Diseases of the Pharynx Practice Questions

Q: A 14-year-old boy presents with a history of frequent nasal bleeding. His Hb was found to be 6.4 g/dL and peripheral smear showed normocytic hypochromic anemia. What is the most probable diagnosis?

Juvenile nasopharyngeal angiofibroma. **Explanation:** The clinical presentation of a **14-year-old male** with **frequent, profuse nasal bleeding (epistaxis)** leading to significant **secondary anemia** (Hb 6.4 g/dL) is a classic "textbook" description of **Juvenile Nasopharyngeal Angiofibroma (JNA)**. **1. Why JNA is the correct answer:** JNA is a benign but locally aggressive, highly vascular tumor that occurs almost exclusively in **adolescent males**. It typically originates in the sphenopalatine foramen. The hallmark symptom is spontaneous, painless, and recurrent profuse epistaxis. The severity of bleeding often leads to chronic iron-deficiency anemia (normocytic hypochromic), as seen in this patient. **2. Why other options are incorrect:** * **Hemangioma:** While vascular, they usually present as smaller, localized lesions on the nasal septum (Little’s area) and rarely cause anemia this severe in an adolescent. * **Antrochoanal polyp:** These present primarily with unilateral nasal obstruction. While they may cause minor mucoid discharge, they do not cause profuse bleeding or systemic anemia. * **Carcinoma of nasopharynx:** While it can cause bleeding, it is rare in this age group and typically presents with a neck mass (level II nodes), hearing loss (serous otitis media), or cranial nerve palsies. **3. High-Yield Clinical Pearls for NEET-PG:** * **Holman-Miller Sign:** Anterior bowing of the posterior wall of the maxillary sinus seen on CT (pathognomonic). * **Diagnosis:** Biopsy is **contraindicated** due to the risk of fatal hemorrhage. Diagnosis is clinical and radiological (Contrast CT/MRI). * **Blood Supply:** Most commonly the **Internal Maxillary Artery** (branch of External Carotid). * **Treatment of Choice:** Surgical excision (usually preceded by preoperative embolization to reduce blood loss).

Q: Hemorrhage occurring 6 hours after tonsillectomy is called as?

Reactionary hemorrhage. ### Explanation Tonsillectomy hemorrhage is classified based on the **timing** of the bleeding relative to the surgery. **1. Why Reactionary Hemorrhage is correct:** Reactionary hemorrhage occurs within **24 hours** of surgery (most commonly between 4–6 hours). It is triggered by a rise in blood pressure as the patient recovers from anesthesia, the wearing off of vasoconstrictors (like adrenaline) used during the procedure, or the slipping of a ligature. Since 6 hours falls within this critical window, it is the correct classification. **2. Why the other options are incorrect:** * **Primary Hemorrhage:** This occurs **during the surgery** or immediately after. It is usually managed by the surgeon on the operating table through ligation or diathermy. * **Secondary Hemorrhage:** This occurs **5–10 days** after surgery. It is almost always due to **infection** of the tonsillar fossa, which causes the premature sloughing of the scab and erosion of a small vessel. **3. High-Yield Clinical Pearls for NEET-PG:** * **Management of Reactionary Hemorrhage:** This is a surgical emergency. The patient must be taken back to the OR to identify the bleeding point and achieve hemostasis. * **Management of Secondary Hemorrhage:** Usually managed conservatively with intravenous antibiotics and observation. If bleeding is profuse, surgical intervention may be required. * **Most common vessel involved:** The **External Palatine Vein** (Paratonsillar vein) is the most common source of bleeding during/after tonsillectomy. * **Arterial source:** The **Tonsillar branch of the Facial Artery** is the main artery supplying the tonsil and a common source of significant arterial bleed.

Q: What is the distinguishing feature of a masticatory space infection?

