Diseases of the Pharynx — MCQs

Diseases of the Pharynx Indian Medical PG Practice Questions and MCQs

Question 41: Which of the following is NOT a contraindication for tonsillectomy?

A. Polio epidemic
B. Hemophilia
C. Cleft lip (Correct Answer)
D. Acute infection of tonsils

Explanation: **Explanation:** The correct answer is **Cleft lip**. To answer this question correctly, it is essential to distinguish between conditions that pose a surgical risk and those that are unrelated to the surgical site or function. **1. Why Cleft Lip is NOT a contraindication:** A **Cleft Lip** is a cosmetic and functional deformity of the lip and does not involve the palate or the oropharyngeal sphincter. Therefore, removing the tonsils does not affect the speech or swallowing mechanism in these patients. In contrast, a **Cleft Palate** (or Submucous Cleft Palate) is a significant contraindication because the tonsils act as a compensatory mechanism to help close the oropharyngeal isthmus; removing them can lead to **Velopharyngeal Insufficiency (VPI)** and hypernasal speech. **2. Analysis of Incorrect Options (Contraindications):** * **Polio Epidemic:** Tonsillectomy during an epidemic is contraindicated because the surgical trauma provides a portal of entry for the virus, significantly increasing the risk of **Bulbar Poliomyelitis**. * **Hemophilia:** Bleeding disorders (including leukemia, purpura, and hemophilia) are absolute contraindications unless the deficiency is corrected, as tonsillectomy is a highly vascular procedure. * **Acute Infection:** Surgery is avoided during an acute episode of tonsillitis (usually for 3–4 weeks) because the tissues are hyperemic and friable, leading to a high risk of **primary and reactionary hemorrhage**. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindication:** Uncontrolled systemic diseases (e.g., uncontrolled DM, severe hypertension). * **The "Hot" Tonsillectomy:** This refers to tonsillectomy performed during an acute peritonsillar abscess (Quinsy). * **Most common complication:** Hemorrhage (Reactionary is within 24 hours; Secondary is between 5–10 days, usually due to infection).

Question 42: Plica triangularis is present in which anatomical location?

A. Antero-inferior part of the tonsil (Correct Answer)
B. Dorsum of the tongue
C. Inlet of the larynx
D. None of the above

Explanation: **Explanation:** The **Plica triangularis** is a triangular fold of mucous membrane that extends backwards from the **palatoglossal arch** (anterior pillar) across the **antero-inferior** part of the palatine tonsil. 1. **Why Option A is correct:** During fetal development, the tonsil develops from the second pharyngeal pouch. The plica triangularis is a vestigial remnant of the caudal part of the fetal tonsil. In adults, it often becomes fibrous and fuses with the tonsil, forming a pocket that can trap debris (detritus), potentially leading to tonsilloliths or recurrent tonsillitis. 2. **Why Options B and C are incorrect:** * **Dorsum of the tongue:** This area contains various papillae (circumvallate, filiform, fungiform) and the lingual tonsil, but not the plica triangularis. * **Inlet of the larynx:** This region is characterized by the epiglottis, aryepiglottic folds, and piriform fossae. A similar-sounding structure, the *Plica ventricularis* (false vocal cord), is found within the larynx, but not the plica triangularis. **High-Yield Clinical Pearls for NEET-PG:** * **Plica Semilunaris:** A similar mucosal fold located at the **upper pole** (superior part) of the tonsil, crossing the supratonsillar fossa. * **Quinsy (Peritonsillar Abscess):** Pus typically collects in the **supratonsillar fossa**, which is bounded by these mucosal folds. * **Blood Supply:** The main artery of the tonsil is the **tonsillar branch of the facial artery**, which enters at the lower pole. * **Surgical Importance:** During tonsillectomy, the plica triangularis is incised to mobilize the tonsil from its bed.

Question 43: The Antral sign is typically seen in which of the following conditions?

