis
 Orchitis
 Testicular atrophy and sterility in 20% of young adults

80. Category = Moderate
Acinic cell carcinoma of the salivary gland arise most often in the
a) Parotid gland
b) Submandibular gland
c) Sublingual gland
d) Minor salivary gland of the palate
e) Minor salivary glands of the lip

81. Answer = A
Pleomorphic adenoma
• Parotid (80-90%%) = 1st
most common site - 80% usually within the superficial
lobe, especially its lower pole. 10% may occur in the deep lobe beneath facial
nerve or an accessory parotid gland
• Submandibular gland (7%) – 2nd
most common site
• Minor salivary glands (3%) – 3rd
most common site
 Palate (posterior lateral aspect of the palate) = most common intraoral site
 Upper lip = 2nd
most common intraoral site
 Buccal mucosa
 Other sites (e.g., nasal cavity, paranasal sinuses,larynx, phaynx and trachea)
▪ Sublingual gland (rare)
Mucoepidermoid carcinoma
▪ Site = parotid gland (1st
most common site), minor glands especially on the palate
(2nd
most common site)
▪ Although the lower lip, floor of mouth, tongue, and retromolar pad areas are
uncommon locations for salivary gland neoplasia, the mucoepidermoid carcinoma
is the most common salivary tumor in each of these sites
▪ Intraosseous tumors also may develop in the jaws
Acinic cell carcinoma
• Parotid gland = 1st most common site
• Minor salivary glands = 2nd most common site
(involving the upper lip and vestibule, buccal and
palatal mucosa)
• The sublingual and submandibular gland are less
commonly involved.
Adenoid cystic carcinoma
• Can occur in any salivary gland but most common
within the minor salivary glands mostly palate
• In the parotid gland, the adenoid cystic carcinoma is
relatively rare, constituting only 2% of all tumors.
• In the submandibular gland, this tumor accounts for
11% to 17% of all tumors and is the most common
malignancy.
Polymorphous low-grade adenocarcinoma
• Exclusively a tumor of the minor salivary glands
• Most common site is the junction of the hard and soft
palates

82. Category = Easy
Salivary gland tumors are most common in
a) Parotid salivary gland
b) Submandibular salivary gland
c) Sublingual salivary gland
d) Minor salivary glands of palate
e) Minor salivary glands of lip

83. Answer = A

84. Category = Moderate
A 36 year old male patient reported to the opd with swelling infront of right ear extending
to the neck. Medical history is non-significant. On inquiring personal history the patient
claims to be a smoker from the past 15 years. A biopsy was taken and sent for
histopathology which revealed cystic spaces lined by two rows of cells within lymphoid
stroma. Your diagnosis will be
a) Warthin’s Tumours
b) Pleomorphic Adenoma
c) Basal Adenoma
d) Cannalicular Adenoma
e) Monomorphic adenoma

85. Answer = A
The Warthin tumor has one of the most distinctive histopathologic patterns of any tumor in
the body
Macroscopic
Smooth, soft
Well capsulated
Variable number of cyst containing
clear or sometimes chocolate colored
fluid
Focal Hemorrhagic area
Microscopic
Ductal Epithelial component (oncocytic in nature)
Forming uniform rows of cells surrounding cystic
spaces. The cells have abundant, finely granular
eosinophilic cytoplasm and are arranged in two
layers.
Papillary projections or
infoldings in cystic spaces
Bilayered epithelium
Outer oncocytic or luminal layer
(consist of tall columnar cells with centrally placed, palisaded
arrangement, and slightly hyperchromatic nuclei cells)
Inner oncocytic layer
(consist of cuboidal or polygonal cells with more
vesicular nuclei)
Cystic
spaces
(Contain
eosinophili
c
coagulum)
Lymphoid aggregates
or component with
germinal centers in a
connective tissue stroma
Lymphoid aggregates
in connective tissue
stroma

86. Category = Moderate
Perineural spread is seen in
a) Mucoepidermoid carcinoma
b) Adenoid cyst carcinoma
c) Peomorphic adenoma
d) Monomorphic adenoma
e) Pleomorphic adenoma

87. Answer = B
Most common intraoral salivary gland malignancy
• Mucoepidermoid carcinoma = 1st most common
• Polymorphous low-grade adenocarcinoma (lobular
carcinoma; terminal duct carcinoma) = 2nd most
common
• Adenoid cystic carcinoma = 3rd most common

