Diseases of the Pharynx — MCQs

Diseases of the Pharynx Indian Medical PG Practice Questions and MCQs

Question 181: What is the ideal time for Quinsy surgery after acute tonsillitis?

A. 2 weeks
B. 4 weeks
C. 6 weeks (Correct Answer)
D. 12 weeks

Explanation: **Explanation:** **1. Why 6 weeks is the correct answer:** Quinsy, or **Peritonsillar Abscess**, is a complication of acute tonsillitis where pus collects between the tonsillar capsule and the superior constrictor muscle. The definitive treatment for recurrent tonsillitis or a history of quinsy is an **Interval Tonsillectomy**. The ideal timing for this procedure is **6 weeks** after the acute episode has subsided. This "cooling-off" period allows the intense inflammatory response, edema, and hypervascularity (increased blood supply) of the peritonsillar tissues to resolve. Operating during this window ensures that the surgical plane between the capsule and the muscle is fibrosed but distinct, significantly reducing the risk of intraoperative hemorrhage. **2. Analysis of incorrect options:** * **A & B (2-4 weeks):** At this stage, the tissues are still friable and hyperemic. Attempting surgery too early increases the risk of excessive bleeding and makes dissection difficult. * **D (12 weeks):** While safe, waiting 3 months is unnecessarily long. It increases the window of risk for a recurrent infection or a second quinsy episode before the surgery can be performed. **3. NEET-PG High-Yield Clinical Pearls:** * **Abscess Tonsillectomy (Quinsy Tonsillectomy):** This refers to performing tonsillectomy *during* the acute phase (immediate). While it provides instant drainage, it carries a high risk of primary hemorrhage and aspiration of pus. * **Most common organism:** *Streptococcus pyogenes* (Group A Beta-hemolytic Strep). * **Clinical Sign:** "Hot potato voice," trismus (due to irritation of the medial pterygoid muscle), and uvular deviation to the opposite side. * **Treatment of choice for acute quinsy:** 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).

Question 182: Goldring's criteria is used to diagnose which condition?

A. Quinsy
B. Ludwig's Angina (Correct Answer)
C. Nasopharyngeal carcinoma
D. Chronic Tonsillitis

Explanation: **Explanation:** **Ludwig’s Angina** is a rapidly spreading, life-threatening cellulitis involving the submandibular, sublingual, and submental spaces. **Goldring’s criteria** (often referred to as Grodinsky’s criteria in some texts) are the clinical diagnostic benchmarks used to identify this condition. The criteria include: 1. The infection must be a **cellulitis**, not an abscess. 2. It involves the **submandibular space** (both sublingual and submaxillary compartments). 3. Presence of **gangrene** with serosanguinous, foul-smelling fluid but little to no frank pus. 4. Involvement of connective tissue, fascia, and muscles, but **not the glandular structures**. 5. Direct spread via **continuity**, rather than through the lymphatics. **Why other options are incorrect:** * **Quinsy (Peritonsillar Abscess):** This is a localized collection of pus between the tonsillar capsule and the superior constrictor muscle. Diagnosis is clinical (trismus, uvular deviation, "hot potato" voice), not based on Goldring’s criteria. * **Nasopharyngeal Carcinoma:** Diagnosis relies on endoscopic biopsy and imaging (CT/MRI). The **TNM staging** and **WHO classification** are the relevant frameworks here. * **Chronic Tonsillitis:** This is a clinical diagnosis based on recurrent sore throats and physical findings like Griesman’s sign (expression of cheesy material from crypts). **High-Yield Clinical Pearls for NEET-PG:** * **Source:** 80% of cases are **odontogenic** (usually the 2nd and 3rd lower molars). * **Clinical Feature:** Characterized by "woody" or "brawny" edema of the neck and **elevation/protrusion of the tongue**, which can lead to acute airway obstruction. * **Management:** The priority is **airway maintenance** (often via tracheostomy). Treatment involves high-dose IV antibiotics and surgical decompression (incision and drainage).

Question 183: Which of the following is NOT included in the hypopharynx?

