Diseases of the Pharynx Practice Questions

Q: A 17-year-old woman is admitted to the hospital with tonsillitis. A tonsillectomy is performed and the patient complains postoperatively of ear pain. Which of the following nerves was most likely injured during the surgical procedure?

Glossopharyngeal nerve. **Explanation:** The correct answer is the **Glossopharyngeal nerve (CN IX)**. This is a classic example of **referred otalgia** (ear pain) following a tonsillectomy. **1. Why Glossopharyngeal nerve is correct:** The glossopharyngeal nerve provides sensory innervation to the **oropharynx** and the **palatine tonsils** via its tonsillar branches. It also provides sensory innervation to the **middle ear** via its tympanic branch (**Jacobson’s nerve**). During a tonsillectomy, the nerve (which lies in the tonsillar bed, deep to the superior constrictor muscle) can be irritated or injured. Due to the shared nerve supply, the brain perceives pain from the oropharynx as originating from the ear. **2. Why other options are incorrect:** * **Auriculotemporal nerve (Branch of V3):** Supplies the TMJ and external auditory canal. While it causes referred ear pain in dental or TMJ issues, it does not innervate the tonsillar fossa. * **Lesser petrosal nerve:** A preganglionic parasympathetic branch of CN IX involved in salivation (parotid gland); it does not carry general somatic sensation from the tonsil. * **Vagus nerve (CN X):** Provides sensation to the laryngopharynx and the external ear (Arnold’s nerve). It causes referred ear pain in cases of laryngeal or hypopharyngeal pathologies (e.g., malignancy), not tonsillitis. **NEET-PG High-Yield Pearls:** * **Tonsillar Bed Anatomy:** The glossopharyngeal nerve is the most common nerve injured during tonsillectomy. * **Referred Otalgia Rule:** Pain in the ear with a normal ear exam should prompt an evaluation of the "4 Ts": **T**ongue, **T**onsil, **T**eeth, and **T**MJ. * **Eagle’s Syndrome:** Elongated styloid process compressing the glossopharyngeal nerve, causing throat and ear pain.

Q: Which of the following statements about pharyngeal diverticula is FALSE?

Lies in the posterior wall of the pharynx. ### Explanation The question refers to **Zenker’s Diverticulum** (Pharyngeal Pouch), which is a pulsion-type diverticulum. **1. Why Option B is the Correct (False) Statement:** While Zenker’s diverticulum originates in the posterior wall of the pharynx at **Killian’s Dehiscence** (a weak area between the thyropharyngeus and cricopharyngeus muscles), it does not remain strictly posterior. As the pouch enlarges, it is restricted by the vertebral column and is forced to deviate, usually to the **left side** of the neck. Therefore, stating it simply "lies in the posterior wall" is clinically inaccurate compared to its lateral presentation. **2. Analysis of Other Options:** * **Option A (True):** It results from **neuromuscular incoordination** where the cricopharyngeal sphincter fails to relax during swallowing, increasing intraluminal pressure. * **Option C (True):** Pharyngeal pouches are anatomical norms in certain animals like **pigs** and camels. * **Option D (True):** The pouch acts as a reservoir where **undigested food accumulates**, leading to symptoms like halitosis (bad breath), regurgitation, and nocturnal aspiration. ### NEET-PG High-Yield Pearls: * **Killian’s Dehiscence:** The site of origin; located between the oblique and transverse fibers of the inferior constrictor. * **Boyce’s Sign:** A gurgling sound heard on pressing the swelling in the neck. * **Investigation of Choice:** **Barium Swallow** (shows a "teapot" or "bag-like" appearance). * **Contraindication:** Rigid Esophagoscopy (high risk of perforation). * **Treatment:** Small pouches require Cricopharyngeal Myotomy; larger ones require **Dohlman’s Procedure** (Endoscopic Stapling).

Q: Prophylactic radiotherapy to the neck is given in which of the following malignancies with palpable swelling?

