Diseases of the Pharynx — MCQs

Diseases of the Pharynx Indian Medical PG Practice Questions and MCQs

Question 151: Which of the following is NOT a feature of Plummer-Vinson syndrome?

A. Iron deficiency anemia
B. Cheilosis
C. Esophageal webs
D. Gastric polyps (Correct Answer)

Explanation: **Plummer-Vinson Syndrome (PVS)**, also known as **Paterson-Brown-Kelly syndrome**, is a clinical triad characterized by iron deficiency anemia, dysphagia, and esophageal webs. It is most commonly seen in middle-aged women and is considered a premalignant condition for post-cricoid carcinoma. ### Why Gastric Polyps is the Correct Answer **Gastric polyps** are not a component of Plummer-Vinson Syndrome. While PVS involves the upper gastrointestinal tract (specifically the esophagus), it does not typically involve the stomach mucosa in the form of polyps. The pathology in PVS is primarily related to mucosal atrophy and epithelial changes due to chronic iron deficiency. ### Explanation of Incorrect Options * **A. Iron deficiency anemia:** This is the hallmark of the syndrome. It leads to depleted iron-dependent enzymes in the epithelium, causing the characteristic mucosal changes. * **B. Cheilosis:** Also known as angular stomatitis, this is a common clinical sign of vitamin B12 and iron deficiency, frequently seen in PVS patients along with glossitis (smooth, red tongue). * **C. Esophageal webs:** These are thin, mucosal folds usually found in the **post-cricoid region** (upper esophagus). They cause the characteristic "painless, intermittent dysphagia" to solids. ### NEET-PG High-Yield Pearls * **Clinical Triad:** Iron deficiency anemia + Dysphagia + Cervical esophageal webs. * **Demographics:** Most common in females (4th–7th decade). * **Premalignant Potential:** High risk of developing **Squamous Cell Carcinoma** of the post-cricoid region and upper esophagus. * **Diagnosis:** Best initial test is a **Barium Swallow** (lateral view) to visualize the web; definitive diagnosis via esophagoscopy. * **Treatment:** Iron supplementation often resolves the dysphagia; persistent webs require endoscopic dilation.

Question 152: Tonsils reach their maximum size by which age?

A. 1 year
B. 3 years
C. 5 years (Correct Answer)
D. 12 years

Explanation: ### Explanation **Correct Answer: C. 5 years** **1. Underlying Medical Concept:** The palatine tonsils are part of the **Waldeyer’s ring**, a collection of lymphoid tissue in the pharynx. Lymphoid tissue in children follows a specific growth trajectory known as the **Scammon’s curve**. Unlike other organs, lymphoid tissue grows rapidly during early childhood to provide local immunity against inhaled and ingested pathogens. The tonsils typically begin to enlarge after birth, reaching their **maximum physiological size between the ages of 3 and 6 years** (with 5 years being the standard peak cited in most ENT textbooks). After this peak, they undergo gradual **physiological atrophy** (involution) starting around puberty. **2. Analysis of Incorrect Options:** * **A. 1 year:** At this age, the immune system is still developing, and the tonsils are relatively small. * **B. 3 years:** While the tonsils are actively enlarging at this stage, they generally continue to grow until they peak closer to age 5 or 6. * **D. 12 years:** By puberty (around 12 years), the tonsils have usually begun the process of involution and are decreasing in size relative to the growing oropharyngeal space. **3. Clinical Pearls for NEET-PG:** * **Physiological vs. Pathological:** Large tonsils in a 5-year-old are often physiological. Surgery (Tonsillectomy) is only indicated if they cause obstructive sleep apnea (OSA) or recurrent infections. * **Blood Supply:** The main artery of the tonsil is the **tonsillar branch of the Facial artery**. * **Nerve Supply:** The sensory supply is provided by the **Glossopharyngeal nerve (CN IX)** and the lesser palatine nerves. *High-yield:* Referred otalgia (ear pain) during tonsillitis occurs via the Glossopharyngeal nerve (Jacobson's nerve). * **Quinsy (Peritonsillar Abscess):** The most common site for a peritonsillar abscess is the **Supratonsillar fossa**.

