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1. Regarding the tonsil, all of the followings are true except:
A. Palatoglossus lies anterior to the tonsil.
B. The tonsil is supplied by the tonsillar artery, a branch of the facial artery.
C. The internal carotid artery lies 2.5cm behind and lateral to the tonsil.
D. Contains 20 crypts.
E. Lymph drains to the upper deep cervical & jugulodigastric lymph nodes.
2. A 66 year old Chinese man presents with a two month history of neck swelling in the right posterior triangle. On further questioning he tells you that his hearing has also declined in the right ear. He also has a blocked nose. What is the likely diagnosis?
A. Lymphoma.
B. Metastatic lymph node from a nasopharyngeal carcinoma.
C. Parotid tumour.
D. Lipoma
E. Metastatic lymph node from a oropharyngeal carcinoma.
3. A 21 year old woman presents with two day history of sore throat aND dysphagia. On examination she is pyrexial with halitosis and cervical lymphadenopathy. What is the likely causative organism for her condition?
A. Epstein-Barr virus.
B. Agranulocytosis.
C. Corynebacterium diphtheriae.
D. Neisseria gonorrhoea.
E. Group A beta-haemolytic streptococcus (Streptococcus pyogenes).
4. Juvenile angiofibroma:
A. Patients have often had repeated episodes of epistaxis.
B. It is a tumour of young girls with a mean age of 14 at presentation.
C. Bone erosion of the greater wing of the sphenoid does not occur.
D. Secretary otitis media does not occur.
E. External beam radiotherapy is first line treatment.
5. A 55 year old man presents with a three month history of swelling on the rightBside of the neck, which has gradually increased in size. He has also been having earache and throat pain for the last two weeks. He tells you that the pain in her ear is so severe that he cannot sleep at night. He has no other symptoms. He is otherwise fit and well. He smokes 10 cigarettes per day and drinks 15 units of alcohol per week. Examination of the neck reveals a 4 cm x 4 cm firm, mobile, non-fluctuant, and non-pulsatile swelling on the right side of the neck. The overlying skin is normal and the mass is not attached to the skin. ENT examination is normal.
A. Branchial cyst.
B. Malignant node containing squamous cell carcinoma.
C. Infective lymph node.
D. Submandibular gland stone.
E. Non-Hodgkin lymphoma.
6. Stridor:
A. It is only a symptom not a sign.
B. Recession of suprasternal, supraclavicular, intercostal and subcostal space
indicate mild form of respiratory difficulty.
C. Cyanosis indicate early stage.
D. Hemangioma can only be congenital.
E. It is never a diagnosis nor a disease.
7. A 27 year old female patient presented with painful and difficulty swallowing, on indirect laryngoscopy, there is pooling of saliva in right pyriform sinus with swollen right arytenoid, the most likely diagnosis is:
