Diseases of the Pharynx Practice Questions

Q: A patient presents with a fish bone stuck in the pyriform sinus. During the removal procedure, there is accidental nerve injury. Which nerve is most likely to be damaged?

Internal branch of the superior laryngeal nerve. ***Internal branch of the superior laryngeal nerve***- This nerve branch runs immediately beneath the **mucosa** of the pyriform sinus before piercing the thyrohyoid membrane, making it highly susceptible to injury during instrumentation or foreign body manipulation in this area.- It is the principal **sensory nerve** supply to the laryngeal cavity above the vocal cords; injury would result in loss of sensation in this region, often leading to laryngeal incompetence and aspiration.*Recurrent laryngeal nerve*- This nerve is located more inferiorly within the **tracheoesophageal groove**, supplying motor innervation to nearly all intrinsic muscles of the larynx.- Injury to the recurrent laryngeal nerve would cause **vocal cord paralysis** and hoarseness, which is less likely given the specific location of minimal trauma in the high hypopharynx.*Glossopharyngeal nerve*- The glossopharyngeal nerve (**CN IX**) supplies sensation to the posterior third of the tongue, tonsils, and **oropharynx**, and is not directly related to the pyriform sinus mucosa.- Injury would primarily manifest as loss of the **gag reflex** and sensory deficits in the posterior pharynx, which is topographically distant from the immediate site of endoscopic manipulation in the hypopharynx.*External branch of the superior laryngeal nerve*- This nerve primarily provides **motor innervation** to the **cricothyroid muscle**, responsible for lengthening and tensing the vocal cords (pitch control).- Anatomically, it descends alongside the **superior thyroid artery** and is situated deeper and more anteriorly, placing it at less risk of superficial mucosal trauma than the internal branch.

Q: Which of the following conditions is associated with Holman-Miller sign in the CT image given below?

Juvenile nasopharyngeal angiofibroma. ***Juvenile nasopharyngeal angiofibroma***- Holman-Miller sign refers to the classic imaging finding of **anterior bowing** of the posterior wall of the **maxillary sinus** due to the aggressive expansion of this benign tumor originating in the **sphenopalatine foramen**.- This highly **vascular** tumor typically affects **adolescent males** and presents with unilateral, recurrent, and severe epistaxis and nasal obstruction.*Maxillary sinusitis*- CT findings usually include non-specific features like **mucoperiosteal thickening**, air-fluid levels, or complete opacification, without significant displacement of the bony walls.- It is an inflammatory condition, caused by infection or allergy, which does not produce the bone displacement characteristic of aggressive local tumor growth like **JNA**.*Nasal polyp*- Nasal polyps arise from the nasal and sinus mucosa (often the **ethmoids**) and cause pressure-induced **bone erosion** or remodeling, but not the specific **anterior bowing** of the posterior maxillary wall.- They are typically associated with conditions such as **allergic rhinitis** or aspirin-exacerbated respiratory disease.*Rhinosporidiosis*- This condition is characterized by proliferative, **friable, strawberry-like masses** within the nasal cavity, caused by the organism *Rhinosporidium seeberi*.- Imaging usually shows only soft tissue masses within the nasal cavity or nasopharynx without the extensive **bony displacement** needed to produce Holman-Miller sign.

Q: A 12-year-old male with a history of recurrent epistaxis presents with nasal obstruction for the past 1 year. On examination the presence of nasal mass and investigation shows bowing of the posterior wall of maxillary sinus. What is the probable diagnosis?

Nasopharyngeal angiofibroma. ***Nasopharyngeal angiofibroma*** - This diagnosis is strongly suggested by the classic triad of **adolescent male** (12 years old), **recurrent epistaxis**, and **nasal obstruction** - the typical presentation of this benign but locally aggressive tumor. - The **Holman-Miller sign** (bowing of the posterior wall of maxillary sinus) is pathognomonic for nasopharyngeal angiofibroma, indicating aggressive expansion and bony remodeling. *Rhinosporidiosis* - This condition presents as **friable, strawberry-like polyps** that may bleed, but doesn't cause the severe, recurrent epistaxis seen in this case. - It does not cause aggressive **bony remodeling** or the characteristic Holman-Miller sign seen on imaging. *Antrochoanal polyp* - While it can cause **unilateral nasal obstruction**, it rarely presents with severe, recurrent **epistaxis** as the predominant feature. - This benign polyp does not cause the aggressive **bony expansion** and Holman-Miller sign characteristic of angiofibroma. *Rhinoscleroma* - This chronic granulomatous infection caused by **Klebsiella rhinoscleromatis** typically presents with firm, sclerotic lesions and **crusting**. - It rarely causes the prominent, recurrent **epistaxis** or the destructive bony changes (Holman-Miller sign) seen in this patient.

