Globus Pharyngeus — MCQs
Which of the following is the MOST common complication associated with GERD?
A man takes peanut and develops tongue swelling, neck swelling, stridor, hoarseness of voice. What is the probable diagnosis?
Which of the following statements regarding the lower esophageal sphincter is TRUE?
A 5-year-old child has a painless, midline neck swelling that moves with swallowing. What is the most likely diagnosis?
A child presenting with recurrent respiratory tract infections, mouth breathing and decreased hearing. Treatment of choice is
A 55-year-old man has a history of difficulty swallowing and frequent choking while eating. A barium swallow shows a posterior pharyngeal diverticulum. What is the most likely diagnosis?
A 1st year medical student presents with recurrent episodes of choking sensation, breathlessness, intense sweating along with feeling of impending doom. Usually the episodes occur prior to exams. What is the most likely diagnosis?
All of the following are true regarding Zenker's diverticulum EXCEPT?
Lingual tonsils arise from which of the following processes?
Tonsiloliths are best treated with:
Globus Pharyngeus Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is the MOST common complication associated with GERD?
- A. Chronic cough
- B. Dental erosion
- C. None of the options
- D. Esophagitis (Correct Answer)
Explanation: ***Esophagitis*** - **Reflux of gastric acid** into the esophagus directly irritates the esophageal lining, leading to inflammation and cellular damage, commonly presenting as esophagitis [1]. - This recurrent irritation causes histological changes such as **basal cell hyperplasia** and **elongation of papillae**, which are hallmarks of reflux-induced injury [1]. *Chronic cough* - While chronic cough can be a symptom of GERD, it is considered an **extraesophageal manifestation** rather than a direct complication of esophageal mucosal damage. - Its prevalence is lower than esophagitis among GERD complications and it's less direct consequence of acid exposure to the esophagus itself. *Dental erosion* - **Acid reflux** can lead to dental erosion due to the direct contact of acidic gastric contents with tooth enamel. - However, this is less common than esophagitis, which is a direct and frequent consequence of **mucosal acid exposure** within the esophagus [1].
Question 2: A man takes peanut and develops tongue swelling, neck swelling, stridor, hoarseness of voice. What is the probable diagnosis?
- A. FB in larynx
- B. Angioneurotic edema (Correct Answer)
- C. Parapharyngeal abscess
- D. FB bronchus
Explanation: Andioneurotic edema - The combination of **tongue swelling**, **neck swelling**, **stridor**, and **hoarseness of voice** following peanut ingestion is highly suggestive of **angioneurotic edema**, a severe allergic reaction that can lead to airway obstruction [1]. - This is a life-threatening condition requiring immediate medical intervention, often associated with generalized **anaphylaxis** when triggered by allergens [2]. *FB in larynx* - While a **foreign body (FB) in the larynx** can cause stridor and hoarseness, the widespread swelling of the tongue and neck points away from a localized laryngeal obstruction [3]. - A laryngeal FB would typically be associated with a more sudden onset of choking and coughing, not diffuse edema [3]. *Parapharyngeal abscess* - A **parapharyngeal abscess** would typically present with **fever**, **severe throat pain**, and **trismus** (difficulty opening the mouth), which are not mentioned in this scenario. - The acute, rapid onset of symptoms after peanut consumption is inconsistent with the slower progression of an abscess. *FB bronchus* - A **foreign body in the bronchus** would primarily cause **coughing**, **wheezing**, and possibly **respiratory distress**, often unilateral, rather than severe global swelling of the tongue and neck. - Inspiratory stridor and hoarseness are more indicative of upper airway involvement than bronchial obstruction.
Question 3: Which of the following statements regarding the lower esophageal sphincter is TRUE?
- A. It relaxes in response to swallowing. (Correct Answer)
- B. It remains contracted during swallowing to prevent regurgitation.
- C. Its tone is primarily influenced by the myogenic properties of the smooth muscle.
- D. It contracts in response to gastric distension.
