Diseases of the Pharynx — MCQs

Diseases of the Pharynx Indian Medical PG Practice Questions and MCQs

Question 31: What is 'Trench mouth'?

A. Submucosal fibrosis
B. Tumor at the uveal angle
C. Ulcerative lesion of the tonsil (Correct Answer)
D. Retention cyst of the tonsil

Explanation: **Explanation:** **Trench Mouth**, also known as **Vincent’s Angina** or Acute Necrotizing Ulcerative Gingivitis (ANUG), is a painful, non-contagious infection of the gums and tonsils. 1. **Why Option C is correct:** The disease is characterized by the formation of "punched-out" **ulcerative lesions** covered by a gray pseudomembrane. When it involves the tonsils (Vincent’s Angina), it typically presents as a unilateral, painful ulcer on the superior pole of the tonsil. It is caused by a symbiotic infection of two organisms: a fusiform bacillus (*Fusobacterium nucleatum*) and a spirochete (*Borrelia vincentii*). The name "Trench Mouth" originated during World War I, as soldiers in the trenches frequently developed this condition due to poor oral hygiene, stress, and malnutrition. 2. **Why other options are incorrect:** * **Option A:** Submucosal fibrosis (OSMF) is a chronic, progressive premalignant condition associated with areca nut chewing, characterized by juxta-epithelial inflammatory reaction and progressive fibrosis of the oral cavity. * **Option B:** This is a distractor; tumors at the uveal angle relate to Ophthalmology, not pharyngeal pathology. * **Option C:** A retention cyst of the tonsil is a benign, yellowish-white cyst formed due to the blockage of a tonsillar crypt, usually asymptomatic and non-ulcerative. **High-Yield Clinical Pearls for NEET-PG:** * **Microbiology:** Look for the "Fusospirochetal complex" in the history. * **Clinical Presentation:** Foul breath (halitosis), metallic taste, and bleeding gums. * **Treatment:** Debridement, hydrogen peroxide mouthwashes, and antibiotics (Penicillin or Metronidazole). * **Differential Diagnosis:** Must be differentiated from Diphtheria (which has a tough, adherent membrane) and infectious mononucleosis.

Question 32: Progressive dysphagia initially for solids and later for liquids is the hallmark feature of carcinoma of which part of the pharynx?

A. Oropharynx
B. Hypopharynx (Correct Answer)
C. Nasopharynx
D. All of the above

Explanation: **Explanation:** The hallmark clinical presentation of **Hypopharyngeal Carcinoma** (specifically the post-cricoid and pyriform sinus regions) is **progressive dysphagia**. Initially, the patient experiences difficulty swallowing solids, which eventually progresses to liquids as the tumor circumferentially involves the lumen or obstructs the food passage. This occurs because the hypopharynx is the narrowest part of the upper food passage, and symptoms often manifest only when the tumor has significantly narrowed the lumen. **Why other options are incorrect:** * **Nasopharynx:** The nasopharynx is primarily a respiratory passage. Carcinoma here typically presents with the "Trotter’s Triad" (conductive hearing loss, palatal paralysis, and trigeminal neuralgia) or a painless neck mass. Dysphagia is not a primary or early feature. * **Oropharynx:** While tumors here can cause dysphagia, the more characteristic early symptoms are "hot potato voice," odynophagia (painful swallowing), or a persistent sore throat. The wide caliber of the oropharynx means obstructive dysphagia often occurs much later compared to the hypopharynx. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** The **Pyriform Sinus** is the most common site for hypopharyngeal cancer. * **Post-cricoid Carcinoma:** Highly associated with **Plummer-Vinson (Paterson-Brown-Kelly) Syndrome** and is more common in females. * **Referred Otalgia:** Often the first symptom of hypopharyngeal cancer, mediated via the **Vagus nerve (Arnold’s nerve)**. * **Speculum sign:** Pooling of saliva in the pyriform fossa (Jackson’s sign) on indirect laryngoscopy is a strong clinical indicator of an obstructive growth in the hypopharynx or esophagus.