A. Adenocarcinoma of pyriform sinus.
B. Squamous cell carcinoma of pyriform sinus.
C. Squamous cell carcinoma of posterior pharyngeal wall.
D. Squamous cell carcinoma of larynx.
E. Squamous cell carcinoma of Postcricoid.
8. The first postoperative day, tonsillectomy fossa is:
A. Red colour.
B. Black colour.
C. Yellow colour.
D. White colour.
E. Flesh colour.
9. Stage ІІІ squamous cell carcinoma of oropharynx is:
A. Metastatic disease.
B. Locally advanced disease.
C. Tumour present in lymph nodes.
D. Best treated by radiotherapy.
E. Best treated by chemotherapy.
10. Palliative treatment of advanced head and neck malignant tumours involves all of the following except:
A. Gastrostomy.
B. Tracheostomy.
C. Pain killers.
D. Nausea and vomiting typically controlled using cyclizine.
E. Antibiotics to treat infections.
11. Radiotherapy is the treatment of choice for:
A. Nasopharyngeal carcinoma.
B. Stage ІІІ squamous cell carcinoma of larynx.
C. Nasopharyngeal adenocarcinoma.
D. Oropharyngeal carcinoma.
E. Hypopharyngeal adenocarcinoma.
12. Commando operation may be used for the treatment of:
A. Nasopharyngeal carcinoma.
B. Stage ІІІ squamous cell carcinoma of larynx.
C. Nasopharyngeal adenocarcinoma.
D. Oropharyngeal carcinoma.
E. Hypopharyngeal carcinoma.
13. All of the following may cause tonsillar ulceration except:
A. Diphtheria.
B. Behget’s syndrome.
C. Vincent’s angina.
D. Agranulocytosis.
E. Papilloma.
14. Early post-tonsillectomy complications include all of the following except:
A. Oedema of uvula.
B. Secondary bleeding.
C. Pneumonia.
D. Referred otalgia.
E. Anaesthetic complications.
15. All of the following are true regarding adenoids except:
A. Produces IgM.
B. Attain maximal size between the ages 3 and 8.
C. Produces IgA.
D. Produces IgG.
E. Produces IgD.
16. Laryngomalacia:
A. The larynx is of an exaggerated adult type.
B. The epiglottis is long and wide and folded backward at each lateral edge.
C. The epiglottis is converted into a delta shaped incomplete cylinder.
D. The glossopharyngeal folds are approximated .
E. None of the above.
17. All are causes of congenital strider except:
A. Acute epiglottitis.
B. Laryngeal web.
C. Subglottic stenosis.
D. Laryngomalacia.
E. Vascular anomaly.
18. Trauma to posterior pillar during tonsillectomy causes:
A. Trismus.
B. Bleeding.
C. Infection.
D. Nasal regurgitation.
E. Ankyloglossia.
19. During a hunting trip a bullet affect one of the hunters in his neck by accident, he developed neck swelling and hoarsed voice, what could be the cause of his voice change:
A. Unilateral vocal cord palsy.
B. Bilateral vocal cord palsy.
C. Laryngeal oedema.
D. All the above.
E. None of the above.
20. Which of the following is part of laryngopharynx:
A. Epiglottis.
B. Cricoids cartilage.
C. Thyroid cartilage.
D. Postcricoid.
E. Arytenoids.
21. Absolute indication of tonsillectomy is:
A. Chronic tonsillitis.
B. Diptheria carrier.
C. Obstructive sleep apnoea .
D. Glassopharyngeal neurectomy.
E. Rheumatic fever.
22. Which of the following is not a complication of acute tonsillitis?
A. Peritonsillar abscess.
B. Bezold’s abscess.
C. Acute rheumatism.
D. Acute nephritis.
E. Acute infection of middle ear cleft.
23. Pyriform fossa lies:
A. Medial to aryepiglottic fold.
B. Lateral to aryepiglottic fold.
C. Inferior to aryepiglottic fold.
D. Superior to aryepiglottic fold.
E. None of the above.
24. A new born baby presented with weak cry and hoarseness, the most probable diagnosis:
A. Laryngomalacia.
B. Subglotic stenosis.
C. Subglotic heamangioma.
D. Vocal cord palsy.
E. Tracheomalacia.
25. Which of the following is not a feature of pharyngeal diphtheria?
A. Enlarged tender cervical lymph nodes.
B. Pyrexia.
C. True membrane.
D. Toxaemia.
E. Bull's neck.
26. Which of the following is not true regarding acute reteropharyngeal abscess:
A. It is common in children.
B. Produces difficulty in breathing and suckling.
C. It is limited to one side of the midline.
D. Incision and drainage is done from outside through carotid sheath.
E. It forms due to suppuration in reteropharyngeal lymph node
27. A 60- year-old man presents to the clinic with a 5 cm solitary lymph node in the upper right cervical region and an abnormal-looking right tonsil. Assuming this is a squamous cell carcinoma nodal metastasis, what is the N classification?
A. N1.
B. N2a.
C. N2b.
D. N2c.
E. N3.
28. Subglottic edema can prove fatal in a child because:
A. Mucosa is lax .
B. Mucosa is poorly adherent.
C. Larynx is comparatively small.
D. Subepithelial tissue is lax.
E. All the above.
29. A 70- year-old smokers presents to the ENT clinic with a 3-month history of dysphagia and weight loss. Flexible nasoendoscopy shows pooling of saliva in the pyriform fossae, with restricted mobility of the right hemi-larynx. Malignancy is suspected. You proceed to general anaesthetic endoscopy. At surgery, you find that he has a 3 cm tumour affecting the right pyriform fossa and extending into post-cricoid region. According to the TMN staging, what T- stage is this malignancy?
A. T1.
B. T2.
C. T2B.
D. T3.
E. T4.
30. A 20- year-old man presents to the ENT clinic with sudden onset high fever of one day duration, on examination: both tonsils are congested with whitish membrane over the right tonsil with petichae over the palate and palpable both jugulodiagastric lymph nodes. What is the most possible diagnosis?
