Diseases of the Pharynx Practice Questions

Q: All of the following are indications for tonsillectomy except?

Foreign body in tonsils. ### Explanation The correct answer is **A. Foreign body in tonsils**. **1. Why "Foreign body in tonsils" is the correct answer:** A foreign body (like a fish bone) lodged in the tonsil is an **acute emergency** managed by simple **removal** using forceps under direct vision or endoscopy. Tonsillectomy is an invasive surgical procedure and is not indicated for the simple removal of a foreign body unless the object is deeply embedded and inaccessible, which is rare. **2. Analysis of Incorrect Options:** * **Unilateral enlargement of tonsils (B):** This is a **mandatory indication** for tonsillectomy to rule out malignancy (e.g., Lymphoma or Squamous Cell Carcinoma), especially in adults. * **Keratosis Pharyngis/Keratin tonsil (C):** While often asymptomatic, if the keratotic patches (hard, white horny projections) cause persistent irritation, foreign body sensation, or cough, tonsillectomy is indicated as a definitive treatment. * **Recurrent Quinsy (D):** A history of **two or more episodes** of peritonsillar abscess (Quinsy) is a strong relative indication for tonsillectomy, usually performed 4–6 weeks after the infection subsides ("Interval Tonsillectomy"). **3. NEET-PG High-Yield Pearls:** * **Paradise Criteria:** The gold standard for recurrent tonsillitis: 7 episodes in 1 year, 5 per year for 2 years, or 3 per year for 3 years. * **Most common indication (Overall):** Recurrent tonsillitis. * **Most common indication (Children):** Obstructive Sleep Apnea (OSA) due to adenotonsillar hypertrophy. * **Eagle’s Syndrome:** Elongated styloid process causing throat pain; tonsillectomy is part of the surgical approach (trans-oral) to excise the process. * **Absolute Contraindications:** Uncontrolled bleeding disorders, acute infection (unless "Tonsillectomy à chaud"), and hemoglobin <10 g/dL.

Q: A 45-year-old patient presents with conductive hearing loss, facial pain in the temporoparietal and lower jaw areas, and an immobile soft palate on the right side. What is the probable diagnosis?

Trotter's syndrome. ### Explanation **Trotter’s Syndrome** (also known as the Sinus of Morgagni Syndrome) is a clinical triad (or tetrad) resulting from the lateral extension of a **Nasopharyngeal Carcinoma (NPC)**. The clinical features in this patient are explained by the local infiltration of the tumor: 1. **Conductive Hearing Loss:** Due to the infiltration of the Eustachian tube orifice, leading to Eustachian tube dysfunction and subsequent serous otitis media (glue ear). 2. **Facial Pain (Temporoparietal/Lower Jaw):** Caused by the involvement of the **Mandibular nerve (V3)** as it exits the Foramen Ovale. 3. **Immobile Soft Palate:** Due to the infiltration of the **Levator Veli Palatini** muscle (ipsilateral palatal palsy). 4. *Note: Trismus (due to pterygoid muscle involvement) is often considered the fourth component.* --- ### Analysis of Incorrect Options: * **A. Sluder’s Neuralgia:** Also known as Sphenopalatine ganglion neuralgia. It presents with lower facial pain and autonomic symptoms (rhinorrhea, lacrimation) but does not cause hearing loss or palatal palsy. * **B. Costen’s Syndrome:** This refers to Temporomandibular Joint (TMJ) dysfunction. While it causes facial pain and ear fullness, it lacks the neurological deficit of an immobile soft palate. * **C. Wallenberg’s Syndrome:** (Lateral Medullary Syndrome) A neurological condition caused by PICA occlusion. It presents with dysphagia, ataxia, and sensory loss, but not conductive hearing loss or V3 distribution pain. --- ### High-Yield Clinical Pearls for NEET-PG: * **Most common site of NPC:** Fossa of Rosenmüller. * **Etiology:** Strongly associated with **Epstein-Barr Virus (EBV)**. * **Earliest Symptom:** Often unilateral serous otitis media in an adult (always rule out NPC in such cases). * **Most common presenting sign:** Level II (Upper deep cervical) lymphadenopathy. * **Treatment of Choice:** Radiotherapy (NPC is highly radiosensitive).

