Diseases of the Pharynx Practice Questions

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.

Q: 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?

Biopsy. **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).

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

Transection of vagus nerve. **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).

Q: 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?

Subtotal laryngectomy. **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.

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

Common in elderly males. **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).

Question 1

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 2

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 3

Thornwaldt's cyst is seen in:

Accepted Answer

Nasopharynx

Answer

Larynx

Answer

Base of tongue

Answer

Floor of mouth

Question 4

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

Question 5

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?

Accepted Answer

Biopsy

Answer

MRI

Answer

Carotid angiography

Answer

CECT scan

Question 6

All of the following are indications or consequences of tonsillectomy except?

Accepted Answer

Transection of vagus nerve

Answer

Transection of Glossopharyngeal nerve

Answer

Eagle's syndrome

Answer

Treatment of sleep apnea

Question 7

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?

Accepted Answer

Subtotal laryngectomy

Answer

LASER excision

Answer

Stripping of the vocal cord

Answer

Radiotherapy

Question 8

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

Accepted Answer

Endoscopy

Answer

Barium meal

Answer

Pharyngoscopy

Answer

X-rays

Question 9

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

Accepted Answer

Glossopharyngeal nerve

Answer

Vagus nerve

Answer

Auriculotemporal nerve

Answer

Greater auricular nerve

Question 10

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

Accepted Answer

Common in elderly males

Answer

Esophageal web

Answer

Predisposes to malignancy

Answer

Koilonychia

Diseases of the Pharynx — MCQs

Diseases of the Pharynx — MCQs

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