88. Category = Easy
A 40 years old patient presented to you with a 1x1cm swelling of lower lip which is soft in
consistency and is adherent to underlying mucosa. Overlying mucosa is bluish in color.
Patient also gave history of watery discharge from the swelling and spontaneous resolution
few weeks ago. Now it has occurred again. You make a clinical diagnosis of Mucocoele.
What would be the best treatment
a) Enucleation
b) Excision
c) Excision with removal of gland
d) Enucleation/excision + removal gland along with some normal mucosa
e) Removal of glands

89. Answer = D
Mucocele/Extravastion cyst
 Salivary ducts, especially those of the minor salivary glands, are occasionally traumatized,
commonly by lip biting, and are severed or disrupted beneath the surface mucosa.
 Rupture of salivary gland duct may leads to extravasation of saliva/spillage of mucin
beneath the surface mucosa into surrounding soft tissue. Over time, secretions accumulate
within the tissue and may produce a pseudocyst (without a true epithelial lining) that
contains thick, viscous saliva.
 These lesions are most common in the mucosa of the lower lip and are known as mucoceles
and the second most common site of mucocele formation is the buccal mucosa.
 Mucocele formation results in an elevated, thinned, and stretched overlying mucosa that
appears as a vesicle filled with a clear or blue-gray mucus or fluid
 The patient frequently relates a history of the lesion filling with fluid, rupture of the fluid
collection, and refilling of the lesion.

90. Category = Easy
Reason of biopsy in necrotizing siaometaplasia
a) Resemblance to inflammatory process
b) Resemblance to aphthous ulcer
c) Resemblance to autoimmune disease
d) Resemblance to malignancy
e) Resemblance to precancerous conditions

91. Answer = D
Necrotizing Sialometaplasia
 A reactive, non-neoplastic inflammatory process that usually affects the minor salivary glands of the palate.
However, it may involve minor salivary glands in any location.
 Unclear origin but is thought to result from vascular infarction of the salivary gland lobules.
 Type of necrosis is coagulative necrosis
 Potential causes of diminished blood flow to the affected area include trauma, local anesthetic injection,
smoking, diabetes mellitus, vascular disease, and pressure from a denture prosthesis.
 The usual age range of affected patients is between 23 and 66 years.
 Lesions usually appear as large (1 to 4 cm), painless or painful, deeply ulcerated areas lateral to the palatal
midline and near the junction of the hard and soft palates. Although lesions are usually unilateral, bilateral
involvement may occur. Some patients may report a prodromal flulike illness before the onset of the
ulceration.
 This condition is of considerable concern because, clinically and histologically, it resembles a malignant
carcinoma (squamous cell carcinoma or mucoepidermoid carcinoma).
 A benign, selflimiting disease process.
 The histopathologic appearance is that of pseudoepitheliomatous hyperplasia, which appears as epithelial
infiltration into underlying tissue similar to a carcinoma. Helpful histologic criteria for distinguishing
necrotizing sialometaplasia from a malignant process include the absence of cellular pleomorphism,
maintenance of the overall salivary lobular morphology, generally nondysplastic appearance of the
squamous islands or nests, and evidence of residual ductal lumina within the epithelial nests.
 The ulcerations usually heal spontaneously within 6 to 10 weeks after onset and require no surgical
management.

92. Category = Moderate
Spindle cell carcinoma is a variant of
a) Adenoid cystic carcinoma
b) Mucoepidermoid carcinoma
c) Squamous cell carcinoma
d) Basal cell carcinoma
e) Acinic cell carcinoma

93. Answer = C
Variants of SCC
 Verrucous Carcinoma
 Spindle Cell (Sarcomatoid) Carcinoma
 Basaloid Squamous Cell Carcinoma = More aggressive

94. Category = Moderate
Pre auricular swelling with facial paralysis. Diagnostic
modalities?
a) Excisional biopsy
b) FNAC
c) Incisional biopsy
d) FNAB
e) Punch biopsy

95. Answer = B

96. Category = Moderate
A 63-year-old non smoking African American female presents with a 3-cm preauricular
single nodular mass. She states that the lesion has been slowly growing over the past 13
years. She is asymptomatic and wants it removed for cosmetic reasons. Examination
reveals that the nodule is freely mobile and not fixed to underlying tissue. The most likely
diagnosis for this lesion is which of the following?
a) Warthin’s tumor
b) Hodgkin’s lymphoma
c) Adenoid cystic carcinoma
d) Pleomorphic adenoma
e) Mucoepidermoid carcinoma