A. Pyriform sinus
B. Post cricoid region
C. Anterior pharyngeal wall (Correct Answer)
D. Posterior pharyngeal wall

Explanation: The **hypopharynx** (laryngopharynx) is the lowermost part of the pharynx, extending from the level of the hyoid bone above to the lower border of the cricoid cartilage (C6 level) below. ### Why "Anterior Pharyngeal Wall" is the Correct Answer: Anatomically, the hypopharynx does not have a true "anterior wall" because the **larynx** sits directly in front of it. The space that would be the anterior wall is occupied by the laryngeal inlet and the posterior surface of the larynx. Therefore, the "Anterior Pharyngeal Wall" is a non-existent anatomical entity in the context of hypopharyngeal subdivisions. ### Analysis of Other Options: The hypopharynx is divided into three specific subsites: * **Pyriform Sinus (Option A):** These are two deep recesses located on either side of the laryngeal inlet. They are the most common site for malignancies in the hypopharynx. * **Post-cricoid Region (Option B):** This area lies behind the cricoid cartilage, extending from the level of the arytenoid cartilages to the lower border of the cricoid. It is a classic site for carcinoma in females with Plummer-Vinson syndrome. * **Posterior Pharyngeal Wall (Option D):** This extends from the level of the hyoid bone to the cricoarytenoid joint. ### NEET-PG High-Yield Pearls: * **Most common site of Hypopharyngeal Cancer:** Pyriform Sinus (often presents with "referred otalgia" via the internal laryngeal nerve). * **Least common site:** Posterior pharyngeal wall. * **Killian’s Dehiscence:** A weak area between the thyropharyngeus and cricopharyngeus muscles (parts of the inferior constrictor) located in the posterior wall, which is the site for **Zenker’s Diverticulum**. * **Nerve Supply:** Sensory supply is primarily via the Vagus nerve (Internal laryngeal nerve).

Question 184: Which of the following is NOT an example of velopharyngeal insufficiency?

A. Cleft lip (Correct Answer)
B. Cleft palate
C. Bifid uvula
D. Palatal paralysis

Explanation: ### Explanation **Velopharyngeal Insufficiency (VPI)** is a structural defect where the soft palate (velum) cannot physically close against the posterior pharyngeal wall. This failure of the "velopharyngeal valve" leads to hypernasal speech (rhinolalia aperta) and nasal regurgitation of food. **Why Cleft Lip is the Correct Answer:** A **Cleft Lip** is an isolated primary palate deformity involving the lip and/or the alveolar ridge. It does not involve the soft palate or the pharyngeal musculature. Therefore, the mechanism of velopharyngeal closure remains intact. While it often co-occurs with a cleft palate, an isolated cleft lip does not cause VPI. **Analysis of Incorrect Options:** * **Cleft Palate:** This is the most common cause of VPI. The structural gap in the hard or soft palate prevents the formation of a seal between the oropharynx and nasopharynx. * **Bifid Uvula:** This is often considered the mildest form of a **Submucous Cleft Palate**. In these cases, while the mucosa may look intact, the underlying levator veli palatini muscles are malinserted (forming the "V" shaped Notch), leading to structural insufficiency. * **Palatal Paralysis:** This occurs due to lesions of the Vagus nerve (CN X) or the Pharyngeal plexus (e.g., in Diphtheria or Bulbar palsy). Although the structure is present, the inability of the muscles to elevate the palate results in functional insufficiency. **High-Yield Clinical Pearls for NEET-PG:** * **Passavant’s Ridge:** A mucosal ridge formed by the contraction of the upper fibers of the **palatopharyngeus** muscle; it aids in velopharyngeal closure. * **Rhinolalia Aperta:** The "open" nasal speech heard in VPI (e.g., cleft palate). * **Rhinolalia Clausa:** The "closed" hyponasal speech heard in nasal obstruction (e.g., adenoid hypertrophy or DNS). * **Gutzmann’s Test:** Used to diagnose VPI; the patient's speech improves when the nose is manually pinched.

