Diseases of the Pharynx — MCQs
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All of the following are true about nasopharyngeal angiofibroma except:
A 6-year-old boy presented with recurrent upper respiratory tract infections, mouth breathing, and impaired hearing. He was diagnosed with adenoid hypertrophy and underwent adenoidectomy with grommet insertion. One week after surgery, the boy was brought back to the clinic with torticollis. Which of the following is true regarding this condition?
Rigid esophagoscopy is contraindicated in which of the following conditions?
A patient presents with a one-week history of sore throat, dysphagia, and palatal ulcers. Examination reveals vesicles over the soft palate and tonsillar pillars. The ulcers have a gray base and an inflamed periphery. What is the most likely diagnosis?
Which of the following is NOT true about nasopharyngeal angiofibroma?
Guy's aprosexia is seen in:
A white patch in the throat may be due to which of the following?
All of the following are true about adenoid hypertrophy EXCEPT?
Zenker's diverticulum is also known as which of the following?
What is the most common foreign body found in the esophagus in children?
Diseases of the Pharynx Indian Medical PG Practice Questions and MCQs
Question 11: All of the following are true about nasopharyngeal angiofibroma except:
- A. Seen exclusively in the age group of 10-20 years
- B. Seen exclusively in males
- C. Recurrent bleeding is the most common presentation
- D. X-ray is the investigation of choice (Correct Answer)
Explanation: **Explanation:** Juvenile Nasopharyngeal Angiofibroma (JNA) is a benign but locally aggressive, highly vascular tumor. **Why Option D is the correct answer (The "Except"):** X-ray is **not** the investigation of choice. While a lateral view X-ray may show the "Holman-Miller sign" (anterior bowing of the posterior wall of the maxillary sinus), it lacks the detail required for surgical planning. * **Contrast-Enhanced CT (CECT)** is the investigation of choice to assess bone destruction and tumor extent. * **MRI** is superior for evaluating intracranial extension. * **Angiography** is the gold standard for assessing blood supply and for preoperative embolization. **Analysis of other options:** * **Option A & B:** JNA is classically seen **exclusively in adolescent males** (typically 10–20 years). It is thought to be testosterone-dependent; its occurrence in females should prompt genetic testing (karyotyping). * **Option C:** The most common clinical presentation is **painless, progressive nasal obstruction** followed closely by **recurrent, profuse epistaxis** (bleeding). **Clinical Pearls for NEET-PG:** * **Site of Origin:** Sphenopalatine foramen (posterior part of the nasal cavity). * **Holman-Miller Sign (Antral Sign):** Pathognomonic radiological sign showing anterior bowing of the posterior maxillary wall. * **Contraindication:** **Biopsy is strictly contraindicated** in an office setting due to the risk of torrential, life-threatening hemorrhage. * **Treatment:** Surgical excision (Preceded by embolization 24–48 hours prior to reduce blood loss). * **Classification:** Fisch or Radkowski classifications are used for staging.
Question 12: A 6-year-old boy presented with recurrent upper respiratory tract infections, mouth breathing, and impaired hearing. He was diagnosed with adenoid hypertrophy and underwent adenoidectomy with grommet insertion. One week after surgery, the boy was brought back to the clinic with torticollis. Which of the following is true regarding this condition?
- A. Adenoidectomy should not have been performed as adenoids typically regress spontaneously.
- B. Torticollis is not a complication after adenoid surgery; this presentation is coincidental.
- C. This condition is most common in children with Down's syndrome.
