Diseases of the Pharynx — MCQs

Diseases of the Pharynx Indian Medical PG Practice Questions and MCQs

Question 231: Which of the following is NOT true about acute retropharyngeal abscess?

A. Dysphagia
B. Swelling on the posterior wall of the pharynx
C. Torticollis
D. Caries of the cervical spine is usually a common cause (Correct Answer)

Explanation: To understand this question, one must distinguish between the two types of retropharyngeal abscess: **Acute** (common in children) and **Chronic** (common in adults). ### **Why Option D is the Correct Answer (The False Statement)** Caries of the cervical spine (Tuberculous origin) is the primary cause of **Chronic Retropharyngeal Abscess**, not the acute form. * **Acute Retropharyngeal Abscess:** Usually occurs in children under 5 years due to suppurative infection of the **Nodes of Rouviere** (retropharyngeal lymph nodes) following an upper respiratory tract infection (URTI). These nodes atrophy after age 5. * **Chronic Retropharyngeal Abscess:** Occurs in adults due to TB of the cervical spine. The pus collects behind the prevertebral fascia. ### **Analysis of Incorrect Options (True Statements)** * **A. Dysphagia:** The abscess creates a bulge in the posterior pharyngeal wall, causing significant pain and mechanical obstruction, leading to difficulty in swallowing (dysphagia) and drooling. * **B. Swelling on the posterior wall:** This is the hallmark clinical sign. In the acute form, the swelling is **paramedian** (limited to one side) because the midline is tethered by the prevertebral fascia to the superior constrictor muscle. * **C. Torticollis:** Due to irritation of the paravertebral muscles and pain, the patient often presents with a stiff neck or "wry neck" (torticollis) and keeps the head tilted to the side of the abscess. ### **High-Yield Clinical Pearls for NEET-PG** * **X-ray Finding:** Lateral view of the neck shows widening of the **prevertebral space**. (Normal: <7mm at C2; <14mm at C6 in children). * **Airway Management:** The biggest risk is airway obstruction or spontaneous rupture leading to aspiration pneumonia. * **Treatment:** Incision and drainage (I&D) are performed via the **intra-oral route** for acute abscesses, whereas chronic (tubercular) abscesses are drained via the **extra-oral (cervical) route** to avoid secondary infection.

Question 232: All of the following are contraindications for rigid esophagoscopy EXCEPT?

A. Trismus
B. Aortic aneurysm
C. Stricture (Correct Answer)
D. None of the above

Explanation: **Explanation:** Rigid esophagoscopy is a surgical procedure used for both diagnostic and therapeutic purposes (e.g., foreign body removal). Understanding its contraindications is crucial for preventing life-threatening complications like esophageal perforation. **Why "Stricture" is the Correct Answer:** A **stricture** is an **indication**, not a contraindication, for rigid esophagoscopy. Rigid esophagoscopy is frequently performed to evaluate the nature of a stricture, obtain biopsies to rule out malignancy, and perform therapeutic interventions such as dilatation (using Jackson’s or gum-elastic bougies). While caution is required to avoid perforation, the presence of a stricture is a primary reason to perform the procedure. **Analysis of Incorrect Options:** * **Trismus (Option A):** This is a **relative contraindication**. Rigid esophagoscopy requires wide mouth opening to introduce the rigid metal tube. If the patient cannot open their mouth (due to peritonsillar abscess, tetanus, or TMJ issues), the scope cannot be safely inserted. * **Aortic Aneurysm (Option B):** This is a **major contraindication**. The esophagus lies in close anatomical proximity to the aorta. The pressure exerted by a rigid metal scope, combined with the lack of flexibility, poses a high risk of rupturing the aneurysm, which is fatal. **Clinical Pearls for NEET-PG:** * **Absolute Contraindications:** Aortic aneurysm, severe cervical spine deformities (e.g., Pott’s disease, advanced cervical spondylosis) which prevent the "sniffing position" required for insertion. * **Relative Contraindications:** Recent myocardial infarction, severe respiratory distress, and trismus. * **Positioning:** Rigid esophagoscopy is performed in the **"Barking Dog" or "Sniffing" position** (extension at the atlanto-occipital joint and flexion at the lower cervical spine). * **Most Common Site of Perforation:** The **Cricopharyngeus** (the narrowest part of the esophagus).

