Diseases of the Pharynx Practice Questions

Q: Trotter's triad is seen in carcinoma of -

Nasopharynx. ***Nasopharynx*** - **Trotter's triad** is a classic presentation of **nasopharyngeal carcinoma**, especially when the tumor involves the fossa of Rosenmüller. - The triad consists of **unilateral conductive deafness** (due to Eustachian tube obstruction), **trigeminal neuralgia** (due to tumor involvement of the gasserian ganglion), and **soft palate paralysis**. *Larynx* - Laryngeal carcinoma typically presents with **hoarseness**, **dysphagia**, and **stridor**, not the specific triad described. - While it can involve cranial nerves, the characteristic combination of symptoms in Trotter's triad is not seen. *Ethmoid sinus* - Carcinoma of the ethmoid sinus usually causes symptoms like **nasal obstruction**, **epistaxis**, and **proptosis** if it extends into the orbit. - It does not typically present with conductive deafness, trigeminal neuralgia, or soft palate paralysis. *Maxilla* - Maxillary carcinoma often presents with **facial swelling**, **pain**, **nasal obstruction**, and dental symptoms. - While it can invade adjacent structures, Trotter's triad is not a typical presentation for this type of cancer.

Q: Tonsillectomy is typically indicated after how many episodes of quinsy (peritonsillar abscess)?

2. ***2*** - For recurrent quinsy (peritonsillar abscess), **tonsillectomy** is generally considered after **two documented episodes** to prevent further recurrences. - This recommendation is based on the increased likelihood of recurrence after a second episode, weighed against the risks and benefits of surgery. *12* - Waiting for 12 episodes of quinsy before considering tonsillectomy is **excessive** and would subject the patient to undue pain, discomfort, and potential complications from multiple infections. - Current guidelines recommend intervention much sooner for recurrent cases to improve patient quality of life and prevent severe outcomes. *4* - While 4 episodes might be considered in some contexts for recurrent tonsillitis, for **recurrent quinsy**, the threshold for tonsillectomy is typically lower due to the more severe nature and potential complications of abscess formation. - Four episodes would be an unnecessarily prolonged delay for a patient experiencing multiple peritonsillar abscesses. *6* - Similar to 4 episodes, 6 episodes of quinsy before tonsillectomy is **not standard practice** as it exceeds the typically recommended intervention threshold. - Prolonged recurrence of quinsy increases the risk of airway obstruction, deep neck space infection, and other serious complications.

Q: Interval tonsillectomy is done how long after quinsy drainage?

4-6 weeks. ***4-6 weeks*** - This interval allows for complete resolution of acute inflammation and edema from the **quinsy (peritonsillar abscess)**, making the surgery safer and reducing operative risks such as increased bleeding and difficulty with tissue planes. - Waiting 4-6 weeks after drainage ensures that the patient is in a healthier state for an elective procedure and minimizes the risk of infection spread during surgery. *2-3 weeks* - This period is generally too short for the complete resolution of the significant inflammation and infection associated with a quinsy. - Performing tonsillectomy too early could lead to increased intraoperative bleeding, difficulty identifying anatomical structures, and a higher risk of complications. *4-6 months* - While this period would certainly allow for full recovery, it is unnecessarily long as the benefits of interval tonsillectomy for recurrent or complicated quinsy are best realized earlier to prevent further episodes. - Waiting this long increases the risk of another episode of quinsy or other related tonsillar infections during the extended waiting period. *12 months* - This is an excessively long waiting period for an interval tonsillectomy following quinsy drainage. - Delays of this magnitude increase the likelihood of additional episodes of tonsillitis or peritonsillar abscesses, defeating the purpose of elective surgery to prevent recurrence.