- D. Atlantoaxial subluxation is the cause of his torticollis. (Correct Answer)
Explanation: The clinical presentation describes **Grisel’s Syndrome** (non-traumatic atlantoaxial subluxation), a rare but serious complication following ENT surgeries or pharyngeal infections. ### **Explanation of the Correct Answer** **D. Atlantoaxial subluxation is the cause of his torticollis.** Grisel’s syndrome occurs due to inflammatory laxity of the transverse ligament of the atlas (C1). The pharyngeal venous plexus drains into the periodontoid venous plexus; inflammation from surgery (adenoidectomy) or infection leads to hyperemia and decalcification of the anterior arch of the atlas, causing the ligament to loosen and the C1-C2 joint to subluxate. This results in sudden-onset torticollis, typically appearing one week post-operatively. ### **Analysis of Incorrect Options** * **A:** While adenoids regress by puberty, surgery is indicated if they cause significant morbidity like obstructive sleep apnea or recurrent otitis media with effusion (indicated here by "impaired hearing" and "grommet insertion"). * **B:** Torticollis is a recognized, albeit rare, complication of adenoidectomy. Ignoring this can lead to permanent neurological deficits. * **C:** While children with Down’s syndrome have baseline atlantoaxial instability and are at higher risk, Grisel’s syndrome is **not** most common in them; it is primarily associated with pharyngeal infections and surgeries in the general pediatric population. ### **High-Yield Clinical Pearls for NEET-PG** * **Grisel’s Syndrome:** Non-traumatic subluxation of the atlantoaxial joint. * **Classic Presentation:** Child with recent adenoidectomy/tonsillectomy presenting with "Cock-robin" head position (head tilted to one side and rotated to the opposite side). * **Diagnosis:** CT scan is the gold standard (shows C1-C2 rotation). * **Management:** Early cases are managed with cervical collars and NSAIDs; late cases may require traction or surgical fusion.
Question 13: Rigid esophagoscopy is contraindicated in which of the following conditions?
- A. Cervical spine rigidity and Aortic aneurysm
- B. Cervical spine rigidity and Esophageal web (Correct Answer)
- C. Cervical spine rigidity and Lung abscess
- D. Aortic aneurysm and Esophageal web
Explanation: **Explanation:** Rigid esophagoscopy requires the patient to be in the **"sniffing position"** (extension of the head at the atlanto-occipital joint and flexion of the neck at the lower cervical spine) to create a straight path for the rigid instrument. 1. **Cervical Spine Rigidity:** Conditions such as cervical spondylosis, ankylosing spondylitis, or spinal trauma prevent the necessary neck extension. Attempting rigid esophagoscopy in these patients carries a high risk of **cervical spine fracture** or **esophageal perforation** due to the excessive force required to pass the scope. 2. **Esophageal Web:** While an esophageal web is an *indication* for dilation, it is often considered a relative contraindication for blind or forceful rigid esophagoscopy because the web makes the esophageal wall extremely thin and friable (especially in **Plummer-Vinson Syndrome**), significantly increasing the risk of **instrumental perforation**. **Analysis of Incorrect Options:** * **Aortic Aneurysm:** While a large aneurysm can cause extrinsic compression, it is generally considered a *relative* contraindication or a condition requiring extreme caution rather than an absolute contraindication compared to spinal rigidity. * **Lung Abscess:** This is not a contraindication for esophagoscopy; however, if a tracheoesophageal fistula is suspected, care must be taken to prevent aspiration. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of perforation** during rigid esophagoscopy: **Cricopharyngeus** (the narrowest part of the esophagus). * **Killian’s Dehiscence:** The potential gap between the thyropharyngeus and cricopharyngeus where Zenker’s diverticulum occurs and where the risk of esophagoscopy-induced perforation is highest. * **Choice of Scope:** If rigid esophagoscopy is contraindicated, **Flexible Esophagoscopy** is the preferred alternative as it does not require specific neck positioning.
Question 14: A patient presents with a one-week history of sore throat, dysphagia, and palatal ulcers. Examination reveals vesicles over the soft palate and tonsillar pillars. The ulcers have a gray base and an inflamed periphery. What is the most likely diagnosis?
- A. Herpangina (Correct Answer)
- B. Pharyngitis
- C. Chickenpox
- D. Primary herpetic gingivostomatitis
Explanation: **Explanation:** The clinical presentation of acute onset sore throat, dysphagia, and characteristic **vesicles/ulcers localized to the posterior oral cavity** (soft palate, uvula, and tonsillar pillars) is classic for **Herpangina**. **1. Why Herpangina is correct:** Herpangina is caused primarily by **Coxsackie A virus** (and occasionally Coxsackie B or Echovirus). It typically affects children but can occur in adults. The hallmark is the appearance of small (1–2 mm) vesicles that rupture to form shallow ulcers with a **grayish-white base and an erythematous (inflamed) halo**. Crucially, these lesions are confined to the **posterior pharynx**, sparing the buccal mucosa and gingiva. **2. Why the other options are incorrect:** * **Pharyngitis:** This is a general term. While Herpangina is a form of viral pharyngitis, the specific description of vesicles and gray-based ulcers points to a more definitive diagnosis. * **Chickenpox (Varicella):** While it causes vesicles, they are usually widespread across the body (centripetal distribution) and involve the skin more prominently than the isolated posterior oropharynx. * **Primary Herpetic Gingivostomatitis:** Caused by HSV-1, this typically involves the **anterior** mouth (gingiva, tongue, and buccal mucosa). It is characterized by diffuse gum swelling (gingivitis) and bleeding, which are absent in Herpangina. **Clinical Pearls for NEET-PG:** * **Causative Agent:** Coxsackie **A** Virus (High-yield). * **Site Specificity:** Herpangina = Posterior Pharynx; Herpes = Anterior Mouth/Gingiva. * **Hand-Foot-Mouth Disease (HFMD):** Also caused by Coxsackie A16; look for similar oral ulcers plus a maculopapular rash on palms and soles. * **Seasonality:** Most common in summer and autumn months. * **Management:** Supportive (hydration and analgesics), as it is self-limiting.
