Diseases of the Pharynx — MCQs

A 70-year-old smoker presents with a 3-month history of dysphagia and weight loss. Flexible nasoendoscopy shows pooling of saliva in the pyriform fossae, with restricted mobility of the right hemi-larynx. Malignancy is suspected. At surgery, you find a 3 cm tumour affecting the right pyriform fossa and extending into the post-cricoid region. According to the TNM staging, what T-stage is this malignancy?

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A child presented with high fever, severe sore throat, and painful swallowing. Her voice was abnormal. Quinsy was diagnosed. What is referred to as Quinsy?

Diseases of the Pharynx Indian Medical PG Practice Questions and MCQs

Question 81: Which nerve is liable to get injured during the removal of a fish bone from the pyriform fossa?

A. Superior laryngeal nerve
B. Internal laryngeal nerve (Correct Answer)
C. External laryngeal nerve
D. Recurrent laryngeal nerve

Explanation: **Explanation:** The **internal laryngeal nerve** is the correct answer due to its specific anatomical location relative to the pyriform fossa. **1. Why the Internal Laryngeal Nerve is correct:** The pyriform fossa is a mucosal-lined depression located on either side of the laryngeal inlet. The **internal laryngeal nerve** (a branch of the Superior Laryngeal Nerve) runs submucosally beneath the mucous membrane of the **floor of the pyriform fossa**. It pierces the thyrohyoid membrane to provide sensory innervation to the larynx above the vocal cords. Because it lies just beneath the thin mucosa, it is highly vulnerable to injury during the removal of impacted foreign bodies (like fish bones) or during the accidental penetration of the fossa by instruments. **2. Why other options are incorrect:** * **Superior Laryngeal Nerve (SLN):** This is the parent trunk. While it is related, it divides into internal and external branches before reaching the fossa. The internal branch is the specific structure at risk within the fossa itself. * **External Laryngeal Nerve:** This nerve remains outside the larynx to supply the cricothyroid muscle. It does not enter the pyriform fossa. * **Recurrent Laryngeal Nerve (RLN):** This nerve ascends in the tracheoesophageal groove and enters the larynx near the cricothyroid joint. It is not located in the floor of the pyriform fossa. **Clinical Pearls for NEET-PG:** * **Sensory Innervation:** The internal laryngeal nerve mediates the **cough reflex**. Injury leads to anesthesia of the supraglottic larynx, increasing the risk of aspiration. * **Foreign Bodies:** The pyriform fossa is the most common site for impacted fish bones in the throat. * **Nerve Block:** The internal laryngeal nerve can be intentionally blocked via the pyriform fossa using topical anesthesia for awake intubation.

Question 82: Killian's dehiscence is found in which anatomical region?

A. Oropharynx
B. Nasopharynx
C. Laryngopharynx (Correct Answer)
D. Lateral nasal wall

Explanation: **Explanation:** **Killian’s dehiscence** is a potential weak area located in the posterior wall of the **laryngopharynx** (specifically the hypopharynx). It is a triangular gap situated between two parts of the inferior constrictor muscle: the upper oblique fibers (**thyropharyngeus**) and the lower horizontal fibers (**cricopharyngeus**). 1. **Why Laryngopharynx is Correct:** The inferior constrictor muscle is the lowermost muscle of the pharynx, forming the wall of the laryngopharynx. Killian’s dehiscence is clinically significant because it is the site of mucosal herniation in **Zenker’s diverticulum** (Pulsion diverticulum) due to high intrapharyngeal pressure during swallowing. 2. **Why other options are incorrect:** * **Oropharynx:** Located above the laryngopharynx; its muscles (middle constrictor) are well-supported and do not contain this specific dehiscence. * **Nasopharynx:** The uppermost part of the pharynx; the primary clinical concern here is the Fossa of Rosenmüller (site for nasopharyngeal carcinoma), not Killian's dehiscence. * **Lateral nasal wall:** This is an intranasal structure containing turbinates and meatuses, unrelated to the pharyngeal musculature. **High-Yield Clinical Pearls for NEET-PG:** * **Zenker’s Diverticulum:** Always occurs through Killian’s dehiscence. It is a "false" diverticulum (contains only mucosa and submucosa). * **Killian-Jamieson Area:** A separate weak area located *below* the cricopharyngeus, on the anterolateral aspect of the esophagus. * **Perforation Risk:** Killian’s dehiscence is the most common site for accidental pharyngeal perforation during rigid esophagoscopy.

