Diseases of the Pharynx Practice Questions

Q: Carcinoma of pyriform fossa usually presents with :

Dysphagia. ***Dysphagia*** - Carcinoma of the **pyriform fossa** is a type of hypopharyngeal cancer, and given its anatomical location, it commonly interferes with swallowing [1]. - The pyriform fossa lies immediately lateral to the laryngeal inlet, and involvement here directly impacts the ability to form a **food bolus** and propel it into the esophagus. *Lump in the neck* - A neck lump can occur, especially if there is **lymph node metastasis**, but it's often a later symptom [1]. - **Dysphagia** usually precedes the development of a palpable neck mass as the primary tumor expands within the pyriform fossa [1]. *Cough* - While aspiration might lead to coughing, it's not the primary presenting symptom. - Cough is more commonly associated with laryngeal involvement or **tracheal invasion**, which can occur with advanced disease. *Hoarseness* - **Hoarseness** is a prominent symptom if the **vocal cords** or recurrent laryngeal nerve are directly involved [2]. - The pyriform fossa is adjacent but distinct from the vocal cords, so hoarseness is not typically the initial or most common symptom unless the tumor extends medially.

Q: A 60-year-old male presents with painless cervical lymphadenopathy. On examination, the right ear reveals conductive hearing loss with a dull tympanic membrane. Moreover, decreased mobility of the soft palate was also noted. What is the probable diagnosis?

Nasopharyngeal carcinoma. ***Nasopharyngeal carcinoma*** - This presentation with **painless cervical lymphadenopathy**, **conductive hearing loss** due to Eustachian tube obstruction, and **cranial nerve involvement** (affecting the soft palate mobility) is highly suggestive of nasopharyngeal carcinoma, which often metastasizes early. - The conductive hearing loss, specifically a **dull tympanic membrane**, points to **otitis media with effusion** secondary to Eustachian tube dysfunction, a common presentation of nasopharyngeal masses obstructing the tube. *Adenoid cystic cancer* - While adenoid cystic carcinoma can cause cranial nerve palsies due to **perineural invasion**, it more commonly arises in the salivary glands and not typically presents with nasopharyngeal masses causing Eustachian tube obstruction. - It usually presents with a **palpable mass** or **pain**, which is not the primary presentation here. *Juvenile nasopharyngeal angiofibroma* - This is a **benign vascular tumor** typically presenting in **adolescent males** with episodes of **severe epistaxis** and **nasal obstruction**. - It does not commonly present with cervical lymphadenopathy or cranial nerve involvement and is rare in a 60-year-old. *Quinsy* - Quinsy, or **peritonsillar abscess**, presents acutely with **severe sore throat**, **fever**, **trismus**, and sometimes **uvular deviation**. - It is an **infectious condition** and does not typically cause painless cervical lymphadenopathy or conductive hearing loss as described.

Q: A child who underwent a tonsillectomy started bleeding while lying in the ward post-operatively. Which of the following is the most appropriate management step?

Take to OT, remove the clot & re-ligation. ***Take to OT, remove the clot & re-ligation*** - **Post-tonsillectomy bleeding** is a surgical emergency requiring immediate intervention to prevent airway compromise and significant blood loss. - The most definitive management involves returning to the **operating theatre** for direct visualization, removal of any obstructing clots, and **re-ligation** of the bleeding vessel. *Conservative management* - **Conservative management** is generally insufficient for significant post-tonsillectomy bleeding, as it does not address the source of hemorrhage and can lead to severe complications. - While minor oozing might be observed, active bleeding often indicates a larger vessel injury that requires **surgical hemostasis**. *Take to OT & pressure packing* - While **pressure packing** can temporarily slow bleeding, it is not a definitive long-term solution as it does not directly identify and treat the bleeding vessel. - Furthermore, pharyngeal packing in a child carries a risk of **airway obstruction** and aspiration, making it less suitable than direct re-ligation. *Cautery* - **Cautery** is a method of hemostasis, but it is typically performed in the operating theatre under direct vision, often after clot removal. - It is not a stand-alone initial management step in the ward for active bleeding without proper surgical assessment and preparation.

Q: A 12-year-old presented with fever and difficulty swallowing. He had swelling in the marked region and was advised to undergo tonsillectomy. Post-surgery the gauze continued to soak with blood. Which of the following vessels must have been injured?