Explanation: ***It relaxes in response to swallowing.*** - The **lower esophageal sphincter (LES)** normally maintains high resting tone to prevent gastroesophageal reflux but **relaxes completely during swallowing** to allow passage of food into the stomach. - This relaxation (called **receptive relaxation**) is mediated by **vagal nerve stimulation** through release of nitric oxide (NO) and vasoactive intestinal peptide (VIP). - The relaxation occurs **before the peristaltic wave arrives**, allowing coordinated transit of the bolus. *It remains contracted during swallowing to prevent regurgitation.* - This is **incorrect** - the LES must **relax during swallowing** to allow food passage into the stomach. - Failure of LES relaxation during swallowing is the pathophysiology of **achalasia**, leading to dysphagia. - The LES only maintains contraction between swallows to prevent reflux. *Its tone is primarily influenced by the myogenic properties of the smooth muscle.* - While the LES contains smooth muscle with intrinsic myogenic properties, its tone is **predominantly regulated by neural and hormonal factors**. - **Neural control:** Vagal cholinergic pathways (increase tone), non-adrenergic non-cholinergic (NANC) pathways with NO and VIP (decrease tone). - **Hormonal factors:** Gastrin increases tone, while progesterone, CCK, and secretin decrease tone. *It contracts in response to gastric distension.* - This is **incorrect** - gastric distension actually triggers **transient LES relaxations (TLESRs)**, which are the primary mechanism of physiological reflux. - TLESRs are vagally mediated reflex responses that allow venting of gastric air. - Increased LES contraction in response to gastric distension would be counterproductive.
Question 4: A 5-year-old child has a painless, midline neck swelling that moves with swallowing. What is the most likely diagnosis?
- A. Branchial cyst
- B. Dermoid cyst
- C. Thyroglossal duct cyst (Correct Answer)
- D. Thyroid nodule
Explanation: ***Thyroglossal duct cyst*** - A **midline neck swelling** that is **painless** and **moves with swallowing** or protrusion of the tongue is a classic presentation of a thyroglossal duct cyst. - This cyst develops from the **remnant of the embryonic thyroglossal duct**, connecting the thyroid gland to the tongue base. *Branchial cyst* - Typically presents as a **lateral neck mass**, usually anterior to the sternocleidomastoid muscle, not midline. - They are remnants of the **branchial arches** and are less likely to move with swallowing. *Dermoid cyst* - While dermoid cysts can occur in the neck and be midline, they are generally **not mobile with swallowing** because they are not attached to the hyoid bone or tongue. - They are congenital cysts formed from trapped skin elements. *Thyroid nodule* - A thyroid nodule would be located in the **lower anterior neck** over the thyroid gland, typically not as high as a thyroglossal duct cyst. - While it might move with swallowing, it is often firmer and may be associated with thyroid dysfunction or a history of radiation exposure, which is not mentioned here.
Question 5: A child presenting with recurrent respiratory tract infections, mouth breathing and decreased hearing. Treatment of choice is
- A. Grommet insertion
- B. Tonsillectomy
- C. Myringotomy
- D. Adenoidectomy (Correct Answer)
Explanation: ***Adenoidectomy*** - The combination of **recurrent respiratory tract infections**, **mouth breathing**, and **decreased hearing** strongly suggests hypertrophied adenoids. - **Adenoidectomy** is the definitive treatment to remove the enlarged adenoids, alleviating airway obstruction and improving Eustachian tube function. *Grommet insertion* - **Grommet insertion** (tympanostomy tubes) is primarily done for **recurrent acute otitis media** or **otitis media with effusion** to ventilate the middle ear. - While it can help hearing loss secondary to middle ear fluid, it doesn't address the underlying cause of recurrent infections and mouth breathing from adenoid hypertrophy. *Tonsillectomy* - **Tonsillectomy** is indicated for **recurrent tonsillitis** or significant **obstructive sleep apnea** due to enlarged tonsils. - Although often performed with adenoidectomy, the primary symptoms described (mouth breathing, recurrent URTIs, hearing loss) point more specifically to adenoid issues than tonsillar hypertrophy alone. *Myringotomy* - **Myringotomy** is a surgical incision into the **eardrum** to drain fluid from the middle ear. - It is often a first step before grommet insertion but doesn't provide a long-term solution for recurrent fluid or address the underlying cause of Eustachian tube dysfunction, which is often adenoid hypertrophy.
