Diseases of the Pharynx Practice Questions

Q: A 70 year old patient presented with history of fever, repeated aspiration and coughing in the night. On examination there is a swelling on left side of neck which produces gurgling sound on compression. Following is the barium swallow study of the patient. What is the most likely diagnosis?

Zenker's diverticulum. ***Zenker's diverticulum*** - The patient's symptoms of **fever**, **repeated aspiration**, and **coughing at night** are classic for a Zenker's diverticulum, particularly in an older patient. - The presence of a **neck swelling** producing a **gurgling sound on compression** (Boyce's sign) is highly indicative of a Zenker's diverticulum, which is essentially a pharyngeal pouch. The barium swallow image likely shows contrast pooling in such a pouch. *Plummer Vinson syndrome* - Characterized by **dysphagia**, **iron-deficiency anemia**, and **esophageal webs**. - While it causes dysphagia, it does not typically present with a gurgling neck swelling or significant aspiration as described. *Dysphagia Lusoria* - This is a rare condition caused by an **aberrant right subclavian artery** compressing the esophagus. - It primarily causes dysphagia due to extrinsic compression, without the associated neck swelling, gurgling sound, or significant aspiration risk from food pooling within a diverticulum. *Laryngocoele* - A laryngocele is an **abnormal sac** or pouch that arises from the **laryngeal ventricle** and may extend externally, presenting as a neck swelling. - While it can cause a neck swelling, it is **air-filled**, not fluid or food-filled, and therefore would not typically produce a gurgling sound on compression or be clearly visible on a barium swallow as a contrast-filled pouch like in the image provided.

Q: A 13-year-old boy presents with right-sided nasal obstruction and recurrent epistaxis for the past 6 months. What is the most likely diagnosis?

JNA. ***JNA (Juvenile Nasopharyngeal Angiofibroma)*** - **Classic presentation**: Adolescent male with **unilateral nasal obstruction** and **recurrent, often profuse epistaxis** - JNA is a **highly vascular benign tumor** that predominantly affects males aged 10-18 years - Though benign, it is **locally aggressive** and can extend into adjacent structures (orbit, skull base) - The combination of age, gender, unilateral symptoms, and recurrent epistaxis makes this the most likely diagnosis *Coagulation disorder* - Would cause **generalized bleeding tendencies**, not localized unilateral nasal obstruction - Epistaxis would typically be **bilateral** and associated with other bleeding manifestations (easy bruising, gum bleeding, prolonged bleeding from cuts) - No mass effect or persistent obstruction would be expected - Other systemic bleeding signs are absent in this presentation *Antrochoanal polyp* - **Benign inflammatory lesion** originating from maxillary sinus, extending through ostium into choana - Can cause nasal obstruction but epistaxis is **much less common and less severe** than in JNA - More commonly associated with **chronic sinusitis symptoms** (rhinorrhea, postnasal drip, facial pressure) - Less vascular than JNA, so recurrent profuse epistaxis would be unusual *Allergic rhinitis* - Characterized by **bilateral symptoms**: nasal obstruction, sneezing, rhinorrhea, and nasal itching - Often has **seasonal pattern** or clear allergen triggers - May cause minor epistaxis from mucosal irritation, but not the **severe recurrent epistaxis** seen here - **Unilateral** persistent obstruction would be atypical for allergic rhinitis

Q: A 25-year-old woman presents with severe throat pain, difficulty swallowing, and trismus. CT neck shows a peritonsillar fluid collection and inflammation. What is the next best step?

Needle aspiration and antibiotics. ***Needle aspiration and antibiotics*** - The presence of a **peritonsillar fluid collection** on CT neck, along with severe throat pain, **dysphagia**, and **trismus**, is indicative of a **peritonsillar abscess (PTA)**. - **Needle aspiration** provides immediate relief by draining the pus and allows for culture-guided antibiotic therapy, while broad-spectrum **antibiotics** address the bacterial infection. *Immediate tonsillectomy* - **Tonsillectomy** is generally reserved for recurrent peritonsillar abscesses or chronic tonsillitis, not as the primary immediate treatment for an acute PTA. - Doing so acutely carries a higher risk of complications due to the **inflammation** and potential compromise of the airway. *Oral corticosteroids* - While corticosteroids can reduce inflammation and pain, they do not resolve the underlying bacterial infection or drain the **pus collection**. - Using **corticosteroids alone** risks worsening the infection by masking symptoms without treating the cause. *Empirical antibiotics alone* - Although antibiotics are crucial for treating the bacterial infection, they may not be sufficient on their own to resolve a **frank abscess**, especially one causing significant symptoms. - **Drainage** is often necessary to achieve clinical improvement and prevent complications such as airway obstruction or spread of infection.