Trismus. **Explanation:** The **masticatory space** contains the muscles of mastication (masseter, medial and lateral pterygoids, and the temporalis tendon), the ramus of the mandible, and the inferior alveolar nerve. **Why Trismus is the Correct Answer:** Trismus (lockjaw) is the hallmark clinical feature of a masticatory space infection. This occurs because the infection causes **inflammatory irritation or "splinting" of the masticatory muscles**, particularly the masseter and the medial pterygoid. Any attempt to open the mouth stretches these inflamed muscles, causing intense pain and reflex spasms, leading to a significant restriction in mouth opening. **Analysis of Incorrect Options:** * **A. Pain:** While pain is almost always present in deep neck space infections, it is a non-specific finding seen in peritonsillar abscesses, parapharyngeal infections, and retropharyngeal abscesses. * **B. Dysphagia:** Difficulty swallowing is more characteristic of infections involving the **parapharyngeal or retropharyngeal spaces**, where the inflammation is closer to the oropharyngeal airway and food passage. * **D. Swelling:** Swelling in masticatory space infections is often localized over the angle of the jaw or the cheek. However, because the infection is deep to the thick masseteric fascia, external swelling may be minimal or late-appearing compared to the early onset of trismus. **NEET-PG High-Yield Pearls:** * **Source of Infection:** Most commonly arises from the **mandibular third molar** (wisdom tooth) infections. * **Clinical Presentation:** Severe trismus with swelling over the ramus of the mandible. * **Management:** Requires intravenous antibiotics and, if an abscess forms, intraoral or extraoral incision and drainage. * **Differential:** If a patient has trismus but *no* dental cause, always rule out a **parapharyngeal space infection** (specifically the anterior compartment).

Q: What does the Holman Miller sign indicate on a PNS CT scan?

Juvenile nasopharyngeal angiofibroma. **Explanation:** The **Holman-Miller sign** (also known as the **Antral Sign**) is a pathognomonic radiological feature of **Juvenile Nasopharyngeal Angiofibroma (JNA)**. **Why it is correct:** JNA is a benign but locally aggressive, highly vascular tumor that typically arises in the sphenopalatine foramen. As the tumor grows, it extends into the pterygopalatine fossa. The pressure exerted by the tumor causes **anterior bowing (displacement) of the posterior wall of the maxillary sinus**. This characteristic forward bowing seen on a CT or MRI scan is the Holman-Miller sign. **Analysis of Incorrect Options:** * **A. Nasopharyngeal Carcinoma:** This is a malignant epithelial tumor. While it can invade surrounding structures, it typically causes bone destruction and infiltration rather than the smooth, pressure-induced remodeling of the maxillary wall seen in JNA. * **C. Carcinoma of the Ethmoidal Sinus:** These are aggressive malignancies that present with irregular bone erosion and opacification of the ethmoid air cells, not the specific anterior bowing of the maxillary antrum. * **D. Esthesioneuroblastoma:** Also known as Olfactory Neuroblastoma, this tumor arises from the olfactory epithelium in the roof of the nasal cavity. It typically presents with a "dumbbell-shaped" mass crossing the cribriform plate. **High-Yield Clinical Pearls for JNA:** * **Demographics:** Almost exclusively seen in **adolescent males**. * **Classic Triad:** Recurrent profuse epistaxis, nasal obstruction, and a mass in the nasopharynx. * **Diagnosis:** Biopsy is **contraindicated** due to the risk of life-threatening hemorrhage. Diagnosis is clinical and radiological. * **Gold Standard Investigation:** Contrast-enhanced CT (CECT) and Angiography (to identify the feeding vessel, usually the **Internal Maxillary Artery**). * **Treatment:** Surgical excision (often preceded by preoperative embolization).

Q: Tonsillectomy following peritonsillar abscess is typically done after how many weeks?

