Diseases of the Pharynx Practice Questions

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

Cleft lip. **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).

Q: Plica triangularis is present in which anatomical location?

Antero-inferior part of the tonsil. **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.

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

Juvenile angiofibroma. **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.

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

Barium Swallow. **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.

Q: Which of the following is false about sideropenic dysphagia?

Pre-cricoid webs. **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.

Q: What complication is NOT seen after adenoidectomy?

Hyponasality. ### 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.

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

Nasopharyngeal carcinoma. **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.

Q: Tonsillectomy is contraindicated in which of the following conditions?

Poliomyelitis epidemic. **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).

Question 1

Which of the following is NOT a contraindication for tonsillectomy?

Accepted Answer

Cleft lip

Answer

Polio epidemic

Answer

Hemophilia

Answer

Acute infection of tonsils

Question 2

Plica triangularis is present in which anatomical location?

Accepted Answer

Antero-inferior part of the tonsil

Answer

Dorsum of the tongue

Answer

Inlet of the larynx

Answer

None of the above

Question 3

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

Accepted Answer

Juvenile angiofibroma

Answer

Otosclerosis

Answer

Chronic suppurative otitis media

Answer

Sinusitis

Question 4

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

Accepted Answer

Barium Swallow

Answer

CECT

Answer

Endoscopy

Answer

Esophageal manometry

Question 5

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

Accepted Answer

Acute retropharyngeal abscess

Answer

Peritonsillar abscess

Answer

Prevertebral abscess

Answer

Parapharyngeal abscess

Question 6

Which of the following is false about sideropenic dysphagia?

Accepted Answer

Pre-cricoid webs

Answer

Pre-malignant potential

Answer

Associated with anemia

Answer

Common in perimenopausal women

Question 7

What complication is NOT seen after adenoidectomy?

Accepted Answer

Hyponasality

Answer

Velopharyngeal insufficiency

Answer

Retropharyngeal abscess

Answer

Base of skull fracture

Question 8

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

Accepted Answer

Nasopharyngeal carcinoma

Answer

Angiofibroma

Answer

Acoustic neuroma

Answer

Otosclerosis

Question 9

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:

Accepted Answer

Infection is posterior to the prevertebral fascia.

Answer

It is usually restricted to one side of the midline.

Answer

Causes difficulty in deglutition and respiration.

Answer

Can be easily palpated by placing a fingertip on the posterior pharyngeal wall.

Question 10

Tonsillectomy is contraindicated in which of the following conditions?

Accepted Answer

Poliomyelitis epidemic

Answer

Small atrophic tonsils

Answer

Quinsy

Answer

Tonsillolith

Diseases of the Pharynx — MCQs

Diseases of the Pharynx — MCQs

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