Question 83: What is the primary treatment for adenoid hypertrophy?

A. Nasal decongestants (Correct Answer)
B. Antibiotics
C. Beta-blockers
D. None of the above

Explanation: ### Explanation **Primary Treatment Approach:** The management of adenoid hypertrophy follows a step-ladder approach. The **primary (initial) treatment** is conservative medical management. Since the main symptom is nasal obstruction caused by inflammatory edema and lymphoid hyperplasia, **nasal decongestants** (often combined with nasal steroid sprays like Mometasone or Fluticasone) are used to reduce mucosal swelling and improve the airway. This provides symptomatic relief and may prevent the need for surgery in mild to moderate cases. **Analysis of Options:** * **A. Nasal decongestants (Correct):** They act as the first line of management to shrink the nasal mucosa and improve drainage, addressing the immediate obstructive symptoms. * **B. Antibiotics:** While used if there is evidence of secondary bacterial infection (adenoiditis), they are not the primary treatment for simple hypertrophy unless an active infection is present. * **C. Beta-blockers:** These have no role in the management of lymphoid tissue or upper airway obstruction. * **D. None of the above:** Incorrect, as medical management is the standard initial protocol. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Diagnostic nasal endoscopy (DNE) is the most accurate; however, X-ray soft tissue nasopharynx (lateral view) is the classic screening tool showing a soft tissue mass narrowing the nasopharyngeal airway. * **Adenoid Facies:** Characterized by an open mouth, elongated face, high-arched palate, and crowded teeth due to chronic mouth breathing. * **Definitive Treatment:** If medical management fails or if there are complications like Obstructive Sleep Apnea (OSA) or recurrent Otitis Media with Effusion (OME), **Adenoidectomy** is the treatment of choice. * **Associated Condition:** Adenoid hypertrophy is the most common cause of **Otitis Media with Effusion (Glue Ear)** in children due to Eustachian tube blockage.

Question 84: What is the most common site of origin for nasopharyngeal carcinoma?

A. Roof
B. Posterior wall
C. Lateral wall (Correct Answer)
D. Anterior wall

Explanation: **Explanation:** **Nasopharyngeal Carcinoma (NPC)** is a unique malignancy with a strong association with the **Epstein-Barr Virus (EBV)**. **Why the Lateral Wall is Correct:** The most common site of origin for NPC is the **lateral wall** of the nasopharynx, specifically within a mucosal depression known as the **Fossa of Rosenmüller**. This fossa is located posterior to the medial end of the Eustachian tube orifice. Because of this proximity, early-stage tumors often obstruct the Eustachian tube, leading to unilateral serous otitis media—a classic clinical presentation. **Analysis of Incorrect Options:** * **Roof and Posterior Wall:** While the tumor can involve the roof (junction of the basisphenoid and basiocciput) and the posterior wall as it grows, these are secondary sites of extension rather than the primary site of origin. * **Anterior Wall:** The anterior wall of the nasopharynx is essentially the posterior choanae (opening into the nasal cavity). Primary malignancy rarely originates here; instead, tumors from the lateral wall may invade anteriorly into the nasal cavity. **High-Yield Clinical Pearls for NEET-PG:** * **Histology:** The most common type (WHO Type 3) is **Undifferentiated Carcinoma** (lymphoepithelioma), which is highly radiosensitive. * **Trotter’s Triad:** A classic diagnostic triad for NPC consisting of: 1. Conductive deafness (Eustachian tube blockage). 2. Ipsilateral temporofacial neuralgia (Trigeminal nerve involvement). 3. Palatal paralysis (Vagus nerve involvement). * **Presentation:** The most common presenting symptom is often a **painless upper deep cervical lymph node mass** (Level II/III). * **Treatment:** Radiotherapy is the primary treatment of choice for the local site and the neck.

