Diseases of the Respiratory Tract-MCQ with Answers

1.             Which one is not included in upper the respiratory tract?

               A.                  Oral cavity.

               B.                  Nasopharynx.

               C.                  Paranasal.

               D.                  Pharynx.

               E.                   Larynx.

2.             What respiratory disease is usually associated with asbestos?

              A.                  Emphysema.

              B.                  COPD.

              C.                  Pneumonia.

              D.                  Mesothelioma.

3.             Which is not a sign of inflammation?

A.                  Redness.

B.                  Pain.

C.                  Heat.

D.                  All are signs of inflammation.

4.             In questioning patient with COLD or FLU, which of the following is most often used to eliminate flu as diagnosis?

A.                  Do you have stuffy / runny nose?

B.                  Do you have muscle aches? 

C.                  Do you have a temperature?

D.                  Do your ears hurt?

               

5.                   What does the “I” stand for in the MIND Paradigm?

A.                  Infectious.

B.                  Inflammatory.

C.                  Immunologic.

D.                  I don’t know.

6.             What is the most important concern you as a dentist have for a patient of COPD?

A.                  Susceptibility to infection.

B.                  Allergies to penicillin.

C.                  Getting something stuck in their throat.

D.                  Local anesthetic adversely affecting them.

7.                 During anaphylactic shock, oxygen should be administered and  _______ epinephrine injected sublingually.

A.                  1 : 1

B.                  1 : 10

C.                  1 : 100

D.                  1 : 1000

8.              What should you NOT do in case of anaphylactic shock?

A.            Call 911.

B.            Give them penicillin.

C.            1 : 1000 epinephrine should be injected.

D.            Administer oxygen.

9.             Rust-colored phlegm may be indicative of:

A.                  Flu plus bronchitis.

B.                  Allergies.

C.                  Cold.

D.                  Flu plus pneumonia.

10.           Which of these is mismatched? (this is a trick question, remember, the MIND concept is based on what histopathologic problem leads To oral cavity problems)

A.                  Metabolic diseases -  pernicious anemia (vit B12 deficiency)

B.                  Immunological diseases - AIDS

C.                  Neoplastic diseases - fibroma

D.                  Developmental diseases – dentigerous cyst

11.          What is your major concern, as a dentist, with treating a patient with  COPD?

A.                  Infection through aerosol inhalation.

B.                  Cardiac arrest.

C.                  Bacteremia.

D.                  There is no problem.

12.          A patient walks into the office and says that she has a sore spot on her gums.  The sore spot could be categorized under:

             A.            Neoplastic disease.

             B.            Metabolic disease.

C.                  Developmental disease.

D.                  All of the above.

13.          Tuberculosis is indicated by:

A.                  Edema.

B.                  Hemoptysis.

C.                  Stridor.

D.                  Runny nose (rhinits).

14.          AIDS belongs to what categories?

             A.            Neoplastic disease.

             B.            Metabolic disease.

C.            Developmental disease.

D.            All of the above.

15.          Which of these definitions is incorrect?

A.                  Hemoptysis – coughing up blood.

B.                  Stridor – dry hack.

C.                  Productive cough – bring up phlegm.

D.                  Dyspnea – shortness of breath.

16.          Regular breathing involves a volume of _____________ of air with each inspiration and expiration, a measure referred to as the tidal volume:

             A.                  500 mL

B.                  200 mL

C.                  100 mL

D.                  900 mL

17.          What is the false definition?

A.                  Stridor – to bring up phlegm.

B.                  Non productive cough – dry hack.

C.                  Hemoptysis – coughing up blood.

D.                  Pulmonary  function test – test for lung capacity.

18.          The term “Red Puffers” describes a person with which type of disease?

A.                  Emphysema.

B.                  Bronchitis.

C.                  Tuberculosis.

D.                  AIDS

19.          Which disease of the upper airway is associated with a yellow nasal discharge?

A.                  Sinusitis.

B.                  Laryngitis.

C.                  Polyps.

D.                  Cancer.

20.          Signs and symptoms of sinusitis include all of the following, except:

A.                  Sneezing.

B.                  Fever.

C.                  Syncope.

D.                  Nasal discharge.

21.          What medications may be used for dental pain if the patient reports aspirin as the possible cause of asthma?