Nasopharyngeal carcinoma. **Explanation:** The correct answer is **Nasopharyngeal Carcinoma (NPC)**. **Why Nasopharyngeal Carcinoma is correct:** Nasopharyngeal carcinoma is unique among head and neck cancers due to its **exceedingly high rate of lymphatic spread**. Even in the absence of clinically palpable nodes (N0 neck), the risk of occult metastasis is approximately 75–90%. Furthermore, NPC is highly **radiosensitive**. Therefore, elective (prophylactic) irradiation of the bilateral neck (Levels II-V and retropharyngeal nodes) is the standard of care for all cases, regardless of whether nodes are palpable, to prevent regional recurrence. **Why other options are incorrect:** * **Laryngeal Carcinoma:** Management of the neck depends strictly on the sub-site and stage. Early glottic cancers have negligible lymphatic drainage and do not require prophylactic treatment. * **Sinuses Malignancy:** Maxillary and ethmoid sinus tumors have relatively sparse lymphatic drainage. Prophylactic neck treatment is generally not indicated unless the tumor involves the oral cavity or skin. * **Tongue Carcinoma:** While tongue cancers have a high rate of nodal metastasis, the primary treatment for a N0 neck is usually elective neck dissection (surgical) rather than prophylactic radiotherapy, especially if the primary tumor is being managed surgically. **High-Yield Clinical Pearls for NEET-PG:** * **EBV Association:** NPC (especially Type II and III) is strongly associated with the Epstein-Barr Virus. * **Fossa of Rosenmüller:** This is the most common site of origin for NPC. * **Trotter’s Triad:** Conductive hearing loss (due to ET blockage), palatal paralysis, and trigeminal neuralgia (ipsilateral) are classic signs of NPC. * **Treatment of Choice:** Radiotherapy is the primary treatment for both the primary tumor and the neck in NPC.

Q: Tonsillectomy is being performed in the given patient. What position is being used?

Rose's position. ***Rose's position*** - **Supine position** with **neck hyperextended** and head tilted back, providing optimal **surgical access** to the oropharynx and tonsillar fossa. - Facilitates **drainage of blood and secretions** away from the airway, reducing risk of **aspiration** during tonsillectomy. *Trendelenburg position* - **Head-down tilt** with legs elevated above the heart level, primarily used for **pelvic** and **lower abdominal surgeries**. - Would cause **blood pooling** in the head and neck area, impairing visualization and increasing **aspiration risk** during throat procedures. *Barking dog position* - **Prone position** with neck flexed and chin tucked, resembling a dog's posture, not suitable for **oral cavity access**. - This position would **obstruct the surgical field** and make **airway management** extremely difficult during tonsillectomy. *Boyce position* - **Lateral decubitus** position with the patient lying on their side, commonly used for **kidney** and **thoracic surgeries**. - Does not provide adequate **visualization** of the tonsillar area and would make **bilateral access** to both tonsils challenging.

Q: A 58-year-old male presents with persistent fullness of the left ear for 3 months and hearing loss. On examination, there is fluid behind the tympanic membrane. Impedance audiometry shows a type B audiogram. What is the next step in the management of this patient?

Endoscopic examination for nasopharyngeal pathology. **Explanation:** The clinical presentation describes **Unilateral Serous Otitis Media (SOM)** in an adult. The persistent fullness, fluid behind the tympanic membrane, and Type B (flat) tympanogram are classic indicators of Eustachian tube dysfunction leading to middle ear effusion. **1. Why Option B is correct:** In an adult, especially a male over 40, **unilateral** serous otitis media is considered **Nasopharyngeal Carcinoma (NPC) until proven otherwise**. The tumor can originate in the Fossa of Rosenmüller, obstructing the pharyngeal opening of the Eustachian tube. Therefore, the mandatory next step is a diagnostic nasal endoscopy (DNE) or fiberoptic nasopharyngoscopy to rule out a space-occupying lesion in the nasopharynx. **2. Why other options are incorrect:** * **Option A (Myringotomy):** While this treats the symptom (fluid), it is premature. One must diagnose the *cause* of the effusion before surgical intervention. * **Option C (Valsalva):** This may temporarily equalize pressure but is ineffective for chronic effusion and delays the diagnosis of a potential malignancy. * **Option D (Antihistamines):** These are used for Eustachian tube dysfunction related to allergies or URIs. In a 58-year-old with persistent unilateral symptoms, medical management without investigation is a clinical error. **High-Yield Clinical Pearls for NEET-PG:** * **Trotter’s Triad (for NPC):** 1. Conductive hearing loss (due to SOM), 2. Ipsilateral facial pain/numbness (CN V involvement), 3. Palatal paralysis (CN X involvement). * **Type B Tympanogram:** Indicates fluid (effusion), perforation, or patent grommet. * **Rule of Thumb:** Any adult with new-onset unilateral middle ear effusion must have their nasopharynx examined.

