Diseases of the Pharynx Practice Questions

Q: The X-ray shown below is diagnostic of what? The finding in the X-ray is marked with a red arrow.

Eagle syndrome. ***Eagle syndrome*** - X-ray shows **elongated styloid process** (>25mm) which is pathognomonic for Eagle syndrome, causing **throat pain** and **dysphagia**. - The **calcified stylohyoid ligament** or elongated styloid process is clearly visible on plain radiographs, making this a definitive radiological diagnosis. *Trigeminal neuralgia* - This is a **clinical diagnosis** based on characteristic **sharp, electric shock-like pain** in trigeminal nerve distribution. - **No specific radiological findings** are seen on plain X-rays; diagnosis relies on clinical presentation and sometimes MRI. *Cervical cord compression* - Requires **MRI or CT myelography** to visualize cord compression and cannot be diagnosed on plain X-rays. - Plain radiographs may show **degenerative changes** but cannot demonstrate actual cord compression or neurological involvement. *Non specific myalgia* - This is a **clinical syndrome** with muscle pain and tenderness without any radiological abnormalities. - **Normal X-ray findings** are expected, and diagnosis is based purely on clinical examination and history.

Q: Which of the following is called the gateway of Tears?

Killian's dehiscence. **Explanation:** **Killian’s dehiscence** is a potential weak spot in the posterior wall of the lower pharynx. It is located between the two parts of the inferior constrictor muscle: the upper oblique fibers (**thyropharyngeus**) and the lower horizontal fibers (**cricopharyngeus**). It is called the **"Gateway of Tears"** because it is the most common site for accidental **iatrogenic perforation** during rigid esophagoscopy. Furthermore, increased intraluminal pressure here leads to the herniation of mucosa, forming a **Zenker’s diverticulum** (pulsion diverticulum). **Analysis of Incorrect Options:** * **Sinus of Morgagni:** This is the space between the base of the skull and the upper border of the superior constrictor muscle. It allows the passage of the Eustachian tube and levator veli palatini. * **Passavant’s Ridge:** A mucosal ridge on the posterior pharyngeal wall formed by the contraction of the palatopharyngeus muscle. It helps in velopharyngeal closure during speech and swallowing. * **Waldeyer’s Ring:** A ring of lymphoid tissue at the entrance of the aerodigestive tract (including palatine, lingual, pharyngeal, and tubal tonsils) that provides local immunity. **High-Yield Clinical Pearls for NEET-PG:** * **Zenker’s Diverticulum:** Always occurs through Killian’s dehiscence. It is a "false" diverticulum as it contains only mucosa and submucosa. * **Killian-Jamieson Area:** A separate weak area located *below* the cricopharyngeus, between the muscle and the esophagus. * **Management:** The gold standard for Zenker’s is endoscopic Dohlman’s procedure (stapling) or open diverticulectomy with cricopharyngeal myotomy.

Q: Which of the following is not a complication of adenoidectomy?

Hyponasality of speech. **Explanation:** Adenoidectomy is the surgical removal of the adenoid lymphoid tissue located in the nasopharynx. Understanding the anatomical changes post-surgery is key to identifying its complications. **1. Why Hyponasality is the Correct Answer:** Adenoids normally occupy space in the nasopharynx. Their presence can cause **hyponasality** (rhinolalia clausa) by obstructing nasal airflow. Removing the adenoids opens the nasopharyngeal airway, which resolves hyponasality but creates a larger space for air to escape during speech. Therefore, the complication of adenoidectomy is **hypernasality** (rhinolalia aperta), not hyponasality. **2. Analysis of Incorrect Options:** * **Velopharyngeal Insufficiency (VPI):** This is a classic complication. The soft palate relies on the adenoid pad to achieve complete closure of the nasopharynx during speech. Removal of this "pad" can result in an inability to seal the nasopharynx, leading to hypernasality and nasal regurgitation of fluids. * **Grisel Syndrome:** This is a rare but high-yield complication involving **non-traumatic atlanto-axial subluxation**. It occurs due to inflammatory edema causing laxity of the anterior transverse ligament of the atlas following local infection or surgery (adenoidectomy). * **Retropharyngeal Abscess:** Post-operative infection or trauma to the posterior pharyngeal wall during curettage can lead to the formation of a retropharyngeal abscess. **Clinical Pearls for NEET-PG:** * **Most common complication:** Post-operative hemorrhage (Primary or Reactionary). * **Grisel Syndrome presentation:** Persistent torticollis (wry neck) following adenoidectomy. * **Contraindication:** Adenoidectomy is strictly contraindicated in children with a **cleft palate** or **submucous cleft palate** because it will precipitate severe velopharyngeal insufficiency. Always palpate the hard palate for a notch before surgery.