A.                  Acetaminophen.

B.                  Propoxyphene.

C.                  A and B

D.                  None of the above.

22.          What is not a sign or symptom of sinusitis?

A.                  Edema.

B.                  Sneezing.

C.                  Fever.

D.                  None of the above.

23.          The following are causal factors of inflammatory diseases, except:

A.                  Trauma.

B.            Nutritional.

B.                  Infective.  (C)

C.                  Reactive.  (D)

24.          What is the most common metabolic problem with oral manifestation?

A.                  Grave’s Disease.

B.                  Lyme Disease.

C.                  A.I.D.S.

D.                  Diabetes.

25.          Which of the following categories would an allergy to cats fall under?

A.                  Metabolic.

B.                  Inflammatory.

C.                  Neoplastic.

D.                  Developmental.

26.          Which type of patient is subject to oral metabolic problems?   

A.                  Cancer.

B.                  Hepatitis.

C.                  Diabetes.

D.                  Heart Disease.

27.          All of the following are associated with pneumonia except:

A.                  Require major antibiotics. (???)

B.                  Coughing and dyspnea.

C.                  Fever.

D.                  Viral infections.

28.          What disorder is an example of a metabolic disease which causes oral manifestations?

A.                  Tuberculosis.

B.                  Diabetes.

C.                  AIDS

D.                  None of the above.

29.          The clinical term for coughing up blood is:

             A.            Dyspnea.

             B.            Hemitis.

             C.            Hemoptysis.

             D.            Corpusclitis.

30.          Which of the following symptoms does not necessarily indicate a sinusitis?

A.                  Increased pressure and/or pain upon bending or lying.

B.                  Nasal fluid discharge.

C.                  Toothache of maxillary and/or mandibular arch.

D.                  Toothache that is alleviated by injection of local anesthetic.

31.          Which is NOT  an effective precaution that you may take if a patient present with COPD?

A.                  Keep patient sitting upright during appointment.

B.                  Antibiotic prophylaxis.

C.                  Rubber Damn.

D.                  Administer O₂ through nasal mask.

32.      In diagnosing a patient with liver problems, a physician may elect to run which tests:

    A.    SMA 20

    B.    BUN (Blood Urea Nitrogen)

    C.    Glycated Hemoglobin

    D.    Angioplasty

33.      After treatment, the patient, who takes medication to control his hypertension stands up and promptly falls backwards.  What is the most probable cause?

    A.    Postural hypotension

    B.    Not enough blood sugar level

    C.    Isomnia

    D.    Diabetes

    E.    Inner ear infection

34.      What is a major concern for dental treatment of a patient who has recently had a kidney transplant?

    A.    Hypertension

    B.    Frequent urination

    C.    When was their last dialysis

    D.    Opportunistic infections as a result of immunosuppression

35.      What is a symptom of hypertension?

Peter J. Note:  Pay attention!  This has the potential to be a trick question.  Be clear about the difference between a sign and a symptom.

    A.    High blood pressure

    B.    Dizziness

    C.    Excessive bleeding

    D.    Swollen ankles

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Mesothelioma and its Differential Diagnosis and Mesothelioma Treatments

Clinical Features of Mesothelioma

• Males >> females
• Age: 7^th and 8^th decades (with broad range)
• Signs and symptoms – shortness of breath, chest pain, recurrent effusions, Bloody pleural effusion,Dyspnoea
• Sites:  Pleura >> peritoneal >> other sites
• Majority associated with asbestos exposure
• Treatment: None proven; recent interest in extrapleural pneumonectomy and chemo/radiotherapy
• Prognosis:  Survival 6 to 18 months (epithelioid greater tha
• sarcomatoid/desmoplastic)
• Survival over five years is rare, but well documented.

