Diseases of the Pharynx Practice Questions

Q: All of the following can give rise to a membrane on the pharynx except?

Staphylococcus aureus. ### Explanation The formation of a **pseudomembrane** on the pharynx is a classic clinical sign of specific infections characterized by tissue necrosis and fibrinous exudate. **1. Why Staphylococcus aureus is the correct answer:** While *Staphylococcus aureus* is a common cause of acute follicular tonsillitis, it typically presents with **purulent exudate** (pus) localized to the tonsillar crypts rather than a cohesive, spreading membrane. It does not typically produce the fibrinous, necrotic layer required to form a true or false membrane on the pharyngeal wall. **2. Analysis of Incorrect Options (Membrane-forming conditions):** * **Corynebacterium diphtheriae:** The hallmark of Diphtheria is a thick, **greyish-white, leathery membrane** that is highly adherent. Attempting to remove it results in bleeding because it involves the underlying epithelium. * **Candida albicans:** Fungal pharyngitis (Oral Thrush) presents as **creamy white, curd-like patches**. These can coalesce into a membrane that, unlike diphtheria, is easily scraped off, leaving an erythematous base. * **Vincent’s Angina:** Caused by a symbiotic infection of *Borrelia vincentii* and *Fusobacterium*, it produces a **dirty grey membrane** over a sloughing ulcer on the tonsil, often accompanied by a characteristic malodor (halitosis). **3. Clinical Pearls for NEET-PG:** * **Differential Diagnosis of Pharyngeal Membrane:** Diphtheria, Vincent’s Angina, Infectious Mononucleosis (EBV), Candidiasis, Agranulocytosis, and Aphthous ulcers. * **Infectious Mononucleosis:** Often presents with a widespread white membrane on the tonsils, associated with posterior cervical lymphadenopathy and splenomegaly. * **High-Yield Distinction:** If the membrane **bleeds on touch**, think Diphtheria; if it is **painless and scrapable**, think Candidiasis.

Q: Which of the following is an indication for tonsillectomy?

Recurrent upper respiratory infection. ### Explanation Tonsillectomy is one of the most common surgical procedures in ENT, and its indications are strictly categorized into absolute and relative indications. **1. Why "Recurrent upper respiratory infection" is correct:** According to the **Paradise Criteria**, recurrent infections are a primary indication for tonsillectomy. Specifically, surgery is indicated if a patient suffers from: * 7 episodes in 1 year, OR * 5 episodes per year for 2 consecutive years, OR * 3 episodes per year for 3 consecutive years. Each episode must be documented with clinical features like fever (>38.3°C), cervical lymphadenopathy, or tonsillar exudate. **2. Why other options are incorrect:** * **Rheumatic Fever and Glomerulonephritis:** Historically, these were considered indications to prevent further streptococcal sequelae. However, current evidence and guidelines (including the American Academy of Otolaryngology) state that tonsillectomy **does not** alter the natural course of these diseases or prevent their recurrence. Therefore, they are no longer considered standard indications for the procedure. **3. High-Yield Clinical Pearls for NEET-PG:** * **Absolute Indications:** 1. Sleep Apnea/Obstructive Sleep Apnea (OSA) due to tonsillar hypertrophy (most common indication in children). 2. Suspicion of malignancy (unilateral tonsillar enlargement). 3. Recurrent peritonsillar abscess (Quinsy). * **Most Common Complication:** Post-operative hemorrhage. * *Primary:* Within 24 hours (usually due to inadequate ligation). * *Secondary:* Between 5–10 days (usually due to infection/sloughing of the clot). * **Eagle’s Syndrome:** Elongated styloid process causing throat pain; tonsillectomy is often the surgical approach for styloidectomy.

Q: Excessive hemorrhage from tonsillectomy is due to injury of which structure?