Q: Which of the following is NOT a contraindication for tonsillectomy?

Cleft lip. **Explanation:** The correct answer is **Cleft lip**. To answer this question correctly, it is essential to distinguish between conditions that pose a surgical risk and those that are unrelated to the surgical site or function. **1. Why Cleft Lip is NOT a contraindication:** A **Cleft Lip** is a cosmetic and functional deformity of the lip and does not involve the palate or the oropharyngeal sphincter. Therefore, removing the tonsils does not affect the speech or swallowing mechanism in these patients. In contrast, a **Cleft Palate** (or Submucous Cleft Palate) is a significant contraindication because the tonsils act as a compensatory mechanism to help close the oropharyngeal isthmus; removing them can lead to **Velopharyngeal Insufficiency (VPI)** and hypernasal speech. **2. Analysis of Incorrect Options (Contraindications):** * **Polio Epidemic:** Tonsillectomy during an epidemic is contraindicated because the surgical trauma provides a portal of entry for the virus, significantly increasing the risk of **Bulbar Poliomyelitis**. * **Hemophilia:** Bleeding disorders (including leukemia, purpura, and hemophilia) are absolute contraindications unless the deficiency is corrected, as tonsillectomy is a highly vascular procedure. * **Acute Infection:** Surgery is avoided during an acute episode of tonsillitis (usually for 3–4 weeks) because the tissues are hyperemic and friable, leading to a high risk of **primary and reactionary hemorrhage**. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindication:** Uncontrolled systemic diseases (e.g., uncontrolled DM, severe hypertension). * **The "Hot" Tonsillectomy:** This refers to tonsillectomy performed during an acute peritonsillar abscess (Quinsy). * **Most common complication:** Hemorrhage (Reactionary is within 24 hours; Secondary is between 5–10 days, usually due to infection).

Q: Plica triangularis is present in which anatomical location?

Antero-inferior part of the tonsil. **Explanation:** The **Plica triangularis** is a triangular fold of mucous membrane that extends backwards from the **palatoglossal arch** (anterior pillar) across the **antero-inferior** part of the palatine tonsil. 1. **Why Option A is correct:** During fetal development, the tonsil develops from the second pharyngeal pouch. The plica triangularis is a vestigial remnant of the caudal part of the fetal tonsil. In adults, it often becomes fibrous and fuses with the tonsil, forming a pocket that can trap debris (detritus), potentially leading to tonsilloliths or recurrent tonsillitis. 2. **Why Options B and C are incorrect:** * **Dorsum of the tongue:** This area contains various papillae (circumvallate, filiform, fungiform) and the lingual tonsil, but not the plica triangularis. * **Inlet of the larynx:** This region is characterized by the epiglottis, aryepiglottic folds, and piriform fossae. A similar-sounding structure, the *Plica ventricularis* (false vocal cord), is found within the larynx, but not the plica triangularis. **High-Yield Clinical Pearls for NEET-PG:** * **Plica Semilunaris:** A similar mucosal fold located at the **upper pole** (superior part) of the tonsil, crossing the supratonsillar fossa. * **Quinsy (Peritonsillar Abscess):** Pus typically collects in the **supratonsillar fossa**, which is bounded by these mucosal folds. * **Blood Supply:** The main artery of the tonsil is the **tonsillar branch of the facial artery**, which enters at the lower pole. * **Surgical Importance:** During tonsillectomy, the plica triangularis is incised to mobilize the tonsil from its bed.

Q: What is a potential consequence of a nasopharyngeal tumor?