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

Gastric polyps. **Plummer-Vinson Syndrome (PVS)**, also known as **Paterson-Brown-Kelly syndrome**, is a clinical triad characterized by iron deficiency anemia, dysphagia, and esophageal webs. It is most commonly seen in middle-aged women and is considered a premalignant condition for post-cricoid carcinoma. ### Why Gastric Polyps is the Correct Answer **Gastric polyps** are not a component of Plummer-Vinson Syndrome. While PVS involves the upper gastrointestinal tract (specifically the esophagus), it does not typically involve the stomach mucosa in the form of polyps. The pathology in PVS is primarily related to mucosal atrophy and epithelial changes due to chronic iron deficiency. ### Explanation of Incorrect Options * **A. Iron deficiency anemia:** This is the hallmark of the syndrome. It leads to depleted iron-dependent enzymes in the epithelium, causing the characteristic mucosal changes. * **B. Cheilosis:** Also known as angular stomatitis, this is a common clinical sign of vitamin B12 and iron deficiency, frequently seen in PVS patients along with glossitis (smooth, red tongue). * **C. Esophageal webs:** These are thin, mucosal folds usually found in the **post-cricoid region** (upper esophagus). They cause the characteristic "painless, intermittent dysphagia" to solids. ### NEET-PG High-Yield Pearls * **Clinical Triad:** Iron deficiency anemia + Dysphagia + Cervical esophageal webs. * **Demographics:** Most common in females (4th–7th decade). * **Premalignant Potential:** High risk of developing **Squamous Cell Carcinoma** of the post-cricoid region and upper esophagus. * **Diagnosis:** Best initial test is a **Barium Swallow** (lateral view) to visualize the web; definitive diagnosis via esophagoscopy. * **Treatment:** Iron supplementation often resolves the dysphagia; persistent webs require endoscopic dilation.

Q: A child presented to the OPD with fever and dysphagia. On examination, the following was visualized. What is your most probable diagnosis?

Peritonsillar abscess. ***Peritonsillar abscess*** - Classic **oropharyngeal visual findings** include **peritonsillar bulge**, **uvular deviation to contralateral side**, and **soft palate fullness** on examination. - Presents with **fever**, **severe dysphagia**, **trismus**, and **muffled voice** due to collection of pus between tonsillar capsule and superior constrictor muscle. *Parapharyngeal abscess* - Located in the **deep neck space** lateral to the pharynx, not typically visible on **direct oropharyngeal examination**. - Presents with **neck swelling**, **torticollis**, and **medial displacement of lateral pharyngeal wall** rather than tonsillar bulge. *Retropharyngeal abscess* - Collection of pus in the **retropharyngeal space**, behind the posterior pharyngeal wall, not visible on routine oral examination. - Typically presents with **neck extension**, **drooling**, **stridor**, and **posterior pharyngeal wall bulging** on lateral neck X-ray. *Follicular Tonsillitis* - Shows **white/yellow exudates** in tonsillar crypts without significant **unilateral swelling** or **uvular deviation**. - Bilateral involvement is common with **less severe dysphagia** and absence of **peritonsillar bulging** or **trismus**.