Question 85: What is the most common cause of parapharyngeal abscess?

A. Removal of tonsil (Correct Answer)
B. Hematogenous spread
C. Penetrating trauma
D. Blunt trauma

Explanation: **Explanation:** The **parapharyngeal space** (lateral pharyngeal space) is a potential space shaped like an inverted pyramid [2]. Infections in this space are serious due to its proximity to the carotid sheath and the retropharyngeal space. **1. Why "Removal of tonsil" is the correct answer:** The most common cause of a parapharyngeal abscess is the spread of infection from surrounding structures, particularly the **palatine tonsils** [2]. Specifically, **post-tonsillectomy infection** or the use of local anesthesia during a tonsillectomy (which can seed bacteria into the space) are the leading clinical triggers [2]. Other frequent causes include odontogenic infections (second most common) and peritonsillar abscess (Quinsy) [1], [2]. **2. Analysis of Incorrect Options:** * **B. Hematogenous spread:** While systemic infections can theoretically seed any space, this is an extremely rare route for a localized parapharyngeal abscess compared to direct contiguous spread. * **C. Penetrating trauma:** Trauma to the lateral pharyngeal wall (e.g., falling with a pencil in the mouth) can cause an abscess, but it is statistically less common than post-surgical or odontogenic causes [2]. * **D. Blunt trauma:** Blunt trauma rarely leads to abscess formation unless it results in a secondary hematoma that becomes infected, making it an infrequent etiology. **Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Characterized by "Trismus" (due to irritation of the medial pterygoid muscle), fever, and a diffuse bulge in the lateral pharyngeal wall (displacing the tonsil medially) [2]. * **Key Sign:** Unlike retropharyngeal abscesses, parapharyngeal abscesses typically present with swelling **behind the angle of the mandible**. * **Complications:** The most dreaded complication is **internal jugular vein thrombosis** (Lemierre’s syndrome) or erosion of the **internal carotid artery**. * **Imaging:** Contrast-enhanced CT (CECT) is the gold standard for diagnosis.

Question 86: The most common site for lodging of a foreign body in the esophagus is:

A. Upper esophagus (Correct Answer)
B. Trachea bifurcation
C. Aortic arch area
D. Lower esophagus

Explanation: The esophagus has four physiological constrictions where foreign bodies (FBs) are most likely to get trapped. **1. Why the Upper Esophagus is Correct:** The most common site for foreign body lodging (approx. 70-75% of cases) is the **Cricopharyngeal sphincter** (the upper esophageal sphincter). This is the narrowest part of the entire esophagus, located at the level of the **C6 vertebra**. In children, coins are the most common FB found here, while in adults, it is often boluses of meat or fish bones. **2. Analysis of Incorrect Options:** * **B. Trachea bifurcation:** This corresponds to the second constriction (level of T4) where the left main bronchus crosses the esophagus. While a site of narrowing, it is wider than the cricopharyngeus. * **C. Aortic arch area:** This is the third constriction (level of T4). Like the tracheal bifurcation, it is a potential site for impaction but statistically less common than the upper sphincter. * **D. Lower esophagus:** This refers to the fourth constriction where the esophagus pierces the diaphragm (level of T10). While FBs can lodge here, it is more common in patients with underlying pathology like achalasia or peptic strictures. **Clinical Pearls for NEET-PG:** * **Most common FB in children:** Coins. * **Most common FB in adults:** Meat bolus/bones. * **Radiology:** On X-ray (Lateral view), a foreign body in the **esophagus** lies posterior to the trachea. On AP view, a coin in the esophagus appears as a **circular disc**, whereas in the trachea, it appears as a **vertical line** (due to the trachealis muscle). * **Management:** Rigid esophagoscopy is the gold standard for removal.

Question 87: What is the commonest lymph node to enlarge in acute tonsillitis?