Question 233: Which spaces are involved in Ludwig's angina?

A. Sublingual space
B. Submandibular space
C. Submaxillary space
D. All of the above (Correct Answer)

Explanation: **Explanation:** Ludwig’s angina is a rapidly spreading, potentially life-threatening **cellulitis** (not an abscess) of the floor of the mouth. The core anatomical concept to remember for NEET-PG is that it involves **bilateral** involvement of three specific subfascial spaces. 1. **Submaxillary Space:** This is the primary site of infection, often originating from the 2nd or 3rd mandibular molars (80% of cases are odontogenic). 2. **Sublingual Space:** The infection spreads superior to the mylohyoid muscle into this space. 3. **Submental Space:** The infection also involves the midline space below the chin. **Why "All of the above" is correct:** In clinical anatomy, the term **Submandibular Space** is an umbrella term that encompasses both the **Submaxillary** and **Submental** spaces. Therefore, Ludwig's angina involves the sublingual, submaxillary, and submental (collectively submandibular) spaces simultaneously. **Why other options are insufficient:** While options A, B, and C are individually involved, selecting only one would be incomplete. The hallmark of Ludwig’s angina is the **multispace** involvement. **High-Yield Clinical Pearls for NEET-PG:** * **Source:** Most common cause is dental infection (mandibular molars). * **Clinical Features:** "Woody" hard swelling of the neck, elevation and protrusion of the tongue (causing potential airway obstruction), and absence of fluctuance (as it is cellulitis). * **Microbiology:** Usually a mixed infection (Streptococcus, Staphylococcus, and anaerobes). * **Management:** The priority is **Airway Maintenance** (tracheostomy if needed), followed by IV antibiotics and surgical decompression (incision and drainage) if medical management fails.

Question 234: An 18-year-old boy presented with repeated epistaxis and a mass arising from the lateral wall of his nose extending into the nasopharynx. All of the following are true regarding his management except?

A. Requires adequate amount of blood to be transfused
B. A lateral rhinotomy approach may be used
C. Transmaxillary approach is used (Correct Answer)
D. Transpalatal approach is used

Explanation: **Explanation:** The clinical presentation of an 18-year-old male with recurrent epistaxis and a mass in the nasopharynx is classic for **Juvenile Nasopharyngeal Angiofibroma (JNA)**. JNA is a benign but locally aggressive, highly vascular tumor. **Why Option C is the "Except" (Correct Answer):** The **Transmaxillary approach** is generally **not** used for JNA because it provides inadequate exposure to the nasopharynx and the pterygopalatine fossa (the tumor's site of origin). Furthermore, it carries a high risk of facial growth retardation in younger patients. While a *Medial Maxillectomy* via a lateral rhinotomy or endoscopic approach is common, a standalone transmaxillary approach is insufficient for the vascular control and visualization required for these tumors. **Analysis of Other Options:** * **Option A (Blood Transfusion):** JNA is extremely vascular. Significant intraoperative blood loss is expected; therefore, preoperative embolization and keeping adequate blood ready for transfusion are mandatory. * **Option B (Lateral Rhinotomy):** This is a traditional external approach used for larger tumors (Fisch Stage II/III) to provide wide access to the nasal cavity and paranasal sinuses. * **Option D (Transpalatal Approach):** This approach (e.g., Wilson’s) is specifically used for tumors confined to the nasopharynx to provide direct access through the roof of the mouth. **NEET-PG High-Yield Pearls for JNA:** * **Origin:** Sphenopalatine foramen (specifically the posterior attachment of the middle turbinate). * **Classic Sign:** **Holman-Miller Sign** (Antral Sign) – Anterior bowing of the posterior wall of the maxillary sinus on CT/MRI. * **Diagnosis:** Clinical and Radiological. **Biopsy is contraindicated** due to the risk of profuse, life-threatening hemorrhage. * **Gold Standard Treatment:** Surgical excision (Endoscopic for small tumors; External/Combined for large ones) preceded by **Digital Subtraction Angiography (DSA)** and embolization 24–48 hours prior.

Question 235: Dohlman's procedure is used for which of the following conditions?