A. Acute membranous tonsillitis.
B. Infectious mononucleosis.
C. Diphtheria.
D. Quinsy.
E. Leukaemia.
31. The least complication of tonsillectomy is:
A. Haemorrhage.
B. Pneumonia.
C. Lung abscess.
D. Atelactesis.
E. Subacute bacterial endocarditis.
32. All are functions of the larynx except:
A. To protect the lungs.
B. To control air flow.
C. Phonation.
D. Generation of speech.
E. To build positive intrathoracic pressure.
33. Stridor:
A. It is an auditory manifestation of disordered respiratory function due to air flow changes within the larynx, trachea, or bronchi.
B. It needs investigations in every case.
C. It is due to turbulence of air flow within a partially obstructed respiratory tract.
D. It can be described in terms of its relationship to the phase of respiratory
cycle.
E. All the above.
34. The most common site of malignant tumours of hypopharynx is:
A. Postcricoid.
B. Cricoids cartilage.
C. Posterior pharyngeal wall.
D. Piriform sinus.
E. Aryepiglottic fold.
35. Which of the following is not true about nasopharyngeal cancer?
A. Metastasizes to cervical lymph nodes.
B. Causes unilateral serous otitis media.
C. Treatment of choice is radiotherapy.
D. EB virus is responsible.
E. Most common nerve involved is vagus.
36. Trismus accompanying quinsy is due to spasm of which muscle?
A. Masseter.
B. Pharyngeal constrictors.
C. Medial pterygoid.
D. Temporalis.
E. Palatopharyngeus.
37. Lymphoid tissue called Waldeyerʼs ring is situated in:
A. Nasopharynx.
B. Upper tow parts of the pharynx.
C. Oropharynx.
D. Base of tongue.
E. Hypopharynx.
38. A 15-year-old has unilateral nasal obstruction, mass in the cheek and recurrent epistaxis, the diagnosis is:
A. Cancer of nasopharynx.
B. Inverted papilloma nose.
C. Maxillary sinusitis.
D. Bleeding tendency.
E. Angiofibroma.
39. A three year old mongol boy get high fever then associated with difficult swallowing and strider, the child was sitting, cannot sleep and drooling saliva, the resident pediatrician sent for lateral cervical X-ray then he asked your opinion about what was looking as a thumb in front of the hypopharynx, your diagnosis was:
A. Acute pharyngitis.
B. Acute simple laryngitis.
C. Laryngo-tracheo-bronchitis.
D. Acute epiglottitis.
E. Croup.
40. What is not correct in acute epiglottitis?
A. Constant supervision in hospital is mandatory.
B. Dyspnea may be progressing and alarming.
C. It is a special form of acute laryngitis, in which the inflammatory changes affect mainly the loosely attached mucosa of the epiglottis.