Question 33: Nasopharyngeal carcinoma causes deafness by which mechanism?

A. Blocking the Eustachian tube (Correct Answer)
B. Serous otitis media
C. Temporal bone metastasis
D. Radiation effects

Explanation: **Explanation:** **Mechanism of Deafness in Nasopharyngeal Carcinoma (NPC):** Nasopharyngeal carcinoma most commonly arises from the **Fossa of Rosenmüller**, which is located immediately posterior to the opening of the Eustachian tube. As the tumor grows, it causes **mechanical obstruction of the Eustachian tube orifice**. This leads to negative middle ear pressure, transudation of fluid, and the development of **Secondary Otitis Media with Effusion (Serous Otitis Media)**. The resulting hearing loss is **conductive** in nature. **Analysis of Options:** * **A (Correct):** This is the primary, initiating mechanism. The physical blockage of the tube by the tumor mass is the root cause of subsequent ear pathology. * **B (Incorrect):** While Serous Otitis Media *is* the condition that causes the deafness, it is the **result** of the Eustachian tube blockage, not the primary mechanism of the tumor itself. In MCQ exams, always prioritize the "proximal" or "initiating" cause. * **C (Incorrect):** Temporal bone metastasis is rare in NPC and would typically present with sensorineural hearing loss or facial nerve palsy rather than simple conductive deafness. * **D (Incorrect):** Radiation can cause Eustachian tube dysfunction or osteoradionecrosis, but this occurs *after* treatment. Deafness is often the **presenting symptom** of the disease itself. **High-Yield Clinical Pearls for NEET-PG:** * **Trotter’s Triad:** A classic presentation of NPC consisting of: 1. Conductive deafness (due to ET blockage). 2. Ipsilateral soft palate paralysis (CN X involvement). 3. Trigeminal neuralgia (CN V involvement causing temporofacial pain). * **Unilateral Serous Otitis Media** in an adult is **Nasopharyngeal Carcinoma** until proven otherwise. Always perform an endoscopic examination of the nasopharynx. * **EBV Association:** NPC is strongly linked to the Epstein-Barr Virus.

Question 34: What is the most common causative organism for acute tonsillitis?

A. Streptococcus pyogenes (Correct Answer)
B. Parainfluenza virus
C. Haemophilus influenzae
D. Corynebacterium species

Explanation: **Explanation:** Acute tonsillitis is an inflammation of the palatine tonsils, most commonly occurring in children and young adults. **1. Why Streptococcus pyogenes is correct:** While viruses (such as Adenovirus and Rhinovirus) are the most frequent cause of sore throats overall, **Group A Beta-Hemolytic Streptococcus (GABHS)**, specifically *Streptococcus pyogenes*, is the **most common bacterial cause** and the most clinically significant pathogen identified in acute tonsillitis. In the context of medical examinations like NEET-PG, when asked for the specific causative organism, *S. pyogenes* is the standard answer due to its association with complications like Rheumatic fever and Post-streptococcal glomerulonephritis. **2. Why the other options are incorrect:** * **Parainfluenza virus:** While viruses cause many cases of pharyngitis, Parainfluenza is more typically associated with Croup (Laryngotracheobronchitis) rather than isolated acute follicular tonsillitis. * **Haemophilus influenzae:** This is a common secondary invader in respiratory infections and a major cause of acute epiglottitis, but it is not the primary pathogen for typical acute tonsillitis. * **Corynebacterium species:** *Corynebacterium diphtheriae* causes Diphtheria, characterized by a "greyish-white tough membrane" on the tonsils. While serious, it is rare due to widespread immunization and is not the "most common" cause. **Clinical Pearls for NEET-PG:** * **Centor Criteria:** Used to clinically differentiate bacterial from viral tonsillitis (Fever, Tonsillar exudates, Tender anterior cervical lymphadenopathy, and Absence of cough). * **Treatment of Choice:** Penicillin remains the drug of choice for GABHS tonsillitis to prevent non-suppurative complications. * **Complication:** The most common complication of acute tonsillitis is **Peritonsillar abscess (Quinsy)**.