A. Rectal prolapse
B. Esophageal achalasia
C. Cancer of the esophagus
D. Zenker's diverticulum (Correct Answer)

Explanation: **Explanation:** **Zenker’s Diverticulum (Correct Answer):** Dohlman’s procedure is a minimally invasive, endoscopic technique used to treat Zenker’s diverticulum (a pulsion diverticulum through Killian’s dehiscence). The procedure involves using a specialized endoscope to visualize the "party wall" (the septum) between the esophagus and the diverticulum. This septum, which contains the hypertonic **Cricopharyngeus muscle**, is divided using electrocautery or a CO2 laser. By dividing this muscle, the diverticulum is incorporated into the esophageal lumen, relieving the obstruction and allowing food to pass freely. **Why other options are incorrect:** * **Rectal prolapse:** This is a surgical condition of the lower GI tract. Common procedures include the Wells procedure, Ripstein procedure, or Delorme’s procedure. * **Esophageal achalasia:** The gold standard surgical treatment is **Heller’s Myotomy** (often with a Dor/Toupet fundoplication) or the endoscopic POEM (Peroral Endoscopic Myotomy) procedure. * **Cancer of the esophagus:** Management typically involves esophagectomy (e.g., Ivor-Lewis, McKeown, or Orringer procedures) depending on the tumor location and stage. **High-Yield Clinical Pearls for NEET-PG:** * **Killian’s Dehiscence:** The site of origin for Zenker’s, located between the thyropharyngeus and cricopharyngeus parts of the inferior constrictor. * **Clinical Triad:** Dysphagia, regurgitation of undigested food, and halitosis (bad breath). * **Boyce’s Sign:** A gurgling sound produced by pressing on the external swelling in the neck. * **Investigation of Choice:** Barium swallow (shows a "flask-shaped" pouch). **Rigid endoscopy is contraindicated** due to the high risk of perforation. * **Modern Alternative:** Endoscopic Stapling (Staple-assisted esophagodiverticulostomy) has largely replaced the laser-based Dohlman’s procedure in many centers.

Question 236: A patient presents with extremely enlarged palatine tonsils. Surgical removal of the tonsils is considered. What is a potential complication of this surgery?

A. Loss of taste in the anterior two-thirds of the tongue.
B. Inability to protrude the tongue.
C. Weakness in opening the mouth due to damage to the lateral pterygoid muscle innervation.
D. Loss of taste in the posterior one-third of the tongue and possible difficulty in swallowing. (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Loss of taste in the posterior one-third of the tongue and possible difficulty in swallowing.** **1. Why the Correct Answer is Right:** The **Glossopharyngeal nerve (CN IX)** is the most commonly injured nerve during tonsillectomy. It lies in the **tonsillar bed**, separated from the palatine tonsil only by the superior constrictor muscle and the pharyngobasilar fascia. During surgery (especially during deep dissection or excessive cautery), this nerve can be damaged. * **Sensory/Taste Deficit:** CN IX provides both general sensation and special sensation (taste) to the **posterior one-third of the tongue**. * **Motor Deficit:** It supplies the stylopharyngeus muscle and contributes to the pharyngeal plexus. Damage can lead to an impaired gag reflex and transient **dysphagia** (difficulty swallowing). **2. Why the Other Options are Wrong:** * **Option A:** Taste in the **anterior two-thirds** is carried by the **Chorda Tympani** (a branch of the Facial nerve, CN VII). This nerve is located in the middle ear and infratemporal fossa, far from the tonsillar fossa. * **Option B:** Protrusion of the tongue is a function of the **Genioglossus muscle**, supplied by the **Hypoglossal nerve (CN XII)**. While CN XII is in the neck, it is not typically at risk during a standard tonsillectomy unless there is a deep neck dissection. * **Option C:** Opening the mouth (lateral pterygoid) is mediated by the **Mandibular nerve (V3)**. These structures are located in the infratemporal fossa, superior and lateral to the surgical site. **3. NEET-PG High-Yield Pearls:** * **Most common nerve injured:** Glossopharyngeal nerve (CN IX). * **Most common artery injured (Primary Hemorrhage):** Paratonsillar vein (most common) or the Tonsillar branch of the **Facial Artery** (main arterial supply). * **Eagle’s Syndrome:** Elongated styloid process causing pain in the tonsillar fossa, often exacerbated after tonsillectomy due to CN IX irritation. * **Referred Earache:** Post-tonsillectomy ear pain is common due to referred pain via the **Tympanic branch of CN IX (Jacobson’s nerve)**.