Q: All are correct about the image shown below except:

Uvula deviated to the affected side. ***Uvula deviated to the affected side*** - In cases of **pharyngeal paralysis**, particularly involving the vagus nerve (CN X), the **uvula deviates *away* from the affected side** due to unopposed action of muscles on the healthy side. - Therefore, deviation to the affected side would be incorrect. *Nasal twang* - A **nasal twang** (or hypernasal speech) is a characteristic symptom of **palatal weakness**, where the soft palate cannot adequately close off the nasopharynx during speech, allowing air to escape through the nose. - This is consistent with a lesion affecting the ipsilateral vagus nerve. *Left-sided dropped palatopharyngeal arch* - The image clearly shows a **lower and more flattened appearance of the left palatopharyngeal arch** compared to the right, indicating weakness or paralysis of the muscles in that area. - This "dropped" appearance is a classic sign of **vagal nerve palsy**, affecting the muscles responsible for elevating the soft palate. *Ipsilateral loss of gag reflex* - The **gag reflex** is primarily mediated by the **glossopharyngeal nerve (CN IX)** for the afferent limb and the **vagus nerve (CN X)** for the efferent limb. - **Unilateral weakness of the soft palate**, as suggested by the dropped arch, is consistent with a lesion of the vagus nerve, which would result in loss of the gag reflex on the ipsilateral side.

Q: All are correct about the condition except:

Biphasic stridor. ***Biphasic stridor*** - The image shows **tonsillitis** with exudates, typically caused by bacterial (e.g., Group A Streptococcus) or viral infections. - **Biphasic stridor** (noise during both inspiration and expiration) indicates significant airway obstruction, usually at the **glottic or subglottic level**, which is **NOT a typical feature** of uncomplicated tonsillitis. - Biphasic stridor suggests more severe conditions like **epiglottitis, severe croup, or laryngeal obstruction**, which have different clinical presentations and management. *Penicillin is drug of choice* - For **Group A Streptococcus (GAS) pharyngitis/tonsillitis**, penicillin remains the **drug of choice** due to its efficacy, narrow spectrum, and low cost. - It effectively eradicates the bacteria and prevents complications like **acute rheumatic fever** and **post-streptococcal glomerulonephritis**. *Modified Centor criteria are used to diagnose the presence of Group A streptococcus infection* - The **Modified Centor criteria** (McIsaac score) are clinical decision tools used to assess the probability of **Group A Streptococcus pharyngitis** and guide further testing or antibiotic treatment. - Criteria include: tonsillar exudates, swollen tender anterior cervical nodes, absence of cough, history of fever, and age adjustment. *Tonsillectomy is advised if >5 episodes occur per year for 2 consecutive years* - Current guidelines for **tonsillectomy** commonly consider recurrent infections as an indication. - The **Paradise criteria** suggest tonsillectomy for **≥7 episodes in 1 year, ≥5 episodes per year for 2 consecutive years, or ≥3 episodes per year for 3 consecutive years**. - This option represents a reasonable threshold within these guidelines.

Q: Which is incorrect about the instrument shown?

Uses a draffin bipod stand. ***Uses a draffin bipod stand*** - The image shows a **Boyle-Davis mouth gag** being used, which is typically self-retaining and **does not require an additional stand** such as a Draffin bipod. - The Draffin bipod stand is primarily used with a **Draffin mouth gag** or similar instruments to provide stability and hands-free retraction. *Boyle Davis gag* - The instrument shown suspending the tongue and keeping the mouth open is indeed a **Boyle-Davis self-retaining mouth gag**, commonly used in tonsillectomies and other oral cavity procedures. - Its design includes a central part that keeps the jaws apart and a tongue blade to depress the tongue. *Used in uvulopalatopharyngoplasty* - The Boyle-Davis mouth gag provides excellent exposure of the **oropharynx**, making it suitable for procedures like **uvulopalatopharyngoplasty (UPPP)**, which aims to improve breathing by reshaping the soft palate and uvula. - It allows for clear visualization and access to the surgical area in the back of the throat. *Used to perform procedures on the tongue* - While its primary function is to retract the tongue and keep the mouth open, it also provides good access for procedures directly on the tongue, such as **tongue base reduction** or biopsy. - The tongue blade component directly depresses the tongue, facilitating its manipulation for surgical access.

