Pharyngitis — MCQs
A patient presents with fever and dysphagia. An image shows a tonsil that is pushed medially. What is the most likely diagnosis?
A 2 year child presented with low grade fever and stridor. What is the likely diagnosis?
What is the drug that can be used for rheumatic fever prophylaxis in a patient with a history of allergy to Penicillin?
Drug of choice for rheumatic fever prophylaxis in a penicillin-allergic patient is?
Which of the following is NOT typically associated with acute bacterial sinusitis?
All of the following are true regarding Zenker's diverticulum EXCEPT?
Lingual tonsils arise from which of the following processes?
Tonsiloliths are best treated with:
Which of the following structures does not form the hypopharynx?
The Irvin Moore sign is positive in which of the following conditions?
Pharyngitis Indian Medical PG Practice Questions and MCQs
Question 1: A patient presents with fever and dysphagia. An image shows a tonsil that is pushed medially. What is the most likely diagnosis?
- A. Parapharyngeal abscess
- B. Retropharyngeal abscess
- C. Peritonsillar abscess (Correct Answer)
- D. Ludwig's angina
Explanation: ***Peritonsillar abscess*** - The image clearly shows **unilateral bulging** of the soft palate and displacement of the tonsil medially, consistent with a peritonsillar abscess. - Patients typically present with **fever**, **dysphagia**, severe sore throat, and a "hot potato" voice. *Parapharyngeal abscess* - A parapharyngeal abscess involves the **deep neck spaces** lateral to the pharynx, often presenting with neck swelling, trismus, and systemic symptoms. - While it can cause pharyngeal bulging, the classic **medial displacement of the tonsil** is more indicative of a peritonsillar abscess. *Retropharyngeal abscess* - This involves the space behind the posterior pharyngeal wall, usually presenting with **dysphagia**, **neck stiffness**, and fever. - Imaging would reveal a **prevertebral soft tissue swelling**, not primarily a medially displaced tonsil. *Ludwig's angina* - Ludwig's angina is a **rapidly spreading cellulitis** of the submandibular and sublingual spaces, typically arising from an odontogenic infection. - It presents with **woody induration** of the neck and floor of the mouth, elevation of the tongue, and potential airway compromise, but not primarily a medially displaced tonsil.
Question 2: A 2 year child presented with low grade fever and stridor. What is the likely diagnosis?
- A. Acute Laryngotracheobronchitis (Correct Answer)
- B. Acute Bacterial Tracheitis
- C. Acute Epiglottitis
- D. Foreign Body aspiration
Explanation: ***Acute Laryngotracheobronchitis*** - The combination of **low-grade fever** and **stridor** in a 2-year-old child strongly suggests **croup**, which is medically known as acute laryngotracheobronchitis. - Croup is characterized by **inflammation** of the larynx, trachea, and bronchi, often presenting with a **barking cough** and inspiratory stridor. The X-ray image would show the characteristic **steeple sign**. *Acute Bacterial Tracheitis* - This is a more severe bacterial infection that can present with stridor but typically shows **higher fever**, **toxic appearance**, and rapid clinical deterioration. - Unlike croup, bacterial tracheitis patients appear **more ill** and may have **purulent secretions** requiring more aggressive management. *Acute Epiglottitis* - A serious condition characterized by **rapid onset of high fever**, **dysphagia**, drooling, and a **"tripod" position**, which are not indicated by the given symptoms. - The stridor in epiglottitis is typically quieter and may indicate more severe airway obstruction compared to the characteristic stridor of croup. *Foreign Body aspiration* - While foreign body aspiration can cause stridor, it is typically an **acute event** with a sudden onset of choking, coughing, and respiratory distress. - There is no mention of a choking episode or sudden onset, and a low-grade fever is less typical for an uncomplicated foreign body aspiration.
Question 3: What is the drug that can be used for rheumatic fever prophylaxis in a patient with a history of allergy to Penicillin?