Patterns of Presentation of Mesothelioma

• Diffuse process of pleura, peritoneum, or pericardium – by far the most common
• Localized pleural, mediastinal, or intraabdominal mass (all rare)-see below
• Metastatic disease, usually as lymphadenopathy (also rare)

 Differential Diagnosis

• When confronted with a potential mesothelioma, one needs to know as much clinical and radiologic information as is available.  The gross findings at the time of surgery or autopsy are extremely useful and these can often be inferred from radiologic studies.  If these features do not fit with the diagnosis that is being considered, then the pathologist should go back and re-assess the problem.
• The differential diagnosis of malignant mesothelioma depends on whether one is dealing with:
• An epithelial/epithelioid proliferation
• A spindle cell/fibroblastic proliferation and the approach to these two settings is entirely different. 
• The basic questions are whether the process is reactive or neoplastic, and if neoplastic is it mesothelioma or some other neoplasm mimicking a mesothelioma?  The diagnostic approach, criteria of malignancy, and ancillary tests, particularly immunostains, for these two groups are entirely different:

            Epithelioid proliferations:

Reactive mesothelial hyperplasia vs. neoplasm

If neoplastic, mesothelioma vs. carcinoma (or melanoma, etc.)

For spindled/fibroblastic proliferations:

Fibrous pleurisy vs. neoplasm

If neoplastic, desmoplastic/sarcomatoid mesothelioma vs. other (sarcoma, melanoma, sarcomatoid carcinoma, etc.)

1.         The distinction of benign mesothelial proliferations from mesothelioma is covered by Churg and recommendations summarized below:

2.         The distinction between mesothelioma and metastatic carcinoma involving the pleura is the most common problem and the one that has engendered the largest number of papers in the literature and the situation in which immunohistochemical staining is most useful.  The following are some of the features that I personally have found helpful over the years in distinguishing mesothelioma from carcinoma:

• Fibrous stroma produced by the proliferation?  This favors a neoplasm.
• Stromal invasion?  This favors a neoplasm; beware of entrapment of mesothelial cells particularly in the pericardium.
• Complex cellular proliferation or cohesive sheet-like proliferation?  Favors neoplasm.
• Are papillae present?  Favors a neoplasm.
• Is necrosis present?  Favors a neoplasm.
• Cytologic features?  Cytologically bland, cells can be seen in reactive mesothelial proliferations and mesothelioma; marked nuclear atypia usually favors carcinoma.
• Nuclear molding?  Favors carcinoma.
• Columnar cell shape?  Favors carcinoma.
• Mucous production?  Faint mucicarmine positivity not uncommon in mesothelioma; intracellular droplet positivity with PASd favors carcinoma (but rarely reported in mesothelioma).
• Cytokeratin stain:  Good to confirm the cells actually stain; strong diffuse positivity characteristic of mesothelioma (as well as, obviously, some carcinomas); CK may highlight stromal invasion
• Electron microscopy?  Rarely helpful (to me!); cases that are diagnostic ultrastructurally tend to be easy light microscopy diagnoses (my bias).

The issue of carcinoma versus mesothelioma remains the most common problem and the vast majority of these cases are recognized with clinical history, knowledge of gross/radiologic findings, knowledge of prior neoplasms, and careful attention to routine histology. Carcinomas look like carcinomas and mesotheliomas look like mesotheliomas!  Immunohistochemistry is usually confirmatory.

Nevertheless, immunohistochemistry is considered by most to be the mainstay in this differential diagnostic problem and the horizon is ever changing as new antibodies are added and older ones are cast aside. The recommendation of an international mesothelioma working group is that one use at least two positive markers for mesothelioma and at least two positive markers for carcinoma in making this distinction. 

Practically speaking most experts do at least 6 antibodies for the carcinoma vs mesothelioma differential. In addition, sex and site of the biopsy are issues in selecting antibody panels; ER/PR stains may be indicated in women and the differential for carcinomas in the abdomen is different for that in the chest. I like a pancytokeratin, not for its discriminatory value, but to highlight the architecture of the proliferation, help highlight invasion, etc.