Q: What is incorrect about the picture shown?

Trendelenburg position. ***Trendelenburg position*** - The image displays the **Rose position** (also known as the tonsillar position), characterized by neck extension and a pillow under the shoulders. - The **Trendelenburg position** involves placing the patient supine with the head lower than the feet, which is not depicted. *Rose position* - The patient's head is **extended** and the shoulders are elevated with a roll, which is characteristic of the Rose position. - This position is commonly used to improve surgical access and visualization for procedures involving the **oral cavity** and pharynx. *Contraindicated in atlantoaxial instability* - The **extreme neck extension** seen in the Rose position can place stress on the **cervical spine**. - This makes it **contraindicated** in conditions like **atlantoaxial instability**, where excessive neck movement could lead to spinal cord compression. *Used for tonsillectomy* - The Rose position is a standard position for **tonsillectomy** and adenoidectomy. - It provides optimal exposure of the **oropharynx** and allows for gravity to aid in drainage of blood away from the surgical site.

Question 1

A patient presents with a fish bone stuck in the pyriform sinus. During the removal procedure, there is accidental nerve injury. Which nerve is most likely to be damaged?

Accepted Answer

Internal branch of the superior laryngeal nerve

Answer

Recurrent laryngeal nerve

Answer

Glossopharyngeal nerve

Answer

External branch of the superior laryngeal nerve

Question 2

Which of the following conditions is associated with Holman-Miller sign in the CT image given below?

Accepted Answer

Juvenile nasopharyngeal angiofibroma

Answer

Nasal polyp

Answer

Rhinosporidiosis

Answer

Maxillary sinusitis

Question 3

A 6-year-old child presents with recurrent episodes of sore throat, fever, and difficulty swallowing for the past 2 years, with 7 documented episodes in the last year. Examination reveals enlarged, inflamed tonsils with exudate. The child has missed significant school days. What is the most appropriate management?

Accepted Answer

Bilateral tonsillectomy

Answer

Adenoidectomy alone

Answer

Continue conservative management with antibiotics for each episode

Answer

Wait and observe for spontaneous resolution

Question 4

Which of the following is incorrect regarding Juvenile Nasopharyngeal Angiofibroma (JNA)?

Accepted Answer

Unilateral cervical lymph nodes are a common feature

Answer

Biopsy is contraindicated

Answer

Epistaxis is the most common presenting symptom

Answer

Only seen in young boys

Question 5

A 12-year-old male with a history of recurrent epistaxis presents with nasal obstruction for the past 1 year. On examination the presence of nasal mass and investigation shows bowing of the posterior wall of maxillary sinus. What is the probable diagnosis?

Accepted Answer

Nasopharyngeal angiofibroma

Answer

Rhinosporidiosis

Answer

Antrochoanal polyp

Answer

Rhinoscleroma

Question 6

All are correct about the image shown below except:

Accepted Answer

Uvula deviated to the affected side

Answer

Nasal twang

Answer

Left-sided dropped palatopharyngeal arch

Answer

Ipsilateral loss of gag reflex

Question 7

All are correct about the condition except:

Accepted Answer

Biphasic stridor

Answer

Penicillin is drug of choice

Answer

Modified Centor criteria are used to diagnose the presence of Group A streptococcus infection

Answer

Tonsillectomy is advised if $>5$ episodes occur per year for 2 consecutive years

Question 8

Which is incorrect about the instrument shown?

Accepted Answer

Uses a draffin bipod stand

Answer

Boyle Davis gag

Answer

Used in uvulopalatopharyngoplasty

Answer

Used to perform procedures on the tongue

Question 9

What is incorrect about the picture shown?

Accepted Answer

Trendelenburg position

Answer

Rose position

Answer

Contraindicated in atlantoaxial instability

Answer

Used for tonsillectomy

Question 10

All are correct about the image shown except:

Accepted Answer

Cervical esophagectomy and removal of radiopaque FB under GA is most preferred modality of treatment

Answer

Foreign body in esophagus

Answer

Most common site of impaction is cricopharynx

Answer

Laryngeal edema

Diseases of the Pharynx — MCQs

Diseases of the Pharynx — MCQs

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