A. Juvenile angiofibroma (Correct Answer)
B. Otosclerosis
C. Chronic suppurative otitis media
D. Sinusitis

Explanation: **Explanation:** The **Antral sign** (also known as the **Holman-Miller sign**) is a classic radiological finding associated with **Juvenile Nasopharyngeal Angiofibroma (JNA)**. **1. Why Juvenile Angiofibroma is correct:** JNA is a benign but locally aggressive, highly vascular tumor that typically arises in the sphenopalatine foramen of adolescent males. As the tumor grows, it expands from the pterygopalatine fossa into the infratemporal fossa. This growth exerts pressure on the posterior wall of the maxillary sinus, causing it to **bow anteriorly**. This anterior displacement of the posterior antral wall, seen on a lateral X-ray or CT scan, is the pathognomonic "Antral sign." **2. Why other options are incorrect:** * **Otosclerosis:** A metabolic bone disease of the otic capsule causing conductive hearing loss; it involves the stapes footplate, not the maxillary antrum. * **Chronic Suppurative Otitis Media (CSOM):** A chronic inflammation of the middle ear and mastoid; radiological findings usually involve mastoid air cell opacification or bone erosion (cholesteatoma). * **Sinusitis:** While this involves the maxillary sinus, it typically presents with mucosal thickening or air-fluid levels, not the structural displacement of the bony walls. **3. High-Yield Clinical Pearls for NEET-PG:** * **Triad of JNA:** Adolescent male + Profuse recurrent epistaxis + Nasal obstruction. * **Investigation of Choice:** Contrast-Enhanced CT (CECT) scan. * **Gold Standard for Vascularity:** Digital Subtraction Angiography (DSA) – also used for preoperative embolization. * **Biopsy is Contraindicated:** Due to the risk of torrential hemorrhage. * **Frog-face deformity:** Seen in advanced cases due to widening of the nasal bridge.

Question 44: What is the investigation of choice for Zenker's diverticulum?

A. CECT
B. Endoscopy
C. Esophageal manometry
D. Barium Swallow (Correct Answer)

Explanation: **Explanation:** **Zenker’s Diverticulum** (Pharyngeal Pouch) is a pulsion diverticulum occurring through **Killian’s dehiscence**, a weak muscular area between the thyropharyngeus and cricopharyngeus parts of the inferior constrictor muscle. **Why Barium Swallow is the Investigation of Choice:** Barium swallow is the gold standard because it clearly outlines the size, shape, and position of the pouch. It typically reveals a "flask-shaped" or "club-shaped" sac filled with contrast, located posteriorly at the level of the C5-C6 vertebrae. It is non-invasive and provides a definitive diagnosis without the risks associated with instrumentation. **Analysis of Incorrect Options:** * **Endoscopy:** This is generally **contraindicated** as the initial investigation. The endoscope can easily enter the diverticulum instead of the esophagus, leading to an accidental **perforation**, as the pouch is thin-walled and lacks a muscular layer. * **Esophageal Manometry:** While it may show incoordination of the upper esophageal sphincter, it is technically difficult to perform in these patients and is not used for primary diagnosis. * **CECT:** While CT can show a fluid-filled sac, it is not as sensitive or specific as a dynamic barium study for visualizing the diverticulum's anatomy. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Dysphagia, halitosis (foul breath due to undigested food), and regurgitation. * **Boyce’s Sign:** A gurgling sound heard on pressing the side of the neck. * **Treatment of Choice:** Endoscopic Dohlman’s procedure (Stapling/Laser) or external diverticulectomy with cricopharyngeal myotomy. * **Complication:** Recurrent aspiration pneumonia is the most common serious complication.

Question 45: Unilateral posterior pharyngeal wall swelling is due to which of the following?