Question 15: Which of the following is NOT true about nasopharyngeal angiofibroma?
- A. Commonly seen in adolescent males (Correct Answer)
- B. Hormonal etiology is suspected
- C. Miller's sign may be positive
- D. Radiotherapy can be considered as a treatment option
Explanation: **Explanation:** Juvenile Nasopharyngeal Angiofibroma (JNA) is a benign but locally aggressive, highly vascular tumor. **1. Why Option A is the correct answer (The "NOT true" statement):** While the question marks Option A as correct, there is a technical nuance in the phrasing. JNA is **exclusively** seen in adolescent males. If the option implies it is *only* "commonly" seen (suggesting it can occur in females), it is technically incorrect. However, in most standard ENT textbooks (Dhingra), JNA is defined by its occurrence in adolescent males. If this was a "Except" type question, and Option A is the intended answer, it may be due to the specific wording or a typo in the question's source; however, clinically, JNA is the classic diagnosis for an adolescent male with epistaxis. **2. Analysis of other options:** * **B. Hormonal etiology:** This is **true**. The tumor is thought to be testosterone-dependent, explaining its exclusive occurrence in males and its tendency to regress after puberty or with anti-androgen therapy. * **C. Miller’s Sign (Holman-Miller Sign):** This is **true**. It refers to the anterior bowing of the posterior wall of the maxillary antrum seen on lateral X-ray or CT, caused by the tumor pushing forward from the pterygopalatine fossa. * **D. Radiotherapy:** This is **true**. While surgery (usually via endoscopic or transpalatal approaches) is the gold standard, radiotherapy is a valid treatment option for intracranial extension or recurrent/inoperable cases. **High-Yield Clinical Pearls for NEET-PG:** * **Origin:** Most commonly from the superior margin of the sphenopalatine foramen. * **Classic Triad:** Adolescent male + Profuse recurrent epistaxis + Nasal obstruction. * **Diagnosis:** Contrast-enhanced CT (CECT) is the investigation of choice. **Biopsy is contraindicated** due to the risk of torrential hemorrhage. * **Angiography:** Shows a characteristic "tumor blush." * **Frog Face Deformity:** Seen in advanced cases due to widening of the nasal bridge.
Question 16: Guy's aprosexia is seen in:
- A. Chronic laryngitis
- B. Chronic adenoiditis (Correct Answer)
- C. Allergic rhinitis
- D. Acute tonsillitis
Explanation: **Explanation:** **Guy’s Aprosexia** is a clinical term used to describe the **inability to concentrate** or maintain attention on a task, often accompanied by mental fatigue and memory impairment. 1. **Why Chronic Adenoiditis is correct:** In chronic adenoiditis, the hypertrophy of the nasopharyngeal tonsils (adenoids) leads to significant nasal obstruction. This results in persistent **mouth breathing** and **obstructive sleep apnea (OSA)**. The resulting chronic nocturnal hypoxia and fragmented sleep lead to daytime somnolence, mental dullness, and a lack of concentration. This constellation of symptoms in a child with "adenoid facies" is classically termed Guy’s aprosexia. 2. **Why other options are incorrect:** * **Chronic laryngitis:** Primarily affects the voice (hoarseness) and does not cause the upper airway obstruction or hypoxia required to produce mental dullness. * **Allergic rhinitis:** While it can cause nasal congestion, it is typically episodic or seasonal and is not the classic association for Guy’s aprosexia in medical literature. * **Acute tonsillitis:** This is a self-limiting inflammatory condition characterized by odynophagia and fever, rather than the chronic obstructive symptoms that lead to cognitive impairment. **High-Yield Clinical Pearls for NEET-PG:** * **Adenoid Facies:** Characterized by an open mouth, prominent upper incisors, high-arched palate, elongated face, and a dull expression. * **Ear Involvement:** Chronic adenoiditis is the most common cause of **Otitis Media with Effusion (Glue Ear)** in children due to Eustachian tube blockage. * **Investigation of Choice:** X-ray soft tissue nasopharynx (lateral view) shows narrowing of the nasopharyngeal air space. * **Treatment:** Adenoidectomy is indicated if there is persistent OSA or recurrent middle ear infections.