- A. Erythromycin (Correct Answer)
- B. Amoxicillin
- C. Streptomycin
- D. Sulfasalazine
Explanation: ***Erythromycin*** - **Erythromycin** is a macrolide antibiotic that is a suitable alternative for **rheumatic fever prophylaxis** in patients with a documented allergy to penicillin. - It effectively covers *Streptococcus pyogenes*, the causative agent of group A streptococcal (GAS) pharyngitis that precedes rheumatic fever. *Amoxicillin* - **Amoxicillin** is a penicillin-class antibiotic and would be contraindicated in a patient with a **penicillin allergy**, as it carries a high risk of cross-reactivity and allergic reaction. - Using amoxicillin in this scenario could lead to severe hypersensitivity reactions, compromising patient safety. *Streptomycin* - **Streptomycin** is an aminoglycoside antibiotic primarily used for infections like **tuberculosis** and severe bacterial endocarditis. - It is not indicated for the treatment of *Streptococcus pyogenes* infections or for **rheumatic fever prophylaxis**. *Sulfasalazine* - **Sulfasalazine** is an anti-inflammatory and immunomodulatory drug primarily used in the management of **inflammatory bowel disease** and **rheumatoid arthritis**. - It has no antimicrobial activity against *Streptococcus pyogenes* and is therefore not used for **rheumatic fever prophylaxis**.
Question 4: Drug of choice for rheumatic fever prophylaxis in a penicillin-allergic patient is?
- A. Vancomycin
- B. Gentamycin
- C. Erythromycin (Correct Answer)
- D. Clindamycin
Explanation: ***Erythromycin*** - **Erythromycin** is the **recommended alternative** for **rheumatic fever prophylaxis** in patients with **penicillin allergy** according to **American Heart Association (AHA) guidelines**. - Typical regimen: **Erythromycin estolate 250 mg BID** or **erythromycin ethylsuccinate 400 mg BID**. - Effective against **Streptococcus pyogenes** (Group A Streptococcus), the causative organism of acute rheumatic fever. - While macrolide resistance exists in some regions, erythromycin remains the **guideline-recommended choice** when penicillin cannot be used. *Clindamycin* - **Clindamycin** is **not recommended** by major guidelines (AHA, WHO) for routine rheumatic fever prophylaxis. - Lacks adequate evidence and official guideline support for this specific indication. - May be considered in specific cases but is not the standard alternative. *Vancomycin* - **Vancomycin** is reserved for **multidrug-resistant infections** such as **MRSA**. - Not indicated for rheumatic fever prophylaxis due to high cost, need for IV administration, and potential for resistance development. - Reserved for life-threatening infections where other options have failed. *Gentamycin* - **Gentamycin** is an **aminoglycoside** used primarily for **severe gram-negative infections**. - Lacks adequate activity against **Streptococcus pyogenes**. - Not appropriate for rheumatic fever prophylaxis.
Question 5: Which of the following is NOT typically associated with acute bacterial sinusitis?
- A. Purulent nasal discharge
- B. Epistaxis (Correct Answer)
- C. Facial pain
- D. Fever
Explanation: ***Epistaxis*** - While possible due to **mucosal inflammation** or irritation from forceful blowing, **epistaxis (nosebleeds)** is not considered a typical or primary symptom of acute bacterial sinusitis. - The main symptoms revolve around pressure, discharge, and systemic signs of infection. *Purulent nasal discharge* - This is a hallmark symptom of acute bacterial sinusitis, indicating the presence of **bacterial infection** and inflammation in the sinuses. - The discharge is often thick, colored (yellow, green), and can be accompanied by a **foul odor**. *Facial pain* - **Facial pain** or pressure, especially around the cheeks, forehead, or eyes, is a characteristic symptom stemming from inflammation and fluid accumulation within the **sinus cavities**. - This pain often worsens when bending forward. *Fever* - **Fever** is a systemic sign of infection and is commonly present in acute bacterial sinusitis, especially in more severe cases. - It indicates the body's immune response to the bacterial invasion.
Question 6: All of the following are true regarding Zenker's diverticulum EXCEPT?