Question 153: Trotter's triad is seen in which of the following conditions?

A. Nasopharyngeal carcinoma (Correct Answer)
B. Maxillary sinusitis
C. Maxillary carcinoma
D. Angiofibroma

Explanation: **Explanation:** **Trotter’s Triad** is a classic clinical diagnostic feature associated with the lateral spread of **Nasopharyngeal Carcinoma (NPC)**, specifically involving the sinus of Morgagni. It occurs due to the local infiltration of the tumor into surrounding structures. The triad consists of: 1. **Conductive Hearing Loss:** Caused by the occlusion of the Eustachian tube orifice, leading to otitis media with effusion. 2. **Ipsilateral Palatal Paralysis:** Resulting from the infiltration of the Levator Veli Palatini muscle or the Vagus nerve. 3. **Trigeminal Neuralgia (Temporofacial pain):** Caused by involvement of the mandibular nerve (V3) as it exits the foramen ovale. **Analysis of Incorrect Options:** * **Maxillary Sinusitis:** Typically presents with facial pain, nasal discharge, and fever; it does not involve the neurological deficits or Eustachian tube dysfunction seen in Trotter’s Triad. * **Maxillary Carcinoma:** Presents with cheek swelling, nasal obstruction, or epiphora (Ohngren’s line). While it can cause pain, it does not typically present with the specific combination of palatal palsy and middle ear effusion. * **Angiofibroma:** A benign but aggressive vascular tumor in adolescent males. It presents with profuse epistaxis and nasal obstruction rather than the neurological triad. **Clinical Pearls for NEET-PG:** * **Most common site for NPC:** Fossa of Rosenmüller. * **Risk Factor:** Strongly associated with **Epstein-Barr Virus (EBV)**. * **Nodal Involvement:** Often presents as a painless neck mass (level II/V nodes); **Rouviere’s node** (lateral retropharyngeal) is the first to be involved. * **Treatment of Choice:** Radiotherapy (NPC is highly radiosensitive).

Question 154: A black colored patch in the mouth is seen in which of the following conditions?

A. Acute tonsillitis
B. Peritonsillar abscess
C. Vincent's angina (Correct Answer)
D. Leukemia

Explanation: **Explanation:** **Vincent’s Angina** (also known as Trench Mouth or Acute Necrotizing Ulcerative Gingivitis/Pharyngitis) is the correct answer. It is caused by a symbiotic infection of two organisms: the Gram-negative anaerobic spirochete ***Borrelia vincentii*** and the fusiform bacillus ***Fusobacterium nucleatum***. Clinically, it presents as a painful, necrotic ulceration of the tonsils and gums. The hallmark of this condition is the formation of a **dirty-grey or blackish slough (pseudomembrane)** over the ulcerated area. When this membrane is removed, it reveals a bleeding granular surface. The "black" appearance is due to tissue necrosis and the specific microbial flora involved. **Analysis of Incorrect Options:** * **Acute Tonsillitis:** Typically presents with an erythematous, congested tonsil with white or yellowish follicular exudates, not a black patch. * **Peritonsillar Abscess (Quinsy):** Characterized by a bulge of the soft palate and anterior pillar with deviation of the uvula. While there is severe inflammation, there is no characteristic black patch. * **Leukemia:** While leukemic infiltration can cause gingival enlargement or secondary necrotic ulcers (due to neutropenia), it is not the classic primary association for a black patch compared to the specific pseudomembrane of Vincent’s Angina. **High-Yield Clinical Pearls for NEET-PG:** * **Microbiology:** Look for the "Fusospirochetal" complex. * **Clinical Sign:** "Halitosis" (foul breath) is very prominent in Vincent’s Angina. * **Treatment:** Penicillin is the drug of choice, along with Metronidazole to cover anaerobes and oxidizing mouthwashes (Hydrogen Peroxide). * **Differential Diagnosis:** Must be differentiated from Diphtheria (greyish-white membrane) and Infectious Mononucleosis.