Question 237: The 'hot potato' voice is characteristically seen in which of the following conditions?

A. Pterygomandibular space infection
B. Retropharyngeal space infection
C. Pretracheal space infection
D. Lateral pharyngeal space infection (Correct Answer)

Explanation: **Explanation:** The **'Hot Potato' voice** (thick, muffled speech as if the patient is speaking with a hot potato in their mouth) is a hallmark clinical sign of infections that cause significant swelling of the oropharynx and displacement of the lateral pharyngeal wall or tongue. **1. Why Lateral Pharyngeal Space Infection is Correct:** The lateral pharyngeal (parapharyngeal) space is located lateral to the pharyngeal constrictors. Infection here (often secondary to tonsillitis or dental infections) leads to significant medial displacement of the lateral pharyngeal wall and tonsil. This narrowing of the oropharyngeal airway and the associated edema of the soft palate and base of the tongue result in the characteristic muffled 'hot potato' voice. **2. Analysis of Incorrect Options:** * **Pterygomandibular space infection:** This primarily presents with severe **trismus** (lockjaw) because it involves the medial pterygoid muscle, but it does not typically cause the classic muffled voice seen in pharyngeal space infections. * **Retropharyngeal space infection:** While this can cause voice changes (often described as a "duck-like" cry in children), the primary symptoms are dysphagia, neck stiffness, and a bulge in the posterior pharyngeal wall rather than the lateral displacement that creates the hot potato quality. * **Pretracheal space infection:** This is located in the anterior neck. It typically presents with localized swelling, pain, and potential respiratory distress, but it does not involve the oropharyngeal structures required to produce a hot potato voice. **Clinical Pearls for NEET-PG:** * **Hot Potato Voice** is most classically associated with **Peritonsillar Abscess (Quinsy)** and **Lateral Pharyngeal Space Infection**. * **Trismus** is a key feature of the **anterior compartment** involvement of the lateral pharyngeal space (due to irritation of the medial pterygoid muscle). * **Complication Alert:** Lateral pharyngeal space infections are dangerous because they can lead to **internal jugular vein thrombosis** (Lemierre’s syndrome) or **carotid artery erosion**.

Question 238: What is the most common organism causing acute tonsillitis?

A. Staph aureus
B. Anaerobes
C. Hemolytic streptococci (Correct Answer)
D. Pneumococcus

Explanation: **Explanation:** **1. Why Hemolytic Streptococci is Correct:** Acute tonsillitis is most frequently caused by bacterial infections, and among these, **Group A Beta-Hemolytic Streptococcus (GABHS)**—also known as *Streptococcus pyogenes*—is the most common causative organism. It accounts for approximately 15–30% of cases in children and 5–10% in adults. The clinical significance of identifying GABHS lies in its potential to cause non-suppurative complications like Rheumatic Fever and Post-Streptococcal Glomerulonephritis. **2. Why Other Options are Incorrect:** * **Staph aureus:** While it can be isolated from tonsillar surfaces, it is more commonly a colonizer or a secondary invader rather than the primary cause of acute follicular tonsillitis. * **Anaerobes:** These are typically associated with chronic tonsillitis, peritonsillar abscesses (Quinsy), or Vincent’s angina, rather than routine acute tonsillitis. * **Pneumococcus (*S. pneumoniae*):** Though it can cause upper respiratory infections, it is a much less frequent cause of primary tonsillitis compared to GABHS. **3. Clinical Pearls for NEET-PG:** * **Viral Etiology:** Remember that globally, **viruses** (Rhinovirus, Adenovirus, EBV) are the overall most common cause of sore throat; however, among *bacterial* causes (and as per standard ENT textbooks like Dhingra), Hemolytic Streptococcus is the top answer. * **Centor Criteria:** Used to clinically differentiate bacterial from viral tonsillitis (Fever, Tonsillar exudates, Tender anterior cervical lymphadenopathy, and Absence of cough). * **Drug of Choice:** Penicillin remains the treatment of choice for GABHS tonsillitis.