Q: Treatment of choice for angiofibroma -

Surgery. ***Surgery*** - **Surgical excision** is considered the **gold standard** and primary treatment for **nasopharyngeal angiofibroma**, especially for localized and resectable tumors. - Complete removal aims to prevent tumor recurrence and alleviate symptoms like **epistaxis** and **nasal obstruction**. *Radiotherapy* - **Radiotherapy** is generally reserved for **recurrent** or **unresectable tumors**, or cases with **intracranial extension**. - It carries risks of side effects such as **growth retardation** and **secondary malignancies**, making it less favorable as a first-line treatment. *Combination of treatments (Surgery and Radiotherapy)* - A **combination** approach is typically utilized for **advanced-stage tumors** where complete surgical resection is challenging, or in cases of recurrence. - It is not the initial treatment for most angiofibromas, which often respond well to surgery alone. *Chemotherapy* - **Chemotherapy** has **limited efficacy** in the treatment of angiofibroma due to the tumor's benign nature and its primary vascular composition. - It is rarely used, even in recurrent or advanced cases, as other modalities like surgery or radiotherapy are more effective.

Q: Nasopharyngeal carcinoma causes deafness by:

Serous effusion. ***Serous effusion*** - **Nasopharyngeal carcinoma** commonly obstructs the **Eustachian tube opening** in the nasopharynx - This obstruction prevents proper ventilation of the middle ear, leading to **accumulation of serous fluid** in the middle ear cavity - Results in **conductive hearing loss**, which is the **most common mechanism** of deafness from the tumor itself - This is often an **early presenting symptom** of nasopharyngeal carcinoma *Metastasis to temporal bone* - While nasopharyngeal carcinoma can metastasize, direct metastasis to the temporal bone is **much less common** than Eustachian tube obstruction - Would typically present with more severe neurological symptoms beyond isolated hearing loss *Radiation therapy* - Radiation therapy is a **treatment complication**, not a mechanism by which the **tumor itself** causes deafness - Can cause **sensorineural hearing loss** due to cochlear damage, but this is a side effect of treatment, not the carcinoma's direct effect *Direct infiltration of middle ear* - Direct tumor invasion of the middle ear occurs in **advanced stages** and is less common than functional Eustachian tube obstruction - **Early-stage hearing loss** from nasopharyngeal carcinoma is primarily due to Eustachian tube dysfunction, not direct infiltration

Q: Dohlman surgery in Zenker's diverticulum is:-

Endoscopic electrocautery technique. ***Endoscopic electrocautery technique*** - The **Dohlman procedure** (Dohlman-Mattsson procedure, 1960) is an **endoscopic electrosurgical technique** that uses **diathermy/electrocautery** to divide the cricopharyngeal muscle (the septum between the esophagus and the diverticulum). - This method creates a common cavity between the esophagus and the diverticulum, allowing food to pass freely and preventing pooling. - It is one of the **classic endoscopic approaches** for treating Zenker's diverticulum and remains widely used. *Endoscopic suturing of pouch* - Endoscopic suturing is not the primary technique for the Dohlman procedure. - The goal is to **divide the septum**, not to suture or reduce the pouch itself. *Laser division of pouch* - **Laser division** of the cricopharyngeal muscle is another endoscopic approach, often called **endoscopic laser diverticulostomy**. - While effective, this is a **different technique** from the Dohlman procedure, which specifically uses electrocautery. *Endoscopic stapling of septum* - **Endoscopic stapling** (using an endoscopic stapler to divide the septum) is associated with the **Collard-Peracchia technique** or endoscopic stapling diverticulostomy. - While this is a modern and effective approach, it is **not the Dohlman procedure**, which historically and traditionally refers to the electrocautery technique.

Q: A 3-year-old boy presents with fever, throat pain, and difficulty swallowing. On examination, there is unilateral tonsillar swelling with deviation of the uvula. What is the most likely diagnosis?

