Adenoid Hypertrophy — MCQs
Treatment of a 6-year-old child with recurrent URI, mouth breathing, failure to grow with high arched palate and impaired hearing is
The facial features shown in the image are characteristic of:
Young's operation is done for:
A 72-year-old man presents to his primary care physician with progressively worsening hearing loss. He states that his trouble with hearing began approximately 7-8 years ago. He is able to hear when someone is speaking to him; however, he has difficulty with understanding what is being said, especially when there is background noise. In addition to his current symptoms, he reports a steady ringing in both ears, and at times experiences dizziness. Medical history is significant for three prior episodes of acute otitis media. Family history is notable for his father being diagnosed with cholesteatoma. His temperature is 98.6°F (37°C), blood pressure is 138/88 mmHg, pulse is 74/min, and respirations are 13/min. On physical exam, when a tuning fork is placed in the middle of the patient's forehead, sound is appreciated equally on both ears. When a tuning fork is placed by the external auditory canal and subsequently on the mastoid process, air conduction is greater than bone conduction. Which of the following is most likely the cause of this patient's symptoms?
All of the following are true regarding Zenker's diverticulum EXCEPT?
X-ray showing an air column between a soft tissue mass and the posterior wall of the nasopharynx is suggestive of which of the following conditions?
What is a possible cause of cervical lymphadenopathy in a 70-year-old man?
The parapharyngeal space is also known as which of the following?
Lingual tonsils arise from which of the following processes?
Tonsiloliths are best treated with:
Adenoid Hypertrophy Indian Medical PG Practice Questions and MCQs
Question 1: Treatment of a 6-year-old child with recurrent URI, mouth breathing, failure to grow with high arched palate and impaired hearing is
- A. Grommet insertion
- B. Tonsillectomy
- C. Myringotomy with grommet insertion
- D. Adenoidectomy with grommet insertion (Correct Answer)
Explanation: ***Adenoidectomy with grommet insertion*** - **Adenoid hypertrophy** frequently leads to mouth breathing, a high-arched palate, and can contribute to recurrent **otitis media with effusion (OME)**, causing impaired hearing and recurrent upper respiratory infections (URI). An adenoidectomy addresses the primary cause of these symptoms related to the nasopharynx. - **Grommet insertion** (tympanostomy tubes) is often performed concurrently or subsequently to manage the eustachian tube dysfunction and OME directly, restoring hearing and preventing further middle ear complications. The combination targets both the causative factor and the resulting hearing impairment. *Grommet insertion* - While grommet insertion treats the **impaired hearing** caused by otitis media with effusion (OME), it does not address the underlying **adenoid hypertrophy** responsible for mouth breathing, high-arched palate, and recurrent URIs. - Failure to treat the underlying cause means the patient is likely to continue experiencing **nasal obstruction** and potentially recurrent OME once the grommets extrude. *Tonsillectomy* - **Tonsillectomy** primarily addresses issues related to enlarged tonsils, such as recurrent tonsillitis or significant airway obstruction. It does not directly account for the combination of symptoms like a high-arched palate, mouth breathing, or impaired hearing. - While tonsil hypertrophy can contribute to airway issues, **adenoid hypertrophy** is more commonly associated with the specific constellation of symptoms presented, especially the chronic nasal obstruction and middle ear problems. *Myringotomy with grommet insertion* - **Myringotomy with grommet insertion** is synonymous with grommet insertion and specifically addresses **middle ear effusion**, thereby improving hearing. - This procedure treats a symptom (hearing impairment due to OME) but does not resolve the root cause of the patient's comprehensive set of symptoms, such as **mouth breathing**, **high-arched palate**, and **recurrent URI**, which are strongly suggestive of adenoid hypertrophy.