D. Systemic antibiotics is not a must to be started immediately.
E. Age incidence is between 1-6 year old.
41. The mouth:
A. Extends from the incisor teeth to the oropharynx.
B. Contain three salivary glands.
C. Separated from the oropharynx by an anatomical barrier.
D. Consists from two main parts only.
E. The valecula is part of its floor.
42. What is wrong about the pharynx?
A. Extends from base of the skull to the sixth cervical vertebra at upper border of the cricoid cartilage.
B. It is the upper part of the respiratory tract.
C. It is the upper part of the digestive tract.
D. About 10 cm in length in adult.
E. The pharyngeal cavity opens in front into the nose, mouth, and larynx.
43. The oral vestibule:
A. Located between the teeth and alveoli.
B. Located between the lips and cheek.
C. The space enclosed by the teeth and alveoli .
D. It is site of drainage of salivary gland.
E. It communicates posteriorly with the oropharynx through the oropharyngeal isthmus.
44. The mylohyoid muscle:
A. It is a depressor of the mandible.
B. It is supplied by maxillary branch of the trigeminal 5th cranial nerve.
C. It is an elevator of the mandible.
D. It is a protractor of the mandible.
E. It is a retractor of the mandible.
45. What is true about lymphatic drainage of the vocal cords?
A. It has poor lymphatic drainage.
B. It has rich lymphatic drainage.
C. It has no lymphatic drainage.
D. It has a lymphatic drainage only in the anterior half.
E. None of the above.
46. Thornwaldt’s cyst is seen in:
A. Floor of mouth.
B. Oropharynx.
C. Nasopharynx.
D. Hypopharynx.
E. Larynx.
47. All of the following statements are true about nasopharyngeal tonsil except:
A. They are lined by squamous epithelium.
B. They are present at birth and disappear by puberty.
C. They are situated in the roof and posterior wall of nasopharynx.
D. They do not have capsule.
E. They do not have crypts.
48. Indications of tracheostomy:
A. In all cases of acute laryngitis.
B. In any intubated patient within 3 days.
C. Unilateral choanal atresia.
D. Ludwig's angina .
E. If there is suspicion of laryngomalacia.
49. Causes of aspiration pneumonia include all but:
A. Laryngomalacia.
B. Myasthenia gravis.
C. Polyneuritis.
D. Tetanus .
E. Cervical cord lesion.
50. Care of tracheostomized patient include:
A. Humidification by wet gauze.
B. Changing the tube.
C. Care of the inflatable cuff.
D. All the above.
E. None of the above.
Answers
Answers
1. D
The tonsils are paired secondary lymphatic organs situated on the side of the
oropharynx between the palatoglossal (anterior tonsillar pillar) & palatopharyngeal folds
(posterior tonsillar pillar). They are part of Waldeyer's ring, a ring of lymphoid tissue
consisting of the adenoids, the tubal tonsils, the palatine tonsils & the lingual tonsils,
which are embedded in the posterior third of the tongue. The tonsil is enclosed by a
fibrous capsule, outside of which is a layer of areolar tissue. This separates the capsule
from the pharyngobasilar fascia covering the superior constrictor muscle that forms the
tonsil bed. Running through the mucosa of each tonsil are 12-15 pits, called crypts . The
main blood supply of the tonsil is from the tonsillar branch of the facial artery.
2. B
Nasopharynx cancer or nasopharyngeal carcinoma (NPC) is the most common
cancer originating in the nasopharynx, the uppermost region of the pharynx ("throat"),
behind the nose where the nasal passages and auditory tubes join the remainder of the
upper respiratory tract. NPC occurs in children and adults. NPC differs significantly from
other cancers of the head and neck in its occurrence, causes, clinical behavior, and
treatment. It is vastly more common in certain regions of East Asia and Africa than
elsewhere, with viral, dietary and genetic factors implicated in its causation. It is most
common in males. It is a squamous cell carcinoma or an undifferentiated type. Squamous
cells are a flat type of cell found in the skin and the membranes that line some body
cavities. Differentiation means how different the cancer cells are from normal cells.
Undifferentiated is a word used to describe cells that do not have their mature features or
functions.
Cervical lymphadenopathy (disease or swelling of the lymph nodes in the neck) is the
initial presentation in many patients, and the diagnosis of NPC is often made by lymph
node biopsy. Symptoms related to the primary tumor include trismus, pain, otitis media,
nasal regurgitation due to paresis (loss of or impaired movement) of the soft palate,
hearing loss and cranial nerve palsies (paralysis). Larger growths may produce nasal
obstruction or bleeding and a "nasal twang". Metastatic spread may result in bone pain or
organ dysfunction. Rarely, a paraneoplastic syndrome of osteoarthropathy (diseases of
joints and bones) may occur with widespread disease.
3. E
Streptococcal pharyngitis, streptococcal tonsillitis, or streptococcal sore throat (known
colloquially as strep throat) is a type of pharyngitis caused by a group A streptococcal
infection. It affects the pharynx including the tonsils and possibly the larynx. Common
symptoms include fever, sore throat, and enlarged lymph nodes. It is the cause of 37% of
sore throats among children and 5-15% in adults.
Strep throat is a contagious infection, spread through close contact with an infected
individual. A definitive diagnosis is made based on the results of a throat culture.
However, this is not always needed as treatment may be decided based on symptoms. In
highly likely or confirmed cases, antibiotics are useful to both prevent complications and
speed recovery. Potential complications include rheumatic fever.
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4. A
It most commonly affects adolescent males.
Nasopharyngeal angiofibroma (also called juvenile nasopharyngeal angiofibroma)
is a histologically benign but locally aggressive vascular tumor that grows in the
back of the nasal cavity.
Conductive hearing loss from eustachian-tube obstruction
Patients with tumors that have extended into the cranial cavity or whose tumors
can't be safely reached by surgery may receive radiation therapy. Also Radiation
therapy helps in case where recurrence is the main problem.