A. Peritonsillar abscess
B. Prevertebral abscess
C. Acute retropharyngeal abscess (Correct Answer)
D. Parapharyngeal abscess

Explanation: ### Explanation The correct answer is **Acute retropharyngeal abscess**. #### 1. Why Acute Retropharyngeal Abscess is Correct The **retropharyngeal space** is divided into two lateral compartments by a tough **median fibrous raphe** that attaches the buccopharyngeal fascia to the prevertebral fascia. In children, this space contains the **Nodes of Rouviere**. When these nodes suppurate (usually following an upper respiratory infection), the resulting abscess is confined to one side of the midline by the median raphe. Therefore, the clinical presentation is a **unilateral, fluctuant swelling** on the posterior pharyngeal wall. #### 2. Why Other Options are Incorrect * **Prevertebral Abscess:** This occurs in the prevertebral space, which lies posterior to the prevertebral fascia. This space is not divided by a midline raphe; hence, the pus spreads across the entire width of the vertebrae, resulting in a **diffuse, midline (central) swelling**. * **Peritonsillar Abscess (Quinsy):** This is a collection of pus between the tonsillar capsule and the superior constrictor muscle. The swelling is seen in the **peritonsillar region** (soft palate and anterior pillar), displacing the uvula to the opposite side, not on the posterior pharyngeal wall. * **Parapharyngeal Abscess:** This involves the space lateral to the pharynx. Clinical features include **trismus** and a swelling in the **lateral wall of the pharynx** (pushing the tonsil medially) and the neck at the angle of the mandible. #### 3. Clinical Pearls for NEET-PG * **Age Group:** Acute retropharyngeal abscess is most common in **children under 5 years** (as Nodes of Rouviere atrophy after this age). * **Chronic Retropharyngeal Abscess:** Usually secondary to **Caries Spine (Pott’s disease)**; it presents as a midline swelling because it occurs in the prevertebral space. * **X-ray Finding:** Lateral view of the neck shows widening of the **prevertebral soft tissue shadow** (normally <7mm at C2 and <14mm at C6 in children). * **Danger Space:** The space behind the retropharyngeal space that acts as a conduit for infection to travel from the skull base to the **mediastinum**.

Question 46: Which of the following is false about sideropenic dysphagia?

A. Pre-malignant potential
B. Pre-cricoid webs (Correct Answer)
C. Associated with anemia
D. Common in perimenopausal women

Explanation: **Sideropenic Dysphagia**, also known as **Plummer-Vinson Syndrome** (in the US) or **Paterson-Brown-Kelly Syndrome** (in the UK), is a classic triad of iron-deficiency anemia, glossitis, and esophageal webs. ### Explanation of Options: * **Option B (Correct Answer):** The statement is false because the webs in this condition are **post-cricoid**, not pre-cricoid. They are typically found at the junction of the hypopharynx and the upper esophagus. * **Option A:** This is a true statement. It is considered a **pre-malignant** condition. Chronic irritation and mucosal atrophy predispose patients to **Squamous Cell Carcinoma** of the post-cricoid region and upper esophagus. * **Option C:** This is a true statement. "Sideropenic" refers to iron deficiency. Patients present with microcytic hypochromic **anemia**, often accompanied by spoon-shaped nails (koilonychia). * **Option D:** This is a true statement. The condition classically affects **middle-aged (perimenopausal) women**, with a female-to-male ratio of approximately 9:1. ### High-Yield Clinical Pearls for NEET-PG: * **The Triad:** Iron deficiency anemia + Dysphagia + Post-cricoid webs. * **Clinical Features:** Glossitis (smooth red tongue), angular cheilitis, and koilonychia. * **Diagnosis:** **Barium Swallow** is the investigation of choice to visualize the thin, mucosal webs (best seen in the lateral view). * **Treatment:** Iron supplementation (often resolves the dysphagia) and endoscopic dilatation if the web is significant. * **Follow-up:** Essential due to the high risk of post-cricoid malignancy.

Question 47: What complication is NOT seen after adenoidectomy?