Question 185: A 12-year-old child presents with a unilateral pink nasal mass. What is the most important investigation prior to undertaking surgery?

A. Ultrasound
B. Fine Needle Aspiration Cytology (FNAC)
C. Biopsy
D. Contrast Computed Tomography (CT) scan (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Contrast Computed Tomography (CT) scan** **Medical Concept:** The clinical presentation of a **unilateral pink nasal mass** in a young patient is highly suspicious for **Juvenile Nasopharyngeal Angiofibroma (JNA)**. JNA is a benign but locally aggressive, highly vascular tumor. The most critical step prior to surgery is a **Contrast-Enhanced CT (CECT) scan** (or MRI) to assess the extent of the tumor and its vascularity. A CT scan is the gold standard for evaluating bony involvement, particularly the widening of the pterygopalatine fossa (the **Holman-Miller sign** or antral sign), which is pathognomonic for JNA. Pre-operative imaging is essential to plan the surgical approach and to consider preoperative embolization to reduce intraoperative bleeding. **Why other options are incorrect:** * **Biopsy (C) & FNAC (B):** These are **strictly contraindicated** in suspected JNA. Because the tumor is extremely vascular and lacks a true capsule, any attempt at tissue sampling can lead to profuse, life-threatening epistaxis. Diagnosis is primarily clinical and radiological. * **Ultrasound (A):** Ultrasound has no role in evaluating deep-seated nasopharyngeal masses as it cannot penetrate the bony structures of the skull base. **Clinical Pearls for NEET-PG:** * **Classic Triad of JNA:** Adolescent male + Profuse recurrent epistaxis + Nasal obstruction. * **Holman-Miller Sign:** Anterior bowing of the posterior wall of the maxillary sinus seen on CT. * **Origin:** Usually arises from the superior margin of the sphenopalatine foramen. * **Investigation of Choice:** Contrast CT (for bone/extent) or Digital Subtraction Angiography (DSA) if embolization is planned. * **Treatment:** Surgical excision (e.g., Transpalatal, Endoscopic, or Maxillary swing approaches) preceded by hormonal therapy or embolization.

Question 186: Radiotherapy is used in the treatment of angiofibroma when it involves which of the following structures?

A. Cheek
B. Orbit
C. Cavernous sinus
D. Middle cranial fossa (Correct Answer)

Explanation: **Explanation:** Juvenile Nasopharyngeal Angiofibroma (JNA) is a benign but locally aggressive, highly vascular tumor. The primary treatment of choice is **surgical excision** (typically via endoscopic or open approaches). However, radiotherapy is reserved for specific, challenging scenarios. **Why Middle Cranial Fossa is Correct:** Radiotherapy is indicated for **unresectable tumors** or cases with **extensive intracranial extension**, particularly when the tumor involves the **middle cranial fossa** or the **cavernous sinus** (though the middle cranial fossa is the classic landmark cited in standard textbooks like Dhingra). When the tumor invades the dura or brain parenchyma in the middle cranial fossa, complete surgical removal becomes high-risk due to potential neurovascular damage and uncontrollable hemorrhage. In such cases, radiotherapy (30-50 Gy) is used to shrink the tumor and induce fibrosis. **Analysis of Incorrect Options:** * **A. Cheek:** Involvement of the cheek (via the infratemporal fossa) is common but accessible surgically. * **B. Orbit:** Orbital extension (via the inferior orbital fissure) can usually be managed surgically without necessitating radiation. * **C. Cavernous Sinus:** While cavernous sinus involvement is a relative indication for radiotherapy, standard NEET-PG curriculum and textbooks prioritize **Middle Cranial Fossa** as the definitive anatomical boundary where surgery becomes prohibitive and radiotherapy is preferred. **Clinical Pearls for NEET-PG:** * **Classic Presentation:** Adolescent male with painless, profuse, recurrent epistaxis and nasal obstruction. * **Site of Origin:** Sphenopalatine foramen (posterior part of the nasal cavity). * **Holman-Miller Sign:** Anterior bowing of the posterior wall of the maxilla (seen on CT/MRI). * **Diagnosis:** Contrast-enhanced CT (CECT) is the investigation of choice. **Biopsy is contraindicated** due to the risk of fatal hemorrhage. * **Pre-operative Step:** Embolization of the feeding artery (usually the **Internal Maxillary Artery**) 24–48 hours before surgery to reduce blood loss.