All cases

  Pankeratin to assess positivity and pattern

Markers favoring mesothelioma:

• Cytokeratin 5/6*
• Calretinin*
• WT-1*
• Thrombomodulin
• HBME1
• Membrane pattern with EM
• D2-40 (new, and many are excited about this one)
• Podoplanin (new, and many are excited about this one)

Markers favoring carcinoma:

• CEA*
• CD15*
• B72.3*
• MOC 31*
• TTF-1 (for lung ca)*
• BerEp4
• BG8
• EMA with cytoplastic pattern
• Surfactant (for lung ca)
• Others (e.g. ER/PR, CDX-2, PSA, etc. depending on situation)

None of these antibodies is perfect and occasional mesotheliomas stain positively (usually only a few cells focally) with carcinoma markers and carcinomas may stain with mesothelioma markers.  Squamous carcinoma, transitional carcinoma, and some others are frequently positive with cytokeratin 5/6 and adenocarcinomas of the lung not uncommonly stains with calretinin.  It is said that cytoplasmic and nuclear staining with calretinin is a good marker for mesothelioma.  The greater number of antibodies that one uses the greater the likelihood for discrepant staining and then one has to take a step back and try to prioritize the findings and keep a mental tally sheet of the positive and negative features that favor one diagnosis over the other.  In a small minority a confident diagnosis is not possible.

There have been a number of studies suggesting specific panels to use in the differential diagnosis of mesothelioma and adenocarcinoma.  Again, no panel is perfect and the antibodies suggested vary from study to study since some labs have their own favorite antibodies.  In the study by Yaziji, et al. a three antibody panel, including calretinin, BG8, and MOC 31 provided 96% sensitivity and specificity for distinguishing epithelioid mesothelioma from adenocarcinoma.  In clinical practice, the senior author (Dr. Gown) said that he would rarely follow this recommendation and usually did at least six antibodies as mentioned above. 

Ordonez has reviewed immunohistochemistry and electron microscopy in the distinction of peritoneal mesothelioma and serous carcinoma and concluded that BerEp-4 and MOC 31 are the best negative mesothelioma markers in this situation and that the best positive markers are D2-40, podoplanin, and calretinin.

3.         Desmoplastic mesothelioma versus fibrous pleuritis.  As defined above, a desmoplastic mesothelioma is a sarcomatoid mesothelioma that has greater than 50% dense collagenized stroma sometimes with a vague storiform appearance.  These regions are not overtly sarcomatous.  Since desmoplastic mesotheliomas may over grow hyaline pleural plaques it is sometimes difficult, if not impossible, to separate the pre-existing benign fibrotic reaction of the pleura from a desmoplastic mesothelioma since the latter may produce regions that are nearly indistinguishable from hyaline pleural plaque.  Abrupt transitions in cellularity are one of the most useful clues that the process is neoplastic.  The separation of desmoplastic mesothelioma from fibrous pleurisy is summarized as follows (from Churg):

The series by Mangano et al. nicely showed that desmoplastic mesothelioma could be separated from fibrous pleurisy on the basis of the presence of a diffuse storiform proliferation of the pleura and one or more of the following features:

• Invasion of the chest wall or lung
• Foci of bland necrosis
• Frankly sarcomatoid foci
• Distant metastases

Immunostaining in the setting of desmoplastic mesothelioma vs. fibrous pleurisy is helpful in highlighting invasion of cytokeratin positive cells into structures adjacent to the pleura such as lung or chest wall.  Doing carcinoma markers in this setting is inappropriate.

While rarely a problem, desmoid tumors may present as pleural masses and could mimic a desmoplastic mesothelioma.  In general these are more localized and have a more extensive soft tissue component.  These have recently been reviewed by Andino, et al.

4.         Sarcomatoid mesothelioma versus other sarcoma.  Distinguishing sarcomatoid mesotheliomas from other sarcomas involving the pleura is such an uncommon scenario that it is rarely encountered by the surgical pathologist.  In such cases careful attention to any prior history of sarcoma, the pattern of growth in the pleural space (sarcomas tend to be multiple nodules rather than more diffuse growth) and selected immunostains based on the histology of the process should allow resolution of most cases.  The only sarcomas seen in the pleura with any frequency, and ones which not uncommonly closely mimic a mesothelioma, are malignant vascular tumors.  When synovial sarcoma is in the differential, molecular studies for the X:18 translocation are useful.

Localized Malignant Mesotheliomas

The US & Canadian Mesothelioma Panel has put together a series of 22 cases that included both pleural and peritoneal locations.