Question 155: Paterson-Kelly syndrome is associated with which deficiency?

A. Iron (Correct Answer)
B. Zinc
C. Magnesium
D. Molybdenum

Explanation: **Explanation:** **Paterson-Kelly Syndrome** (also known as **Plummer-Vinson Syndrome**) is characterized by a classic triad of **Iron Deficiency Anemia (IDA)**, dysphagia, and esophageal webs. 1. **Why Iron is correct:** The underlying pathophysiology is linked to chronic iron deficiency. Iron is essential for the rapid turnover of mucosal cells. A deficiency leads to mucosal atrophy in the upper alimentary tract, resulting in the formation of a post-cricoid **esophageal web**. This web causes mechanical obstruction, leading to dysphagia (difficulty swallowing). 2. **Why other options are incorrect:** * **Zinc:** Deficiency typically causes Acrodermatitis enteropathica, growth retardation, and impaired wound healing, but not esophageal webs. * **Magnesium:** Deficiency leads to neuromuscular irritability (tetany) and arrhythmias. * **Molybdenum:** Deficiency is extremely rare and usually associated with genetic metabolic disorders (sulfite oxidase deficiency), not anemia or webs. **Clinical Pearls for NEET-PG:** * **Demographics:** Most commonly seen in middle-aged women. * **Clinical Features:** Glossitis (smooth red tongue), angular cheilitis, and **koilonychia** (spoon-shaped nails). * **Pre-malignant Condition:** It is a significant risk factor for **Post-cricoid Carcinoma** (Squamous Cell Carcinoma). Regular follow-up is mandatory. * **Diagnosis:** Best initial screening is a Hemoglobin/Iron profile; the web is best visualized via a **Barium Swallow** (shows a filling defect in the upper esophagus). * **Treatment:** Iron supplementation often resolves the dysphagia; however, physical dilation of the web may be required if symptoms persist.

Question 156: What condition causes the "frog face" deformity of the nose?

A. Rhinoscleroma
B. Angiofibroma (Correct Answer)
C. Antral polyp
D. Ethmoidal polyp

Explanation: **Explanation:** **Juvenile Nasopharyngeal Angiofibroma (JNA)** is a benign but locally aggressive, highly vascular tumor typically seen in adolescent males. The **"Frog Face" deformity** occurs due to the tumor's expansion from the nasopharynx into the ethmoidal sinuses and the orbit. This leads to the widening of the nasal bridge, proptosis (bulging of eyes), and lateral displacement of the maxilla, giving the patient a characteristic frog-like appearance. **Why other options are incorrect:** * **Rhinoscleroma:** This chronic granulomatous condition (caused by *Klebsiella rhinoscleromatis*) typically causes a **"Hebra Nose"** (woody hard swelling of the nose) rather than the broad facial deformity seen in JNA. * **Antral Polyp (Killian's Polyp):** These usually present with unilateral nasal obstruction. While they can grow large, they rarely cause significant bony expansion or facial deformity. * **Ethmoidal Polyp:** Multiple ethmoidal polyps can lead to a widening of the nasal bridge (often called **"Woakes’ Syndrome"**), but they do not typically produce the full "frog face" profile associated with the massive expansion of an angiofibroma. **High-Yield Clinical Pearls for NEET-PG:** * **Origin:** Sphenopalatine foramen. * **Classic Triad:** Adolescent male + Profuse recurrent epistaxis + Nasal obstruction. * **Radiology:** **Holman-Miller Sign** (Antral sign) – anterior bowing of the posterior wall of the maxillary sinus. * **Diagnosis:** Contrast-enhanced CT (CECT) is the investigation of choice. **Biopsy is contraindicated** due to the risk of torrential hemorrhage. * **Treatment:** Surgical excision (Pre-operative embolization is often done to reduce blood loss).