Question 17: A white patch in the throat may be due to which of the following?
- A. Streptococcus (Correct Answer)
- B. Actinomycetes
- C. Sporotrichosis
- D. All of these
Explanation: **Explanation:** The presence of a **white patch** or membrane in the throat is a classic clinical finding in acute pharyngitis and tonsillitis. **1. Why Streptococcus is correct:** Group A Beta-Hemolytic **Streptococcus (GABHS)** is the most common bacterial cause of acute tonsillopharyngitis. It typically presents with a follicular or membranous exudate on the tonsils. This "white patch" represents an inflammatory exudate consisting of fibrin, leucocytes, and dead epithelial cells. In clinical practice, this must be differentiated from the "pseudomembrane" of Diphtheria, which is greyish-white and bleeds on removal. **2. Why the other options are incorrect:** * **Actinomycetes:** While *Actinomyces israelii* can affect the cervicofacial region, it typically presents as "lumpy jaw" with chronic, granulomatous abscesses and multiple draining sinuses discharging **sulfur granules**, rather than a white patch in the throat. * **Sporotrichosis:** This is a fungal infection (Rose gardener's disease) that usually presents with cutaneous nodules following the lymphatic drainage. While mucosal involvement can occur, it is extremely rare and presents as chronic granulomatous ulcers, not an acute white patch. **High-Yield Clinical Pearls for NEET-PG:** * **Differential Diagnosis of a White Patch/Membrane in Throat:** 1. **Membranous Tonsillitis:** (Streptococcus, Staphylococci) 2. **Diphtheria:** Thick, leathery, adherent greyish membrane. 3. **Infectious Mononucleosis (EBV):** Extensive white exudate with generalized lymphadenopathy and splenomegaly. 4. **Candidiasis (Thrush):** Curdy white patches that can be easily scraped off. 5. **Vincent’s Angina:** Greyish-yellow membrane associated with foul breath. 6. **Agranulocytosis:** Necrotic ulcers with a greyish membrane. * **Centor Criteria:** Used to clinically predict the likelihood of Streptococcal pharyngitis (Tonsillar exudate, Tender anterior cervical nodes, Fever, Absence of cough).
Question 18: All of the following are true about adenoid hypertrophy EXCEPT?
- A. Adenoid facies
- B. Rhinolalia clausa
- C. Apnea
- D. Unilateral hearing loss (Correct Answer)
Explanation: **Explanation:** Adenoid hypertrophy refers to the pathological enlargement of the nasopharyngeal tonsils. To understand the clinical presentation, one must consider the anatomical location of the adenoids in the midline of the nasopharynx. **Why Option D is the Correct Answer (The Exception):** Adenoids are located in the midline of the nasopharynx, directly between the openings of the right and left Eustachian tubes. Hypertrophy typically causes **bilateral** Eustachian tube obstruction, leading to bilateral negative middle ear pressure and **bilateral** Otitis Media with Effusion (OME). Therefore, **unilateral hearing loss** is atypical for adenoid hypertrophy and should instead raise suspicion of a localized pathology, such as a juvenile nasopharyngeal angiofibroma or nasopharyngeal carcinoma in adults. **Analysis of Incorrect Options:** * **A. Adenoid Facies:** Chronic mouth breathing due to nasal obstruction leads to characteristic facial features: an elongated face, dull expression, open mouth, crowded teeth, and a high-arched palate. * **B. Rhinolalia Clausa:** Nasal obstruction prevents normal nasal resonance during speech, resulting in "hyponasality" or *rhinolalia clausa* (e.g., "m" sounds like "b"). * **C. Apnea:** Severe hypertrophy can lead to Obstructive Sleep Apnea (OSA), characterized by snoring, gasping, and periods of apnea during sleep. **High-Yield Clinical Pearls for NEET-PG:** * **Investigation of Choice:** X-ray soft tissue nasopharynx (lateral view) shows narrowing of the nasopharyngeal airway. * **Gold Standard Investigation:** Flexible Nasopharyngoscopy. * **Treatment:** Adenoidectomy is indicated if there is OSA, recurrent otitis media, or craniofacial growth anomalies. * **St. John’s Sign:** A radiological sign on a lateral X-ray where the soft tissue shadow of the adenoids obliterates the nasopharyngeal air space.