5. B
Metastatic squamous neck cancer with occult primary is a disease in which
squamous cell cancer spreads to lymph nodes in the neck and it is not known
where the cancer first formed in the body.
Possible signs of metastatic squamous neck cancer with occult primary include
a lump or pain in the neck or throat.
Tests that examine the tissues of the neck, respiratory tract, and upper part of
the digestive tract are used to detect (find) and diagnose metastatic squamous
neck cancer and the primary tumor.
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6. E
Stridor is an auditory manifestation of disordered respiratory function due to air flow
changes within the larynx , trachea ,or bronchi. It’s a symptom or sign of many
conditions.
7. E
Causes for pooling of saliva in the pyriform fossa:
Pooling of saliva in the pyriform fossa is not only caused by growth affecting this area
causing obstruction to saliva being swallowed, but also due to intense cricopharyngeal
muscle spasm.
1. Malignant growth involving the deep portion of the pyriform fossa
2. Foreign body being lodged in the pyriform fossa.
3. Growth involving the crico pharynx (Postcricoid) or upper oesophagus can also cause
pooling of saliva.
8. D
The throat will have a thick white coating where the tonsils used to be. This is the
normal healing process and does not indicate infection.
9. C
Stages of squamous cell carcinoma of oropharynx
Stage 0 carcinoma in situ
Abnormal cells are found in the lining of the oropharynx, These may become cancer and
spread into nearby normal tissue.
Stage 1
Cancer has formed and is 20 millimetres or smaller and has not spread outside the
oropharynx.
Stage 2
Cancer has formed and is larger than 20 millimetres but not larger than 40 millimetres.
Also it has not yet spread outside the oropharynx.
Stage 3
Cancer is larger than 40 millimetres and has not spread outside the oropharynx
Any size and has spread to only one lymph node on the same side of the neck as
the cancer. The lymph node with cancer is 30 millimetres or smaller.
Stage 4A
Cancer has spread to tissues near the oropharynx, including the voice box, roof of
the mouth, lower jaw, muscle of the tongue or central muscles of the jaw and may
have spread to one or more nearby lymph nodes; none larger than 60 millimetres.
Cancer is any size and has spread to one lymph node that is larger than 30
millimetres but not larger than 60 millimetres on the same side of the neck as the
cancer or to more than one lymph node, none larger than 60 millimetres, on one
of both sides of the neck.
Stage 4B
Cancer surrounds the main artery in the neck or has spread to bones in the jaw or
skull, to muscle in the side of the jaw or to the upper part of the throat behind the
nose and may have spread to nearby lymph nodes
Cancer has spread to a lymph node that is larger than 60 millimetres and may
have spread to tissues around the oropharynx.
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Stage 4C
Cancer has spread to other parts of the body; the tumor may be any size and may have
spread to lymph nodes.
10. E
The following are some of the most common potential problems which can arise in
the last days and hours of a patient's life:
1. Pain -Suffering from uncontrolled pain is a significant fear of those at end
of life. Typically controlled using morphine or diamorphine; or other
opioids.
2. Agitation Delirium, terminal anguish, restlessness (e.g. thrashing,
plucking, or twitching). Typically controlled using midazolam, or other
benzodiazepines. Symptoms may also sometimes be alleviated by
rehydration, which may reduce the effects of some toxic drug metabolites.
3. Respiratory Tract Secretions Saliva and other fluids can accumulate in the
oropharynx and upper airways when patients become too weak to clear
their throats, leading to a characteristic gurgling or rattle-like sound
("death rattle"). While apparently not painful for the patient, the
association of the symptom with impending death can create fear and
uncertainty for those at the bedside. The secretions may be controlled
using drugs such as scopolamine (hyoscine), glycopyrronium, or atropine.
Rattle may not be controllable if caused by deeper fluid accumulation in
the bronchi or the lungs, such as occurs with pneumonia or some tumours.
4. Nausea and vomitingTypically controlled using cyclizine; or other anti-
emetics.
5. Dyspnea (breathlessness) Typically controlled using morphine or
diamorphine.
11. A
Radiotherapy: The method of choice for nasopharyngeal carcinoma, because surgical
removal of the primary growth is rarely possible; metastases are often present when the
patient is first seen; and the tumours are usually anaplastic and highly radiosensitive.
12. D
The commando procedure is done for cancers affecting the oropharyngeal region.