Question 157: During tonsillectomy, which of the following structures is NOT typically injured?

A. Glossopharyngeal nerve
B. Paratonsillar vein
C. Tonsillar branch of facial artery
D. External carotid artery (Correct Answer)

Explanation: **Explanation:** The **External Carotid Artery (ECA)** is located approximately **2 cm lateral** to the tonsillar fossa, separated from the superior constrictor muscle by the stylopharyngeus muscle and the parapharyngeal space. Due to this anatomical distance, it is not typically at risk during a routine tonsillectomy. **Analysis of Options:** * **Glossopharyngeal Nerve (CN IX):** This nerve lies in the tonsillar bed, just deep to the superior constrictor muscle. It is the most common nerve injured during tonsillectomy, leading to loss of taste and sensation in the posterior 1/3rd of the tongue and referred earache. * **Paratonsillar Vein (Gatekeeper’s Vein):** This is the most common source of **venous bleeding** during tonsillectomy. It descends from the soft palate to the tonsillar bed and is usually divided during the procedure. * **Tonsillar Branch of Facial Artery:** This is the **main arterial supply** to the tonsil. It enters the lower pole by piercing the superior constrictor muscle and is the most common source of **primary arterial hemorrhage**. **High-Yield Clinical Pearls for NEET-PG:** * **Main Artery:** Tonsillar branch of the Facial Artery. * **Most common nerve injured:** Glossopharyngeal nerve. * **Post-Tonsillectomy Hemorrhage:** * **Reactionary (within 24 hours):** Usually due to slipping of a ligature or rise in BP. * **Secondary (5–10 days):** Usually due to **infection** (most common cause). * **Eagle’s Syndrome:** Elongated styloid process causing throat pain post-tonsillectomy due to irritation of the glossopharyngeal nerve.

Question 158: What are the Nodes of Rouvier?

A. Retropharyngeal node (Correct Answer)
B. Parapharyngeal node
C. Adenoids
D. None of the above

Explanation: **Explanation:** The **Nodes of Rouvier** are the most superior of the **lateral retropharyngeal lymph nodes**. They are located in the retropharyngeal space, situated between the posterior pharyngeal wall and the prevertebral fascia, specifically at the level of the atlas (C1) near the base of the skull. **Why Option A is Correct:** The retropharyngeal lymph nodes are divided into medial and lateral groups. The lateral group, specifically the highest node in this chain, is eponymously named the Node of Rouvier. These nodes receive lymphatic drainage from the nasopharynx, soft palate, and posterior ethmoid sinuses. **Why the Other Options are Incorrect:** * **Option B (Parapharyngeal node):** These are located lateral to the pharyngeal wall in the parapharyngeal space. While they are part of the deep neck nodes, they are not synonymous with the Nodes of Rouvier. * **Option C (Adenoids):** These are a collection of subepithelial lymphoid tissue (Waldeyer’s ring) located in the nasopharynx, not a specific deep neck lymph node. **Clinical Pearls for NEET-PG:** 1. **Clinical Significance:** The Node of Rouvier is often the first site of metastasis for **Nasopharyngeal Carcinoma (NPC)**. 2. **Surgical Importance:** Because of their proximity to the internal carotid artery, these nodes are difficult to access surgically and are often treated with radiotherapy. 3. **Suppuration:** In children, infection in these nodes can lead to a **Retropharyngeal Abscess**. These nodes typically atrophy and disappear by the age of 4–6 years, which is why retropharyngeal abscesses are more common in young children.

Question 159: Pseudomembrane formation over the tonsils and pharynx is caused by which of the following?