Q: A 15-year-old male presents with hemorrhage 5 hours after tonsillectomy. What is the best treatment for this patient?

Re-explore immediately. ### **Explanation** This patient is presenting with **Reactionary Hemorrhage**, a critical complication of tonsillectomy occurring within the first 24 hours (most commonly within 4–6 hours) post-surgery. **1. Why "Re-explore immediately" is correct:** Reactionary hemorrhage is usually caused by the slipping of a ligature or the opening of a vessel that was constricted by adrenaline during surgery. In a 15-year-old, the primary concern is the risk of aspiration and hypovolemic shock. The standard management protocol involves: * Moving the patient back to the **Operating Theater (OT)**. * Inducing anesthesia (with a cuffed endotracheal tube to protect the airway). * Removing the clot to identify the bleeding point and achieving hemostasis via ligation or diathermy. **2. Why other options are incorrect:** * **External gauze packing:** This is ineffective as the bleeding is internal (within the tonsillar fossa). It does not provide the necessary pressure to stop arterial bleeding. * **Antibiotics and mouth wash:** These are used to manage **Secondary Hemorrhage** (occurring 5–10 days post-op due to infection), not acute reactionary bleeding. * **Irrigation with cold saline:** While mild cold compresses or ice chips may be used for very minor oozing, they are insufficient for active hemorrhage requiring medical intervention. **3. Clinical Pearls for NEET-PG:** * **Primary Hemorrhage:** Occurs during surgery (managed by ligation/diathermy). * **Reactionary Hemorrhage (2–24 hours):** Due to slipping of ligatures or rise in BP post-anesthesia. **Management:** Re-exploration. * **Secondary Hemorrhage (5–10 days):** Due to infection of the surgical bed. **Management:** Conservative (Antibiotics); if severe, ligation may be needed. * **High-Yield Fact:** The most common vessel involved in tonsillectomy bleeding is the **Paratonsillar vein**. The main artery of the tonsil is the **Tonsillar branch of the Facial artery**.

Q: All of the following are features of Paterson-Brown-Kelly syndrome, except?

Megaloblastic anemia. **Explanation:** Paterson-Brown-Kelly syndrome (also known as **Plummer-Vinson syndrome**) is characterized by a classic triad of **Iron Deficiency Anemia (IDA)**, dysphagia, and esophageal webs. **Why Option B is the correct answer:** The syndrome is specifically associated with **microcytic hypochromic anemia** (Iron Deficiency Anemia), not megaloblastic anemia. Megaloblastic anemia is caused by Vitamin B12 or Folate deficiency and is not a component of this syndrome. The iron deficiency leads to mucosal atrophy and subsequent web formation. **Analysis of incorrect options:** * **Option A (Esophageal mucosal webs):** These are thin, eccentric, mucosal projections usually found in the **post-cricoid region**. They are a hallmark feature and the primary cause of dysphagia in these patients. * **Option C & D (Glossitis and Cheilosis):** These are common epithelial manifestations of chronic iron deficiency. Patients typically present with a smooth, red, "beefy" tongue (glossitis) and cracks at the corners of the mouth (angular cheilosis). Other features include koilonychia (spoon-shaped nails) and achlorhydria. **Clinical Pearls for NEET-PG:** 1. **Demographics:** Most commonly seen in middle-aged females. 2. **Pre-malignant potential:** It is considered a pre-malignant condition. It significantly increases the risk of **Post-cricoid Squamous Cell Carcinoma**. 3. **Diagnosis:** The investigation of choice to visualize the web is a **Barium Swallow** (lateral view), though video-fluoroscopy or endoscopy can also be used. 4. **Treatment:** Management includes iron supplementation and endoscopic dilatation of the webs if symptoms persist.