This term is coined ‘commando procedure’ as it’s a surgical attack on the diseased
tissue. The head and neck surgery involves resection of the mandible with the floor of the
mouth and the dissection of the entire lymphatic system of the neck along with the
sternoclidomastoid muscle and internal jugular vein.
13. E
Differential diagnosis of ulceration of the tonsil
A working diagnosis can usually be determined from the history & clinical examination.
Investigations include a full blood count, chest radiograph, serological tests & biopsy.
Possible causes include:
1. Infection.
• Acute streptococcal tonsillitis.
• Diphtheria.
• Infectious mononucleosis.
• Vincent's angina.
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2. Neoplasm.
• Squamous cell carcinoma.
• Lymphoma.
• Salivary gland tumours (adenoid cystic carcinoma).
3. Blood diseases.
• Agranulocytosis.
• Leukaemia.
4. Other causes.
• Aphthous ulceration.
• Behget's syndrome.
• Acquired immunodeficiency syndrome (AIDS).
14. E
Early post-tonsillectomy complications include
• Secondary haemorrhage.
• Haematoma and oedema of the uvula.
• Infection (may lead to secondary haemorrhage).
• Earache (referred pain or acute otitis media).
• Pulmonary complications (pneumonia and lung abscess are rare).
• Subacute bacterial endocarditis (if the patient has a cardiac defect).
Anaesthetic complications might be included in a peroperative or immediate post-
tonsillectomy complications.
15. E
The adenoids are a mass of lymphoid tissue found at the junction of the roof &
posterior wall of the nasopharynx. They are a normal structure with a function in the
production of antibodies (lgA, IgG & IgM). The size of the adenoids varies, but in
general they attain their maximal size between the ages of 3 & 8 years & then regress.
16. E
The larynx is of an exaggerated infantile type. The epiglottis is long and narrow and
folded backward at each lateral edge. This convert the epiglottis into an omega shaped
incomplete cylinder. The aryepiglottic folds are also approximated. The laryngeal inlet is
therefore reduced to a cruciate slit the edges of which sucked together by each
inspiration.
17. A
Acute simple laryngitis is an acute superficial inflammation of the laryngeal mucus
membrane. Which is an acquired and not a congenital condition.
18. D
One of the functions of the posterior pillars with the soft palate is to close the
velopharyngeal isthmus during swallowing and trauma to it can lead to nasal
regurgitation.
19. D
Hoarseness refers to a difficulty making sounds when trying to speak. Vocal sounds
may be weak, breathy, scratchy, or husky, and the pitch or quality of the voice may
change.
Hoarseness is most often caused by a problem with the vocal cords, which are part of
your voice box (larynx) in the throat. When the vocal cords become inflamed or infected,
they swell. This can cause hoarseness.
43
All the mentioned conditions can result from this kind of trauma and these lead to
hoarseness.
20. D
Laryngopharynx (hypopharynx) can be divided into three sub-sites:
1. piriform sinus
2. postcricoid area
3. posterior pharyngeal wall
21. C
Reports suggest that the decline has mainly involved tonsillectomies performed for
infectious indications, while the number of tonsillectomies performed for obstructive
indications may have actually increased.
22. B
Bezold's abscess, an abscess (a collection of pus surrounded by inflamed tissue)
behind the sternocleidomastoid muscle in the neck and is a complication of mastoiditis.
23. B
It lies between the aryepiglottic fold medially and the wall of the pharynx laterally.
24. D
Vocal cord paralysis is the second most common congenital laryngeal abnormality.
This must be differentiated from the commonest congenital laryngeal abnormality,
laryngomalacia. Stridor is the predominant presenting symptom in both of these
conditions. Other symptoms of vocal cord paralysis in children include obstruction, weak
cry, dysphagia, and aspiration. The diagnosis can usually be made by flexible endoscopy
at the bedside.
25 C
Onset of symptoms of respiratory diphtheria typically follows an incubation period of
2-5 days (range, 1-10 d). Symptoms initially are general and nonspecific, often
resembling a typical viral upper respiratory infection (URI). Respiratory involvement
typically begins with sore throat and mild pharyngeal inflammation. Development of a
localized or coalescing pseudomembrane can occur in any portion of the respiratory tract.
The pseudomembrane is characterized by the formation of a dense, gray debris layer
composed of a mixture of dead cells, fibrin, RBCs, WBCs, and organisms.
