Diseases of the Pharynx

Diseases of the Pharynx Indian Medical PG Question 1: Modafinil is approved by FDA for treatment of all except:

• A. Narcolepsy
• B. Shift work sleep disorder (SWSD)
• C. Obstructive sleep apnea syndrome (OSAS)
• D. Lethargy in depression (Correct Answer)

Diseases of the Pharynx Explanation: ***Lethargy in depression*** - Modafinil is **not FDA-approved** for treating lethargy or fatigue specifically in the context of depression. Its primary indications are for disorders of excessive daytime sleepiness. - While it may be used off-label in some cases for depression-related fatigue, it lacks formal FDA approval and specific efficacy data for this indication. *Narcolepsy* - Modafinil is **FDA-approved** as a wakefulness-promoting agent for the treatment of excessive daytime sleepiness associated with **narcolepsy**. - It helps reduce the frequency and severity of sleep attacks by promoting wakefulness through effects on **dopamine**, **norepinephrine**, and **histamine** systems in the brain. *Shift work sleep disorder (SWSD)* - Modafinil is **FDA-approved** to improve wakefulness in patients with excessive sleepiness associated with **shift work sleep disorder**. - It helps individuals working non-traditional hours (night shifts, rotating shifts) maintain alertness during their work periods. *Obstructive sleep apnea syndrome (OSAS)* - Modafinil is **FDA-approved** as an **adjunctive treatment** for residual excessive daytime sleepiness in patients with **obstructive sleep apnea/hypopnea syndrome (OSAHS)** who are receiving adequate treatment with CPAP. - It addresses persistent sleepiness that remains even after appropriate primary airway management.

Diseases of the Pharynx Indian Medical PG Question 2: Not true about parapharyngeal abscess?

• A. Torticollis
• B. Trismus
• C. Drooling of saliva
• D. Horner's syndrome (Correct Answer)

Diseases of the Pharynx Explanation: ***Horner's syndrome*** - While parapharyngeal abscess is close to the **sympathetic chain**, Horner's syndrome (ptosis, miosis, anhydrosis) is a **rare complication**, not a common or typical presentation, making this statement the most likely to be false regarding usual clinical features. - The inflammatory process usually affects the adjacent structures, such as pterygoid muscles, pharyngeal muscles, and carotid sheath, rather than directly compressing the **sympathetic fibers** in the majority of cases. *Torticollis* - **Torticollis**, or neck stiffness and deviation, is a common symptom due to irritation and spasm of the neck muscles adjacent to the inflamed parapharyngeal space. - The inflammatory process can cause pain and muscle guarding, leading to the characteristic head tilt. *Drooling of saliva* - **Drooling of saliva** occurs due to odynophagia (painful swallowing) and dysphagia (difficulty swallowing) making patients reluctant to swallow, allowing saliva to accumulate and spill from the mouth. - The inflammation and swelling in the parapharyngeal space can obstruct the pharynx, making swallowing difficult and painful. *Trismus* - **Trismus**, or difficulty opening the mouth, is a characteristic feature of parapharyngeal abscess due to inflammation and spasm of the **medial pterygoid muscle**, which is located near the parapharyngeal space. - The abscess can directly irritate or compress the **masticatory muscles**, limiting jaw movement.

Diseases of the Pharynx Indian Medical PG Question 3: Regarding "Quinsy" all of the following are correct EXCEPT:

• A. It is an abscess in the peritonsillar region
• B. In early stage, intravenous broad spectrum antibiotics may resolve it
• C. Pus may be seen pointing underneath the thin mucosa in all cases and is diagnostic (Correct Answer)
• D. Severe trismus is caused by spasm induced by pterygoid muscles

Diseases of the Pharynx Explanation: ***Pus may be seen pointing underneath the thin mucosa in all cases and is diagnostic*** - While **pus** is present in a peritonsillar abscess, it is **not always visibly "pointing"** underneath the mucosa. - The diagnosis of quinsy relies on clinical presentation and physical examination findings like **uvular deviation** and **trismus**, not solely on visible pus pointing. *It is an abscess in the peritonsillar region* - **Quinsy** is indeed an alternative name for a **peritonsillar abscess**, which is a collection of pus located lateral to the tonsil. - This abscess typically forms due to an infection that spreads from the tonsil itself into the surrounding loose connective tissue. *In early stage, intravenous broad spectrum antibiotics may resolve it* - In the initial stages of a **peritonsillar abscess**, before significant pus collection, **intravenous broad-spectrum antibiotics** can sometimes successfully resolve the infection. - This approach aims to reduce inflammation and prevent further progression to a full-blown abscess requiring drainage. *Severe trismus is caused by spasm induced by pterygoid muscles* - **Trismus**, or difficulty opening the mouth, is a characteristic symptom of quinsy and is caused by irritation and **spasm of the pterygoid muscles**. - This muscle spasm occurs due to the close anatomical relationship between the **peritonsillar abscess** and the pterygoid muscles.