Question 2: The facial features shown in the image are characteristic of:
- A. Frog face deformity
- B. Adenoid facies (Correct Answer)
- C. Ashen grey facies
- D. Thyrotoxicosis
Explanation: ***Adenoid facies*** - The image displays characteristic features of adenoid facies, including a **long, open-mouthed face**, a **pinched nose**, and possibly a **high-arched palate** due to chronic mouth breathing from enlarged adenoids. - This chronic condition often leads to a dull expression, sometimes with **strabismus** (crossed eyes) as seen in the image, and a forward head posture. *Frog face deformity* - This deformity is characterized by **ocular hypertelorism** (widely spaced eyes), a **flat nasal bridge**, and a **short nose**, often associated with conditions like Apert syndrome. - While there is some facial dysmorphology, the specific combination of features does not align with a typical frog face. *Ashen grey facies* - This refers to a **pale, grayish complexion**, often indicative of severe cardiovascular compromise like **circulatory collapse** or **shock**. - The child in the image has a normal skin tone for their ethnicity and does not show signs of acute circulatory distress. *Thyrotoxicosis* - **Thyrotoxicosis** (hyperthyroidism) in children can cause symptoms like **exophthalmos** (bulging eyes), **tachycardia**, weight loss, and an enlarged thyroid gland. - While the child's eyes appear wide-set and sometimes strabismic, these are more consistent with the long-term effects of chronic mouth breathing on facial development rather than acute thyroid dysfunction.
Question 3: Young's operation is done for:
- A. Allergic rhinitis
- B. Vasomotor rhinitis
- C. Atrophic rhinitis (Correct Answer)
- D. Antrochoanal polyp
Explanation: ***Atrophic rhinitis*** - **Young's operation** is a surgical procedure specifically designed to treat **atrophic rhinitis**. - The goal of the surgery is to narrow the nasal passages by creating a **synechia** (adhesion) to reduce airflow and improve the humidification and temperature of inspired air. *Allergic rhinitis* - Allergic rhinitis is primarily managed with **medical therapy**, including antihistamines, nasal corticosteroids, and allergen avoidance. - Surgical intervention, if considered, typically involves procedures like turbinate reduction, not Young's operation, and is less common for this condition. *Vasomotor rhinitis* - Vasomotor rhinitis is a **non-allergic, non-infectious condition** characterized by fluctuating nasal congestion and rhinorrhea, often triggered by irritants or temperature changes. - Treatment usually involves **medical management** with anticholinergics or nasal corticosteroids, and sometimes turbinate reduction, but not Young's operation. *Antrochoanal polyp* - An antrochoanal polyp is a benign growth originating in the **maxillary sinus** and extending into the choana. - The primary treatment is **surgical removal**, typically via endoscopic sinus surgery, which is distinct from Young's operation.
Question 4: A 72-year-old man presents to his primary care physician with progressively worsening hearing loss. He states that his trouble with hearing began approximately 7-8 years ago. He is able to hear when someone is speaking to him; however, he has difficulty with understanding what is being said, especially when there is background noise. In addition to his current symptoms, he reports a steady ringing in both ears, and at times experiences dizziness. Medical history is significant for three prior episodes of acute otitis media. Family history is notable for his father being diagnosed with cholesteatoma. His temperature is 98.6°F (37°C), blood pressure is 138/88 mmHg, pulse is 74/min, and respirations are 13/min. On physical exam, when a tuning fork is placed in the middle of the patient's forehead, sound is appreciated equally on both ears. When a tuning fork is placed by the external auditory canal and subsequently on the mastoid process, air conduction is greater than bone conduction. Which of the following is most likely the cause of this patient's symptoms?
- A. Stapedial abnormal bone growth
- B. Endolymphatic hydrops
- C. Cochlear hair cell degeneration (Correct Answer)
- D. Accumulation of desquamated keratin debris
Explanation: ***Cochlear hair cell degeneration*** - The patient's **progressive, bilateral hearing loss** over several years, difficulty understanding speech in noise, and **tinnitus** are classic symptoms of **presbycusis**, which results from age-related **degeneration of cochlear hair cells**. - The **normal Weber test** (no lateralization) and **Rinne test** (air conduction > bone conduction) indicate a **sensorineural hearing loss**, consistent with cochlear pathology rather than conductive issues. *Stapedial abnormal bone growth* - This condition (**otosclerosis**) causes **conductive hearing loss** due to fixation of the stapes, which would present with an **abnormal Rinne test** (bone conduction > air conduction) in the affected ear. - While it can cause progressive hearing loss and tinnitus, the normal Rinne test contradicts this diagnosis. *Endolymphatic hydrops* - This is the underlying pathology of **Ménière's disease**, which typically presents with episodic vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness. - The patient's dizziness is non-episodic, and the absence of fluctuating hearing loss and aural fullness makes Ménière's less likely. *Accumulation of desquamated keratin debris* - This describes a **cholesteatoma**, which typically causes **conductive hearing loss** and often presents with otorrhea, earache, and possibly vestibular symptoms. - The normal Rinne test (indicating sensorineural loss) and lack of otorrhea or earache make cholesteatoma unlikely, despite a family history.