Paratonsillar vein. **Explanation:** The **paratonsillar vein** (also known as the external palatine vein) is the most common cause of excessive or troublesome primary hemorrhage during tonsillectomy. 1. **Why Paratonsillar Vein is Correct:** This vein descends from the soft palate, crosses the lateral surface of the tonsillar capsule, and enters the pharyngeal venous plexus. During the dissection of the tonsil from its bed, this vein is frequently injured. Because it is a venous structure located in the loose areolar tissue of the tonsillar bed, it can bleed profusely, making it the primary culprit for immediate intraoperative or early postoperative bleeding. 2. **Why Other Options are Incorrect:** * **Tonsillar Artery:** While this is the *main* arterial supply (a branch of the facial artery), it is usually ligated or cauterized during the procedure. It causes significant bleeding if missed, but statistically, the paratonsillar vein is the more frequent source of "excessive" oozing. * **Ascending Palatine Artery & Lingual Artery:** These are nearby vascular structures (branches of the facial and external carotid arteries, respectively) that provide collateral supply. While they contribute to the vascularity of the region, they are not the most common source of surgical hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Hemorrhage:** Occurs during the surgery or within 24 hours. Most common cause: **Paratonsillar vein**. * **Reactionary Hemorrhage:** Occurs within 24 hours (usually due to slipping of a ligature or rise in BP). * **Secondary Hemorrhage:** Occurs 5–10 days post-op. Most common cause: **Infection**. * **Main Arterial Supply:** Tonsillar branch of the **Facial Artery**. * **Safety Landmark:** The **Internal Carotid Artery** lies approximately 2.5 cm posterolateral to the tonsil.

Q: A 79-year-old retired opera singer presents with dysphagia, which has become progressively worse during the last 5 years. He states that he is sometimes aware of a lump on the left side of his neck and that he hears gurgling sounds during swallowing. He sometimes regurgitates food during eating. What is the likely diagnosis?

Zenker's (pharyngoesophageal) diverticulum. **Explanation:** The clinical presentation is classic for **Zenker’s Diverticulum (ZD)**, a pulsion diverticulum occurring through **Killian’s dehiscence** (a weak area between the thyropharyngeal and cricopharyngeal parts of the inferior constrictor muscle). **Why Option D is Correct:** * **Demographics:** Typically affects elderly males (79-year-old). * **Gurgling sounds (Boyce’s sign):** Caused by air and fluid mixing within the diverticulum during swallowing. * **Regurgitation:** Undigested food trapped in the sac is regurgitated, often leading to halitosis (bad breath) or aspiration. * **Neck Lump:** A "lump" that may appear or change size during meals (usually on the left side due to the esophagus's slight leftward inclination). **Why Incorrect Options are Wrong:** * **A. Carcinoma of the esophagus:** While it causes progressive dysphagia in the elderly, it typically presents with significant weight loss and would not explain the gurgling sounds or the regurgitation of *undigested* food from a neck pouch. * **B. Foreign body:** This presents acutely with sudden onset dysphagia and odynophagia, not a 5-year progressive history. * **C. Plummer-Vinson Syndrome:** Characterized by the triad of iron-deficiency anemia, glossitis, and esophageal webs. It primarily affects middle-aged women and does not present with a neck lump or gurgling sounds. **High-Yield Clinical Pearls for NEET-PG:** * **Investigation of Choice:** Barium Swallow (shows a pouch behind the esophagus). * **Contraindication:** Rigid esophagoscopy (high risk of accidental perforation of the thin-walled sac). * **Treatment:** Endoscopic Dohlman’s procedure (stapling the party wall) or open diverticulectomy with cricopharyngeal myotomy. * **Killian-Jamieson Diverticulum:** A similar pouch but located *below* the cricopharyngeus, lateral to the recurrent laryngeal nerve.

Q: What is true about Plummer-Vinson syndrome?