97. Answer = D

98. Category = Moderate
Histopathological grading of mucoepidermoid carcinoma is based on
a) Amount of cyst formation
b) Amount of cyst formation and Degree of cytologic atypia
c) Relative numbers of mucous, epidermoid, and intermediate cells
d) Degree of cytologic atypia and relative numbers of mucous, epidermoid,
and intermediate cells
e) Amount of cyst formation, Degree of cytologic atypia and relative
numbers of mucous, epidermoid, and intermediate cells

99. Answer = E

100. Category = Difficult (FCPS PART 2 MCQ PAST PAPERS)
A patient came with preauricular swelling, the swelling was slowly
progressive and firm in consistency diagnosis
a) Pleomorphic adenoma
b) Warthin tumor
c) Adenoid cystic carcinoma
d) Mucoepidermoid carcinoma
e) Acinic cell carcinoma

101. Answer = A
Pleomorphic adenoma
 Typically appears as a painless, slowly growing (intermittent growth), firm mass or nodule that
does not ulcerate skin or mucosa
 No fixation to deeper tissues as well as overlying skin
 Pleomorphic adenoma of the parotid appear as a swelling overlying the mandibular ramus in
front of the ear
 Solitary tumors are round with smooth surface; recurrent tumors are frequently multinodular
 Initially, the tumor is movable but becomes less mobile as it grows larger.
 Palatal tumors presenting as smooth-surfaced, dome shaped masses. If the tumor is
traumatized, then secondary ulceration may occur. Because of the tightly bound nature of the
hard palate mucosa, tumors in this location are not movable, although those in the lip or buccal
mucosa frequently are mobile. Localized discomfort is usually present during mastication,
talking or breathing
 Facial nerve palsy is rare.
 Sometimes these lesions grow in a medial direction between the ascending ramus and
stylomandibular ligament, resulting in a dumbbell-shaped tumor that appears as a mass of the
lateral pharyngeal wall or soft palate = indicates deep lobe of parotid is affected
 Rarely bilateral pleomorphic adenomas of the parotid glands develop in either a synchronous or
metachronous fashion

102. Category = Difficult (FCPS PART 2 MCQ PAST PAPERS)
A patient came with palatal swelling since 6 months, there is no pain
associated with it
a) Polymorphous low grade adenocarcinoma
b) Adenoid cystic
c) Acinic cell carcinoma
d) Monomorphic adenoma
e) Warthin tumor

103. Answer = A
Polymorphous low-grade adenocarcinoma
• Second most common intraoral salivary gland malignancy.
• Most common site is the junction of the hard and soft palates
• Male-to-female ratio is 3 : 1, with a mean age of 56 years.
• These tumors present as slow-growing, asymptomatic masses that may become
ulcerated.
• Histopathologic examination = Many cell shapes and patterns (polymorphous). Histologic
appearance shows an infiltrative proliferation of ductal epithelial cells in an “Indianfile”
pattern. This lesion shows a neurotropic predilection for invasionof and propagation along
the surrounding nerves.

104. Category = Difficult (FCPS PART 2 MCQ PAST PAPERS)
A 25 years old presents with preauricular swelling, the swelling is
unilateral, the patient has history of smoking since 25 years diagnosis
a) Pleomorphic adenoma
b) Warthin tumor
c) Mucoepidermoid
d) Acinic cell carcinoma
e) Adenoid cysticcarcinoma

105. Answer = B
 Age = 6th
and 7th
decade of life
 Sex = more common in males due to smoking
 Site = It almost exclusively affects the parotid gland, specifically
the tail of the parotid gland near the angle of the mandible. In
rare instances, the Warthin tumor has been reported within the
submandibular gland or minor salivary glands.
 Association with smoking (Smokers have an eightfold greater
risk for Warthin tumor)
 Bilateral involvement that may or may not be simultaneous in
10% of cases (association with smoking also may help explain
the frequent bilaterality of the tumor, because any tumorigenic
effects of smoking would be manifested in both parotids). Most
of these bilateral tumors do not occur simultaneously but are
metachronous (occurring at different times) = unique feature
 This lesion presents as a slow-growing, soft, painless , nodular
mass in the inferior pole of parotid gland. It may be firm or
fluctuant to palpation
 However, because the lymphoid component is often less
pronounced in these extraparotid sites, the pathologist should
exercise caution to avoid overdiagnosis of a lesion better
classified as a papillary cystadenoma or a salivary duct cyst with
oncocytic ductal metaplasia.