Diseases of the Pharynx Practice Questions

Q: A child who underwent a tonsillectomy started bleeding while lying in the ward post-operatively. Which of the following is the most appropriate management step?

Take to OT, remove the clot & re-ligation. ***Take to OT, remove the clot & re-ligation*** - **Post-tonsillectomy bleeding** is a surgical emergency requiring immediate intervention to prevent airway compromise and significant blood loss. - The most definitive management involves returning to the **operating theatre** for direct visualization, removal of any obstructing clots, and **re-ligation** of the bleeding vessel. *Conservative management* - **Conservative management** is generally insufficient for significant post-tonsillectomy bleeding, as it does not address the source of hemorrhage and can lead to severe complications. - While minor oozing might be observed, active bleeding often indicates a larger vessel injury that requires **surgical hemostasis**. *Take to OT & pressure packing* - While **pressure packing** can temporarily slow bleeding, it is not a definitive long-term solution as it does not directly identify and treat the bleeding vessel. - Furthermore, pharyngeal packing in a child carries a risk of **airway obstruction** and aspiration, making it less suitable than direct re-ligation. *Cautery* - **Cautery** is a method of hemostasis, but it is typically performed in the operating theatre under direct vision, often after clot removal. - It is not a stand-alone initial management step in the ward for active bleeding without proper surgical assessment and preparation.

Q: A 12-year-old presented with fever and difficulty swallowing. He had swelling in the marked region and was advised to undergo tonsillectomy. Post-surgery the gauze continued to soak with blood. Which of the following vessels must have been injured?

Paratonsillar vein. ***Paratonsillar vein*** - The **paratonsillar vein**, also known as the **external palatine vein**, is the major vein draining the palatine tonsil and usually the primary source of **post-tonsillectomy hemorrhage**. - Its superficial location and tendency to be large and thin-walled make it particularly vulnerable to injury during **tonsillectomy**, leading to persistent bleeding. *Ascending pharyngeal artery* - The ascending pharyngeal artery contributes to the blood supply of the tonsil, but it is a **deep-seated artery** that is less frequently injured during tonsillectomy compared to the paratonsillar vein. - While its injury could lead to significant bleeding, it's not the most common vascular source of hemorrhage in this context. *Tonsillar branch of facial artery* - The **tonsillar branch of the facial artery** is a significant arterial supply to the tonsil. However, arterial bleeding is typically more pulsatile and rapid, whereas persistent soaking of gauze suggests venous bleeding. - While injury to this artery can occur, the **paratonsillar vein** is a more common source of persistent oozing hemorrhage post-tonsillectomy. *Retromandibular vein* - The **retromandibular vein** is located posterior to the mandible and is not directly associated with the tonsillar bed. - Injury to this vein during a **tonsillectomy** is highly unlikely due to its anatomical position.

Q: What is the most common presentation of nasopharyngeal carcinoma?

Neck lymph node. ***Neck lymph node*** - The most common initial symptom of nasopharyngeal carcinoma is a **painless neck mass** due to metastasis to cervical lymph nodes. - This occurs in a significant percentage of patients, often even before local symptoms from the primary tumor are prominent. *Loss of smell* - While possible in advanced stages if the tumor invades the **olfactory nerves** or directly obstructs the nasal cavity, it is not typically the initial or most common presentation. - This symptom is more indicative of conditions directly affecting the **olfactory epithelium** or nerves, not early nasopharyngeal carcinoma. *Blockage of nose* - **Nasal obstruction** or stuffiness can occur as the tumor grows and localizes within the nasopharynx, but it is less common as an initial symptom than a palpable neck mass. - This symptom might also be attributed to other common conditions like sinusitis or allergies, delaying diagnosis. *Blood tinged discharge* - **Epistaxis (nosebleeds)** or blood-tinged sputum/discharge can be a symptom, especially with later-stage tumors that are ulcerating or bleeding. - However, it is reported less frequently as the presenting symptom compared to cervical lymphadenopathy.

Q: A patient presented with 2 days history of fever. On examination there was a swelling in the neck and one side tonsil was pushed to midline. What is the most likely diagnosis:-