The web is most common in the postcricoid region.. **Plummer-Vinson Syndrome (PVS)**, also known as Paterson-Brown-Kelly syndrome, is a classic triad of **iron-deficiency anemia, dysphagia, and esophageal webs**. ### **Explanation of the Correct Option** * **Option C is correct:** The characteristic esophageal web in PVS is almost always located in the **postcricoid region** (upper esophagus). These are thin, eccentric, mucosal folds covered by squamous epithelium. Because the web is located high up, patients typically present with "high dysphagia" localized to the throat. ### **Analysis of Incorrect Options** * **Options A & B:** Esophageal webs in PVS are rarely found in the mid or lower esophagus. Webs in the lower esophagus are typically associated with **Schatzki rings**, which are circumferential and located at the squamocolumnar junction, unlike the proximal, semi-circumferential webs of PVS. * **Option D:** PVS is not a vascular disorder. It is an acquired condition linked to nutritional deficiencies (iron, Vitamin B12, and riboflavin). The dysphagia is due to the mechanical obstruction caused by the mucosal web, not abnormal vessels. ### **High-Yield Clinical Pearls for NEET-PG** * **Demographics:** Most common in middle-aged females (4th–7th decade). * **Clinical Features:** Glossitis (smooth red tongue), angular stomatitis, and **koilonychia** (spoon-shaped nails). * **Premalignant Potential:** PVS is a significant risk factor for **Postcricoid Carcinoma** (Squamous Cell Carcinoma). Regular surveillance is mandatory. * **Diagnosis:** **Barium Swallow** (lateral view) is the investigation of choice to visualize the thin web. * **Treatment:** Iron supplementation often resolves the symptoms; however, persistent webs may require endoscopic dilation.

Q: Quinsy refers to which of the following conditions?

Peritonsillar abscess. **Explanation:** **Quinsy** is the clinical term for a **Peritonsillar Abscess**. It is a collection of pus in the potential space between the **tonsillar capsule** and the **superior constrictor muscle** (the peritonsillar space). It usually occurs as a complication of acute follicular tonsillitis. * **Why Option B is correct:** The infection typically starts at the **crypta magna** and spreads to the peritonsillar space. Clinical features include severe odynophagia (painful swallowing), "hot potato voice," trismus (due to irritation of the pterygoid muscles), and a deviated uvula to the opposite side. **Analysis of Incorrect Options:** * **A. Intra-tonsillar abscess:** This is a rare collection of pus *within* the substance of the tonsil itself, rather than in the surrounding space. * **C. Submandibular abscess:** Also known as Ludwig’s Angina (when involving sublingual and submental spaces), this typically arises from dental infections, not the tonsils. * **D. Retropharyngeal abscess:** This occurs in the space behind the pharynx (prevertebral fascia). It is more common in children due to suppuration of the lymph nodes of Rouviere and presents with neck stiffness and respiratory distress. **High-Yield Clinical Pearls for NEET-PG:** 1. **Management:** The treatment of choice is **Incision and Drainage** at the point of maximum bulge (usually lateral to the junction of the anterior pillar and a horizontal line through the base of the uvula). 2. **Interval Tonsillectomy:** Performed 4–6 weeks after the infection subsides to prevent recurrence. 3. **Most common organism:** *Streptococcus pyogenes* (Group A Beta-hemolytic Strep). 4. **Key Sign:** Deviation of the **uvula** to the contralateral side is a hallmark diagnostic feature.

Q: "Trotter triad" is seen in which anatomical region?

Nasopharynx. **Explanation:** **Trotter’s Triad** is a classic clinical diagnostic cluster associated specifically with **Nasopharyngeal Carcinoma** (NPC). It occurs due to the local infiltration of the tumor into the lateral wall of the nasopharynx and the skull base. **Why Nasopharynx is correct:** The triad consists of three distinct symptoms caused by the tumor's proximity to specific anatomical structures: 1. **Conductive Hearing Loss:** Due to the blockage of the **Eustachian tube** opening, leading to serous otitis media. 2. **Ipsilateral Temporofacial Neuralgia:** Caused by involvement of the **Mandibular nerve (V3)** as it exits the Foramen Ovale. 3. **Palatal Paralysis/Immobility:** Resulting from infiltration of the **Levator Veli Palatini** muscle. **Why other options are incorrect:** * **Hypopharynx:** Tumors here typically present with dysphagia, odynophagia, or referred otalgia (via the Arnold’s or Jacobson’s nerve), but do not involve the V3 nerve or Eustachian tube in this specific pattern. * **Larynx:** Laryngeal pathologies primarily present with hoarseness of voice, stridor, or chronic cough. **NEET-PG High-Yield Pearls:** * **Etiology:** Strongly associated with **Epstein-Barr Virus (EBV)** and dietary factors like salted fish (nitrosamines). * **Most common site:** Fossa of Rosenmüller. * **Most common symptom:** Painless upper cervical lymphadenopathy (often Level II or V). * **Treatment of Choice:** Radiotherapy (it is a highly radiosensitive tumor). Surgery is generally reserved for salvage. * **Imaging:** Contrast-enhanced MRI is the preferred modality to assess skull base involvement.