Trotter's syndrome.. **Explanation:** **Trotter’s Syndrome** (also known as the Sinus of Morgagni Syndrome) is a classic clinical triad associated with the lateral spread of a **Nasopharyngeal Carcinoma (NPC)**. The tumor infiltrates the parapharyngeal space, leading to three specific features: 1. **Ipsilateral Conductive Hearing Loss:** Due to Eustachian tube blockage causing serous otitis media. 2. **Ipsilateral Palatal Paralysis:** Due to involvement of the Vagus (X) nerve or the Levator veli palatini muscle. 3. **Ipsilateral Temporofacial Neuralgia:** Due to involvement of the Mandibular nerve (V3) as it exits the Foramen Ovale, causing pain in the lower jaw and tongue. **Analysis of Incorrect Options:** * **Horner’s Syndrome:** Caused by damage to the cervical sympathetic chain. While advanced NPC can cause this via nodal metastasis, it is not a specific "syndrome" defining the tumor's local spread like Trotter’s. * **Eagle’s Syndrome:** Characterized by an elongated styloid process or calcified stylohyoid ligament, leading to recurrent throat pain and dysphagia. * **Frey’s Syndrome:** Also known as auriculotemporal syndrome; it involves gustatory sweating following parotid surgery, caused by misdirected autonomic nerve fibers. **NEET-PG High-Yield Pearls:** * **Most common site of NPC:** Fossa of Rosenmüller. * **EBV Association:** Nasopharyngeal carcinoma is strongly linked to the Epstein-Barr Virus. * **Clinical Triad of Trotter’s:** 1. Hearing loss, 2. Palatal palsy, 3. V3 Neuralgia. * **Early Sign:** The earliest sign of NPC is often an asymptomatic level II (upper jugulodigastric) lymph node enlargement.

Q: What is the investigation of choice for Zenker's diverticulum?

Barium Swallow. **Explanation:** **Zenker’s Diverticulum** (Pharyngeal Pouch) is a pulsion diverticulum occurring through **Killian’s dehiscence**, a weak muscular area between the thyropharyngeus and cricopharyngeus parts of the inferior constrictor muscle. **Why Barium Swallow is the Investigation of Choice:** Barium swallow is the gold standard because it clearly outlines the size, shape, and position of the pouch. It typically reveals a "flask-shaped" or "club-shaped" sac filled with contrast, located posteriorly at the level of the C5-C6 vertebrae. It is non-invasive and provides a definitive diagnosis without the risks associated with instrumentation. **Analysis of Incorrect Options:** * **Endoscopy:** This is generally **contraindicated** as the initial investigation. The endoscope can easily enter the diverticulum instead of the esophagus, leading to an accidental **perforation**, as the pouch is thin-walled and lacks a muscular layer. * **Esophageal Manometry:** While it may show incoordination of the upper esophageal sphincter, it is technically difficult to perform in these patients and is not used for primary diagnosis. * **CECT:** While CT can show a fluid-filled sac, it is not as sensitive or specific as a dynamic barium study for visualizing the diverticulum's anatomy. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Dysphagia, halitosis (foul breath due to undigested food), and regurgitation. * **Boyce’s Sign:** A gurgling sound heard on pressing the side of the neck. * **Treatment of Choice:** Endoscopic Dohlman’s procedure (Stapling/Laser) or external diverticulectomy with cricopharyngeal myotomy. * **Complication:** Recurrent aspiration pneumonia is the most common serious complication.

Q: Which of the following is false about sideropenic dysphagia?