Paratonsillar vein. ***Paratonsillar vein*** - The **paratonsillar vein**, also known as the **external palatine vein**, is the major vein draining the palatine tonsil and usually the primary source of **post-tonsillectomy hemorrhage**. - Its superficial location and tendency to be large and thin-walled make it particularly vulnerable to injury during **tonsillectomy**, leading to persistent bleeding. *Ascending pharyngeal artery* - The ascending pharyngeal artery contributes to the blood supply of the tonsil, but it is a **deep-seated artery** that is less frequently injured during tonsillectomy compared to the paratonsillar vein. - While its injury could lead to significant bleeding, it's not the most common vascular source of hemorrhage in this context. *Tonsillar branch of facial artery* - The **tonsillar branch of the facial artery** is a significant arterial supply to the tonsil. However, arterial bleeding is typically more pulsatile and rapid, whereas persistent soaking of gauze suggests venous bleeding. - While injury to this artery can occur, the **paratonsillar vein** is a more common source of persistent oozing hemorrhage post-tonsillectomy. *Retromandibular vein* - The **retromandibular vein** is located posterior to the mandible and is not directly associated with the tonsillar bed. - Injury to this vein during a **tonsillectomy** is highly unlikely due to its anatomical position.

Q: What is the most common presentation of nasopharyngeal carcinoma?

Neck lymph node. ***Neck lymph node*** - The most common initial symptom of nasopharyngeal carcinoma is a **painless neck mass** due to metastasis to cervical lymph nodes. - This occurs in a significant percentage of patients, often even before local symptoms from the primary tumor are prominent. *Loss of smell* - While possible in advanced stages if the tumor invades the **olfactory nerves** or directly obstructs the nasal cavity, it is not typically the initial or most common presentation. - This symptom is more indicative of conditions directly affecting the **olfactory epithelium** or nerves, not early nasopharyngeal carcinoma. *Blockage of nose* - **Nasal obstruction** or stuffiness can occur as the tumor grows and localizes within the nasopharynx, but it is less common as an initial symptom than a palpable neck mass. - This symptom might also be attributed to other common conditions like sinusitis or allergies, delaying diagnosis. *Blood tinged discharge* - **Epistaxis (nosebleeds)** or blood-tinged sputum/discharge can be a symptom, especially with later-stage tumors that are ulcerating or bleeding. - However, it is reported less frequently as the presenting symptom compared to cervical lymphadenopathy.

Q: A patient presented with 2 days history of fever. On examination there was a swelling in the neck and one side tonsil was pushed to midline. What is the most likely diagnosis:-

Quinsy. ***Quinsy (Peritonsillar abscess)*** - **Quinsy** is a **peritonsillar abscess** that presents with fever, severe throat pain, and the pathognomonic sign of **unilateral tonsil pushed toward the midline**. - The abscess forms in the **peritonsillar space** (between the tonsillar capsule and superior constrictor muscle), causing **medial displacement of the tonsil** and **bulging of the soft palate**. - Patients typically have **trismus, dysphagia, "hot potato voice"** and may have visible neck swelling. - This clinical presentation exactly matches the description: tonsil pushed to midline is the **classic finding for peritonsillar abscess**. *Parapharyngeal abscess* - A **parapharyngeal abscess** involves the deep parapharyngeal space lateral to the pharynx. - While it can cause neck swelling and fever, it typically causes **fullness and induration of the lateral pharyngeal wall** rather than prominent medial displacement of the tonsil itself. - The **tonsil is usually NOT pushed to the midline** in parapharyngeal abscess; instead, there is lateral pharyngeal wall bulging. - Often presents with more prominent external neck swelling below the angle of mandible. *Retropharyngeal abscess* - A **retropharyngeal abscess** occurs in the retropharyngeal space behind the posterior pharyngeal wall. - Presents with **posterior pharyngeal wall bulge**, neck stiffness, and dysphagia. - Does **NOT cause medial displacement of the tonsil** as the abscess is posterior, not lateral to the tonsil. *Tonsillitis* - **Acute tonsillitis** causes bilateral tonsillar inflammation with erythema and exudates. - While both tonsils may be enlarged, there is **no unilateral medial displacement** of one tonsil. - Less likely to cause significant neck swelling compared to deep space infections.