Removal of the membrane reveals a bleeding, edematous mucosa. The distribution of
the membrane varies from local (eg, tonsillar, pharyngeal) to widely covering the entire
tracheobronchial tree. The membrane is intensely infectious, and droplet and contact
precautions must be followed when examining or caring for infected patients. A
combination of cervical adenopathy and swollen mucosa imparts a "bull's neck"
appearance to many of the infected patients; this is shown in the image below. The most
frequent cause of death is airway obstruction or suffocation following aspiration of the
pseudomembrane.
44
26. C
The abscess lies in the potential space between the Buccopharyngeal &
prevertebral fasciae.
The acute abscess is caused by suppuration in the retropharyngeal lymph nodes,
which become infected from the nasopharynx & oropharynx. The commonest
organism is streptococcus pneumoniae.
27. B
Nx lymph nodes cannot be assessed
N0 no regional nodes involved
N1 single ipsilateral lymph node < 3 cm in diameter
N2a single ipsilateral lymph node between 3 and 6 cm in diameter
N2b multiple ipsilateral lymph nodes, none larger than 6 cm diameter
N2c bilateral or contralateral lymph nodes, none larger than 6 cm diameter
N3 lymph node larger than 6 cm in diameter
28. E
The subglottis is defined as the area of the larynx housed by the cricoid cartilage that
extends from 5 mm beneath the true vocal cords to the inferior aspect of the cricoid ring.
A reactive inflammatory response causes subglottic edema. Narrowing of the airway can
be life threatening in infants and young children because of their small airway and lax
tissues.
29. B
Tumour staging
Site
Stage
TNM Classification
Tumour
Tx
not defined
T0
no primary tumour or carcinoma in situ
T1
One subsite & less than 2 cm diameter in greatest dimention.
T2
More than one subsite & tumour 2 to 4 cm diameter in greatest
dimention. Without fixation of hemilarynx
T3
tumour over 4 cm diameter With fixation of hemilarynx
45
T4
tumour invades surrounding structures
Nodes
Nx
lymph nodes cannot be assessed
N0
no regional nodes involved
N1
single ipsilateral lymph node < 3 cm in diameter
N2a
single ipsilateral lymph node between 3 and 6 cm in diameter
N2b
multiple ipsilateral lymph nodes, none larger than 6 cm diameter
N2c
bilateral or contralateral lymph nodes, none larger than 6 cm diameter
N3
lymph node larger than 6 cm in diameter
Metastasis
Mx
not assessed
M0
no distant metastases
M1
distant metastasis present
30. B
It is the disease of young adults and it can be confirmed by monospot test called paul
bunel test. The other conditions usually show more signs and symptoms which are
evident at examination.
31. C
The most common complication of tonsillectomy is Haemorrhage.
32. D
Articulation structures such as palate, tongue, …etc are responsible for generation of
speech.
33. E
Stridor is a high-pitched musical breath sound resulting from turbulent air flow in the
larynx or lower in the bronchial tree. Stridor is a physical sign which is caused by a
narrowed or obstructed airway. It can be inspiratory, expiratory or biphasic, although it is
usually heard during inspiration. Inspiratory stridor often occurs in children with "croup."
It may be indicative of serious airway obstruction from severe conditions such as
epiglottitis, a foreign body lodged in the airway, or a laryngeal tumor. Stridor should
always command attention to establish its cause. Visualization of the airway by medical
experts equipped to control the airway may be needed.
34. D
In order of frequency of occurrence of malignant tumours of hypopharynx:
1. Piriform sinus: 60%
2. Post cricoid area: 30%
3. Postertior pharyngeal wall: 10%
35. E
Cervical lymphadenopathy (disease or swelling of the lymph nodes in the
neck) is the initial presentation in many patients, and the diagnosis of NPC is
often made by lymph node biopsy.
Symptoms of local invasion (Trotterۥs triad)
1. Conductive deafness: due to infiltration of the eustachian tube. This may
proceed to secretory otitis media.
2. Elevation and immobility of the homolateral soft palate: due to direct
infil¬tration.
46
3. Pain in the side of the head: due to involvement of the Vth cranial nerve, from
infiltration via the foramen lacerum. Pain may also be felt in the ear, upper or
lower jaws, and the tongue.
Radiotherapy is the method of choice, because surgical removal of the
primary growth is rarely possible; metastases are often present when the
patient is first seen; and the tumours are usually anaplastic and highly
radiosensitive.
Nasopharyngeal carcinoma (NPC) is caused by a combination of factors:
viral, environmental influences, and heredity. The viral influence is associated
with infection with Epstein-Barr virus (EBV).