Q: A 25-year-old male presents with a history of recurrent tonsillitis and obstructive sleep apnea. Physical examination reveals significantly enlarged tonsils. What is the recommended treatment?

Tonsillectomy. ***Tonsillectomy*** - This patient presents with both **recurrent tonsillitis** and **obstructive sleep apnea (OSA)** due to significantly enlarged tonsils, which are classic indications for a tonsillectomy. - Removing the enlarged tonsils directly addresses the source of both the recurrent infections and the airway obstruction. *Antibiotic therapy* - While antibiotics treat acute episodes of **bacterial tonsillitis**, they do not prevent recurrence or address the underlying anatomical obstruction causing **OSA**. - Long-term use of antibiotics for recurrent infections is not a sustainable or definitive solution and carries risks of **antibiotic resistance**. *Watchful waiting* - This approach is generally reserved for mild, infrequent tonsillitis without significant complications like **OSA**. - In this case, the presence of **obstructive sleep apnea** indicates a more severe condition requiring intervention to prevent long-term health consequences. *Steroid injections* - **Steroid injections** could temporarily reduce tonsil inflammation but would not provide a lasting solution for recurrent tonsillitis or chronic anatomical obstruction causing **OSA**. - They are not a standard treatment for either recurrent tonsillitis or **obstructive sleep apnea** in the long term.

Q: During a tonsillectomy, which major artery must be carefully avoided because of its close proximity to the tonsils?

Facial artery. ***Facial artery*** - The **tonsillar branch of the facial artery** is the primary arterial supply to the palatine tonsil and lies in **direct proximity to the tonsillar bed**. - This branch ascends along the lateral surface of the superior pharyngeal constrictor muscle and penetrates it to reach the tonsil, making it the most commonly encountered artery during tonsillectomy. - It is the **major artery that must be carefully identified and controlled** during dissection to prevent significant intraoperative and postoperative hemorrhage. - The facial artery itself arises from the external carotid artery and is a substantial vessel whose injury can cause considerable bleeding. *External carotid artery* - While the **external carotid artery** is the parent vessel that gives rise to branches supplying the tonsils, it is located in the carotid sheath **lateral to the pharynx and NOT in close proximity** to the tonsillar bed during routine tonsillectomy. - Surgeons do not typically encounter this artery in the standard surgical field unless there is aberrant anatomy or extensive deep dissection beyond normal planes. *Maxillary artery* - The **maxillary artery** is a terminal branch of the external carotid artery located in the **infratemporal fossa**, which is not in direct proximity to the tonsillar fossa. - This artery supplies deeper structures and is not routinely at risk during standard tonsillectomy procedures. *Internal carotid artery* - The **internal carotid artery** lies posterolateral to the tonsil, typically **1-2.5 cm away** and separated by the superior pharyngeal constrictor muscle and other fascial layers. - While injury to this artery is a rare but **catastrophic complication**, it is not considered in close proximity to the routine surgical dissection plane and is not the primary vascular structure of concern during standard tonsillectomy.

Q: Which muscle is commonly associated with a tonsillectomy?

Palatoglossus. ***Palatoglossus*** - The **palatoglossus muscle** forms the **anterior pillar (palatoglossal arch)** of the tonsillar fossa, which houses the palatine tonsil. - During a **tonsillectomy**, the tonsil is removed from its bed between the anterior and posterior pillars. The **palatoglossus** is the **first structure encountered** during dissection and defines the anterior boundary. - It is intimately related to the tonsillar capsule and commonly manipulated during the procedure. *Palatopharyngeus* - The **palatopharyngeus muscle** forms the **posterior pillar (palatopharyngeal arch)** of the tonsillar fossa. - While equally important in tonsillectomy (defining the posterior boundary and surgical field), the question typically refers to the **anterior pillar** when asking about the "commonly associated" muscle. - Both pillars are critical anatomical landmarks, but palatoglossus is conventionally cited as the primary associated muscle. *Tensor veli palatini* - This muscle is primarily involved in **tensing the soft palate** and opening the **Eustachian tube**. - It is located superior to the tonsillar region and is not directly associated with the tonsillectomy procedure. *Levator veli palatini* - The **levator veli palatini** elevates the soft palate during swallowing and speech. - Like the tensor veli palatini, it is located superior to the tonsil and not directly involved in the tonsillectomy surgical field.

