Diseases of the Pharynx Practice Questions

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

Stricture. **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).

Q: Which spaces are involved in Ludwig's angina?

All of the above. **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.

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

Zenker's diverticulum. **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.

Q: What is the most common organism causing acute tonsillitis?

Hemolytic streptococci. **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.

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

Juvenile angiofibroma. **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).

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

Antihistaminics. **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.

Question 1

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

Accepted Answer

Caries of the cervical spine is usually a common cause

Answer

Dysphagia

Answer

Swelling on the posterior wall of the pharynx

Answer

Torticollis

Question 2

All of the following are contraindications for rigid esophagoscopy EXCEPT?

Accepted Answer

Stricture

Answer

Trismus

Answer

Aortic aneurysm

Answer

None of the above

Question 3

Which spaces are involved in Ludwig's angina?

Accepted Answer

All of the above

Answer

Sublingual space

Answer

Submandibular space

Answer

Submaxillary space

Question 4

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?

Accepted Answer

Transmaxillary approach is used

Answer

Requires adequate amount of blood to be transfused

Answer

A lateral rhinotomy approach may be used

Answer

Transpalatal approach is used

Question 5

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

Accepted Answer

Zenker's diverticulum

Answer

Rectal prolapse

Answer

Esophageal achalasia

Answer

Cancer of the esophagus

Question 6

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

Accepted Answer

Loss of taste in the posterior one-third of the tongue and possible difficulty in swallowing.

Answer

Loss of taste in the anterior two-thirds of the tongue.

Answer

Inability to protrude the tongue.

Answer

Weakness in opening the mouth due to damage to the lateral pterygoid muscle innervation.

Question 7

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

Accepted Answer

Lateral pharyngeal space infection

Answer

Pterygomandibular space infection

Answer

Retropharyngeal space infection

Answer

Pretracheal space infection

Question 8

What is the most common organism causing acute tonsillitis?

Accepted Answer

Hemolytic streptococci

Answer

Staph aureus

Answer

Anaerobes

Answer

Pneumococcus

Question 9

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

Accepted Answer

Juvenile angiofibroma

Answer

Nasal polyp

Answer

Nasal carcinoma

Answer

Rhinoscleroma

Question 10

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

Accepted Answer

Antihistaminics

Answer

Antibiotics

Answer

Marsupialization

Answer

Removal of lining

Diseases of the Pharynx — MCQs

Diseases of the Pharynx — MCQs

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