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?
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?
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: 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 10: 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.
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