Diseases of the Pharynx — MCQs

Diseases of the Pharynx Indian Medical PG Practice Questions and MCQs

Question 131: A 13-year-old boy presents with swelling in the cheek with recurrent epistaxis. What is the most likely cause?

A. Angiofibroma (Correct Answer)
B. Carcinoma of Nasopharynx
C. Rhabdomyosarcoma
D. None of the above

Explanation: **Explanation:** The clinical presentation of a **13-year-old boy** with **recurrent epistaxis** and a **cheek swelling** is a classic "spotter" for **Juvenile Nasopharyngeal Angiofibroma (JNA)**. **Why Angiofibroma is Correct:** JNA is a benign but locally aggressive, highly vascular tumor that occurs almost exclusively in **adolescent males** (testosterone-dependent). It typically originates at the sphenopalatine foramen. * **Epistaxis:** Due to the extreme vascularity of the tumor. * **Cheek Swelling:** As the tumor grows, it spreads laterally from the pterygopalatine fossa into the infratemporal fossa, causing a characteristic bulge in the cheek (known as **Frog Face deformity** in advanced cases or **Holman-Miller sign** on imaging). **Why Other Options are Incorrect:** * **B. Carcinoma of Nasopharynx:** While it can cause epistaxis and nasal obstruction, it is rare in early adolescence and more commonly presents with cervical lymphadenopathy and serous otitis media rather than a cheek swelling. * **C. Rhabdomyosarcoma:** This is the most common soft tissue sarcoma in children. While it can occur in the head and neck, it typically presents as a rapidly enlarging, painful mass and is less likely to present with the classic triad of adolescent male + profuse epistaxis + cheek swelling. **NEET-PG High-Yield Pearls:** * **Holman-Miller Sign (Antral Sign):** Forward bowing of the posterior wall of the maxillary sinus seen on CT/MRI. * **Investigation of Choice:** Contrast-Enhanced CT (CECT) scan. * **Gold Standard Diagnosis:** Digital Subtraction Angiography (DSA) – shows a "tumor blush." * **Contraindication:** **Biopsy is strictly contraindicated** in the OPD due to the risk of torrential hemorrhage. * **Treatment:** Surgical excision (usually preceded by preoperative embolization to reduce blood loss).

Question 132: What is the distinguishing feature of a masticatory space infection?

A. Pain
B. Dysphagia
C. Trismus (Correct Answer)
D. Swelling

Explanation: **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).

Question 133: What is the management of a prevertebral abscess diagnosed as tuberculosis in a 44-year-old woman experiencing difficulty in swallowing?

A. Urgent drainage (Correct Answer)
B. Starting anti-tuberculosis chemotherapy (AKT)
C. Observation (wait and watch)
D. MRI of the cervical spine

Explanation: **Explanation:** The correct management for a prevertebral abscess, even when tubercular in origin, is **Urgent Drainage**. **1. Why Urgent Drainage is Correct:** A prevertebral abscess is located in the potential space between the prevertebral fascia and the vertebral bodies. Unlike a retropharyngeal abscess (which is limited by the midline raphe), a prevertebral abscess can track laterally and, more critically, expand anteriorly. In this patient, the symptom of **dysphagia (difficulty swallowing)** indicates significant mass effect. If left undrained, the abscess poses an immediate risk of **airway obstruction** or spontaneous rupture leading to **aspiration pneumonia**. While tuberculosis requires medical therapy, the mechanical compression and risk of acute respiratory distress necessitate surgical decompression first. Drainage is typically performed via a **trans-cervical approach** (along the anterior border of the sternocleidomastoid) rather than trans-orally to prevent secondary infection and facilitate better access to the cervical spine. **2. Why Other Options are Incorrect:** * **B. Starting AKT:** While Anti-Tubercular Therapy (AKT) is the definitive treatment for the underlying infection (Pott’s spine), it does not provide immediate relief for the mechanical obstruction. AKT is started *after* or concurrently with surgical drainage. * **C. Observation:** This is contraindicated due to the high risk of airway compromise and downward spread into the posterior mediastinum (mediastinitis). * **D. MRI of the cervical spine:** While MRI is the gold standard for diagnosing the extent of Pott’s spine and cord compression, the question asks for *management* in a symptomatic patient. Clinical stabilization via drainage takes precedence over further imaging once the diagnosis is established. **Clinical Pearls for NEET-PG:** * **Retropharyngeal Abscess:** Common in children; presents as a midline bulge; usually pyogenic. * **Prevertebral Abscess:** Common in adults; often due to TB of the cervical spine (Pott’s disease); presents as a lateral bulge. * **Danger Space:** Located between the alar fascia and prevertebral fascia; acts as a conduit for infection to spread from the neck to the diaphragm.

