Diseases of the Pharynx — MCQs

Diseases of the Pharynx Indian Medical PG Practice Questions and MCQs

Question 61: All of the following are features of Paterson-Brown-Kelly syndrome, except?

A. Esophageal mucosal webs
B. Megaloblastic anemia (Correct Answer)
C. Glossitis
D. Cheilosis

Explanation: **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.

Question 62: Retropharyngeal space infection is mainly due to spread of which of the following?

A. Cervical tuberculosis
B. Meningoencephalitis
C. Mumps
D. Odontogenic infections (Correct Answer)

Explanation: **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.

Question 63: Thornwaldt's cyst is seen in:

A. Larynx
B. Nasopharynx (Correct Answer)
C. Base of tongue
D. Floor of mouth

Explanation: **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.

Question 64: Which condition is characterized by a lump in the throat that does not interfere with swallowing?

A. Globus hystericus (Correct Answer)
B. Cervical spondylosis
C. Pharyngeal diverticula
D. Carcinoma esophagus

Explanation: **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 65: A 10-year-old boy presents with nasal obstruction and intermittent profuse epistaxis. He has a firm pinkish mass in the nasopharynx. Which of the following investigations is NOT indicated in this case?

A. MRI
B. Carotid angiography
C. CECT scan
D. Biopsy (Correct Answer)

Explanation: **Explanation:** The clinical presentation of a young male (10 years old) with nasal obstruction, profuse epistaxis, and a firm pinkish mass in the nasopharynx is classic for **Juvenile Nasopharyngeal Angiofibroma (JNA)**. **Why Biopsy is NOT indicated (Correct Option):** JNA is a highly vascular, non-encapsulated tumor. Performing a biopsy is **strictly contraindicated** because it can trigger torrential, life-threatening hemorrhage that is difficult to control in an outpatient or office setting. Diagnosis is primarily clinical and radiological. **Why other options are indicated:** * **CECT Scan (Option C):** This is the initial investigation of choice. It shows the extent of the tumor and the characteristic **Holman-Miller sign** (anterior bowing of the posterior wall of the maxillary sinus). * **MRI (Option A):** Superior for evaluating soft tissue extension, especially into the orbit, cavernous sinus, or intracranial fossa. * **Carotid Angiography (Option B):** Essential for mapping the blood supply (most commonly the **Internal Maxillary Artery**) and is typically performed 24–48 hours before surgery for **pre-operative embolization** to reduce intraoperative blood loss. **Clinical Pearls for NEET-PG:** * **Demographics:** Occurs almost exclusively in adolescent males (testosterone-dependent). * **Site of Origin:** Sphenopalatine foramen. * **Pathology:** Composed of thin-walled blood vessels lacking a muscular coat (hence the profuse bleeding). * **Treatment of Choice:** Surgical excision (Endoscopic or Open approaches like Weber-Fergusson).

Question 66: All of the following are indications or consequences of tonsillectomy except?

A. Transection of Glossopharyngeal nerve
B. Eagle's syndrome
C. Treatment of sleep apnea
D. Transection of vagus nerve (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Transection of vagus nerve**. **1. Why the Vagus Nerve is Incorrect:** The vagus nerve (CN X) lies within the carotid sheath, which is situated deep to the superior constrictor muscle in the parapharyngeal space. During a routine tonsillectomy, the dissection occurs in the peritonsillar space (between the tonsillar capsule and the superior constrictor). Because the muscle acts as a protective barrier, the vagus nerve is not at risk of transection during the procedure. **2. Analysis of Other Options:** * **Transection of Glossopharyngeal nerve (A):** The glossopharyngeal nerve (CN IX) lies in the tonsillar bed, just lateral to the superior constrictor muscle. It is the most commonly injured nerve during tonsillectomy (via deep sutures or excessive cautery), leading to loss of taste and sensation in the posterior 1/3rd of the tongue. * **Eagle’s Syndrome (B):** This condition involves an elongated styloid process or calcified stylohyoid ligament causing throat pain. Tonsillectomy is a recognized surgical treatment to access and transsect the styloid process (trans-oral approach). * **Treatment of Sleep Apnea (C):** Adenotonsillar hypertrophy is the most common cause of Obstructive Sleep Apnea (OSA) in children. Tonsillectomy (often with adenoidectomy) is the first-line surgical indication for pediatric OSA. **High-Yield Clinical Pearls for NEET-PG:** * **Most common nerve injured:** Glossopharyngeal nerve (CN IX). * **Most common vessel injured:** External palatine vein (Paratonsillar vein). * **Most common artery involved in primary hemorrhage:** Facial artery (specifically the tonsillar branch). * **Lethal Hemorrhage:** Injury to the Internal Carotid Artery (rare, occurs if the artery is tortuous/aberrant). * **Referred Earache:** Post-tonsillectomy pain is referred to the ear via the glossopharyngeal nerve (Jacobson’s nerve).