8 weeks. **Explanation:** The standard management for a peritonsillar abscess (Quinsy) involves immediate incision and drainage followed by a course of antibiotics. However, because Quinsy often recurs, an **interval tonsillectomy** is recommended. **Why 8 weeks is the correct answer:** Performing surgery during the acute phase of infection is avoided due to extreme vascularity and tissue friability, which significantly increases the risk of intraoperative hemorrhage. Waiting for **6 to 8 weeks** (with 8 weeks being the standard textbook recommendation for NEET-PG) allows the acute inflammation and edema to subside and the surrounding tissues to fibrose. This makes the dissection of the tonsil from its bed safer and reduces the risk of primary and reactionary hemorrhage. **Analysis of Incorrect Options:** * **3 weeks (Option A):** This is too early. The inflammatory process is still resolving, and the risk of bleeding remains high. * **6 weeks (Option C):** While some clinical practices consider 6 weeks acceptable, standard academic guidelines and competitive exams prioritize **8 weeks** as the optimal window for complete resolution. * **12 weeks (Option D):** While safe, waiting 3 months is unnecessarily long and increases the window of time during which a patient might suffer a recurrent episode of tonsillitis or abscess. **High-Yield Clinical Pearls for NEET-PG:** * **Abscess Tonsillectomy (Quinsy Tonsillectomy):** This refers to performing the surgery *during* the acute phase. It is rarely done but may be indicated in children who cannot cooperate with drainage under local anesthesia. * **Most common site for Quinsy:** The superior pole of the tonsil (peritonsillar space). * **Most common organism:** *Streptococcus pyogenes* (Group A Beta-hemolytic Strep). * **Clinical Sign:** Deviation of the uvula to the opposite side and presence of trismus (due to irritation of the medial pterygoid muscle).

Q: Which of the following is FALSE about Zenker Diverticulum?

It is associated with cervical webs. **Explanation:** Zenker’s Diverticulum (ZD) is a **pulsion diverticulum** caused by the herniation of the pharyngeal mucosa through a point of weakness in the posterior pharyngeal wall. **Why Option D is False:** Zenker’s Diverticulum is primarily associated with **cricopharyngeal hypertrophy** or incoordination (achalasia), leading to increased intraluminal pressure. It is **not** typically associated with cervical webs. Cervical webs are classically associated with **Plummer-Vinson Syndrome** (Paterson-Brown-Kelly Syndrome), which presents with iron deficiency anemia and post-cricoid dysphagia. **Analysis of Other Options:** * **Option A:** ZD is a disease of the elderly, most commonly presenting in patients **> 50–60 years** due to age-related loss of muscle elasticity. * **Option B:** It is indeed the **most common** diverticulum of the esophagus (specifically, it is a "false" diverticulum of the pharyngoesophageal junction). * **Option C:** It occurs through **Killian’s Dehiscence**, a triangular weak area between the thyropharyngeus and cricopharyngeus muscles (both parts of the inferior constrictor). **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Dysphagia, Halitosis (due to food stagnation), and Regurgitation of undigested food. * **Boyce’s Sign:** Gurgling sound on pressing the lateral side of the neck. * **Investigation of Choice:** Barium Swallow (shows a "pouch" behind the esophagus). * **Management:** Endoscopic Dohlman’s procedure (stapling) or Cricopharyngeal Myotomy. * **Risk:** Endoscopy/NG tube insertion is risky due to the high chance of pouch perforation.

Q: Which of the following statements regarding the nasopharynx is incorrect?