Question 134: Tonsillectomy following peritonsillar abscess is typically done after how many weeks?

A. 3 weeks
B. 8 weeks (Correct Answer)
C. 6 weeks
D. 12 weeks

Explanation: **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).

Question 135: What is another name for the parapharyngeal space?

A. Retropharyngeal space
B. Pyriform sinus
C. Lateral pharyngeal space (Correct Answer)
D. All of the above

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. It is bounded medially by the buccopharyngeal fascia and laterally by the pterygoid muscles and the parotid gland. It is divided into prestyloid and poststyloid compartments by the styloid process and its attached muscles. **Why Option C is correct:** The term "lateral pharyngeal space" is the anatomical synonym for the parapharyngeal space because of its position lateral to the superior constrictor muscle of the pharynx. **Why other options are incorrect:** * **A. Retropharyngeal space:** This is a separate midline space located *behind* the pharynx, between the buccopharyngeal fascia and the prevertebral fascia. It is separated from the parapharyngeal space by the carotid sheath. * **B. Pyriform sinus:** This is a clinical landmark within the laryngopharynx (hypopharynx), not a deep neck space. It is a mucosal recess located on either side of the laryngeal inlet. **High-Yield Clinical Pearls for NEET-PG:** * **Shape:** Inverted pyramid with its apex at the greater cornu of the hyoid bone. * **Contents (Poststyloid):** Internal carotid artery, internal jugular vein, cranial nerves IX, X, XI, XII, and the cervical sympathetic chain. * **Clinical Significance:** Infections (often from the tonsils or teeth) can lead to a parapharyngeal abscess, characterized by **trismus** (due to medial pterygoid involvement) and **bulging of the lateral pharyngeal wall** (displacing the tonsil medially). * **Danger:** It communicates with the retropharyngeal and submandibular spaces, providing a route for the spread of infection to the mediastinum.

Question 136: Which of the following is FALSE about Zenker Diverticulum?

A. Most common age of presentation is > 50 years
B. It is the most common type of esophageal diverticulum
C. It occurs via Kilian's dehiscence
D. It is associated with cervical webs (Correct Answer)

Explanation: **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.

Question 137: Which of the following statements regarding the nasopharynx is incorrect?

A. It is also called the epipharynx.
B. The lateral wall features the pharyngeal opening of the Eustachian tube.
C. The fossa of Rosenmuller corresponds to the internal carotid artery.
D. Passavant's muscle is formed by the stylopharyngeus muscle. (Correct Answer)

Explanation: ### 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 138: Ludwig's angina occurs due to infection of which space?

A. Submandibular space (Correct Answer)
B. Retropharyngeal space
C. Pharyngomaxillary space
D. Peritonsillar space

Explanation: **Explanation:** **Ludwig’s Angina** is a rapidly spreading, life-threatening cellulitis (not an abscess) involving the **submandibular space**. This space is anatomically divided by the mylohyoid muscle into the sublingual space (above) and the submaxillary space (below). In Ludwig’s angina, the infection must involve **all three compartments** (bilateral submaxillary and sublingual spaces) to meet the clinical definition. * **Why Submandibular Space is correct:** The most common cause (80%) is dental infection, typically involving the **2nd and 3rd mandibular molars**. Their roots extend below the mylohyoid line, allowing infection to spread directly into the submandibular space. * **Why other options are incorrect:** * **Retropharyngeal space:** Infection here (Retropharyngeal abscess) usually occurs in children due to suppuration of the nodes of Rouviere or in adults due to trauma/Pott’s disease. * **Pharyngomaxillary (Parapharyngeal) space:** Infection here presents with trismus and lateral pharyngeal wall bulging, often following tonsillitis or dental work. * **Peritonsillar space:** Infection here (Quinsy) is a localized complication of acute tonsillitis, characterized by uvular deviation to the opposite side. **High-Yield Clinical Pearls for NEET-PG:** 1. **Key Clinical Features:** "Woody" hard swelling of the neck, elevation and protrusion of the tongue (causing airway obstruction), and absence of fluctuance (as it is cellulitis). 2. **Primary Risk:** Asphyxia due to laryngeal edema is the most common cause of death. 3. **Management:** Airway maintenance is the priority (Tracheostomy if needed). Treatment involves high-dose IV antibiotics and surgical decompression (incision and drainage) if medical therapy fails. 4. **Microbiology:** Usually a mixed infection (Streptococcus, Staphylococcus, and anaerobes).