Q: A black colored patch in the mouth is seen in which of the following conditions?

Vincent's angina. **Explanation:** **Vincent’s Angina** (also known as Trench Mouth or Acute Necrotizing Ulcerative Gingivitis/Pharyngitis) is the correct answer. It is caused by a symbiotic infection of two organisms: the Gram-negative anaerobic spirochete ***Borrelia vincentii*** and the fusiform bacillus ***Fusobacterium nucleatum***. Clinically, it presents as a painful, necrotic ulceration of the tonsils and gums. The hallmark of this condition is the formation of a **dirty-grey or blackish slough (pseudomembrane)** over the ulcerated area. When this membrane is removed, it reveals a bleeding granular surface. The "black" appearance is due to tissue necrosis and the specific microbial flora involved. **Analysis of Incorrect Options:** * **Acute Tonsillitis:** Typically presents with an erythematous, congested tonsil with white or yellowish follicular exudates, not a black patch. * **Peritonsillar Abscess (Quinsy):** Characterized by a bulge of the soft palate and anterior pillar with deviation of the uvula. While there is severe inflammation, there is no characteristic black patch. * **Leukemia:** While leukemic infiltration can cause gingival enlargement or secondary necrotic ulcers (due to neutropenia), it is not the classic primary association for a black patch compared to the specific pseudomembrane of Vincent’s Angina. **High-Yield Clinical Pearls for NEET-PG:** * **Microbiology:** Look for the "Fusospirochetal" complex. * **Clinical Sign:** "Halitosis" (foul breath) is very prominent in Vincent’s Angina. * **Treatment:** Penicillin is the drug of choice, along with Metronidazole to cover anaerobes and oxidizing mouthwashes (Hydrogen Peroxide). * **Differential Diagnosis:** Must be differentiated from Diphtheria (greyish-white membrane) and Infectious Mononucleosis.

Q: Stylalgia may present with ear pain. Which nerve may refer the pain?

Glossopharyngeal nerve. **Explanation:** **Stylalgia (Eagle’s Syndrome)** occurs due to an elongated styloid process or calcification of the stylohyoid ligament. This anatomical variation causes irritation of the surrounding structures, primarily the **Glossopharyngeal nerve (CN IX)**, which passes in close proximity to the styloid process. **Why Glossopharyngeal nerve is correct:** The Glossopharyngeal nerve provides sensory innervation to the oropharynx and the base of the tongue. It also gives off the **Jacobson’s nerve (tympanic branch)**, which provides sensory supply to the middle ear. In Stylalgia, irritation of CN IX in the tonsillar fossa results in **referred otalgia** (ear pain) via this tympanic branch. This is a classic example of pain originating in the pharynx being felt in the ear. **Why other options are incorrect:** * **Auriculotemporal nerve (CN V3):** While it causes referred otalgia, it is typically associated with Temporomandibular Joint (TMJ) disorders or molar tooth pathologies, not the styloid process. * **Posterior auricular nerve:** This is a branch of the Facial nerve (CN VII) primarily supplying motor function to muscles behind the ear; it is not the mediator for referred pain in Stylalgia. * **Occipital nerve:** This supplies the scalp and back of the head; irritation here leads to occipital neuralgia, not pharyngeal-related ear pain. **High-Yield NEET-PG Pearls:** * **Eagle’s Syndrome Presentation:** Characterized by "3 Ts": **T**hroat pain, **T**innitus/Otalgia, and **T**ongue pain (especially during swallowing). * **Diagnosis:** Palpation of the elongated styloid process in the tonsillar fossa triggers pain. * **Treatment:** Medical (NSAIDs/Carbamazepine) or Surgical (Styloidectomy via trans-oral or cervical approach). * **Other nerves causing referred otalgia:** V3 (teeth/TMJ), CN X (larynx/hypopharynx), and C2-C3 spinal nerves (cervical spine).

Q: During tonsillectomy, which of the following structures is NOT typically injured?