Question 5: All of the following are true regarding Zenker's diverticulum EXCEPT?
- A. It is a false diverticulum
- B. It occurs in children (Correct Answer)
- C. It is a posterior pharyngeal pulsion diverticulum
- D. The most common site for the diverticulum is Killian's dehiscence
Explanation: **Explanation:** Zenker’s diverticulum is a **pulsion diverticulum** caused by the herniation of the pharyngeal mucosa through a site of weakness in the muscular wall. 1. **Why Option B is the correct answer (False statement):** Zenker’s diverticulum is a disease of the **elderly**, typically occurring in the 7th or 8th decade of life. It is almost never seen in children because it is an acquired condition resulting from long-term incoordination of the cricopharyngeal muscle and increased intraluminal pressure. 2. **Why Option A is wrong (True statement):** It is a **false diverticulum** because it consists only of the mucosa and submucosa. A "true" diverticulum would involve all layers of the visceral wall, including the muscularis. 3. **Why Option C is wrong (True statement):** It is a **pulsion diverticulum** (pushed out by pressure) and it occurs **posteriorly** in the midline of the pharynx. 4. **Why Option D is wrong (True statement):** The anatomical site of herniation is **Killian’s dehiscence**, a triangular area of weakness between the thyropharyngeus and cricopharyngeus parts of the inferior constrictor muscle. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Regurgitation of undigested food, halitosis (foul breath due to stagnant food), dysphagia, and a gurgling sound in the neck (Boyce’s sign). * **Diagnosis:** The investigation of choice is a **Barium Swallow**, which shows a pouch behind the esophagus. * **Management:** Endoscopic Dohlman’s procedure (stapling the party wall) or open diverticulectomy with cricopharyngeal myotomy. * **Complication:** Aspiration pneumonia is the most common serious complication.
Question 6: X-ray showing an air column between a soft tissue mass and the posterior wall of the nasopharynx is suggestive of which of the following conditions?
- A. Ethmoidal polyp
- B. Antrochoanal polyp (Correct Answer)
- C. Nasal myiasis
- D. None of the above
Explanation: ### Explanation **Correct Answer: B. Antrochoanal polyp** The characteristic radiological sign described—an **air column between the soft tissue mass and the posterior pharyngeal wall**—is a classic diagnostic feature of an **Antrochoanal Polyp (ACP)**. **Why it is correct:** An Antrochoanal polyp originates from the maxillary sinus mucosa, exits through the accessory ostium, and extends into the choana and nasopharynx. Because the polyp is pedunculated and hangs down from the choana into the oropharynx, it does not typically adhere to the posterior pharyngeal wall. On a lateral neck or skull X-ray, air can pass behind the mass, creating a visible radiolucent "air gap" or column. This distinguishes it from other fixed nasopharyngeal masses. **Why the other options are incorrect:** * **Ethmoidal Polyp:** These are usually multiple, bilateral, and originate from the ethmoid air cells. They rarely grow large enough to present as a solitary mass in the nasopharynx with a distinct posterior air column. * **Nasal Myiasis:** This is a parasitic infestation of the nose by maggots (*Chrysomya bezziana*). It presents with foul-smelling discharge, pain, and tissue destruction, not as a discrete nasopharyngeal soft tissue mass on X-ray. **High-Yield Clinical Pearls for NEET-PG:** * **Origin:** ACP most commonly arises from the **maxillary sinus** (specifically the lateral wall or floor). * **Clinical Presentation:** Usually **unilateral** nasal obstruction in children and young adults. * **Radiology:** On X-ray (Water’s view), you will see opacification of the involved maxillary sinus. On CT, it shows a "dumbbell-shaped" mass extending through the ostium. * **Treatment:** The treatment of choice is **Functional Endoscopic Sinus Surgery (FESS)** to remove the polyp and its base to prevent recurrence. Historically, the Caldwell-Luc operation was used.