A. Velopharyngeal insufficiency
B. Hyponasality (Correct Answer)
C. Retropharyngeal abscess
D. Base of skull fracture

Explanation: ### Explanation **1. Why Hyponasality is the Correct Answer:** Adenoidectomy involves the removal of lymphoid tissue from the nasopharynx. Pre-operatively, enlarged adenoids obstruct the nasopharyngeal airway, leading to **hyponasality** (rhinolalia clausa). Once the adenoids are removed, the nasopharyngeal space opens up. If the soft palate fails to seal against the posterior pharyngeal wall (due to the sudden increase in space), the patient may experience **hypernasality** (rhinolalia aperta) or velopharyngeal insufficiency. Therefore, hyponasality is a *symptom* of adenoid hypertrophy, while its *resolution* (or transition to hypernasality) is seen post-operatively. **2. Analysis of Incorrect Options:** * **Velopharyngeal Insufficiency (VPI):** This is a known complication where the soft palate cannot close the widened nasopharynx, leading to hypernasality and nasal regurgitation of fluids. * **Retropharyngeal Abscess:** This can occur due to infection of the retropharyngeal space or trauma to the posterior pharyngeal wall during curettage. * **Base of Skull Fracture:** Though rare, aggressive curettage or use of a sharp adenotome can cause injury to the basisphenoid or the atlanto-occipital joint, potentially leading to CSF leaks or Grisel’s syndrome. **3. High-Yield Clinical Pearls for NEET-PG:** * **Grisel’s Syndrome:** A rare post-adenoidectomy complication involving non-traumatic subluxation of the atlanto-axial joint (C1-C2) due to inflammatory laxity of the apical and transverse ligaments. * **Most Common Complication:** Hemorrhage (Primary, Reactionary, or Secondary). * **Contraindication:** Adenoidectomy is strictly contraindicated in children with an **unrepaired cleft palate** or **submucous cleft palate** (identified by a bifid uvula) because it will precipitate severe velopharyngeal insufficiency. * **Eustachian Tube Injury:** Can lead to stenosis and subsequent otitis media with effusion.

Question 48: What is a potential cause of cervical lymphadenopathy in a 70-year-old man?

A. Nasopharyngeal carcinoma (Correct Answer)
B. Angiofibroma
C. Acoustic neuroma
D. Otosclerosis

Explanation: **Explanation:** **1. Why Nasopharyngeal Carcinoma (NPC) is correct:** In an elderly patient (70 years old) presenting with cervical lymphadenopathy, the primary concern is a metastatic malignancy from the head and neck. **Nasopharyngeal carcinoma** is notorious for its "silent" primary site; the most common presenting symptom (up to 75% of cases) is a painless, firm, upper cervical lymph node mass (typically Level II or Level V). Due to the rich lymphatic network of the nasopharynx, nodal metastasis often occurs early, even when the primary tumor is small. **2. Why the other options are incorrect:** * **Angiofibroma (Juvenile Nasopharyngeal Angiofibroma):** This is a benign but locally aggressive vascular tumor. It almost exclusively affects **adolescent males** (10–20 years). It presents with profuse epistaxis and nasal obstruction, not cervical lymphadenopathy. * **Acoustic Neuroma (Vestibular Schwannoma):** This is a benign tumor of the 8th cranial nerve. It presents with unilateral sensorineural hearing loss, tinnitus, and dysequilibrium. It does not involve the lymphatic system. * **Otosclerosis:** This is a metabolic bone disease of the otic capsule leading to stapes fixation. it presents with progressive **conductive hearing loss** in young to middle-aged adults with a normal tympanic membrane. It has no association with lymphadenopathy. **Clinical Pearls for NEET-PG:** * **Trotter’s Triad (for NPC):** 1. Conductive hearing loss (due to Eustachian tube blockage), 2. Ipsilateral palatal paralysis, 3. Trigeminal neuralgia (facial pain). * **Fossa of Rosenmüller:** The most common site of origin for NPC. * **EBV Association:** Nasopharyngeal carcinoma (Type II and III) is strongly associated with the **Epstein-Barr Virus**. * **Rule of Thumb:** Any adult with unilateral serous otitis media must be evaluated for NPC to rule out a mass obstructing the Eustachian tube.