Q: Retropharyngeal space infection is mainly due to spread of which of the following?

Odontogenic infections. **Explanation:** The **Retropharyngeal space** is a potential space located between the buccopharyngeal fascia (anteriorly) and the prevertebral fascia (posteriorly). It extends from the base of the skull to the superior mediastinum. **Why Odontogenic Infections are the correct answer:** In adults, the most common cause of retropharyngeal space infection is the **direct spread of infection** from the oral cavity, specifically **odontogenic infections** (dental abscesses) or trauma (e.g., fishbone injury, iatrogenic instrumentation). While children often develop retropharyngeal abscesses due to the suppuration of **Gillette’s nodes** (which atrophy after age 5), adults lack these nodes, making dental and traumatic origins the primary etiologies. **Analysis of Incorrect Options:** * **Cervical Tuberculosis:** This typically involves the **prevertebral space** (behind the prevertebral fascia), leading to a "cold abscess." While it can bulge into the pharynx, it is anatomically distinct from the retropharyngeal space. * **Meningoencephalitis:** This is an infection of the brain and meninges. There is no direct anatomical pathway for this to spread to the retropharyngeal space. * **Mumps:** This is a viral infection of the parotid glands. While it causes swelling in the parapharyngeal area, it does not typically lead to a retropharyngeal space infection. **High-Yield Clinical Pearls for NEET-PG:** * **Danger Space:** Located behind the retropharyngeal space (between the alar and prevertebral fascia). It is a direct conduit for infection to spread to the **posterior mediastinum**. * **Radiology:** On a lateral X-ray of the neck, the prevertebral soft tissue shadow at C2 should be **<7mm** and at C6 should be **<14mm (in children)** or **<22mm (in adults)**. * **Complication:** The most feared complication of a retropharyngeal abscess is **mediastinitis** or airway obstruction.

Q: Thornwaldt's cyst is seen in:

Nasopharynx. **Explanation:** **Thornwaldt’s cyst** (also known as a nasopharyngeal bursa) is a benign, developmental midline cyst located in the **nasopharynx**. It arises due to a persistent communication between the embryonic notochord and the pharyngeal endoderm. When the opening of this potential space becomes obstructed (often due to inflammation or trauma), fluid accumulates, forming a cyst. It is typically found in the midline of the posterior nasopharyngeal wall, just above the superior constrictor muscle and deep to the adenoids. **Analysis of Options:** * **Nasopharynx (Correct):** This is the anatomical site where the notochord remnants interface with the pharyngeal mucosa. * **Larynx:** Cysts here are usually saccular cysts or vallecular cysts, unrelated to the notochord. * **Base of tongue:** Common midline pathologies here include Lingual Thyroid or Thyroglossal duct cysts. * **Floor of mouth:** This is the classic site for a Ranula (mucocele) or a Dermoid cyst. **Clinical Pearls for NEET-PG:** * **Asymptomatic:** Most Thornwaldt’s cysts are incidental findings on MRI or endoscopy. * **Symptoms:** If infected or large, it can cause halitosis (due to drainage of foul-smelling fluid), post-nasal drip, or eustachian tube dysfunction. * **Imaging:** On MRI, it appears as a well-circumscribed, high-signal intensity lesion on T2-weighted images in the midline of the nasopharynx. * **Treatment:** No treatment is required if asymptomatic. If symptomatic, marsupialization or endoscopic excision is the preferred approach.

Q: Which condition is characterized by a lump in the throat that does not interfere with swallowing?