Q: A patient is complaining of a "lump in the throat" without any difficulty in deglutition. Which muscle is involved in this condition?

Cricopharyngeal muscle. **Explanation:** The clinical presentation described—a sensation of a "lump in the throat" without actual difficulty in swallowing (dysphagia)—is characteristic of **Globus Pharyngeus** (formerly known as Globus Hystericus). **Why the Cricopharyngeal muscle is correct:** The cricopharyngeus muscle forms the **lower esophageal sphincter (LES)** and is the main component of the **Killian’s dehiscence** anatomy. In Globus Pharyngeus, the primary underlying mechanism is often **hypertonicity or spasm** of the cricopharyngeal muscle. This increased resting pressure creates a persistent sensation of a foreign body or "lump." Crucially, because it is a functional sensation rather than a mechanical obstruction, there is no true dysphagia; in fact, the sensation often temporarily improves during the act of swallowing food. **Analysis of Incorrect Options:** * **B. Thyropharyngeus muscle:** This is the upper part of the inferior constrictor. While it works with the cricopharyngeus during swallowing, it is not the site of localized spasm associated with the "lump" sensation. * **C. Stylopharyngeus muscle:** This is a longitudinal muscle (innervated by the Glossopharyngeal nerve) that elevates the larynx and pharynx. It is not involved in the tonic closure of the esophageal inlet. **NEET-PG High-Yield Pearls:** * **Globus Pharyngeus:** Often associated with **GERD/LPR** (Laryngopharyngeal Reflux) or psychological stress. * **Killian’s Dehiscence:** A potential space between the thyropharyngeus and cricopharyngeus; it is the site of herniation for **Zenker’s Diverticulum**. * **Diagnosis of Exclusion:** Before diagnosing Globus, organic causes (like malignancy or post-cricoid webs) must be ruled out via endoscopy or barium swallow if red flags are present.

Q: In allergic pharyngitis, what causes the granularity observed in the posterior pharynx?

Hyperplasia of the submucosal lymphoid tissue. **Explanation:** The posterior pharyngeal wall is rich in **submucosal lymphoid follicles**, which form a part of Waldeyer’s ring (specifically the lateral pharyngeal bands and scattered nodules). In cases of chronic irritation—such as **allergic pharyngitis**, chronic sinusitis (post-nasal drip), or acid reflux—these lymphoid follicles undergo **reactive hyperplasia**. This cellular proliferation causes the follicles to become enlarged and elevated, resulting in the characteristic "cobblestone" or **granular appearance** seen on clinical examination. **Analysis of Options:** * **Option A (Hyperplasia of the mucous membrane):** While the mucosa may appear congested or edematous, the specific "granules" are discrete elevations caused by underlying lymphoid tissue, not a generalized thickening of the epithelium. * **Option B (Hyperplasia of the sebaceous glands):** Sebaceous glands are not typically found in the pharyngeal mucosa. This is a distractor (likely confused with Fordyce spots, which occur in the oral mucosa). * **Option D (Inspissated mucous):** Thickened mucus may cling to the pharynx, but it can be cleared by coughing or swallowing. Granularity refers to fixed anatomical elevations within the tissue. **Clinical Pearls for NEET-PG:** * **Granular Pharyngitis** is most commonly associated with **Chronic Sinusitis** (due to persistent post-nasal drip) and **Mouth Breathing**. * The lateral pharyngeal bands may also undergo hyperplasia, known as **Lateral Pharyngitis**. * **Treatment focus:** In allergic pharyngitis, the primary management involves identifying the allergen and using antihistamines or nasal steroid sprays rather than local throat treatments.

Q: What is the most common cause of a chronic retropharyngeal abscess?