Q: A 15 years old Male presented with history of fever since 2 days, unable to swallow the food with muffled voice. On examination it is noted right tonsil is shifted to midline. What is the diagnosis:

Quincy. ***Quincy (Peritonsillar abscess)*** - This patient's presentation with **fever**, **dysphagia**, **muffled voice** (hot potato voice), and **tonsil shifted to the midline** is classic for a **peritonsillar abscess (Quincy)**. - The affected tonsil is pushed **medially toward the midline** by the collection of pus between the tonsillar capsule and the superior constrictor muscle. - The uvula is typically deviated to the **contralateral side**, and patients often have **trismus** and difficulty opening the mouth. - This is the **most common deep neck space infection** and typically follows acute tonsillitis. *Parapharyngeal abscess* - A **parapharyngeal abscess** would present with **severe trismus**, **neck swelling**, **torticollis**, and **bulging of the lateral pharyngeal wall**. - While it can push the tonsil medially, it more characteristically causes **anterolateral displacement** of the entire pharyngeal wall rather than isolated tonsillar displacement. - Patients typically have more pronounced **systemic toxicity** and **neck involvement** than seen with peritonsillar abscess. *Acute tonsillitis* - **Acute tonsillitis** presents with **bilateral tonsillar enlargement**, exudates, and pharyngeal erythema. - It does not cause **displacement of the tonsil to the midline** or significant **muffled voice**. - While fever and dysphagia are present, the physical examination finding of tonsillar shift indicates a suppurative complication (abscess formation). *Acute retropharyngeal abscess* - An **acute retropharyngeal abscess** occurs in the retropharyngeal space behind the posterior pharyngeal wall. - It presents with **neck stiffness**, **stridor**, **drooling**, **bulging of the posterior pharyngeal wall**, and **reluctance to extend the neck**. - It would **not cause visible displacement of the tonsil to the midline** as the abscess is in a different anatomical space. - More common in **young children** (under 5 years) than adolescents.

Question 1

Carcinoma of pyriform fossa usually presents with :

Accepted Answer

Dysphagia

Answer

Lump in the neck

Answer

Cough

Answer

Hoarseness

Question 2

Regarding "Quinsy" all of the following are correct EXCEPT:

Accepted Answer

Pus may be seen pointing underneath the thin mucosa in all cases and is diagnostic

Answer

It is an abscess in the peritonsillar region

Answer

In early stage, intravenous broad spectrum antibiotics may resolve it

Answer

Severe trismus is caused by spasm induced by pterygoid muscles

Question 3

A 60-year-old male presents with painless cervical lymphadenopathy. On examination, the right ear reveals conductive hearing loss with a dull tympanic membrane. Moreover, decreased mobility of the soft palate was also noted. What is the probable diagnosis?

Accepted Answer

Nasopharyngeal carcinoma

Answer

Adenoid cystic cancer

Answer

Juvenile nasopharyngeal angiofibroma

Answer

Quinsy

Question 4

A child who underwent a tonsillectomy started bleeding while lying in the ward post-operatively. Which of the following is the most appropriate management step?

Accepted Answer

Take to OT, remove the clot & re-ligation

Answer

Conservative management

Answer

Take to OT & pressure packing

Answer

Cautery

Question 5

A 12-year-old presented with fever and difficulty swallowing. He had swelling in the marked region and was advised to undergo tonsillectomy. Post-surgery the gauze continued to soak with blood. Which of the following vessels must have been injured?

Accepted Answer

Paratonsillar vein

Answer

Ascending pharyngeal artery

Answer

Tonsillar branch of facial artery

Answer

Retromandibular vein

Question 6

What is the most common cause of deafness in a patient with Nasopharyngeal Carcinoma:

Accepted Answer

Fluid accumulation in the middle ear due to eustachian tube obstruction

Answer

Middle ear Infection

Answer

Metastasis to Temporal Bone

Answer

Infiltration of Tumour into middle ear

Question 7

What is the most common presentation of nasopharyngeal carcinoma?

Accepted Answer

Neck lymph node

Answer

Loss of smell

Answer

Blockage of nose

Answer

Blood tinged discharge

Question 8

A patient presented with 2 days history of fever. On examination there was a swelling in the neck and one side tonsil was pushed to midline. What is the most likely diagnosis:-

Accepted Answer

Quinsy

Answer

Retropharyngeal abscess

Answer

Parapharyngeal abscess

Answer

Tonsillitis

Question 9

A 15 years old Male presented with history of fever since 2 days, unable to swallow the food with muffled voice. On examination it is noted right tonsil is shifted to midline. What is the diagnosis:

Accepted Answer

Quincy

Answer

Acute tonsillitis

Answer

Parapharyngeal abscess

Answer

Acute retropharyngeal abscess

Question 10

A 6-year-old boy came to the hospital with complaints of sore throat and difficulty in swallowing. His left tonsil was pushed medially and had swelling over the left side upper part of neck. What will be the diagnosis?

Accepted Answer

Peritonsillar abscess

Answer

Ludwig's angina

Answer

Retropharyngeal abscess

Answer

Parapharyngeal abscess

Diseases of the Pharynx — MCQs

Diseases of the Pharynx — MCQs

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