Question 139: A 40-year-old patient presents with koilonychia, iron deficiency, and dysphagia. What is the most likely diagnosis?

A. Plummer-Vinson syndrome (Correct Answer)
B. Achalasia cardia
C. Zollinger-Ellison syndrome
D. None of the above

Explanation: ### Explanation The correct answer is **Plummer-Vinson syndrome (PVS)**, also known as Paterson-Brown-Kelly syndrome. **1. Why Option A is Correct:** Plummer-Vinson syndrome is classically characterized by a clinical triad: * **Iron Deficiency Anemia:** Presents with systemic symptoms and signs like **koilonychia** (spoon-shaped nails) and glossitis. * **Dysphagia:** Usually painless and progressive, specifically for solids. * **Post-cricoid Esophageal Webs:** These are thin, mucosal folds in the upper esophagus that cause the obstruction. The patient in the question exhibits the complete classic presentation: iron deficiency (anemia), koilonychia (the physical manifestation of chronic iron deficiency), and dysphagia (due to the web). **2. Why Other Options are Incorrect:** * **Option B (Achalasia cardia):** This is a motility disorder of the lower esophageal sphincter (LES). While it causes dysphagia, it typically involves both solids and liquids from the start and is not associated with iron deficiency or koilonychia. * **Option C (Zollinger-Ellison syndrome):** This involves gastrin-secreting tumors leading to severe peptic ulcer disease and diarrhea. It does not cause esophageal webs or koilonychia. **3. NEET-PG High-Yield Pearls:** * **Demographics:** Most common in middle-aged females (4th to 5th decade). * **Pre-malignant Condition:** PVS is a significant risk factor for **Post-cricoid Squamous Cell Carcinoma**. Regular follow-up is essential. * **Diagnosis:** The investigation of choice to visualize the web is a **Barium Swallow** (lateral view), though esophagoscopy can be both diagnostic and therapeutic (by rupturing the web). * **Treatment:** The primary treatment is **Iron supplementation**, which often resolves the dysphagia. Mechanical dilation is reserved for persistent webs.

Question 140: Dysphagia lusoria is caused by:

A. Neural anomaly
B. Malabsorption
C. Vascular anomaly (Correct Answer)
D. Other

Explanation: **Explanation:** **Dysphagia Lusoria** (literally "dysphagia by a trick of nature") is a clinical condition where difficulty in swallowing occurs due to extrinsic compression of the esophagus by a **vascular anomaly**. The most common underlying cause is an **aberrant right subclavian artery**. In this congenital anomaly, the right subclavian artery arises directly from the aortic arch (distal to the left subclavian) instead of the brachiocephalic trunk. To reach the right side, the artery typically passes behind the esophagus (retro-esophageal), creating a mechanical indentation that leads to dysphagia. **Analysis of Options:** * **Option C (Correct):** It is fundamentally a vascular malformation causing mechanical obstruction. * **Option A (Incorrect):** While the name sounds similar to neurological conditions, there is no primary neural deficit or motor incoordination involved. * **Option B (Incorrect):** Malabsorption is a functional disorder of the small intestine and does not cause structural dysphagia. **High-Yield Clinical Pearls for NEET-PG:** * **Barium Swallow Finding:** Shows a characteristic **oblique or spiral indentation** on the posterior aspect of the esophagus at the level of the 3rd or 4th thoracic vertebrae. * **Bayford’s Syndrome:** Another name for Dysphagia Lusoria, named after David Bayford who first described it in 1787. * **Associated Sign:** It may be associated with a "Kommerell’s diverticulum" (a dilation at the origin of the aberrant vessel). * **Treatment:** Most cases are asymptomatic and managed conservatively; severe cases require surgical vascular reconstruction.

Practice by Chapter

Pharyngitis

Practice Questions

Tonsillitis

Practice Questions

Peritonsillar Abscess

Practice Questions

Retropharyngeal Abscess

Practice Questions

Adenoid Hypertrophy

Practice Questions

Sleep-Disordered Breathing

Practice Questions

Obstructive Sleep Apnea

Practice Questions

Nasopharyngeal Carcinoma

Practice Questions

Oropharyngeal Carcinoma

Practice Questions

Hypopharyngeal Carcinoma

Practice Questions

Dysphagia

Practice Questions

Globus Pharyngeus

Practice Questions

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