Peritonsillar abscess. ***Peritonsillar abscess*** - This is the most common deep neck infection and typically presents with **unilateral tonsillar swelling**, **uvular deviation**, fever, and severe sore throat with difficulty swallowing (dysphagia) or speaking (muffled voice). - It usually develops as a complication of **acute tonsillitis**, where infection spreads from the tonsil into the peritonsillar space. *Parapharyngeal abscess* - While it can cause fever and severe throat pain, it typically presents with **trismus**, neck swelling below the angle of the mandible, and medial displacement of the lateral pharyngeal wall, rather than direct uvula deviation. - This type of abscess is located in the **parapharyngeal space**, which is lateral to the pharynx, and causes more diffuse swelling. *Ludwig's angina* - This is a rapidly spreading cellulitis of the **submandibular** and **sublingual spaces** and does not primarily involve the tonsils or cause uvular deviation. - Patients typically present with **symmetrical submental swelling**, painful swallowing, and tongue elevation, which can lead to airway obstruction. *Retropharyngeal abscess* - This abscess forms in the space behind the posterior pharyngeal wall and is more common in young children. - It often causes **neck stiffness**, muffled voice, stridor, and difficulty breathing, but less commonly presents with unilateral tonsillar swelling and uvular deviation.

Q: A 70 year old patient presented with history of fever, repeated aspiration and coughing in the night. On examination there is a swelling on left side of neck which produces gurgling sound on compression. Following is the barium swallow study of the patient. What is the most likely diagnosis?

Zenker's diverticulum. ***Zenker's diverticulum*** - The patient's symptoms of **fever**, **repeated aspiration**, and **coughing at night** are classic for a Zenker's diverticulum, particularly in an older patient. - The presence of a **neck swelling** producing a **gurgling sound on compression** (Boyce's sign) is highly indicative of a Zenker's diverticulum, which is essentially a pharyngeal pouch. The barium swallow image likely shows contrast pooling in such a pouch. *Plummer Vinson syndrome* - Characterized by **dysphagia**, **iron-deficiency anemia**, and **esophageal webs**. - While it causes dysphagia, it does not typically present with a gurgling neck swelling or significant aspiration as described. *Dysphagia Lusoria* - This is a rare condition caused by an **aberrant right subclavian artery** compressing the esophagus. - It primarily causes dysphagia due to extrinsic compression, without the associated neck swelling, gurgling sound, or significant aspiration risk from food pooling within a diverticulum. *Laryngocoele* - A laryngocele is an **abnormal sac** or pouch that arises from the **laryngeal ventricle** and may extend externally, presenting as a neck swelling. - While it can cause a neck swelling, it is **air-filled**, not fluid or food-filled, and therefore would not typically produce a gurgling sound on compression or be clearly visible on a barium swallow as a contrast-filled pouch like in the image provided.

Q: A 13-year-old boy presents with right-sided nasal obstruction and recurrent epistaxis for the past 6 months. What is the most likely diagnosis?

JNA. ***JNA (Juvenile Nasopharyngeal Angiofibroma)*** - **Classic presentation**: Adolescent male with **unilateral nasal obstruction** and **recurrent, often profuse epistaxis** - JNA is a **highly vascular benign tumor** that predominantly affects males aged 10-18 years - Though benign, it is **locally aggressive** and can extend into adjacent structures (orbit, skull base) - The combination of age, gender, unilateral symptoms, and recurrent epistaxis makes this the most likely diagnosis *Coagulation disorder* - Would cause **generalized bleeding tendencies**, not localized unilateral nasal obstruction - Epistaxis would typically be **bilateral** and associated with other bleeding manifestations (easy bruising, gum bleeding, prolonged bleeding from cuts) - No mass effect or persistent obstruction would be expected - Other systemic bleeding signs are absent in this presentation *Antrochoanal polyp* - **Benign inflammatory lesion** originating from maxillary sinus, extending through ostium into choana - Can cause nasal obstruction but epistaxis is **much less common and less severe** than in JNA - More commonly associated with **chronic sinusitis symptoms** (rhinorrhea, postnasal drip, facial pressure) - Less vascular than JNA, so recurrent profuse epistaxis would be unusual *Allergic rhinitis* - Characterized by **bilateral symptoms**: nasal obstruction, sneezing, rhinorrhea, and nasal itching - Often has **seasonal pattern** or clear allergen triggers - May cause minor epistaxis from mucosal irritation, but not the **severe recurrent epistaxis** seen here - **Unilateral** persistent obstruction would be atypical for allergic rhinitis

Q: A 25-year-old woman presents with severe throat pain, difficulty swallowing, and trismus. CT neck shows a peritonsillar fluid collection and inflammation. What is the next best step?