- A. It is a false diverticulum
- B. It occurs in children (Correct Answer)
- C. It is a posterior pharyngeal pulsion diverticulum
- D. The most common site for the diverticulum is Killian's dehiscence
Explanation: **Explanation:** Zenker’s diverticulum is a **pulsion diverticulum** caused by the herniation of the pharyngeal mucosa through a site of weakness in the muscular wall. 1. **Why Option B is the correct answer (False statement):** Zenker’s diverticulum is a disease of the **elderly**, typically occurring in the 7th or 8th decade of life. It is almost never seen in children because it is an acquired condition resulting from long-term incoordination of the cricopharyngeal muscle and increased intraluminal pressure. 2. **Why Option A is wrong (True statement):** It is a **false diverticulum** because it consists only of the mucosa and submucosa. A "true" diverticulum would involve all layers of the visceral wall, including the muscularis. 3. **Why Option C is wrong (True statement):** It is a **pulsion diverticulum** (pushed out by pressure) and it occurs **posteriorly** in the midline of the pharynx. 4. **Why Option D is wrong (True statement):** The anatomical site of herniation is **Killian’s dehiscence**, a triangular area of weakness between the thyropharyngeus and cricopharyngeus parts of the inferior constrictor muscle. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Regurgitation of undigested food, halitosis (foul breath due to stagnant food), dysphagia, and a gurgling sound in the neck (Boyce’s sign). * **Diagnosis:** The investigation of choice is a **Barium Swallow**, which shows a pouch behind the esophagus. * **Management:** Endoscopic Dohlman’s procedure (stapling the party wall) or open diverticulectomy with cricopharyngeal myotomy. * **Complication:** Aspiration pneumonia is the most common serious complication.
Question 7: Lingual tonsils arise from which of the following processes?
- A. Developmental anomalies (Correct Answer)
- B. Carcinomatous transformation
- C. Hyperplasia
- D. Repeated trauma in the area
Explanation: **Explanation:** The **lingual tonsils** are part of the **Waldeyer’s ring**, located on the posterior third of the tongue. While they are normal anatomical structures, their clinical presentation as symptomatic masses or significant enlargements is primarily attributed to **developmental anomalies** during embryogenesis. They arise from the endoderm of the second pharyngeal pouch. In the context of "ectopic" or "accessory" lymphoid tissue appearing in unusual locations or presenting as congenital masses, they are classified under developmental variations. **Analysis of Options:** * **A. Developmental anomalies (Correct):** The formation and distribution of lymphoid tissue in the base of the tongue are determined during fetal development. Variations in the size and extent of this tissue are developmental in nature. * **B. Carcinomatous transformation:** While Squamous Cell Carcinoma (SCC) can occur in the lingual tonsils, it is a malignant change, not the *origin* of the tissue itself. * **C. Hyperplasia:** Compensatory hyperplasia (e.g., after palatine tonsillectomy) can make lingual tonsils more prominent, but the *existence* of the tissue is developmental. * **D. Repeated trauma:** Chronic irritation may cause inflammation (tonsillitis), but it does not give rise to the tonsillar tissue. **High-Yield Clinical Pearls for NEET-PG:** * **Waldeyer’s Ring:** Comprises the Nasopharyngeal (adenoid), Tubal, Palatine, and Lingual tonsils. * **Lingual Tonsil Hypertrophy:** Can cause "Lump in the throat" sensation (Globus pharyngeus) and is a known cause of difficult intubation (obscuring the epiglottis). * **Symptom:** Large lingual tonsils can lead to **Obstructive Sleep Apnea (OSA)** in adults. * **Nerve Supply:** The posterior 1/3rd of the tongue (including lingual tonsils) is supplied by the **Glossopharyngeal nerve (CN IX)**.
Question 8: Tonsiloliths are best treated with:
- A. Antibiotics
- B. Hydrogen peroxide (Correct Answer)
- C. Steroids
- D. None of the above
Explanation: **Explanation:** **Tonsilloliths** (tonsil stones) are calcified aggregates of cellular debris, food particles, and mucus that lodge within the **tonsillar crypts**. They are frequently associated with chronic tonsillitis and halitosis (bad breath). **Why Hydrogen Peroxide is the correct answer:** The primary goal in managing tonsilloliths is mechanical removal and chemical debridement of the crypts. **Hydrogen peroxide (H₂O₂)**, typically used as a diluted gargle, acts as an oxidizing agent. Its effervescent action helps mechanically dislodge debris from deep within the crypts and provides an antiseptic environment that reduces the bacterial load (especially anaerobes) responsible for the foul odor. It is a standard conservative treatment to prevent the recurrence of these concretions. **Why other options are incorrect:** * **Antibiotics:** While tonsilloliths are associated with bacteria, they are structural concretions rather than an acute infection. Antibiotics do not remove the physical stone and are not indicated unless there is secondary acute tonsillitis. * **Steroids:** These are used to reduce inflammation (e.g., in infectious mononucleosis or severe acute tonsillitis). They have no role in dissolving or removing calcified debris. **High-Yield Clinical Pearls for NEET-PG:** * **Composition:** Tonsilloliths are primarily composed of calcium salts (hydroxyapatite), but can also contain magnesium and phosphorus. * **Clinical Presentation:** Often asymptomatic, but the most common complaint is **halitosis** or a foreign body sensation in the throat. * **Definitive Treatment:** For recurrent, symptomatic cases, the definitive treatment is **Tonsillectomy** or **Laser Cryptolysis** (using CO₂ laser to obliterate the crypts). * **Diagnosis:** Usually clinical; however, on CT scans, they appear as high-density radiopaque masses in the oropharyngeal region.