Q: During a tonsillectomy, which structure is at risk of injury that could potentially lead to hemorrhage?

Tonsillar branch of facial artery. ***Tonsillar branch of facial artery*** - The **tonsillar branch of the facial artery** (also called the tonsillar artery) is the **primary arterial supply** to the palatine tonsil. - It pierces the **superior constrictor muscle** to enter the tonsillar fossa and is located within the **lateral aspect of the tonsillar bed**. - This vessel is the **most common source of hemorrhage** during and after tonsillectomy, causing both **primary** (within 24 hours) and **secondary** (after 24 hours) post-tonsillectomy bleeding. - Surgeons routinely encounter and must control this vessel during dissection of the tonsil from its fossa, making it the **most clinically relevant vessel at risk**. *Internal carotid artery* - The **internal carotid artery** lies posterolateral to the tonsillar fossa, separated by the **superior constrictor muscle** and pharyngeal fascia. - Injury to this vessel during tonsillectomy is **extremely rare** and would require deep, aberrant dissection through the pharyngeal wall or presence of an anatomical anomaly. - While such an injury would be catastrophic, it is **not a routine surgical risk** in standard tonsillectomy technique. *Lingual artery* - The **lingual artery** primarily supplies the tongue and courses deep in the floor of the mouth. - It is anatomically **distant from the tonsillar fossa** and not at risk during standard tonsillectomy. *Recurrent laryngeal nerve* - The **recurrent laryngeal nerve** is located in the **tracheoesophageal groove** in the lower neck, far removed from the tonsillar fossa. - This is a **nerve** (not a vessel), and injury would cause **hoarseness**, not hemorrhage. - It is not at risk during tonsillectomy.

Q: A 60-year-old male presents with a neck mass and a history of smoking. On examination, there is a mass in the tonsillar fossa. What is the most likely diagnosis?

Tonsillar carcinoma. ***Tonsillar carcinoma*** - A 60-year-old male with a **history of smoking** and a **neck mass** with a mass in the **tonsillar fossa** is highly suggestive of tonsillar carcinoma, a common head and neck cancer. - **Smoking** is a major risk factor for this type of cancer, and a persistent, localized mass in the tonsillar area in an older patient should raise high suspicion. *Tonsillitis* - **Tonsillitis** is typically an inflammatory condition, often infectious, presenting with **acute sore throat**, fever, and bilateral tonsillar enlargement, which is less likely to be a discrete mass in an older adult without acute inflammatory signs. - While tonsillitis can cause swollen tonsils, a **unilateral, firm mass** in a smoker strongly points away from this diagnosis due to its acute and benign nature. *Lymphoma* - **Lymphoma** can present as a neck mass or tonsillar mass, but it often involves other **lymphoid tissues** and might be associated with systemic symptoms like B-symptoms (fever, night sweats, weight loss), which are not mentioned. - While a possibility, **tonsillar carcinoma** is more directly linked to the presented risk factor (smoking) and the specific localization in an older male. *Benign tonsillar hypertrophy* - **Benign tonsillar hypertrophy** is common in children and usually presents as bilateral enlargement without a clear mass, typically not associated with smoking or unilateral presentation in an adult. - In a 60-year-old smoker, any new or persistent tonsillar mass should be considered malignant until proven otherwise, making benign hypertrophy highly unlikely.

Q: Which of the following statements about quinsy is true?

It is usually unilateral.. ***It is usually unilateral.*** - **Quinsy**, or **peritonsillar abscess**, typically forms on one side, causing asymmetric swelling of the soft palate and displacement of the uvula away from the affected side. - This **unilateral presentation** is a key diagnostic feature distinguishing it from other oropharyngeal infections. - **This is the most definitive correct statement** among the options. *It is a collection of pus inside the tonsil.* - Quinsy is a collection of pus in the **peritonsillar space**, located lateral and superior to the tonsil, not within the tonsil itself. - The tonsil itself is usually displaced medially by the surrounding abscess. - An **intratonsillar abscess** is a different and much rarer condition. *It can present with toxic symptoms, but septicemia is rare.* - This statement is **partially true** but less precise than stating quinsy is unilateral. - While septicemia is relatively uncommon with appropriate treatment, it remains a significant potential complication requiring vigilance. - Patients frequently present with **systemic toxicity** including fever, chills, and malaise, and untreated cases can progress to deeper space infections and sepsis. - The term "rare" is somewhat subjective, making this a less definitive answer. *Antibiotics alone are always sufficient for treatment.* - This is **incorrect**. Although antibiotics are crucial for treating the bacterial infection, **drainage** of the pus is almost always necessary for effective resolution. - **Needle aspiration** or **incision and drainage** is the standard of care in conjunction with antibiotic therapy. - Antibiotics alone may be considered only in very early presentations before frank abscess formation.