Question 187: Long-standing obstruction due to enlarged tonsils and adenoids can cause:

A. Left ventricular hypertrophy
B. Bundle branch block
C. Cor pulmonale (Correct Answer)
D. Cardiac ischaemia

Explanation: **Explanation:** The correct answer is **Cor pulmonale**. **Pathophysiology:** Long-standing upper airway obstruction due to adenotonsillar hypertrophy leads to a state of chronic alveolar hypoventilation. This results in **chronic hypoxia** and **hypercapnia**. Hypoxia is a potent stimulus for **pulmonary vasoconstriction** (Euler-Liljestrand reflex). Persistent vasoconstriction leads to pulmonary arterial hypertension, which increases the afterload on the right ventricle. Over time, this causes right ventricular hypertrophy and eventual right-sided heart failure, known as **Cor pulmonale**. **Analysis of Incorrect Options:** * **A & D (Left Ventricular Hypertrophy & Cardiac Ischaemia):** Adenotonsillar obstruction primarily affects the pulmonary circulation and the right side of the heart. LVH is typically a result of systemic hypertension or aortic stenosis, not pulmonary issues. Ischaemia is related to coronary artery disease. * **B (Bundle Branch Block):** While severe right ventricular strain can sometimes lead to right bundle branch block (RBBB), it is a secondary conduction finding rather than the primary clinical consequence of the obstruction. **Clinical Pearls for NEET-PG:** * **Adenoid Facies:** Characterized by an open mouth, dull expression, hitched-up upper lip, crowded teeth, and a high-arched palate due to chronic mouth breathing. * **Sleep Study:** Polysomnography is the gold standard for diagnosing Obstructive Sleep Apnea (OSA) in these patients. * **Treatment:** Adenotonsillectomy is the definitive treatment and can often reverse early-stage pulmonary hypertension in children. * **High-Yield Association:** Always associate chronic upper airway obstruction in children with **Pulmonary Hypertension** and **Right Heart Failure**.

Question 188: What is the most common cause of unilateral middle ear serous effusion in an adult?

A. Tuberculosis
B. Foreign body
C. Nasopharyngeal carcinoma (Correct Answer)
D. Chronic suppurative otitis media

Explanation: **Explanation:** In an adult, **unilateral serous otitis media (Otitis Media with Effusion)** is considered **Nasopharyngeal Carcinoma (NPC)** until proven otherwise. **Why Nasopharyngeal Carcinoma is correct:** The nasopharynx houses the opening of the **Eustachian tube** (located in the lateral wall, just anterior to the Fossa of Rosenmüller). NPC typically originates in the Fossa of Rosenmüller. As the tumor grows, it mechanically obstructs the Eustachian tube orifice. This leads to negative middle ear pressure, transudation of fluid, and subsequent conductive hearing loss. This presentation is a classic component of **Trotter’s Triad** (unilateral conductive deafness, palatal paralysis, and trigeminal neuralgia). **Why other options are incorrect:** * **Tuberculosis:** While TB can affect the middle ear (painless otorrhoea with multiple perforations), it is a rare cause of isolated serous effusion in adults compared to malignancy. * **Foreign Body:** This is a common cause of unilateral nasal discharge or ear canal irritation in children, but it rarely causes isolated middle ear effusion in adults. * **Chronic Suppurative Otitis Media (CSOM):** This involves a perforated tympanic membrane and active or inactive infection (discharge), whereas serous effusion occurs behind an **intact** eardrum. **High-Yield Clinical Pearls for NEET-PG:** * **Rule of Thumb:** Any adult presenting with new-onset unilateral glue ear must undergo **diagnostic nasal endoscopy (DNE)** to visualize the nasopharynx. * **Most common site for NPC:** Fossa of Rosenmüller. * **Associated Virus:** Epstein-Barr Virus (EBV). * **Trotter’s Triad:** 1. Conductive deafness (Eustachian tube block), 2. Ipsilateral soft palate immobility (Vagus nerve involvement), 3. Temporofacial pain (Trigeminal nerve involvement).