Needle aspiration and antibiotics. ***Needle aspiration and antibiotics*** - The presence of a **peritonsillar fluid collection** on CT neck, along with severe throat pain, **dysphagia**, and **trismus**, is indicative of a **peritonsillar abscess (PTA)**. - **Needle aspiration** provides immediate relief by draining the pus and allows for culture-guided antibiotic therapy, while broad-spectrum **antibiotics** address the bacterial infection. *Immediate tonsillectomy* - **Tonsillectomy** is generally reserved for recurrent peritonsillar abscesses or chronic tonsillitis, not as the primary immediate treatment for an acute PTA. - Doing so acutely carries a higher risk of complications due to the **inflammation** and potential compromise of the airway. *Oral corticosteroids* - While corticosteroids can reduce inflammation and pain, they do not resolve the underlying bacterial infection or drain the **pus collection**. - Using **corticosteroids alone** risks worsening the infection by masking symptoms without treating the cause. *Empirical antibiotics alone* - Although antibiotics are crucial for treating the bacterial infection, they may not be sufficient on their own to resolve a **frank abscess**, especially one causing significant symptoms. - **Drainage** is often necessary to achieve clinical improvement and prevent complications such as airway obstruction or spread of infection.

Question 1

Trotter's triad is seen in carcinoma of -

Accepted Answer

Nasopharynx

Answer

Larynx

Answer

Ethmoid sinus

Answer

Maxilla

Question 2

Tonsillectomy is typically indicated after how many episodes of quinsy (peritonsillar abscess)?

Accepted Answer

2

Answer

12

Answer

4

Answer

6

Question 3

Interval tonsillectomy is done how long after quinsy drainage?

Accepted Answer

4-6 weeks

Answer

2-3 weeks

Answer

4-6 months

Answer

12 months

Question 4

Treatment of choice for angiofibroma -

Accepted Answer

Surgery

Answer

Radiotherapy

Answer

Combination of treatments (Surgery and Radiotherapy)

Answer

Chemotherapy

Question 5

Nasopharyngeal carcinoma causes deafness by:

Accepted Answer

Serous effusion

Answer

Metastasis to temporal bone

Answer

Radiation therapy

Answer

Direct infiltration of middle ear

Question 6

Dohlman surgery in Zenker's diverticulum is:-

Accepted Answer

Endoscopic electrocautery technique

Answer

Endoscopic suturing of pouch

Answer

Laser division of pouch

Answer

Endoscopic stapling of septum

Question 7

A 3-year-old boy presents with fever, throat pain, and difficulty swallowing. On examination, there is unilateral tonsillar swelling with deviation of the uvula. What is the most likely diagnosis?

Accepted Answer

Peritonsillar abscess

Answer

Parapharyngeal abscess

Answer

Ludwig's angina

Answer

Retropharyngeal abscess

Question 8

A 70 year old patient presented with history of fever, repeated aspiration and coughing in the night. On examination there is a swelling on left side of neck which produces gurgling sound on compression. Following is the barium swallow study of the patient. What is the most likely diagnosis?

Accepted Answer

Zenker's diverticulum

Answer

Plummer vinson syndrome

Answer

Dysphagia Lusoria

Answer

Laryngocoele

Question 9

A 13-year-old boy presents with right-sided nasal obstruction and recurrent epistaxis for the past 6 months. What is the most likely diagnosis?

Accepted Answer

JNA

Answer

Coagulation disorder

Answer

Antrochoanal polyp

Answer

Allergic rhinitis

Question 10

A 25-year-old woman presents with severe throat pain, difficulty swallowing, and trismus. CT neck shows a peritonsillar fluid collection and inflammation. What is the next best step?

Accepted Answer

Needle aspiration and antibiotics

Answer

Immediate tonsillectomy

Answer

Oral corticosteroids

Answer

Empirical antibiotics alone

Diseases of the Pharynx — MCQs

Diseases of the Pharynx — MCQs

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