Passavant's muscle is formed by the stylopharyngeus muscle.. ### Explanation **1. Why Option D is the Correct (Incorrect Statement) Answer:** Passavant’s muscle (or Passavant’s ridge) is **not** formed by the stylopharyngeus. It is formed by the horizontal fibers of the **Palatopharyngeus muscle** (specifically the superior constrictor and palatopharyngeus complex). During swallowing or speech, these fibers contract to form a ridge on the posterior pharyngeal wall, which meets the elevated soft palate to seal the nasopharyngeal isthmus (velopharyngeal closure). The stylopharyngeus is a longitudinal muscle that elevates the larynx and pharynx. **2. Analysis of Other Options:** * **Option A:** The nasopharynx is indeed referred to as the **epipharynx** (the uppermost part of the pharynx). * **Option B:** The lateral wall of the nasopharynx contains the **Eustachian tube orifice**, which is bounded superiorly and posteriorly by the torus tubarius. * **Option C:** The **Fossa of Rosenmuller** (pharyngeal recess) lies behind the torus tubarius. It is the most common site for Nasopharyngeal Carcinoma. Its deep relation is the **internal carotid artery**, making it a critical anatomical landmark during surgery. **3. High-Yield Clinical Pearls for NEET-PG:** * **Fossa of Rosenmuller:** Most common site of origin for Nasopharyngeal Carcinoma (NPC). * **Trotter’s Triad (NPC):** 1. Conductive deafness (Eustachian tube blockage), 2. Ipsilateral temporofacial neuralgia (CN V involvement), 3. Palatal paralysis (CN X involvement). * **Passavant’s Ridge:** Essential for preventing nasal regurgitation of food and hypernasal speech. * **Eustachian Tube:** Connects the nasopharynx to the middle ear; its dysfunction leads to Otitis Media with Effusion (OME).

Question 1

What is true about juvenile nasopharyngeal angiofibroma?

Accepted Answer

Increased incidence in females.

Answer

Hormones are not used in treatment.

Answer

Surgery is the treatment of choice.

Answer

It is a malignant tumor.

Question 2

A 14-year-old boy presents with a history of frequent nasal bleeding. His Hb was found to be 6.4 g/dL and peripheral smear showed normocytic hypochromic anemia. What is the most probable diagnosis?

Accepted Answer

Juvenile nasopharyngeal angiofibroma

Answer

Hemangioma

Answer

Antrochoanal polyp

Answer

Carcinoma of nasopharynx

Question 3

Trismus associated with infection of the lateral pharyngeal space is related to the irritation of which muscle?

Accepted Answer

Medial pterygoid

Answer

Buccinator

Answer

Masseter

Answer

Lateral pterygoid

Question 4

Hemorrhage occurring 6 hours after tonsillectomy is called as?

Accepted Answer

Reactionary hemorrhage

Answer

Primary hemorrhage

Answer

Secondary hemorrhage

Answer

None of the above

Question 5

What is the distinguishing feature of a masticatory space infection?

Accepted Answer

Trismus

Answer

Pain

Answer

Dysphagia

Answer

Swelling

Question 6

What does the Holman Miller sign indicate on a PNS CT scan?

Accepted Answer

Juvenile nasopharyngeal angiofibroma

Answer

Nasopharyngeal carcinoma

Answer

Carcinoma of the ethmoidal sinus

Answer

Esthesioneuroblastoma

Question 7

What is the management of a prevertebral abscess diagnosed as tuberculosis in a 44-year-old woman experiencing difficulty in swallowing?

Accepted Answer

Urgent drainage

Answer

Starting anti-tuberculosis chemotherapy (AKT)

Answer

Observation (wait and watch)

Answer

MRI of the cervical spine

Question 8

Tonsillectomy following peritonsillar abscess is typically done after how many weeks?

Accepted Answer

8 weeks

Answer

3 weeks

Answer

6 weeks

Answer

12 weeks

Question 9

Which of the following is FALSE about Zenker Diverticulum?

Accepted Answer

It is associated with cervical webs

Answer

Most common age of presentation is > 50 years

Answer

It is the most common type of esophageal diverticulum

Answer

It occurs via Kilian's dehiscence

Question 10

Which of the following statements regarding the nasopharynx is incorrect?

Accepted Answer

Passavant's muscle is formed by the stylopharyngeus muscle.

Answer

It is also called the epipharynx.

Answer

The lateral wall features the pharyngeal opening of the Eustachian tube.

Answer

The fossa of Rosenmuller corresponds to the internal carotid artery.

Diseases of the Pharynx — MCQs

Diseases of the Pharynx — MCQs

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