Q: Which of the following statements is true about Quincke's disease?

Edema of uvula. Edema of uvula - **Quincke's disease** is an historical term used to describe isolated, acute, and often **recurrent edema of the uvula**, which presents as a sudden swelling. - It is often considered a form of **angioedema** specifically affecting the uvula, with varying etiologies including allergic, idiopathic, or hereditary causes [1]. *Bacterial infection* - While uvular edema can sometimes accompany bacterial infections in the throat, Quincke's disease specifically refers to the **isolated edema** rather than the underlying infection itself. - Other signs of bacterial infection, such as **fever**, **purulence**, or severe systemic symptoms, are not defining characteristics of Quincke's disease. *Peritonsillar abscess* - A **peritonsillar abscess (quinsy)** is a collection of pus behind the tonsil and is a distinct condition with different symptoms including severe **unilateral throat pain**, trismus, and muffled voice. - While both can cause throat discomfort, a peritonsillar abscess is an **infectious process** requiring drainage, unlike Quincke's disease which is primarily angioedema [1]. *Vocal cord edema* - **Vocal cord edema** primarily affects the larynx, leading to **hoarseness** or stridor, and can potentially cause airway compromise. - Quincke's disease is specifically localized to the **uvula**, affecting swallowing and causing a "foreign body" sensation, but typically does not involve the vocal cords.

Question 1

A 70 year old patient presented with history of fever, repeated aspiration and coughing in the night. On examination there is a swelling on left side of neck which produces gurgling sound on compression. Following is the barium swallow study of the patient. What is the most likely diagnosis?

Accepted Answer

Zenker's diverticulum

Answer

Plummer vinson syndrome

Answer

Dysphagia Lusoria

Answer

Laryngocoele

Question 2

A 13-year-old boy presents with right-sided nasal obstruction and recurrent epistaxis for the past 6 months. What is the most likely diagnosis?

Accepted Answer

JNA

Answer

Coagulation disorder

Answer

Antrochoanal polyp

Answer

Allergic rhinitis

Question 3

A 25-year-old woman presents with severe throat pain, difficulty swallowing, and trismus. CT neck shows a peritonsillar fluid collection and inflammation. What is the next best step?

Accepted Answer

Needle aspiration and antibiotics

Answer

Immediate tonsillectomy

Answer

Oral corticosteroids

Answer

Empirical antibiotics alone

Question 4

A 25-year-old male presents with a history of recurrent tonsillitis and obstructive sleep apnea. Physical examination reveals significantly enlarged tonsils. What is the recommended treatment?

Accepted Answer

Tonsillectomy

Answer

Antibiotic therapy

Answer

Watchful waiting

Answer

Steroid injections

Question 5

During a tonsillectomy, which major artery must be carefully avoided because of its close proximity to the tonsils?

Accepted Answer

Facial artery

Answer

Maxillary artery

Answer

Internal carotid artery

Answer

External carotid artery

Question 6

Which muscle is commonly associated with a tonsillectomy?

Accepted Answer

Palatoglossus

Answer

Tensor veli palatini

Answer

Levator veli palatini

Answer

Palatopharyngeus

Question 7

During a tonsillectomy, which structure is at risk of injury that could potentially lead to hemorrhage?

Accepted Answer

Tonsillar branch of facial artery

Answer

Recurrent laryngeal nerve

Answer

Internal carotid artery

Answer

Lingual artery

Question 8

A 60-year-old male presents with a neck mass and a history of smoking. On examination, there is a mass in the tonsillar fossa. What is the most likely diagnosis?

Accepted Answer

Tonsillar carcinoma

Answer

Tonsillitis

Answer

Lymphoma

Answer

Benign tonsillar hypertrophy

Question 9

Which of the following statements about quinsy is true?

Accepted Answer

It is usually unilateral.

Answer

It is a collection of pus inside the tonsil.

Answer

It can present with toxic symptoms, but septicemia is rare.

Answer

Antibiotics alone are always sufficient for treatment.

Question 10

Which of the following statements is true about Quincke's disease?

Accepted Answer

Edema of uvula

Answer

Bacterial infection

Answer

Peritonsillar abscess

Answer

Vocal cord edema

Diseases of the Pharynx — MCQs

Diseases of the Pharynx — MCQs

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