Pre-cricoid webs. **Sideropenic Dysphagia**, also known as **Plummer-Vinson Syndrome** (in the US) or **Paterson-Brown-Kelly Syndrome** (in the UK), is a classic triad of iron-deficiency anemia, glossitis, and esophageal webs. ### Explanation of Options: * **Option B (Correct Answer):** The statement is false because the webs in this condition are **post-cricoid**, not pre-cricoid. They are typically found at the junction of the hypopharynx and the upper esophagus. * **Option A:** This is a true statement. It is considered a **pre-malignant** condition. Chronic irritation and mucosal atrophy predispose patients to **Squamous Cell Carcinoma** of the post-cricoid region and upper esophagus. * **Option C:** This is a true statement. "Sideropenic" refers to iron deficiency. Patients present with microcytic hypochromic **anemia**, often accompanied by spoon-shaped nails (koilonychia). * **Option D:** This is a true statement. The condition classically affects **middle-aged (perimenopausal) women**, with a female-to-male ratio of approximately 9:1. ### High-Yield Clinical Pearls for NEET-PG: * **The Triad:** Iron deficiency anemia + Dysphagia + Post-cricoid webs. * **Clinical Features:** Glossitis (smooth red tongue), angular cheilitis, and koilonychia. * **Diagnosis:** **Barium Swallow** is the investigation of choice to visualize the thin, mucosal webs (best seen in the lateral view). * **Treatment:** Iron supplementation (often resolves the dysphagia) and endoscopic dilatation if the web is significant. * **Follow-up:** Essential due to the high risk of post-cricoid malignancy.

Question 1

What is the standard surgical approach for glossopharyngeal neurectomy?

Accepted Answer

Tonsillectomy approach

Answer

Transpalatal approach

Answer

Transmandibular approach

Answer

Transpharyngeal approach

Question 2

All of the following are indications for tonsillectomy except?

Accepted Answer

Foreign body in tonsils

Answer

Unilateral enlargement of tonsils with suspected malignancy

Answer

Keratin tonsil

Answer

Recurrent quinsy

Question 3

A 45-year-old patient presents with conductive hearing loss, facial pain in the temporoparietal and lower jaw areas, and an immobile soft palate on the right side. What is the probable diagnosis?

Accepted Answer

Trotter's syndrome

Answer

Sluder's neuralgia

Answer

Costen's syndrome

Answer

Wallenberg's syndrome

Question 4

Which of the following is NOT a contraindication for tonsillectomy?

Accepted Answer

Cleft lip

Answer

Polio epidemic

Answer

Hemophilia

Answer

Acute infection of tonsils

Question 5

Plica triangularis is present in which anatomical location?

Accepted Answer

Antero-inferior part of the tonsil

Answer

Dorsum of the tongue

Answer

Inlet of the larynx

Answer

None of the above

Question 6

A 70-year-old male presents with hearing loss and tinnitus. On examination, he was observed to have a conductive type of deafness and a dull tympanic membrane on the right side. Lymph nodal enlargement of 3 × 3 cm was noted in the posterior triangle of the neck. Tympanogram revealed a type B wave. What is the most likely diagnosis?

Accepted Answer

Nasopharyngeal malignancy

Answer

Middle ear tumor

Answer

Acoustic neuroma

Answer

Tuberculosis of the middle ear

Question 7

What is a potential consequence of a nasopharyngeal tumor?

Accepted Answer

Trotter's syndrome.

Answer

Horner's syndrome.

Answer

Eagles syndrome.

Answer

Frey's syndrome.

Question 8

What is the investigation of choice for Zenker's diverticulum?

Accepted Answer

Barium Swallow

Answer

CECT

Answer

Endoscopy

Answer

Esophageal manometry

Question 9

Unilateral posterior pharyngeal wall swelling is due to which of the following?

Accepted Answer

Acute retropharyngeal abscess

Answer

Peritonsillar abscess

Answer

Prevertebral abscess

Answer

Parapharyngeal abscess

Question 10

Which of the following is false about sideropenic dysphagia?

Accepted Answer

Pre-cricoid webs

Answer

Pre-malignant potential

Answer

Associated with anemia

Answer

Common in perimenopausal women

Diseases of the Pharynx — MCQs

Diseases of the Pharynx — MCQs

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