Caries of the cervical spine. ### Explanation The retropharyngeal space is divided into two types of abscesses based on clinical presentation: **Acute** and **Chronic**. **1. Why "Caries of the cervical spine" is correct:** Chronic retropharyngeal abscesses are almost always **tubercular** in origin. This occurs via two mechanisms: * **Caries of the cervical spine (Pott’s Disease):** The infection spreads from the vertebral body to the space behind the prevertebral fascia. * **Tuberculosis of the retropharyngeal lymph nodes:** Secondary to infection in the deep cervical nodes. Because the abscess forms behind the prevertebral fascia, it is typically midline and associated with chronic symptoms like neck pain and stiffness. **2. Why the other options are incorrect:** * **Suppuration of retropharyngeal lymph nodes (Option D):** This is the most common cause of **Acute** retropharyngeal abscess, typically seen in children under 5 years of age following an upper respiratory tract infection (URTI). * **Infective foreign body (Option A):** Traumatic perforation (e.g., fish bone, endoscope) leads to an **Acute** abscess, often presenting with rapid onset of dysphagia and respiratory distress. * **Caries of the teeth (Option B):** Dental infections typically lead to **Ludwig’s Angina** (submandibular space) or parapharyngeal abscesses, not retropharyngeal abscesses. **3. High-Yield Clinical Pearls for NEET-PG:** * **Acute Abscess:** Most common in **children**; usually **lateral** to the midline (due to the Median Raphe); caused by pyogenic infection of the Nodes of Rouviere. * **Chronic Abscess:** Most common in **adults**; usually **midline** (behind prevertebral fascia); caused by **Tuberculosis**. * **X-ray Finding:** Lateral view of the neck shows widening of the prevertebral shadow (Normal: <6mm at C2, <2cm at C6). * **Treatment:** Incision and drainage for acute; antitubercular therapy (ATT) with aspiration for chronic.

Question 1

All of the following can give rise to a membrane on the pharynx except?

Accepted Answer

Staphylococcus aureus

Answer

Corynebacterium

Answer

Candida

Answer

Vincent's angina

Question 2

Which of the following is an indication for tonsillectomy?

Accepted Answer

Recurrent upper respiratory infection

Answer

Rheumatic fever

Answer

Glomerulonephritis

Answer

All

Question 3

Excessive hemorrhage from tonsillectomy is due to injury of which structure?

Accepted Answer

Paratonsillar vein

Answer

Ascending palatine artery

Answer

Tonsillar artery

Answer

Lingual artery

Question 4

A 79-year-old retired opera singer presents with dysphagia, which has become progressively worse during the last 5 years. He states that he is sometimes aware of a lump on the left side of his neck and that he hears gurgling sounds during swallowing. He sometimes regurgitates food during eating. What is the likely diagnosis?

Accepted Answer

Zenker's (pharyngoesophageal) diverticulum

Answer

Carcinoma of the esophagus

Answer

Foreign body in the esophagus

Answer

Plummer-Vinson (Kelly-Patteson) syndrome

Question 5

What is true about Plummer-Vinson syndrome?

Accepted Answer

The web is most common in the postcricoid region.

Answer

The web is most common in the lower esophagus.

Answer

The web is most common in the mid esophagus.

Answer

It occurs due to abnormal vessels.

Question 6

Quinsy refers to which of the following conditions?

Accepted Answer

Peritonsillar abscess

Answer

Intra-tonsillar abscess

Answer

Submandibular abscess

Answer

Retropharyngeal abscess

Question 7

"Trotter triad" is seen in which anatomical region?

Accepted Answer

Nasopharynx

Answer

Hypopharynx

Answer

Larynx

Answer

All of the above

Question 8

A patient is complaining of a "lump in the throat" without any difficulty in deglutition. Which muscle is involved in this condition?

Accepted Answer

Cricopharyngeal muscle

Answer

Thyropharyngeus muscle

Answer

Stylopharyngeus muscle

Answer

None

Question 9

In allergic pharyngitis, what causes the granularity observed in the posterior pharynx?

Accepted Answer

Hyperplasia of the submucosal lymphoid tissue

Answer

Hyperplasia of the mucous membrane

Answer

Hyperplasia of the sebaceous glands

Answer

Inspissated mucous

Question 10

What is the most common cause of a chronic retropharyngeal abscess?

Accepted Answer

Caries of the cervical spine

Answer

Infective foreign body

Answer

Caries of the teeth

Answer

Suppuration of the retropharyngeal lymph node

Diseases of the Pharynx — MCQs

Diseases of the Pharynx — MCQs

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