A. Jugulo-omohyoid
B. Jugulo-digastric (Correct Answer)
C. Posterior cervical
D. Submandibular

Explanation: ### Explanation **Correct Option: B. Jugulo-digastric** The palatine tonsils are primarily drained by the deep cervical lymph nodes. The **Jugulo-digastric lymph node** (also known as the **"Tonsillar node"**) is a member of the upper deep cervical group, located just below the angle of the mandible, where the posterior belly of the digastric muscle crosses the internal jugular vein. Because it receives the direct lymphatic drainage from the tonsils, it is the first and most common node to become enlarged and tender during acute tonsillitis. **Analysis of Incorrect Options:** * **A. Jugulo-omohyoid:** This node is located where the omohyoid muscle crosses the internal jugular vein. It primarily drains the **tongue** (specifically the lateral margins and tip), not the tonsils. * **C. Posterior cervical:** These nodes are located along the spinal accessory nerve. They are typically enlarged in conditions like **Rubella** (Post-auricular/Occipital) or **Infectious Mononucleosis**, rather than isolated acute bacterial tonsillitis. * **D. Submandibular:** These nodes drain the submandibular salivary glands, floor of the mouth, gums, and anterior part of the tongue. While they may enlarge in oral cavity infections, they are not the primary drainage site for the tonsils. **Clinical Pearls for NEET-PG:** * **Phorbe’s Node:** Another name for the Jugulo-digastric node. * **Waldeyer’s Ring:** The palatine tonsils are part of this lymphoid ring, which also includes the adenoids (nasopharyngeal tonsil), lingual tonsils, and tubal tonsils. * **Blood Supply:** The main artery of the tonsil is the **Tonsillar branch of the Facial Artery**. * **Pain Referral:** Pain from acute tonsillitis is often referred to the ear via the **Glossopharyngeal nerve (CN IX)**.

Question 88: What is the distance from the central incisor to the cricopharyngeal sphincter?

A. 15 cm (Correct Answer)
B. 25 cm
C. 40 cm
D. 50 cm

Explanation: **Explanation:** The distance from the **central incisors** is a standard clinical measurement used in endoscopy (esophagoscopy) to locate anatomical landmarks and constrictions of the esophagus. **1. Why 15 cm is correct:** The **cricopharyngeal sphincter** (upper esophageal sphincter) is the first and narrowest constriction of the esophagus. It is located at the level of the **C6 vertebra**, which corresponds to a distance of approximately **15 cm** from the upper central incisor teeth in an average adult. This is a critical landmark for endoscopists, as it represents the most common site for accidental perforation during instrumentation. **2. Analysis of Incorrect Options:** * **25 cm (Option B):** This represents the distance from the incisors to the **mid-esophagus**, specifically where the left main bronchus and the arch of the aorta cross the esophagus (the second constriction). * **40 cm (Option C):** This is the distance from the incisors to the **gastroesophageal junction** (lower esophageal sphincter), where the esophagus pierces the diaphragm at the level of T10. * **50 cm (Option D):** This distance extends beyond the stomach and is not a standard anatomical landmark for esophageal constrictions. **High-Yield Clinical Pearls for NEET-PG:** * **Total Length of Esophagus:** 25 cm. * **Four Constrictions (Distance from Incisors):** 1. **Cricopharyngeal Sphincter:** 15 cm (Narrowest part). 2. **Aortic Arch:** 22 cm. 3. **Left Main Bronchus:** 27 cm. 4. **Diaphragmatic Hiatus:** 40 cm. * **Killian’s Dehiscence:** A potential weak spot between the thyropharyngeus and cricopharyngeus muscles, often the site for **Zenker’s Diverticulum** formation. * **Foreign Bodies:** Most commonly lodge at the level of the cricopharyngeus (15 cm mark).

Question 89: A 70-year-old smoker presents with a 3-month history of dysphagia and weight loss. Flexible nasoendoscopy shows pooling of saliva in the pyriform fossae, with restricted mobility of the right hemi-larynx. Malignancy is suspected. At surgery, you find a 3 cm tumour affecting the right pyriform fossa and extending into the post-cricoid region. According to the TNM staging, what T-stage is this malignancy?