Quinsy. ***Quinsy (Peritonsillar abscess)*** - **Quinsy** is a **peritonsillar abscess** that presents with fever, severe throat pain, and the pathognomonic sign of **unilateral tonsil pushed toward the midline**. - The abscess forms in the **peritonsillar space** (between the tonsillar capsule and superior constrictor muscle), causing **medial displacement of the tonsil** and **bulging of the soft palate**. - Patients typically have **trismus, dysphagia, "hot potato voice"** and may have visible neck swelling. - This clinical presentation exactly matches the description: tonsil pushed to midline is the **classic finding for peritonsillar abscess**. *Parapharyngeal abscess* - A **parapharyngeal abscess** involves the deep parapharyngeal space lateral to the pharynx. - While it can cause neck swelling and fever, it typically causes **fullness and induration of the lateral pharyngeal wall** rather than prominent medial displacement of the tonsil itself. - The **tonsil is usually NOT pushed to the midline** in parapharyngeal abscess; instead, there is lateral pharyngeal wall bulging. - Often presents with more prominent external neck swelling below the angle of mandible. *Retropharyngeal abscess* - A **retropharyngeal abscess** occurs in the retropharyngeal space behind the posterior pharyngeal wall. - Presents with **posterior pharyngeal wall bulge**, neck stiffness, and dysphagia. - Does **NOT cause medial displacement of the tonsil** as the abscess is posterior, not lateral to the tonsil. *Tonsillitis* - **Acute tonsillitis** causes bilateral tonsillar inflammation with erythema and exudates. - While both tonsils may be enlarged, there is **no unilateral medial displacement** of one tonsil. - Less likely to cause significant neck swelling compared to deep space infections.

Q: A 15 years old Male presented with history of fever since 2 days, unable to swallow the food with muffled voice. On examination it is noted right tonsil is shifted to midline. What is the diagnosis:

Quincy. ***Quincy (Peritonsillar abscess)*** - This patient's presentation with **fever**, **dysphagia**, **muffled voice** (hot potato voice), and **tonsil shifted to the midline** is classic for a **peritonsillar abscess (Quincy)**. - The affected tonsil is pushed **medially toward the midline** by the collection of pus between the tonsillar capsule and the superior constrictor muscle. - The uvula is typically deviated to the **contralateral side**, and patients often have **trismus** and difficulty opening the mouth. - This is the **most common deep neck space infection** and typically follows acute tonsillitis. *Parapharyngeal abscess* - A **parapharyngeal abscess** would present with **severe trismus**, **neck swelling**, **torticollis**, and **bulging of the lateral pharyngeal wall**. - While it can push the tonsil medially, it more characteristically causes **anterolateral displacement** of the entire pharyngeal wall rather than isolated tonsillar displacement. - Patients typically have more pronounced **systemic toxicity** and **neck involvement** than seen with peritonsillar abscess. *Acute tonsillitis* - **Acute tonsillitis** presents with **bilateral tonsillar enlargement**, exudates, and pharyngeal erythema. - It does not cause **displacement of the tonsil to the midline** or significant **muffled voice**. - While fever and dysphagia are present, the physical examination finding of tonsillar shift indicates a suppurative complication (abscess formation). *Acute retropharyngeal abscess* - An **acute retropharyngeal abscess** occurs in the retropharyngeal space behind the posterior pharyngeal wall. - It presents with **neck stiffness**, **stridor**, **drooling**, **bulging of the posterior pharyngeal wall**, and **reluctance to extend the neck**. - It would **not cause visible displacement of the tonsil to the midline** as the abscess is in a different anatomical space. - More common in **young children** (under 5 years) than adolescents.

Q: Angiofibroma bleeds profusely because:

Vessels lack a contractile component. ***Vessels lack a contractile component*** - The distinctive feature of angiofibroma is the presence of **abundant, thin-walled blood vessels** that lack the typical muscular or elastic contractile layers found in normal arteries. - This structural deficiency prevents effective **vasoconstriction** and vessel closure, leading to severe and prolonged bleeding when injured. *It has multiple sites of origin* - While angiofibromas typically arise from the **nasopharynx**, their propensity to bleed is not related to having multiple sites of origin. - Their origin site does not inherently determine the vascular structure or bleeding risk. *It lacks a capsule* - The absence of a capsule can make surgical resection challenging and contribute to incomplete excision, but it does not directly explain the **profuse bleeding** from within the tumor itself. - Bleeding is primarily due to the internal vascular architecture rather than the presence or absence of a surrounding capsule. *None of the options* - This option is incorrect because the statement "Vessels lack a contractile component" accurately explains why angiofibromas bleed profusely. - The other options are not the primary reason for the extensive bleeding characteristic of these tumors.

Q: Type of speech seen in nasopharyngeal carcinoma -

Rhinolalia clausa. ***Rhinolalia clausa*** - This is also known as **hyponasal speech** or **closed nasality**, where there is insufficient nasal airflow during speech. - In **nasopharyngeal carcinoma**, the tumor can obstruct the nasopharynx, preventing air from flowing into the nasal cavity during vocalization, leading to this type of speech. *Hot potato voice* - This type of dysphonia is characterized by **muffled speech** as if the speaker is trying to talk with a hot object in their mouth. - It is typically associated with conditions causing **pharyngeal or tonsillar swelling** or peritonsillar abscess, which are distinct from nasopharyngeal carcinoma. *Hoarse voice* - **Hoarseness** results from abnormal vibration of the vocal cords, leading to a rough or breathy voice. - While possible in advanced nasopharyngeal carcinoma due to cranial nerve involvement affecting vocal cords, it is not the primary or most characteristic speech alteration from the tumor's location within the nasopharynx. *Rhinolalia aperta* - Also known as **hypernasal speech** or **open nasality**, this occurs when there is excessive nasal airflow during speech, making non-nasal sounds sound nasal. - This is typically caused by **velopharyngeal insufficiency** or defects that prevent proper closure between the oral and nasal cavities, such as a cleft palate, which is the opposite of the obstruction seen in nasopharyngeal carcinoma.