A. Gram-positive bacilli (Correct Answer)
B. Gram-negative bacilli
C. Single-stranded RNA virus
D. Catalase-negative cocci

Explanation: **Explanation:** The clinical presentation of a **pseudomembrane** over the tonsils and pharynx is the hallmark of **Faucial Diphtheria**, caused by ***Corynebacterium diphtheriae***. 1. **Why Option A is Correct:** *Corynebacterium diphtheriae* is a **Gram-positive, non-motile, club-shaped bacillus**. It produces a potent exotoxin that causes epithelial necrosis and inflammation. The resulting exudate coagulates into a tough, leathery, greyish-white "pseudomembrane" that is firmly adherent; attempting to remove it causes bleeding. 2. **Why the other options are Incorrect:** * **Option B (Gram-negative bacilli):** While organisms like *Klebsiella* can cause respiratory infections, they do not typically present with the classic thick, adherent pseudomembrane seen in diphtheria. * **Option C (ssRNA virus):** This refers to viruses like **Infectious Mononucleosis (EBV)** or Coxsackievirus. While EBV causes an exudative tonsillitis that can mimic a membrane, the causative agent (EBV) is a dsDNA virus, and the "membrane" is usually non-adherent and friable. * **Option D (Catalase-negative cocci):** This refers to **Streptococci** (e.g., *S. pyogenes*). Acute follicular tonsillitis presents with yellowish spots of pus (exudate) that may coalesce, but it does not form a true, tough pseudomembrane. **High-Yield Clinical Pearls for NEET-PG:** * **Schick Test:** Used to determine the immune status of an individual toward diphtheria. * **Culture Media:** Löffler's serum slope (rapid growth) and Potassium Tellurite agar (black colonies). * **Staining:** Albert’s stain reveals **metachromatic granules** (Volutin/Babes-Ernst granules) in a "Chinese letter" arrangement. * **Complications:** Myocarditis (most common cause of death) and palatal paralysis (cranial nerve involvement). * **Management:** Immediate administration of Anti-Diphtheritic Serum (ADS) is the priority.

Question 160: Adenoidectomy is contraindicated in which of the following conditions?

A. Large adenoids
B. Large tonsils
C. Cleft lip
D. Cleft palate (Correct Answer)

Explanation: **Explanation:** The correct answer is **Cleft palate**. **1. Why Cleft Palate is the Correct Answer:** Adenoidectomy is strictly contraindicated in children with an overt, submucous, or repaired cleft palate. The adenoid mass acts as a structural "bolus" in the nasopharynx, helping the soft palate achieve **velopharyngeal closure** during speech and swallowing. If the adenoids are removed in a patient with a cleft palate (where the soft palate is already short or dysfunctional), a large gap is created between the soft palate and the posterior pharyngeal wall. This leads to **Velopharyngeal Insufficiency (VPI)**, resulting in hypernasal speech (rhinolalia aperta) and nasal regurgitation of fluids. **2. Why the Other Options are Incorrect:** * **Large Adenoids (A):** This is the primary **indication** for the surgery, especially if they cause obstructive sleep apnea (OSA), mouth breathing, or recurrent otitis media. * **Large Tonsils (B):** This is not a contraindication. In fact, adenoidectomy is frequently performed alongside tonsillectomy (Adenotonsillectomy) if both tissues are hypertrophied. * **Cleft Lip (C):** An isolated cleft lip (without an associated cleft palate) does not affect the mechanics of the velopharyngeal valve and is therefore not a contraindication for adenoidectomy. **3. High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications:** Cleft palate, Submucous cleft palate (look for a bifid uvula, notch in the hard palate, and zona pellucida), and bleeding disorders. * **Relative Contraindications:** Acute infection (URI) and children under 3 years of age (due to risk of regrowth and significant blood loss). * **The "Bifid Uvula" Rule:** Always palpate the palate and check the uvula before surgery; a bifid uvula is a clinical red flag for a submucous cleft. * **Most common complication:** Hemorrhage (Primary or Reactionary). * **Most common nerve injured:** Glossopharyngeal nerve (rare, more common in tonsillectomy).

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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