External carotid artery. **Explanation:** The **External Carotid Artery (ECA)** is located approximately **2 cm lateral** to the tonsillar fossa, separated from the superior constrictor muscle by the stylopharyngeus muscle and the parapharyngeal space. Due to this anatomical distance, it is not typically at risk during a routine tonsillectomy. **Analysis of Options:** * **Glossopharyngeal Nerve (CN IX):** This nerve lies in the tonsillar bed, just deep to the superior constrictor muscle. It is the most common nerve injured during tonsillectomy, leading to loss of taste and sensation in the posterior 1/3rd of the tongue and referred earache. * **Paratonsillar Vein (Gatekeeper’s Vein):** This is the most common source of **venous bleeding** during tonsillectomy. It descends from the soft palate to the tonsillar bed and is usually divided during the procedure. * **Tonsillar Branch of Facial Artery:** This is the **main arterial supply** to the tonsil. It enters the lower pole by piercing the superior constrictor muscle and is the most common source of **primary arterial hemorrhage**. **High-Yield Clinical Pearls for NEET-PG:** * **Main Artery:** Tonsillar branch of the Facial Artery. * **Most common nerve injured:** Glossopharyngeal nerve. * **Post-Tonsillectomy Hemorrhage:** * **Reactionary (within 24 hours):** Usually due to slipping of a ligature or rise in BP. * **Secondary (5–10 days):** Usually due to **infection** (most common cause). * **Eagle’s Syndrome:** Elongated styloid process causing throat pain post-tonsillectomy due to irritation of the glossopharyngeal nerve.

Question 1

All of the following are true about Zenker's Diverticulum except?

Accepted Answer

It is an outpouching of the posterior pharyngeal wall.

Answer

Dohlman's procedure is used for its treatment.

Answer

It is a false diverticulum.

Answer

Boyce sign is associated with it.

Question 2

The X-ray shown below is diagnostic of what? The finding in the X-ray is marked with a red arrow.

Accepted Answer

Eagle syndrome

Answer

Trigeminal neuralgia

Answer

Cervical cord compression

Answer

Non specific myalgia

Question 3

Which of the following is called the gateway of Tears?

Accepted Answer

Killian's dehiscence

Answer

Sinus of Morgagni

Answer

Passavant's ridge

Answer

Waldeyer's ring

Question 4

What is not characteristic of Eagle's syndrome?

Accepted Answer

Excessive lacrimation

Answer

Pain during mandibular movement

Answer

Stabbing type pain originating in the tonsillar regions

Answer

Pain subsides when the jaws are closed

Question 5

Which of the following is not a complication of adenoidectomy?

Accepted Answer

Hyponasality of speech

Answer

Retropharyngeal abscess

Answer

Velopharyngeal insufficiency

Answer

Grisel syndrome

Question 6

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

Accepted Answer

Gastric polyps

Answer

Iron deficiency anemia

Answer

Cheilosis

Answer

Esophageal webs

Question 7

A child presented to the OPD with fever and dysphagia. On examination, the following was visualized. What is your most probable diagnosis?

Accepted Answer

Peritonsillar abscess

Answer

Parapharyngeal abscess

Answer

Retropharyngeal abscess

Answer

Follicular Tonsillitis

Question 8

A black colored patch in the mouth is seen in which of the following conditions?

Accepted Answer

Vincent's angina

Answer

Acute tonsillitis

Answer

Peritonsillar abscess

Answer

Leukemia

Question 9

Stylalgia may present with ear pain. Which nerve may refer the pain?

Accepted Answer

Glossopharyngeal nerve

Answer

Auriculotemporal nerve

Answer

Posterior auricular nerve

Answer

Occipital nerve

Question 10

During tonsillectomy, which of the following structures is NOT typically injured?

Accepted Answer

External carotid artery

Answer

Glossopharyngeal nerve

Answer

Paratonsillar vein

Answer

Tonsillar branch of facial artery

Diseases of the Pharynx — MCQs

Diseases of the Pharynx — MCQs

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