Q: Haemorrhage during tonsillectomy is usually from:

Paratonsillar vein. ***Paratonsillar vein*** - The **paratonsillar veins** are the most common source of immediate bleeding during tonsillectomy, being superficial and directly encountered during **capsular dissection**. - These veins provide **venous drainage** from the tonsillar bed and are routinely injured during the surgical procedure, though bleeding is usually **easily controlled** with cautery or pressure. *Lingual artery* - The **tonsillar branch of the lingual artery** is more commonly associated with **late/secondary hemorrhage** occurring hours to days after surgery, not during the procedure. - While it can contribute to bleeding during surgery, it runs deeper in the **inferior tonsillar pole** and is less frequently the primary source of intraoperative hemorrhage. *Maxillary artery* - The **maxillary artery** is anatomically distant from the tonsillar fossa, running deep within the **infratemporal fossa**. - While its branches (like the **ascending pharyngeal artery**) can contribute to tonsillar bleeding, the main trunk itself is not a direct source during tonsillectomy. *Middle meningeal artery* - The **middle meningeal artery** supplies the **dura mater** and runs entirely within the **cranial cavity** through the foramen spinosum. - It has no anatomical relationship with the **oropharynx** or tonsillar fossa, making it impossible to be involved in tonsillectomy hemorrhage.

Question 1

A child who underwent a tonsillectomy started bleeding while lying in the ward post-operatively. Which of the following is the most appropriate management step?

Accepted Answer

Take to OT, remove the clot & re-ligation

Answer

Conservative management

Answer

Take to OT & pressure packing

Answer

Cautery

Question 2

A 12-year-old presented with fever and difficulty swallowing. He had swelling in the marked region and was advised to undergo tonsillectomy. Post-surgery the gauze continued to soak with blood. Which of the following vessels must have been injured?

Accepted Answer

Paratonsillar vein

Answer

Ascending pharyngeal artery

Answer

Tonsillar branch of facial artery

Answer

Retromandibular vein

Question 3

What is the most common cause of deafness in a patient with Nasopharyngeal Carcinoma:

Accepted Answer

Fluid accumulation in the middle ear due to eustachian tube obstruction

Answer

Middle ear Infection

Answer

Metastasis to Temporal Bone

Answer

Infiltration of Tumour into middle ear

Question 4

What is the most common presentation of nasopharyngeal carcinoma?

Accepted Answer

Neck lymph node

Answer

Loss of smell

Answer

Blockage of nose

Answer

Blood tinged discharge

Question 5

A patient presented with 2 days history of fever. On examination there was a swelling in the neck and one side tonsil was pushed to midline. What is the most likely diagnosis:-

Accepted Answer

Quinsy

Answer

Retropharyngeal abscess

Answer

Parapharyngeal abscess

Answer

Tonsillitis

Question 6

A 15 years old Male presented with history of fever since 2 days, unable to swallow the food with muffled voice. On examination it is noted right tonsil is shifted to midline. What is the diagnosis:

Accepted Answer

Quincy

Answer

Acute tonsillitis

Answer

Parapharyngeal abscess

Answer

Acute retropharyngeal abscess

Question 7

A 6-year-old boy came to the hospital with complaints of sore throat and difficulty in swallowing. His left tonsil was pushed medially and had swelling over the left side upper part of neck. What will be the diagnosis?

Accepted Answer

Peritonsillar abscess

Answer

Ludwig's angina

Answer

Retropharyngeal abscess

Answer

Parapharyngeal abscess

Question 8

Angiofibroma bleeds profusely because:

Accepted Answer

Vessels lack a contractile component

Answer

It has multiple sites of origin

Answer

It lacks a capsule

Answer

None of the options

Question 9

Type of speech seen in nasopharyngeal carcinoma -

Accepted Answer

Rhinolalia clausa

Answer

Hot potato voice

Answer

Hoarse voice

Answer

Rhinolalia aperta

Question 10

Haemorrhage during tonsillectomy is usually from:

Accepted Answer

Paratonsillar vein

Answer

Facial artery

Answer

Ascending pharyngeal artery

Answer

Lingual artery

Diseases of the Pharynx — MCQs

Diseases of the Pharynx — MCQs

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