Question 189: True about Plummer-Vinson syndrome?

A. Web is most common in the mid esophagus
B. Web is most common in the lower esophagus
C. Web is most common in the postcricoid region (Correct Answer)
D. None of the above

Explanation: **Explanation:** Plummer-Vinson Syndrome (also known as Paterson-Brown-Kelly Syndrome) is characterized by a classic triad of **Iron Deficiency Anemia (IDA)**, **Dysphagia**, and **Cervical Esophageal Webs**. **Why Option C is Correct:** The esophageal web in this syndrome is a thin, mucosal fold that typically occurs in the **postcricoid region** (the uppermost part of the esophagus). This is the hallmark anatomical location. The dysphagia is usually painless and progressive, initially for solids. **Why Other Options are Incorrect:** * **Options A & B:** Webs in Plummer-Vinson syndrome are almost exclusively found in the upper esophagus (postcricoid). Webs in the **mid-esophagus** are rare and often associated with other conditions like pemphigoid. Webs/rings in the **lower esophagus** are typically referred to as **Schatzki rings**, which are distinct from the cervical webs seen in this syndrome and are often associated with hiatal hernias. **High-Yield Clinical Pearls for NEET-PG:** * **Epidemiology:** Most commonly seen in middle-aged females. * **Clinical Features:** Glossitis (smooth red tongue), angular stomatitis, and **koilonychia** (spoon-shaped nails) due to chronic iron deficiency. * **Pre-malignant Potential:** It is considered a pre-malignant condition. There is a significantly increased risk of developing **Squamous Cell Carcinoma** of the postcricoid region and upper esophagus. * **Diagnosis:** Best diagnosed via **Barium Swallow** (shows a shelf-like projection) or upper GI endoscopy. * **Treatment:** Iron supplementation often improves the dysphagia; however, physical dilation of the web may be required.

Question 190: All of the following are true about Thornwaldt's abscess except?

A. Also called as pharyngeal bursitis
B. Presents as persistent postnasal drip
C. Antitubercular treatment is given (Correct Answer)
D. Marsupialization is done

Explanation: **Explanation:** **Thornwaldt’s Abscess** (or Tornwaldt’s cyst) is a benign midline nasopharyngeal lesion. It occurs due to the persistence of the **notochordal remnant**, which leads to the formation of a cyst in the bursa pharyngea (located between the longus capitis muscles). 1. **Why Option C is the Correct Answer (False Statement):** Thornwaldt’s abscess is a developmental/anatomical pathology, not an infectious granulomatous disease. Therefore, **Antitubercular Treatment (ATT) has no role** in its management. The "abscess" usually forms when a pre-existing cyst becomes secondarily infected by pyogenic bacteria, not *Mycobacterium tuberculosis*. 2. **Analysis of Other Options:** * **Option A:** It is indeed called **pharyngeal bursitis** because it involves the inflammation/infection of the pharyngeal bursa. * **Option B:** The most common clinical presentation is a **persistent, foul-smelling postnasal drip**. Other symptoms include occipital headache, halitosis, and Eustachian tube dysfunction. * **Option D:** The definitive treatment is surgical. **Marsupialization** or endoscopic excision of the cyst wall is performed to prevent recurrence. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Always in the **midline** of the posterior nasopharyngeal wall (above the superior constrictor). * **Diagnosis:** Best visualized via **Nasal Endoscopy** (smooth midline swelling) or **MRI** (shows a high-signal intensity cyst on T2 images). * **Differential Diagnosis:** Must be differentiated from Adenoiditis or a Rathke’s pouch cyst (which is usually more superior/anterior).

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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