Question 67: A chronic smoker with a history of hoarseness of voice is found to have fixation of the vocal cords on examination. What is the most likely treatment required?

A. LASER excision
B. Subtotal laryngectomy (Correct Answer)
C. Stripping of the vocal cord
D. Radiotherapy

Explanation: **Explanation:** The clinical presentation of a chronic smoker with hoarseness and **fixation of the vocal cords** strongly suggests a diagnosis of **Stage T3 Laryngeal Carcinoma**. In laryngeal cancer, vocal cord fixation occurs due to the invasion of the thyroarytenoid muscle, involvement of the cricoarytenoid joint, or extension into the paraglottic space. **Why Subtotal Laryngectomy is correct:** For T3 lesions (where the cord is fixed), the standard of care involves aggressive management. **Subtotal laryngectomy** (or near-total laryngectomy) is indicated to ensure adequate oncological margins while attempting to preserve some laryngeal function (phonation/deglutition) without a permanent tracheostomy in selected cases. In many clinical scenarios of T3/T4 disease, Total Laryngectomy or Chemoradiotherapy are also considered, but among the given choices, subtotal laryngectomy is the most appropriate surgical intervention for a fixed cord. **Why other options are incorrect:** * **LASER excision & Stripping of the vocal cord:** These are reserved for T1 (early) lesions or benign conditions like Reinke’s edema/vocal nodules. They are insufficient for invasive T3 tumors with cord fixation. * **Radiotherapy:** While used for T1/T2 lesions with excellent results, radiotherapy alone has lower control rates for T3 lesions with cord fixation compared to surgical intervention or concurrent chemoradiotherapy. **Clinical Pearls for NEET-PG:** * **T1:** Mobile cord, limited to one/both sub-sites. * **T2:** Supraglottic/Subglottic extension with **impaired** mobility (but not fixed). * **T3:** Tumor limited to the larynx with **vocal cord fixation**. * **T4:** Invasion through thyroid cartilage or into extrinsic tissues (trachea, tongue, neck). * **High-Yield:** The most common site of laryngeal cancer is the **Glottis**, but the **Supraglottis** has a higher rate of lymphatic metastasis.

Question 68: Which investigation is the investigation of choice in a case of stricture esophagus caused by corrosive poisoning?

A. Endoscopy (Correct Answer)
B. Barium meal
C. Pharyngoscopy
D. X-rays

Explanation: **Explanation:** The investigation of choice for evaluating a stricture of the esophagus following corrosive ingestion is **Endoscopy (Flexible Esophagoscopy)**. 1. **Why Endoscopy is Correct:** It is the most definitive diagnostic tool because it allows for **direct visualization** of the esophageal mucosa. It helps determine the exact site, length, and degree of the stricture. More importantly, endoscopy is both diagnostic and therapeutic; it is essential for performing **dilatation** (using Savary-Gilliard or balloon dilators), which is the primary treatment for corrosive strictures. 2. **Why other options are incorrect:** * **Barium Meal:** While a Barium Swallow (not meal) is excellent for mapping the "roadmap" of a stricture (showing its length and contour), it cannot assess the health of the mucosa or allow for therapeutic intervention. It is often a complementary study, not the primary choice. * **Pharyngoscopy:** This only visualizes the pharynx and the upper esophageal sphincter. It is insufficient for evaluating the entire length of the esophagus where corrosive strictures typically occur. * **X-rays:** Plain X-rays are useful only to rule out acute complications like perforation (pneumomediastinum) or to detect radio-opaque foreign bodies; they cannot diagnose or grade a stricture. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** In the acute phase of corrosive ingestion, endoscopy should ideally be done within **24–48 hours** to assess the grade of injury. It is contraindicated after 48 hours to 2 weeks due to the high risk of perforation (the "softening" phase). * **Most Common Site:** The sites of physiological narrowing (e.g., cricopharynx, mid-esophagus) are most prone to stricture formation. * **Cancer Risk:** Corrosive strictures significantly increase the long-term risk of **Squamous Cell Carcinoma** of the esophagus (latent period of 20–40 years). * **Management:** The first-line treatment for established strictures is **repeated dilatation**. If dilatation fails, colonic transposition or gastric pull-up is required.