Question 7: What is a possible cause of cervical lymphadenopathy in a 70-year-old man?
- A. Nasopharyngeal carcinoma (Correct Answer)
- B. Angiofibroma
- C. Acoustic neuroma
- D. Otosclerosis
Explanation: **Explanation:** **1. Why Nasopharyngeal Carcinoma (NPC) is correct:** In an elderly patient (70 years old) presenting with an isolated neck lump (cervical lymphadenopathy), a malignancy of the upper aerodigestive tract must be the first suspicion. **Nasopharyngeal carcinoma** is notorious for being "clinically silent" in its early stages; the primary tumor is often small, but it metastasizes early to the cervical lymph nodes. In fact, **cervical lymphadenopathy is the most common presenting symptom (60-80% of cases)**, typically involving the upper deep cervical (Level II) and posterior triangle nodes (Level V). **2. Why the other options are incorrect:** * **Angiofibroma (Juvenile Nasopharyngeal Angiofibroma):** This is a benign but locally aggressive vascular tumor. It occurs almost exclusively in **adolescent males** (10–20 years). It presents with profuse epistaxis and nasal obstruction, not cervical lymphadenopathy. * **Acoustic Neuroma (Vestibular Schwannoma):** This is a benign tumor of the 8th cranial nerve. It presents with unilateral sensorineural hearing loss, tinnitus, and dysequilibrium. It does not metastasize to lymph nodes. * **Otosclerosis:** This is a metabolic bone disease of the otic capsule causing conductive hearing loss. It is a localized ear pathology with no lymphatic involvement. **NEET-PG High-Yield Pearls:** * **Trottier’s Triad (NPC):** 1. Conductive hearing loss (due to Eustachian tube blockage), 2. Ipsilateral facial pain/numbness (CN V involvement), 3. Palatal paralysis (CN X involvement). * **Risk Factor:** Strongly associated with **Epstein-Barr Virus (EBV)**. * **Node of Rouviere:** The lateral retropharyngeal node is often the first site of metastasis in NPC. * **Rule of Thumb:** In any adult with unilateral serous otitis media, always examine the nasopharynx to rule out NPC.
Question 8: The parapharyngeal space is also known as which of the following?
- A. Retropharyngeal space
- B. Pyriform sinus
- C. Lateral pharyngeal space (Correct Answer)
- D. Pterygomaxillary space
Explanation: ### Explanation The **parapharyngeal space** (also known as the **lateral pharyngeal space** or pharyngomaxillary space) is a potential space shaped like an inverted pyramid, located lateral to the pharynx. **1. Why "Lateral Pharyngeal Space" is Correct:** The space is anatomically situated lateral to the pharyngeal wall. It is bounded medially by the buccopharyngeal fascia (covering the superior constrictor muscle) and laterally by the mandible, medial pterygoid muscle, and the deep lobe of the parotid gland. Because of its lateral position relative to the pharynx, it is synonymous with the lateral pharyngeal space. **2. Why Other Options are Incorrect:** * **Retropharyngeal space:** This is located **posterior** to the pharynx, between the buccopharyngeal fascia and the prevertebral fascia. It is a midline space, not lateral. * **Pyriform sinus:** This is a physiological recess of the **laryngopharynx** located on either side of the laryngeal inlet. It is a mucosal space, not a deep fascial neck space. * **Pterygomaxillary space:** This is a small area located between the maxilla and the pterygoid process, often considered a subset or related area of the infratemporal fossa, but it does not encompass the entire parapharyngeal region. **3. Clinical Pearls for NEET-PG:** * **Shape:** Inverted pyramid with the apex at the **greater cornu of the hyoid bone** and the base at the **skull base**. * **Compartments:** Divided by the styloid process into the **Pre-styloid** (contains internal maxillary artery, fat, and deep lobe of parotid) and **Post-styloid** (contains carotid artery, internal jugular vein, cranial nerves IX, X, XI, XII, and cervical sympathetic chain). * **Clinical Sign:** Infection or tumors here cause **medial displacement of the tonsil** and lateral pharyngeal wall. * **Trismus:** Common in pre-styloid involvement due to irritation of the medial pterygoid muscle.