A. T1
B. T2 (Correct Answer)
C. T4a
D. T3

Explanation: ### Explanation The patient presents with a classic picture of **Hypopharyngeal Carcinoma**. The TNM staging for the hypopharynx (which includes the pyriform sinus, post-cricoid region, and posterior pharyngeal wall) is based on the size of the tumor and the number of subsites involved. **Why T2 is correct:** According to the AJCC (8th Edition) staging for Hypopharyngeal Cancer: * **T1:** Tumor limited to one subsite and/or ≤ 2 cm in greatest dimension. * **T2:** Tumor invades **more than one subsite** (e.g., pyriform fossa AND post-cricoid region) or an adjacent site, OR measures **> 2 cm but ≤ 4 cm** in greatest dimension, without fixation of the hemilarynx. * In this case, the tumor is **3 cm** (fits the >2 to ≤4 cm criteria) and involves **two subsites** (pyriform fossa and post-cricoid), making it a T2 lesion. **Analysis of Incorrect Options:** * **T1:** Incorrect because the tumor is > 2 cm and involves more than one subsite. * **T3:** Incorrect because T3 requires the tumor to be > 4 cm OR involve **fixation of the hemilarynx**. The question states "restricted mobility," which implies paresis/sluggishness, not complete fixation (vocal cord paralysis). * **T4a:** Incorrect as this stage requires invasion of thyroid/cricoid cartilage, hyoid bone, thyroid gland, or central compartment soft tissue. **Clinical Pearls for NEET-PG:** 1. **Chevalier Jackson’s Sign:** Pooling of saliva in the pyriform fossa (as seen here) is a classic sign of hypopharyngeal malignancy or an esophageal foreign body. 2. **Most common site:** The **pyriform fossa** is the most common subsite for hypopharyngeal cancer (approx. 70%). 3. **Prognosis:** Hypopharyngeal cancers often present late (Stage III/IV) because the area is "clinically silent" and has a rich lymphatic network leading to early nodal metastasis. 4. **Mobility vs. Fixation:** Always distinguish between "impaired/restricted mobility" (T2) and "fixation" (T3) in laryngeal and hypopharyngeal staging.

Question 90: A child presented with high fever, severe sore throat, and painful swallowing. Her voice was abnormal. Quinsy was diagnosed. What is referred to as Quinsy?

A. Peritonsillar abscess (Correct Answer)
B. Retropharyngeal abscess
C. Parapharyngeal abscess
D. Any of the above

Explanation: **Explanation:** **Quinsy** is the clinical term for a **Peritonsillar Abscess (PTA)**. It is a collection of pus in the potential space between the tonsillar capsule and the superior constrictor muscle. It typically occurs as a complication of acute follicular tonsillitis. **Why Option A is correct:** The clinical presentation described—high fever, severe odynophagia (painful swallowing), and an abnormal voice—is classic for Quinsy. The "abnormal voice" is specifically known as a **"Hot Potato Voice"** (muffled speech) due to edema and restricted movement of the soft palate. Other hallmark signs include **trismus** (difficulty opening the mouth due to irritation of the medial pterygoid muscle) and uvular deviation to the opposite side. **Why other options are incorrect:** * **Retropharyngeal Abscess:** This occurs in the space behind the pharynx (Prevertebral space). It is more common in infants and presents with neck stiffness and inspiratory stridor rather than trismus. * **Parapharyngeal Abscess:** This involves the lateral pharyngeal space. While it also causes trismus and fever, the swelling is typically located behind the posterior pillar and at the angle of the mandible, rather than the peritonsillar region. **NEET-PG High-Yield Pearls:** * **Most common organism:** *Streptococcus pyogenes* (Group A Strep). * **Site of infection:** Usually starts in the **Crypta Magna**. * **Management:** The gold standard is **Incision and Drainage (I&D)** at the point of maximum bulge (usually lateral to the junction of the anterior pillar and a horizontal line through the base of the uvula). * **Interval Tonsillectomy:** Performed 4–6 weeks after the abscess resolves to prevent recurrence.

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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