Question 6: A 55-year-old man has a history of difficulty swallowing and frequent choking while eating. A barium swallow shows a posterior pharyngeal diverticulum. What is the most likely diagnosis?
- A. Zenker's diverticulum (Correct Answer)
- B. Esophageal stricture
- C. GERD
- D. Achalasia
Explanation: ***Zenker's diverticulum*** - A **Zenker's diverticulum** is a **pseudodiverticulum** that occurs due to herniation of the pharyngeal mucosa at Killian's triangle, often causing dysphagia and regurgitation in older adults. - The **barium swallow** revealing a **posterior pharyngeal diverticulum** is a classic finding for Zenker's, and the symptoms of difficulty swallowing and choking are consistent with food lodging in the pouch. *Esophageal stricture* - An **esophageal stricture** is a narrowing of the esophagus, which would cause difficulty swallowing (dysphagia), but typically wouldn't lead to a **posterior pharyngeal diverticulum** on barium swallow. - While strictures can cause choking, the primary finding described in the barium swallow points away from a simple stricture. *GERD* - **Gastroesophageal reflux disease (GERD)** can cause dysphagia due to **esophagitis** or stricture formation, but it is not typically associated with a **posterior pharyngeal diverticulum**. - The main symptoms of GERD include **heartburn** and acid regurgitation, though atypical symptoms exist, the diverticulum is not characteristic. *Achalasia* - **Achalasia** is a motility disorder characterized by impaired relaxation of the **lower esophageal sphincter** and loss of peristalsis in the esophageal body, leading to dysphagia and regurgitation. - A barium swallow in achalasia typically shows a **dilated esophagus** with a "bird's beak" appearance at the LES, not a posterior pharyngeal diverticulum.
Question 7: A 1st year medical student presents with recurrent episodes of choking sensation, breathlessness, intense sweating along with feeling of impending doom. Usually the episodes occur prior to exams. What is the most likely diagnosis?
- A. Panic attack (Correct Answer)
- B. Acute stress disorder
- C. Generalised anxiety disorder
- D. Phobia
Explanation: ***Panic attack (Panic Disorder)*** - The sudden onset of intense fear or discomfort, along with symptoms like **choking sensation**, **breathlessness**, **sweating**, and **feeling of impending doom**, are characteristic of a **panic attack**. - The **recurrent episodes** occurring prior to exams indicate **Panic Disorder**, which is defined by recurrent unexpected panic attacks followed by persistent concern about future attacks. - The situational trigger (exams) suggests a pattern consistent with panic disorder, where attacks may be situationally predisposed. *Acute stress disorder* - This condition occurs within **one month of exposure to a traumatic event** and involves dissociative symptoms, intrusions, avoidance, and arousal symptoms. - The patient describes recurrent episodes tied to exams, not a single acute traumatic event with subsequent stress response. *Generalised anxiety disorder* - Characterized by excessive and **uncontrollable worry** about various events or activities for **at least six months**. - While anxiety is present, the sudden, intense, **episodic nature** of symptoms with a distinct "feeling of impending doom" points away from the chronic, pervasive worry of GAD. - GAD presents with chronic anxiety rather than discrete panic episodes. *Phobia* - A phobia is an **irrational and intense fear** of a specific object or situation (e.g., specific phobia) or social situations (social anxiety disorder). - While exam-related anxiety can be severe, the description points to a **full-blown panic response** with multiple autonomic symptoms (choking, breathlessness, sweating) and psychological distress (impending doom). - Unlike a phobia where avoidance is the primary feature, this patient experiences discrete panic episodes with characteristic somatic symptoms.
Question 8: 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 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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