Question 35: The pharyngeal diverticulum is a protrusion of the mucosa between which anatomical structures?

A. The two parts of the inferior constrictor muscle of the pharynx (Correct Answer)
B. The two parts of the middle constrictor muscle of the pharynx
C. The two parts of the superior constrictor muscle of the pharynx
D. Cricopharyngeal muscle and the posterior part of the suprahyoid membrane

Explanation: ### Explanation The pharyngeal diverticulum, commonly known as **Zenker’s Diverticulum**, is a pulsion diverticulum caused by increased intraluminal pressure during swallowing. **1. Why Option A is Correct:** The diverticulum occurs at a site of potential weakness called **Killian’s Dehiscence**. This triangular area is located on the posterior pharyngeal wall between the two components of the **inferior constrictor muscle**: * **Thyropharyngeus:** The upper, oblique fibers. * **Cricopharyngeus:** The lower, horizontal fibers (acting as the upper esophageal sphincter). Incoordination between pharyngeal contraction and cricopharyngeal relaxation leads to mucosal herniation through this gap. **2. Why the Other Options are Incorrect:** * **Options B & C:** The superior and middle constrictors are well-supported by overlapping muscle layers. There are no naturally occurring weak areas between their internal parts that lead to diverticula formation. * **Option D:** The suprahyoid membrane is located anteriorly and superiorly in the neck. Zenker’s diverticulum is strictly a posterior midline phenomenon occurring at the level of the C5-C6 vertebrae. **3. Clinical Pearls for NEET-PG:** * **Type:** It is a **false diverticulum** because it involves only the mucosa and submucosa (not the muscular layer). * **Clinical Presentation:** Characterized by dysphagia, **halitosis** (due to fermenting food), and **regurgitation** of undigested food. * **Boyce’s Sign:** A gurgling sound heard on pressing the external swelling in the neck. * **Diagnosis:** **Barium Swallow** is the investigation of choice (shows a "pouch"). * **Management:** Endoscopic Dohlman’s procedure (stapling the party wall) or open diverticulectomy with cricopharyngeal myotomy.

Question 36: A patient complains of dysphagia, halitosis, and regurgitation of undigested food consumed several days prior. What is the most likely cause?

A. Esophageal cancer
B. Zenker's diverticulum (Correct Answer)
C. Corrosive esophagitis
D. Diffuse esophageal spasm

Explanation: ### Explanation The clinical triad of **dysphagia, halitosis (foul breath), and regurgitation of undigested food** is classic for **Zenker’s Diverticulum**. **1. Why Zenker’s Diverticulum is Correct:** Zenker’s diverticulum is a **pulsion diverticulum** (false diverticulum) occurring through **Killian’s dehiscence**, a weak area between the thyropharyngeus and cricopharyngeus muscles. The primary pathology is the failure of the cricopharyngeal sphincter to relax during swallowing. As the sac enlarges, it traps food particles. The decomposition of this trapped food leads to **halitosis** and the **regurgitation of undigested food** (often from days prior), which is the hallmark of this condition. **2. Why Other Options are Incorrect:** * **Esophageal Cancer:** While it presents with progressive dysphagia and weight loss, the regurgitation is usually of recently consumed food, and halitosis is not a primary feature unless the obstruction is total and long-standing. * **Corrosive Esophagitis:** This follows an acute ingestion of acids/alkalis. It leads to strictures and dysphagia, but the history would emphasize the caustic insult rather than chronic halitosis and undigested food regurgitation. * **Diffuse Esophageal Spasm (DES):** This presents with "corkscrew esophagus" on imaging, characterized by retrosternal chest pain and intermittent dysphagia to both solids and liquids, not food trapping. **3. NEET-PG High-Yield Pearls:** * **Location:** Killian’s dehiscence (between the two parts of the inferior constrictor). * **Boyce’s Sign:** A gurgling sound heard on the side of the neck when pressure is applied to the diverticulum. * **Investigation of Choice:** **Barium Swallow** (shows a pouch behind the esophagus). * **Contraindication:** Rigid Esophagoscopy (high risk of accidental perforation of the thin-walled sac). * **Treatment:** Endoscopic Dohlman’s procedure (stapling the party wall) or Cricopharyngeal Myotomy.