Question 239: A young patient presents with headache, epiphora, and bilateral nasal obstruction, but no fever. What is the most likely diagnosis?

A. Nasal polyp
B. Juvenile angiofibroma (Correct Answer)
C. Nasal carcinoma
D. Rhinoscleroma

Explanation: **Explanation:** The clinical presentation of a young male with headache, bilateral nasal obstruction, and epiphora—in the absence of fever—is highly suggestive of **Juvenile Nasopharyngeal Angiofibroma (JNA)**. **Why Juvenile Angiofibroma is correct:** JNA is a benign but locally aggressive, highly vascular tumor primarily affecting adolescent males. * **Nasal Obstruction:** As the tumor grows in the nasopharynx, it causes progressive obstruction (often bilateral as it fills the space). * **Epiphora:** This occurs due to the tumor's pressure on or invasion of the nasolacrimal duct. * **Headache:** This results from pressure effects or secondary sinusitis due to ostial blockage. * **Absence of Fever:** This helps rule out infectious etiologies like acute rhinosinusitis. **Why other options are incorrect:** * **Nasal Polyp:** While they cause obstruction, they are typically painless and rarely cause epiphora unless they are massive (e.g., Antrochoanal polyp), but JNA is a more classic "exam" diagnosis for this triad in a young patient. * **Nasal Carcinoma:** Usually presents in older age groups and is often associated with cervical lymphadenopathy and constitutional symptoms. * **Rhinoscleroma:** A chronic granulomatous condition characterized by "woody" hard swelling and foul-smelling discharge; it typically follows a specific three-stage progression (Atrophic, Granulomatous, Cicatricial). **High-Yield Clinical Pearls for NEET-PG:** * **Origin:** Most commonly from the sphenopalatine foramen. * **Classic Sign:** **Holman-Miller Sign** (Antral Sign) – Anterior bowing of the posterior wall of the maxillary sinus seen on CT/MRI. * **Diagnosis:** Biopsy is **contraindicated** due to the risk of torrential hemorrhage. Diagnosis is clinical and radiological (Contrast CT/Angiography). * **Treatment of Choice:** Surgical excision (often preceded by preoperative embolization to reduce blood loss).

Question 240: Which of the following is NOT a component of the treatment for Thornwaldt's abscess?

A. Antibiotics
B. Marsupialization
C. Removal of lining
D. Antihistaminics (Correct Answer)

Explanation: **Explanation:** **Thornwaldt’s Cyst (or Abscess)** is a clinical entity arising from the **Thornwaldt bursa**, a midline embryological remnant formed by the persistent adhesion of the notochord to the pharyngeal ectoderm. When this bursa becomes infected or obstructed, it forms a cyst or an abscess in the nasopharynx. **Why Antihistaminics are NOT used:** Antihistaminics (Option D) are primarily used for allergic conditions like allergic rhinitis or urticaria. They have no role in the management of an anatomical midline cyst or a localized bacterial infection (abscess). Therefore, they are the "except" in this clinical scenario. **Analysis of Other Options:** * **Antibiotics (Option A):** Since the question specifies an "abscess" (infected cyst), systemic antibiotics are necessary to control the acute infection and prevent complications like cellulitis or sepsis. * **Marsupialization (Option B):** This is the surgical treatment of choice. By opening the cyst and suturing the edges, the cavity is kept open to drain freely, preventing recurrence. * **Removal of lining (Option C):** To ensure the cyst does not reform, the epithelial lining of the bursa must be addressed or destroyed during the surgical procedure (often via endoscopic debridement or cauterization). **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Always found in the **midline** of the nasopharynx, specifically over the basisphenoid (near the adenoids). * **Clinical Presentation:** Often asymptomatic, but can cause post-nasal drip, halitosis, occipital headache, or Eustachian tube dysfunction. * **Diagnosis:** Best visualized via **nasopharyngoscopy** or **MRI** (shows a well-circumscribed midline mass). * **Differential Diagnosis:** Must be distinguished from a Rathke’s pouch cyst or an adenoid abscess.

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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