Diseases of the Pharynx Indian Medical PG Question 4: A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?

• A. 48%
• B. 12%
• C. 24%
• D. 3% (Correct Answer)

Diseases of the Pharynx Explanation: ***3%*** - **Purely cystic thyroid nodules** (as described in this case with "isolated cystic swelling") have a **very low risk of malignancy**, typically **2-3%** or less. - According to **ATA guidelines** and **TIRADS classification**, purely cystic nodules are considered **low suspicion** lesions. - The cystic nature suggests a **benign process** such as a degenerated adenoma, colloid cyst, or simple cyst. - **Fine needle aspiration (FNA)** may still be considered if the nodule is >2 cm or has any suspicious solid components, but is often not required for purely cystic lesions. *48%* - This percentage is **significantly higher** than the actual malignancy risk for a purely cystic thyroid swelling. - Such a **high risk** would typically be associated with **solid nodules** exhibiting highly suspicious ultrasound features such as: - Microcalcifications - Irregular or spiculated margins - Taller-than-wide shape - Marked hypoechogenicity - Extrathyroidal extension *24%* - This percentage represents a **moderate to high risk** of malignancy, which is **not characteristic** of an isolated purely cystic thyroid swelling. - A risk in this range might be seen with: - **Mixed solid-cystic nodules** with predominantly solid components - Solid nodules with **intermediate suspicious features** on ultrasound *12%* - While lower than 24% or 48%, 12% is still **considerably higher** than the generally accepted malignancy risk for purely cystic thyroid nodules. - This risk level could be plausible for: - **Predominantly cystic nodules** with some eccentric solid components - Solid nodules with **mildly suspicious** features on ultrasound

Diseases of the Pharynx Indian Medical PG Question 5: Patient with obstructive sleep apnea-hypopnea syndrome is unlikely to have which of the following?

• A. Absence of snoring
• B. Bradycardia during sleep episodes (Correct Answer)
• C. Normal oxygen saturation throughout sleep
• D. Decreased neck circumference

Diseases of the Pharynx Explanation: ***Bradycardia during sleep episodes*** - While patients with **obstructive sleep apnea (OSA)** commonly experience various cardiovascular complications, **bradycardia** during apneic episodes is *less typical* than **tachycardia**. - The body's initial response to apnea and **hypoxia** usually involves a sympathetic surge leading to tachycardia upon arousal, followed by bradycardia if the apnea is prolonged. However, the dominant pattern is often elevated heart rate variability. *Normal oxygen saturation throughout sleep* - Patients with OSA frequently experience intermittent **hypoxemia** due to repeated apneas and hypopneas, leading to significant drops in **oxygen saturation** [1]. - A *normal oxygen saturation throughout sleep* would effectively rule out significant OSA, as desaturation is a hallmark of the condition [1]. *Absence of snoring* - **Snoring** is a classic and highly prevalent symptom of OSA, caused by the vibration of upper airway tissues as air struggles to pass through an obstructed pharynx. - While not all snorers have OSA, the *absence of snoring* makes OSA less likely, although it can occur in some subsets of patients, particularly those with central sleep apnea or certain anatomical variations. *Decreased neck circumference* - A **large neck circumference** is a well-established anatomical risk factor for OSA, indicating increased soft tissue in the neck that can contribute to upper airway collapse. - A *decreased neck circumference* would generally be protective against OSA, making it less likely for an individual to have the condition.

Diseases of the Pharynx Flashcard 1 of 5

Question: Pressure on the anterior pillar expresses frank pus or cheesy material from the tonsil, in cases of _____ tonsillitis, known as Irwin-Moore sign

Answer: chronic

Diseases of the Pharynx Flashcard 2 of 5

Question: Quinsy presents with marked _____ and hot-potato voice

Answer: odynophagia

Diseases of the Pharynx Flashcard 3 of 5

Question: _____ and difficulty in breathing are prominent symptoms of acute retropharyngeal abscess

Answer: Dysphagia

Diseases of the Pharynx Flashcard 4 of 5

Question: Acute _____pharyngeal abscess presents as a bulge on one side of the midline and not as a midline bulge

Answer: retro

Diseases of the Pharynx Flashcard 5 of 5

Question: _____ is due to blockage of a tonsillar crypt and appears as a yellowish swelling over the tonsil and can be easily drained

Answer: Tonsillar cyst