Question 37: What is the most common site of origin of nasopharyngeal angiofibroma?

A. Roof of nasopharynx
B. Sphenopalatine foramen (Correct Answer)
C. Vault of skull
D. Lateral wall of nose

Explanation: ### Explanation **Juvenile Nasopharyngeal Angiofibroma (JNA)** is a benign but locally aggressive, highly vascular tumor typically seen in adolescent males. **1. Why Sphenopalatine Foramen is Correct:** The current consensus on the site of origin for JNA is the **sphenopalatine foramen**, specifically at the junction where the sphenoid process of the palatine bone meets the horizontal portion of the pterygoid process. The tumor typically arises from the superior margin of this foramen and expands into the pterygopalatine fossa and the nasopharynx. **2. Analysis of Incorrect Options:** * **A. Roof of nasopharynx:** While the tumor clinically presents as a mass in the nasopharynx, this is a site of *extension*, not the primary site of origin. * **C. Vault of skull:** The tumor can erode the skull base (specifically the sphenoid bone) in advanced stages, but it does not originate here. * **D. Lateral wall of nose:** The tumor often pushes the lateral wall of the nose medially as it grows, but the primary nidus is more posterior and lateral at the sphenopalatine foramen. **3. Clinical Pearls for NEET-PG:** * **Demographics:** Almost exclusively seen in **adolescent males** (testosterone-dependent). * **Classic Triad:** Adolescent male + Profuse recurrent epistaxis + Nasal obstruction. * **Holman-Miller Sign (Antral Sign):** Forward bowing of the posterior wall of the maxillary sinus seen on CT/MRI. * **Diagnosis:** Contrast-enhanced CT (CECT) is the investigation of choice. **Biopsy is contraindicated** due to the risk of torrential hemorrhage. * **Treatment:** Surgical excision (Pre-operative embolization is often done to reduce blood loss).

Question 38: Which of the following are indications for adenoidectomy in children?

A. Recurrent rhinosinusitis
B. Chronic otitis media with effusion
C. Dental malocclusion
D. All of the above (Correct Answer)

Explanation: **Explanation:** Adenoidectomy is one of the most common pediatric surgical procedures. The adenoids (nasopharyngeal tonsils) are part of Waldeyer’s ring; when they undergo pathological hypertrophy or become a reservoir for infection, they impact surrounding structures. **Why "All of the above" is correct:** 1. **Recurrent Rhinosinusitis:** Enlarged adenoids act as a **nidus for infection** (biofilms) and can physically obstruct the sinus ostia, preventing normal mucociliary clearance. This leads to persistent or recurrent sinus infections. 2. **Chronic Otitis Media with Effusion (COME):** The adenoids are located near the opening of the **Eustachian tube**. Hypertrophy causes mechanical obstruction, while chronic adenoiditis leads to ascending infection. This results in negative middle ear pressure and fluid accumulation (Glue Ear). Adenoidectomy is often performed alongside grommet insertion. 3. **Dental Malocclusion:** Chronic nasal obstruction leads to obligatory **mouth breathing**. This results in "Adenoid Facies," characterized by a high-arched palate, narrow upper arch, and protruding incisors (malocclusion). **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Indications:** Sleep Apnea (OSAS) and suspicion of malignancy. * **Relative Indications:** Chronic adenoiditis, recurrent otitis media, and craniofacial growth anomalies. * **Adenoid Facies:** Key features include an elongated face, dull expression, open mouth, and hitched-up upper lip. * **Contraindications:** Overt or submucous **cleft palate** (risk of velopharyngeal insufficiency and hypernasal speech) and bleeding diathesis. * **Investigation of Choice:** Lateral view X-ray of the nasopharynx (soft tissue) to assess the airway space.

Question 39: What is the standard surgical approach for glossopharyngeal neurectomy?