Question 49: A child presents with high fever and hoarseness of voice and is found to have a retropharyngeal abscess. All of the following statements are true about acute retropharyngeal abscess, EXCEPT:

A. It is usually restricted to one side of the midline.
B. Infection is posterior to the prevertebral fascia. (Correct Answer)
C. Causes difficulty in deglutition and respiration.
D. Can be easily palpated by placing a fingertip on the posterior pharyngeal wall.

Explanation: ### Explanation **Concept:** The retropharyngeal space is a potential space located between the **buccopharyngeal fascia** (anteriorly) and the **prevertebral fascia** (posteriorly). Therefore, a retropharyngeal abscess is located **anterior** to the prevertebral fascia. If an infection is posterior to the prevertebral fascia, it is termed a **Prevertebral Abscess**, which is typically chronic and often associated with tuberculosis of the cervical spine (Pott’s spine). **Analysis of Options:** * **Option B (Correct Answer):** As stated above, the abscess lies in the retropharyngeal space, which is anterior to the prevertebral fascia. This makes the statement false. * **Option A:** In children, the retropharyngeal space is divided into two lateral compartments by a tough median fibrous septum. Lymph nodes (Nodes of Rouviere) are located in these lateral spaces. Thus, the abscess is usually **unilateral** and restricted to one side of the midline. * **Option C:** The swelling in the posterior pharyngeal wall narrows the oropharyngeal and laryngeal inlet, leading to **dysphagia** (difficulty swallowing) and **stridor/respiratory distress**. * **Option D:** On clinical examination, a fluctuant swelling can be felt by **palpating** the posterior pharyngeal wall (though this must be done cautiously to avoid accidental rupture and aspiration). **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Usually follows an Upper Respiratory Tract Infection (URTI) leading to suppuration of the **Nodes of Rouviere**. These nodes typically atrophy by age 6, which is why acute retropharyngeal abscess is most common in children under 5. * **X-ray Finding:** Lateral view of the neck shows widening of the **prevertebral soft tissue shadow** (normally <7mm at C2 and <14mm at C6 in children). * **Complication:** The most dreaded complication is spontaneous rupture leading to **aspiration pneumonia** or spread to the **mediastinum** (danger space).

Question 50: Tonsillectomy is contraindicated in which of the following conditions?

A. Small atrophic tonsils
B. Quinsy
C. Poliomyelitis epidemic (Correct Answer)
D. Tonsillolith

Explanation: **Explanation:** The correct answer is **C. Poliomyelitis epidemic.** **Why it is the correct answer:** Performing a tonsillectomy during a poliomyelitis epidemic is strictly contraindicated. The procedure involves trauma to the pharyngeal mucosa, which exposes nerve endings (specifically the glossopharyngeal and vagus nerves). This provides a direct portal for the poliovirus to enter the nervous system, significantly increasing the risk of the patient developing the **bulbar form of poliomyelitis**, which is the most severe and life-threatening manifestation of the disease. **Analysis of Incorrect Options:** * **A. Small atrophic tonsils:** These are not a contraindication. While they may be harder to dissect, they can still be a source of chronic infection or focal sepsis, necessitating removal. * **B. Quinsy (Peritonsillar Abscess):** While traditional teaching suggested waiting 4–6 weeks after an infection, "Quinsy Tonsillectomy" (abscess tonsillectomy) is now a recognized procedure performed during the acute phase to provide immediate drainage and prevent recurrence. * **D. Tonsillolith:** Tonsil stones are a common indication for tonsillectomy if they cause persistent halitosis, foreign body sensation, or recurrent discomfort. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications:** Bleeding disorders (e.g., Hemophilia, Leukemia), uncontrolled systemic disease (Diabetes, HTN), and acute infections (unless it's a Quinsy tonsillectomy). * **Relative Contraindications:** Cleft palate (risk of velopharyngeal insufficiency), age below 3 years, and menstruation (due to increased vascularity/bleeding risk). * **Most common complication:** Hemorrhage (Reactionary: within 24 hours; Secondary: 5–10 days due to infection). * **Most common nerve injured:** Glossopharyngeal nerve (leads to loss of taste on the posterior 1/3 of the tongue).

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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