• 15 men, 7 women; age 37-83 years; mean 62.4
• 20 pleural, 2 peritoneal
• Mean size: 6.1 cm
• 15 epithelial, 6 biphasic, 1 sarcomatous
• Immunohistochemistry and ultrastructural studies as for diffuse mesothelioma
• Follow-up in 11 cases; 7 dead of disease at 7 months to 6 years, 1 dead of unrelated causes, 3 (27%) alive at 6-18 months.  Those who died tended to die of metastatic disease as opposed to local spread.
• Based on these studies, localized malignant mesothelioma is now recognized as an unusual variant of malignant mesothelioma.  These appear as localized masses that are usually pleural based.  In the peritoneum they may involve adjacent structures and simulate primary tumors of the colon, stomach, liver, etc.

ASBESTOS AND MESOTHELIOMAS

While the vast majority of mesotheliomas are associated with asbestos exposure (the exact percent varies with the series) one essentially never encounters asbestos bodies in routine histologic sections of the pleura and the tumors that arise therein.  The search for asbestos bodies should be in lung tissue if it is included with the pleural biopsy.  The identification of asbestos bodies (even a single body) in routine histologic material of the lung suggests significant prior exposure and can be used to support an asbestos-associated mesothelioma.  An attribution of cause or association between a mesothelioma and asbestos exposure can also be made if there is sufficient documentation of exposure in the clinical history.

Mesothilioma Treatment

1. Palliative compensation
2. Seek specialist Advice

Differential Diagnosis of Odontalgia (Dental Pain)

Common features of Odontogenic pain

• Presence of etiologic factors for an odontogenic origin, (e.g. Caries, leakage of restorations, trauma, fracture).
• Ability to reproduce chief complaint during examination.
• Pain reduction by local anesthetic.
• Unilateral pain.
• Pain Qualities: dull, aching, throbbing.
• Localized pain.  
• Sensitivity to temperature.     
• Sensitivity to percussion , digital pressure.

Selected features of Non-odontogenic pain

• NO apparent factors for odontogenic pain, (e.g. no caries, leakage of restorations, trauma, fracture) .
• No consistent relief of pain by local anesthetic.
• Bilateral pain or multiple painful teeth.
• Chronic pain that is no responsive to dental treatment.
• Pain Qualities: Burning, electric shooting, stabbing, dull ache.
• Pain that occurs with a headache.
• Increased pain associated with palpation of trigger point or muscles.
• Increased pain associated with emotional stress, physical exercise, head position, etc.

Mechanisms of Non-odontogenic pain

Referred pain explained by CONVERGENCE. Certain afferent sensory nerve neurons have peripheral terminals that innervate different tissues, yet their central terminals converge onto the same second-order projection neuron located in the trigeminal nuclear complex.

A Systemic Disorder that interacts with pulpal or periradicular tissue. The systemic disorder serves as an etiologic factor for pain that originates from pulpal or periradicular nociceptors but is not derived from dental pathoses, thus dental treatment is ineffective in reducing pain. (e.g., HERPES ZOSTER, MALIGNANT NEOPLASIA, SICKLE CELL ANEMIA AND DEVELOPMENTAL DISORDER.

Psychosocial or behavioral factors may contribute to the perception of chronic craniofacial or dental pain. (e.g. Somatoform pain disorder and Munchausen syndrome)

Types of Non-odontogenic pain

1. Non-odontogenic dental pain of musculoskeletal origin

• Myofascial pain: Temporomandibular dysfunction 

Etiology: this classification is an umbrella term for several chronic pain disorders involving masticatory and proximate muscles and the Temporomandibular joint (TMJ). 

Muscles involved:

• Superior belly of the Masseter muscle - Maxillary Posterior Teeth
• Inferior belly of the Masseter muscle – Mandibular Molar Teeth
• Anterior Digastric muscle – Mandibular Anterior Teeth
• Temporal muscle – Maxillary Anterior or Posterior Teeth

2. Non-odontogenic dental pain of neuropathic origin

• Trigeminal neuralgia – (tic douloureux)

 Unclear etiology. Vascular compression of the trigeminal nerve is a common hypothesis.

• Atypical Odontalgia - (Phantom toothache, deafferentation pain)

Unknown etiology but is often associated with trauma or inflammation in the region. Hx of lack of response to multiple endodontic treatment s or extractions. Pain may change location with time. 10 times more prevelant that trigeminal neuralgia. 3% of patients receiving pulpal extirpation may actually have atypical odontalgia.