Question 69: Referred pain from tonsils to the middle ear is along which nerve?

A. Vagus nerve
B. Glossopharyngeal nerve (Correct Answer)
C. Auriculotemporal nerve
D. Greater auricular nerve

Explanation: The correct answer is **Glossopharyngeal nerve (CN IX)**. ### **Explanation** The phenomenon of referred pain occurs when sensory fibers from two different anatomical sites converge on the same nucleus in the brainstem. 1. **The Mechanism (Jacobson’s Nerve):** The tonsils are primarily supplied by the **tonsillar branch of the Glossopharyngeal nerve (CN IX)**. This same nerve gives off a branch called the **Tympanic nerve (Jacobson’s nerve)**, which provides sensory innervation to the middle ear. Because both the tonsils and the middle ear share the same parent nerve (CN IX), the brain misinterprets pain signals from an inflamed tonsil (e.g., acute tonsillitis or post-tonsillectomy) as originating from the ear. ### **Analysis of Incorrect Options** * **Vagus nerve (CN X):** Supplies the laryngopharynx and larynx. It causes referred ear pain from the pyriform fossa or larynx via its **Arnold’s nerve** (auricular branch), which supplies the external auditory canal. * **Auriculotemporal nerve (Branch of V3):** This nerve supplies the TMJ and the external ear. It is responsible for referred ear pain during dental procedures or TMJ disorders. * **Greater auricular nerve (C2, C3):** Supplies the skin over the parotid gland and the lower part of the pinna. It is involved in referred pain from cervical spine pathology. ### **High-Yield Clinical Pearls for NEET-PG** * **Post-Tonsillectomy Pain:** Referred otalgia is a classic post-operative symptom due to CN IX irritation. * **Eagle’s Syndrome:** Elongated styloid process compressing the Glossopharyngeal nerve, causing throat pain and referred ear pain. * **Trotter’s Triad (Nasopharyngeal Ca):** Includes conductive deafness, palatal palsy, and neuralgia of CN V3 (not CN IX), leading to ear pain. * **Summary of Referred Otalgia:** * **Middle Ear (CN IX):** Tonsils, base of tongue. * **External Ear (CN X):** Larynx, Hypopharynx. * **External Ear (CN V3):** Teeth, TMJ, anterior 2/3 of tongue.

Question 70: Which of the following is NOT a feature of Plummer-Vinson syndrome?

A. Esophageal web
B. Predisposes to malignancy
C. Koilonychia
D. Common in elderly males (Correct Answer)

Explanation: **Explanation:** Plummer-Vinson Syndrome (also known as **Paterson-Brown-Kelly Syndrome**) is characterized by a classic triad of **Iron Deficiency Anemia (IDA)**, **Dysphagia**, and **Cervical Esophageal Webs**. **Why Option D is the correct answer:** Plummer-Vinson Syndrome is characteristically seen in **middle-aged females** (typically between 30–50 years of age), not elderly males. The higher prevalence in females is attributed to blood loss during menstruation and nutritional deficiencies. **Analysis of Incorrect Options:** * **Option A (Esophageal web):** This is a hallmark feature. These are thin, mucosal folds usually found in the post-cricoid region (upper esophagus), causing dysphagia to solids. * **Option B (Predisposes to malignancy):** It is considered a **premalignant condition**. It significantly increases the risk of developing **Squamous Cell Carcinoma** of the post-cricoid region and upper esophagus. * **Option C (Koilonychia):** Since the syndrome is rooted in chronic iron deficiency, patients often present with systemic signs of IDA, such as **koilonychia** (spoon-shaped nails), glossitis (smooth red tongue), and angular cheilitis. **High-Yield Clinical Pearls for NEET-PG:** * **Investigation of Choice:** Barium Swallow (shows the web as a filling defect, best seen in the lateral view). * **Treatment:** Iron supplementation (often resolves the dysphagia) and endoscopic dilatation for persistent webs. * **Association:** It is frequently associated with an increased risk of **Post-cricoid carcinoma**. * **Mnemonic:** **P**lummer-Vinson = **P**remalignant, **P**ost-cricoid web, **P**allor (Anemia).

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

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free