Question 9: Which of the following structures does not form the hypopharynx?
- A. Epiglottis (Correct Answer)
- B. Pyriform fossa
- C. Posterior pharyngeal wall
- D. Post cricoid region
Explanation: **Explanation:** The pharynx is divided into three parts: Nasopharynx, Oropharynx, and Hypopharynx (Laryngopharynx). The **Hypopharynx** extends from the level of the hyoid bone above to the lower border of the cricoid cartilage (C6 level) below. **1. Why Epiglottis is the Correct Answer:** The **Epiglottis** is a component of the **Larynx**, not the pharynx. Specifically, its lingual surface is associated with the oropharynx (vallecula), but the structure itself is the superior-most cartilage of the laryngeal framework. Therefore, it does not form a part of the hypopharyngeal walls. **2. Analysis of Incorrect Options (Subdivisions of Hypopharynx):** The hypopharynx is anatomically divided into three distinct regions: * **Pyriform Fossa (Sinus):** These are two deep recesses situated on either side of the laryngeal inlet. It is the most common site for malignancies in the hypopharynx. * **Post-cricoid Region:** This area lies behind the cricoid cartilage, extending from the level of the arytenoid cartilages to the lower border of the cricoid. It is a frequent site for carcinoma in females with Plummer-Vinson syndrome. * **Posterior Pharyngeal Wall:** This extends from the level of the hyoid bone to the level of the cricoarytenoid joint. **Clinical Pearls for NEET-PG:** * **Most common site of Hypopharyngeal Cancer:** Pyriform Fossa. * **Killian’s Dehiscence:** A weak area between the thyropharyngeus and cricopharyngeus muscles (parts of the inferior constrictor) located in the hypopharynx; it is the site for **Zenker’s Diverticulum**. * **Nerve Supply:** The internal laryngeal nerve (sensory) lies submucosally in the pyriform fossa, making it a site for local anesthesia blocks.
Question 10: The Irvin Moore sign is positive in which of the following conditions?
- A. Adenoid hypertrophy
- B. Acute tonsillitis
- C. Chronic tonsillitis (Correct Answer)
- D. Epiglottitis
Explanation: **Explanation:** The **Irvin Moore sign** is a classic clinical sign used to diagnose **Chronic Tonsillitis**. It refers to the presence of **persistent congestion or erythema of the anterior pillar** of the fauces. In chronic tonsillitis, the repeated bouts of infection lead to chronic inflammation and hypervascularity of the surrounding lymphoid tissue and mucosal folds, specifically the anterior pillar. **Why the correct answer is right:** * **Chronic Tonsillitis:** The Irvin Moore sign indicates chronic infection where the pillars remain dusky red even when the patient is asymptomatic. Other signs of chronic tonsillitis include the **squeeze test** (expression of cheesy material/pus from crypts upon applying pressure on the anterior pillar) and enlargement of the **jugulodigastric lymph nodes**. **Why the other options are wrong:** * **Adenoid hypertrophy:** This presents with nasal obstruction, mouth breathing, and "adenoid facies." Clinical signs are usually seen via posterior rhinoscopy or X-ray nasopharynx (lateral view), not on the tonsillar pillars. * **Acute tonsillitis:** While the pillars are red in acute stages, the Irvin Moore sign specifically refers to the *persistent* congestion seen in the chronic state. Acute cases present with fever, odynophagia, and follicular exudates. * **Epiglottitis:** This is a supraglottic emergency characterized by the "thumb sign" on X-ray and the "tripod position." It does not involve specific diagnostic signs on the anterior tonsillar pillars. **Clinical Pearls for NEET-PG:** * **Squeeze Test:** Positive in chronic follicular tonsillitis. * **Most common organism in Chronic Tonsillitis:** *Streptococcus pyogenes* (Beta-hemolytic Strep). * **Complication to watch:** Peritonsillar abscess (Quinsy), which presents with trismus and uvular deviation to the opposite side.
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