Question 19: Zenker's diverticulum is also known as which of the following?
- A. Prepharyngeal diverticulum
- B. Pharyngobasilar diverticulum
- C. Pharyngotympanic diverticulum
- D. Hypopharyngeal diverticulum (Correct Answer)
Explanation: **Explanation:** **Zenker’s Diverticulum** is a pulsion diverticulum caused by the herniation of the pharyngeal mucosa through a point of weakness in the muscular wall of the hypopharynx. 1. **Why the correct answer is right:** Zenker’s diverticulum occurs specifically at **Killian’s dehiscence**, a triangular area of weakness located between the thyropharyngeus and cricopharyngeus muscles. Both these muscles are components of the inferior constrictor muscle of the **hypopharynx**. Because the pouch originates in the hypopharyngeal wall just above the upper esophageal sphincter, it is anatomically classified as a **hypopharyngeal diverticulum**. 2. **Why the incorrect options are wrong:** * **Prepharyngeal diverticulum:** This is not a standard anatomical term. Zenker’s is located posteriorly, not anteriorly (pre-). * **Pharyngobasilar diverticulum:** The pharyngobasilar fascia is located at the uppermost part of the pharynx, near the skull base (nasopharynx). Zenker’s occurs much lower, at the junction of the pharynx and esophagus. * **Pharyngotympanic diverticulum:** This term refers to the Eustachian tube (pharyngotympanic tube) and is unrelated to esophageal pouches. **High-Yield Clinical Pearls for NEET-PG:** * **Type:** It is a **false diverticulum** because it involves only the mucosa and submucosa (not the muscular layer). * **Mechanism:** Caused by neuromuscular incoordination (failure of the cricopharyngeus to relax during swallowing). * **Clinical Features:** Dysphagia, **halitosis** (due to rotting food in the pouch), and **regurgitation** of undigested food. * **Boyce’s Sign:** A gurgling sound heard on pressing the side of the neck. * **Investigation of Choice:** Barium Swallow (shows the pouch). * **Management:** Endoscopic Dohlman’s procedure (stapling) or open cricopharyngeal myotomy.
Question 20: What is the most common foreign body found in the esophagus in children?
- A. Coin (Correct Answer)
- B. Food
- C. Crayon
- D. Marble
Explanation: **Explanation:** In the pediatric population, the most common site for foreign body (FB) entrapment is the **esophagus**, specifically at the level of the **cricopharyngeus (C6 level)**, which is the narrowest part of the esophagus. **1. Why Coins are the Correct Answer:** Coins are the most frequently ingested foreign bodies in children worldwide. This is due to their ubiquitous presence in households, their shiny appearance which attracts toddlers, and their size, which allows them to be easily swallowed but often prevents them from passing through the physiological constrictions of the esophagus. **2. Analysis of Incorrect Options:** * **Food (B):** While food bolus impaction is the most common cause of esophageal obstruction in **adults** (often associated with underlying pathology like Schatzki rings or strictures), it is less common in children unless they have eosinophilic esophagitis or post-tracheoesophageal fistula repair. * **Crayon (C) and Marble (D):** While these are common objects handled by children, statistical data consistently shows they are less frequently ingested or impacted compared to coins. **Clinical Pearls for NEET-PG:** * **Most common site of impaction:** Cricopharyngeus (Upper Esophageal Sphincter). * **X-ray Appearance:** On an AP view, a coin in the **esophagus** appears as a **circular disc** (coronal plane), whereas a coin in the **trachea** appears as a **vertical line** (sagittal plane). * **Management:** Rigid esophagoscopy is the gold standard for removal. * **Emergency:** Disc batteries (button batteries) are a surgical emergency due to the risk of liquefactive necrosis and perforation within hours.
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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