• Glosspharyngeal neuralgia

Unknown etiology but may involve vascular compression of the Ninth  cranial nerve. Severe, shock like pain that lasts for only a few seconds. Elicited by swallowing, talking or chewing. No pain referred to teeth. Distribution of pain includes the posterior mandible, oropahranyx, tonsillar fossa and ear.

• Neuralgia inducing cavitational oseomylelitis/osteonecrosis - (NICO)

Hypothesis that certain forms of chronic orofacial pain are caused by cavitation defects in the mandible or maxilla, a condition called NICO. Propose etiology is chronic inflammation or c=necrosis from bacterial osteomyelitis or vascular pathosis following extraction.

Controversial and not supported by scientific evidence.

3. Non-odontogenic dental pain of neurovascular origin

• Migraine - Migraine with aura - (Classic migraine), & Migraine without Aura - (Common Migraine)

Unknown etiology, a neurovascular hypothesis postulating vasodilation of cephalic and cerebral arteries with activation of sensitized perivascular nociceptors.

Pain is characterized by: pain not restricted to a tooth (i.e., diffuse pain); unilateral dull, throbbing pain quality, pain unrelieved by a diagnostic block and pain not altered by intraoral thermal stimuli.

•  Cluster Headache (Sluder neuralgia)

Unknown etiology but hypothesized to be caused by episodic vasodilation activating perivascular nociceptors. The term Cluster denotes the observation that these pain episode often last 6 to 8 weeks and then are followed by relatively long pain free period.

Pain is not restricted to a tooth (i.e. pain includes retro-orbital and sinus regions) pain exacerbated by drugs or occurring during sleep, pain unrelieved by diagnostic intraoral anesthetic block and pain not altered by intraoral thermal stimulation. Pain distribution is maxillary posterior teeth, sinus and retro-orbital areas. Rhinorrhea, nasal congestion and lacrimation from the involved eye may occur.

4. Non-Odontogenic dental pain due to inflammatory conditions

Sinusitis

Etiology: (1.) Bacterial infection and (2.) allergies. Both referred pain and an acute neuritis of dental nerves leaving the apical foramina and coursing through the floor of the sinus occurs. Pain is not restricted to a single tooth. Patients report a sense of pressure or fullness in the infraorbital region over the involved sinus. Malar and Maxillary alveolar regions are involved. Teeth in area test VITAL.

5. Non-odontogenic dental pain due to systemic disorders

Several systemic disorders can lead to non-odontogenic pain.

• Cardiac Pain – Left posterior mandible not relived by local anesthetic.
• Herpes Zoster – Dental pain preceding the eruption of vesicles. Mixed case reports, with some with pulpagia like symptoms and others reporting necrosis with PA radiolucencies.
• Sickle cell anemia - Patients with Sickle Cell anemia may present with non-odontogenic pain. And

In a 12 month study, 68% of 51 patients with sickle cell anemia reported dental pain with no evident dental pathosis.

• Neoplastic Disease – reports of dental pain as an initial or sever symptom in patients with glioblastoma multiforme, osteoblastoma, metases from breast, lung or prostrate; osteoma, carcinoma, sarcoma, non-hodgkin lymphoma and Burkitt lymphoma. Key findings that prompted consideration of non-odontogenic origin of the dental pain included subsequent paresthesia or anesthesia, positive response to pulp testing, failure of dental treatment, diffuse or spreading nature of pain, unusual appearance to radiographic lesions.

• Multiple Sclerosis – may be the initial presenting symptom in a patient with MS.  Felt like a toothache with no associated dental pathosis then progressed to “electric” shock like pain.

• Menstrual Cycle – Pulpal pain correlated with menstrual cycles has been reported

6.  Non-odontogenic dental pain of psychogenic origin - (Idiopathic pain disorder).

Patients who have pain that is caused by psychogenic mechanism are appropriately placed in this category The term Somatoform pain disorder is used to describe a cognitive perception of pain that has no demonstrable physical basis. Four sub-types include: somatic delusion, somatization disorder, depression & converson.

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