Question 9: Lingual tonsils arise from which of the following processes?
- A. Developmental anomalies (Correct Answer)
- B. Carcinomatous transformation
- C. Hyperplasia
- D. Repeated trauma in the area
Explanation: **Explanation:** The **lingual tonsils** are part of the **Waldeyer’s ring**, located on the posterior third of the tongue. While they are normal anatomical structures, their clinical presentation as symptomatic masses or significant enlargements is primarily attributed to **developmental anomalies** during embryogenesis. They arise from the endoderm of the second pharyngeal pouch. In the context of "ectopic" or "accessory" lymphoid tissue appearing in unusual locations or presenting as congenital masses, they are classified under developmental variations. **Analysis of Options:** * **A. Developmental anomalies (Correct):** The formation and distribution of lymphoid tissue in the base of the tongue are determined during fetal development. Variations in the size and extent of this tissue are developmental in nature. * **B. Carcinomatous transformation:** While Squamous Cell Carcinoma (SCC) can occur in the lingual tonsils, it is a malignant change, not the *origin* of the tissue itself. * **C. Hyperplasia:** Compensatory hyperplasia (e.g., after palatine tonsillectomy) can make lingual tonsils more prominent, but the *existence* of the tissue is developmental. * **D. Repeated trauma:** Chronic irritation may cause inflammation (tonsillitis), but it does not give rise to the tonsillar tissue. **High-Yield Clinical Pearls for NEET-PG:** * **Waldeyer’s Ring:** Comprises the Nasopharyngeal (adenoid), Tubal, Palatine, and Lingual tonsils. * **Lingual Tonsil Hypertrophy:** Can cause "Lump in the throat" sensation (Globus pharyngeus) and is a known cause of difficult intubation (obscuring the epiglottis). * **Symptom:** Large lingual tonsils can lead to **Obstructive Sleep Apnea (OSA)** in adults. * **Nerve Supply:** The posterior 1/3rd of the tongue (including lingual tonsils) is supplied by the **Glossopharyngeal nerve (CN IX)**.
Question 10: Tonsiloliths are best treated with:
- A. Antibiotics
- B. Hydrogen peroxide (Correct Answer)
- C. Steroids
- D. None of the above
Explanation: **Explanation:** **Tonsilloliths** (tonsil stones) are calcified aggregates of cellular debris, food particles, and mucus that lodge within the **tonsillar crypts**. They are frequently associated with chronic tonsillitis and halitosis (bad breath). **Why Hydrogen Peroxide is the correct answer:** The primary goal in managing tonsilloliths is mechanical removal and chemical debridement of the crypts. **Hydrogen peroxide (H₂O₂)**, typically used as a diluted gargle, acts as an oxidizing agent. Its effervescent action helps mechanically dislodge debris from deep within the crypts and provides an antiseptic environment that reduces the bacterial load (especially anaerobes) responsible for the foul odor. It is a standard conservative treatment to prevent the recurrence of these concretions. **Why other options are incorrect:** * **Antibiotics:** While tonsilloliths are associated with bacteria, they are structural concretions rather than an acute infection. Antibiotics do not remove the physical stone and are not indicated unless there is secondary acute tonsillitis. * **Steroids:** These are used to reduce inflammation (e.g., in infectious mononucleosis or severe acute tonsillitis). They have no role in dissolving or removing calcified debris. **High-Yield Clinical Pearls for NEET-PG:** * **Composition:** Tonsilloliths are primarily composed of calcium salts (hydroxyapatite), but can also contain magnesium and phosphorus. * **Clinical Presentation:** Often asymptomatic, but the most common complaint is **halitosis** or a foreign body sensation in the throat. * **Definitive Treatment:** For recurrent, symptomatic cases, the definitive treatment is **Tonsillectomy** or **Laser Cryptolysis** (using CO₂ laser to obliterate the crypts). * **Diagnosis:** Usually clinical; however, on CT scans, they appear as high-density radiopaque masses in the oropharyngeal region.
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