Globus hystericus. **Explanation:** **Globus hystericus** (now more commonly termed *Globus pharyngeus*) is a clinical condition characterized by a persistent or intermittent sensation of a "lump" or foreign body in the throat. The hallmark of this condition is that it **does not interfere with swallowing**; in fact, the sensation often improves during the ingestion of food or liquids. It is frequently associated with gastroesophageal reflux disease (GERD), upper esophageal sphincter spasms, or psychological stress. **Analysis of Incorrect Options:** * **Cervical spondylosis:** While osteophytes can occasionally cause a sensation of pressure, they typically do not present as a classic "lump" and are more associated with neck pain or stiffness. * **Pharyngeal diverticula (e.g., Zenker’s):** These cause true **dysphagia** (difficulty swallowing), regurgitation of undigested food, and halitosis. * **Carcinoma esophagus:** This presents with **progressive dysphagia** (initially for solids, then liquids) and weight loss. Any "lump" sensation that interferes with swallowing must be investigated to rule out malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis of Exclusion:** Globus is a diagnosis made only after a thorough ENT examination (including flexible laryngoscopy) rules out organic lesions. * **Key Differentiator:** If the patient reports difficulty swallowing (dysphagia) or pain on swallowing (odynophagia), it is **not** globus. * **Association:** Up to 80% of cases are linked to **Laryngopharyngeal Reflux (LPR)**. Proton Pump Inhibitors (PPIs) are often the first line of management. * **Psychological Aspect:** While historically linked to "hysteria," it is now recognized as a physical sensation often exacerbated by anxiety.

Question 1

A 17-year-old woman is admitted to the hospital with tonsillitis. A tonsillectomy is performed and the patient complains postoperatively of ear pain. Which of the following nerves was most likely injured during the surgical procedure?

Accepted Answer

Glossopharyngeal nerve

Answer

Auriculotemporal nerve

Answer

Lesser petrosal nerve

Answer

Vagus nerve

Question 2

Which of the following statements about pharyngeal diverticula is FALSE?

Accepted Answer

Lies in the posterior wall of the pharynx

Answer

Results due to neuromuscular incoordination

Answer

They are normal in pigs

Answer

Food may get accumulated

Question 3

Prophylactic radiotherapy to the neck is given in which of the following malignancies with palpable swelling?

Accepted Answer

Nasopharyngeal carcinoma

Answer

Laryngeal carcinoma

Answer

Sinuses malignancy

Answer

Tongue carcinoma

Question 4

Tonsillectomy is being performed in the given patient. What position is being used?

Accepted Answer

Rose's position

Answer

Trendelenburg position

Answer

Barking dog position

Answer

Boyce position

Question 5

A 58-year-old male presents with persistent fullness of the left ear for 3 months and hearing loss. On examination, there is fluid behind the tympanic membrane. Impedance audiometry shows a type B audiogram. What is the next step in the management of this patient?

Accepted Answer

Endoscopic examination for nasopharyngeal pathology

Answer

Myringotomy with grommet insertion

Answer

Valsalva maneuver

Answer

Antihistamines

Question 6

A 15-year-old male presents with hemorrhage 5 hours after tonsillectomy. What is the best treatment for this patient?

Accepted Answer

Re-explore immediately

Answer

External gauze packing

Answer

Antibiotics and mouth wash

Answer

Irrigation with cold saline

Question 7

All of the following are features of Paterson-Brown-Kelly syndrome, except?

Accepted Answer

Megaloblastic anemia

Answer

Esophageal mucosal webs

Answer

Glossitis

Answer

Cheilosis

Question 8

Retropharyngeal space infection is mainly due to spread of which of the following?

Accepted Answer

Odontogenic infections

Answer

Cervical tuberculosis

Answer

Meningoencephalitis

Answer

Mumps

Question 9

Thornwaldt's cyst is seen in:

Accepted Answer

Nasopharynx

Answer

Larynx

Answer

Base of tongue

Answer

Floor of mouth

Question 10

Which condition is characterized by a lump in the throat that does not interfere with swallowing?

Accepted Answer

Globus hystericus

Answer

Cervical spondylosis

Answer

Pharyngeal diverticula

Answer

Carcinoma esophagus

Diseases of the Pharynx — MCQs

Diseases of the Pharynx — MCQs

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