A. Tonsillectomy approach (Correct Answer)
B. Transpalatal approach
C. Transmandibular approach
D. Transpharyngeal approach

Explanation: **Explanation:** Glossopharyngeal neuralgia is characterized by paroxysms of severe, stabbing pain in the distribution of the IX cranial nerve (throat, base of tongue, and ear). When medical management fails, surgical intervention is required. **Why Option A is Correct:** The **Tonsillectomy approach** (transoral approach) is the standard extracranial surgical method for glossopharyngeal neurectomy. The glossopharyngeal nerve lies in the **tonsillar bed**, specifically deep to the superior constrictor muscle. By performing a tonsillectomy, the surgeon gains direct access to the nerve as it passes through the pharyngeal wall. This approach is often preferred for peripheral neurectomy or when elongated styloid processes (Eagle’s Syndrome) are being addressed simultaneously. **Analysis of Incorrect Options:** * **B. Transpalatal approach:** Primarily used for accessing the nasopharynx or the skull base (e.g., juvenile nasopharyngeal angiofibroma); it does not provide adequate exposure to the lateral oropharyngeal wall where the IX nerve resides. * **C. Transmandibular approach:** A highly invasive "mandibular swing" procedure used for large tumors of the oropharynx or tongue base; it is excessive for a simple neurectomy. * **D. Transpharyngeal approach:** While the nerve is in the pharynx, this term is non-specific. The specific surgical gateway is via the tonsillar fossa. **Clinical Pearls for NEET-PG:** * **Eagle’s Syndrome:** Glossopharyngeal pain caused by an elongated styloid process or calcified stylohyoid ligament. Treatment involves styloidectomy via the tonsillectomy approach. * **Nerve Course:** The IX nerve is the only nerve found in the tonsillar bed, making it vulnerable during tonsillectomy (leading to loss of taste/sensation in the posterior 1/3 of the tongue). * **Gold Standard:** While the tonsillectomy approach is the standard *extracranial* route, **Microvascular Decompression (MVD)** in the posterior fossa is often considered the definitive *intracranial* treatment.

Question 40: All of the following are indications for tonsillectomy except?

A. Foreign body in tonsils (Correct Answer)
B. Unilateral enlargement of tonsils with suspected malignancy
C. Keratin tonsil
D. Recurrent quinsy

Explanation: ### Explanation The correct answer is **A. Foreign body in tonsils**. **1. Why "Foreign body in tonsils" is the correct answer:** A foreign body (like a fish bone) lodged in the tonsil is an **acute emergency** managed by simple **removal** using forceps under direct vision or endoscopy. Tonsillectomy is an invasive surgical procedure and is not indicated for the simple removal of a foreign body unless the object is deeply embedded and inaccessible, which is rare. **2. Analysis of Incorrect Options:** * **Unilateral enlargement of tonsils (B):** This is a **mandatory indication** for tonsillectomy to rule out malignancy (e.g., Lymphoma or Squamous Cell Carcinoma), especially in adults. * **Keratosis Pharyngis/Keratin tonsil (C):** While often asymptomatic, if the keratotic patches (hard, white horny projections) cause persistent irritation, foreign body sensation, or cough, tonsillectomy is indicated as a definitive treatment. * **Recurrent Quinsy (D):** A history of **two or more episodes** of peritonsillar abscess (Quinsy) is a strong relative indication for tonsillectomy, usually performed 4–6 weeks after the infection subsides ("Interval Tonsillectomy"). **3. NEET-PG High-Yield Pearls:** * **Paradise Criteria:** The gold standard for recurrent tonsillitis: 7 episodes in 1 year, 5 per year for 2 years, or 3 per year for 3 years. * **Most common indication (Overall):** Recurrent tonsillitis. * **Most common indication (Children):** Obstructive Sleep Apnea (OSA) due to adenotonsillar hypertrophy. * **Eagle’s Syndrome:** Elongated styloid process causing throat pain; tonsillectomy is part of the surgical approach (trans-oral) to excise the process. * **Absolute Contraindications:** Uncontrolled bleeding disorders, acute infection (unless "Tonsillectomy à chaud"), and hemoglobin <10 g/dL.

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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