36. C
Trismus, or lockjaw, refers to reduced opening of the jaws caused by spasm of
the muscles of mastication, or may generally refer to all causes of limited
mouth opening. It is a common problem with a variety of causes, and may
interfere with eating, speech, oral hygiene, and could alter facial appearance.
There is an increased risk of aspiration. Temporary trismus is much more
common than permanent trismus, and may be distressing and painful, and
limit or prevent medical examination or treatments requiring access to the oral
cavity.
Quinsy because of its proximity to the parapharyngeal musculature there is
associated spasm particularly of the pterygoid muscles.
37. B
Waldeyerʼs ring is a ring of lymphatic tissue formed by the two palatine tonsils, the
nasopharyngeal tonsil (adenoids), the tubal tonsils (around the Eustachian opening), the
lingual tonsil, and intervening lymphoid tissue
38. E
Nasopharyngeal angiofibroma (also called juvenile nasopharyngeal angiofibroma)
is a histologically benign but locally aggressive vascular tumor that grows in the back of
the nasal cavity. It most commonly affects adolescent males. Patients with angiofibroma
usually present with one-sided nasal obstruction and recurrent bleeding.
39. D
Acute epiglottitis: it is a special form of acute laryngitis, in which the inflammatory
changes affect mainly the loosely attached mucosa of the epiglottis. localized edema may
obstruct the air way especially in children, in whom H. influinzae may be the causal
organism. Age incidence isbetween1-6 year old.
40. D
Intravenous antibiotics against H.influinzae in high doses (amoxicillin+ clavulanic
acid) is a must to be started immediately .
41. D
The mouth extends from the lips to the anterior pillar of the fauces.
The mouth consists from two parts:-
1. Vestibule.
2. Mouth proper.
It communicates posteriorly with the oropharynx through the oropharyngeal
isthmus.
47
The floor is formed by the anterior 2/3 of the tongue
The sublingual and the submandibular salivary glands open under the tongue
in the floor of the mouth while the duct of the parotid gland opens in to the
vestibule against the second upper molar tooth.
42. A
Extends from base of the skull to the sixth cervical vertebra at lower border of the
cricoid cartilage.
43. D
The oral vestibule lies between the lips and cheek on one side and the teeth
and alveoli on the other side.
The mouth proper is the site of drainage of salivary gland which
communicates posteriorly with the oropharynx through the oropharyngeal
isthmus.
44. A
The mylohyoid muscle is one of the depressors of the mandible, with the muscles of
mastication it is supplied by mandibular branch of the trigeminal 5th cranial nerve.
45. C
The vocal cords separate the supraglottis from the subglottis and it is devoid from
lymphatic drainage . This explain the delay in lymphatic metastasis in glottis carcinoma.
46. C
It is an embryological remnant located at the midline of the posterior wall of the
nasopharynx.
47. A
They are lined by respiratory epithelium (pseudostratified ciliated columnar
epithelium with goblet cells).
48. D
Indications for tracheostomy:-
1-relief of upper respiratory obstruction.
a-congenital: bilateral caoanal atresia , laryngeal web, laryngeal cyst ,upper tracheal
stenosis, and tracheo- esophageal anomalies.
b-traumatic: internal (inhalation of steam or irritant fumes, foreign body or swallowing
of corrosive) or external (blow on the larynx , gun shot , or cut throat).
c-infections: acute epiglottitis, acute laryngotracheo bronchitis, diphtheria , Ludwig's
angina , retropharyngeal abscess, or parapharyngeal abscess.
d-tumors: malignant tumors of tongue , upper trachea, , pharynx , larynx , or thyroid
gland.
e- bilateral recurrent laryngeal palsies: after thyroidectomy or bulbar palsy .
f- cord fixation : due to rheumatoid arthritis.
g-other causes of glottic obstruction: like hemophilia , angioneurotic oedema…….
2-protection of lower respiratory tract: bulbar and pseudobulbar palsy, coma (head injury
or drug abuse), myasthenia gravis, polyneuritis, tetanus , cervical cord lesion ,
myasthenia gravis.…
3-assist ventilation: in conditions that cause respiratory insufficiency :-
a-pulmonary disease : chronic bronchitis , emphysema , and postoperative pneumonia .
48
b-severe chest injury: flial chest.
c-neuromuscular incoordination that cause stagnation of bronchial secretion or the need
for artificial or intermittent positive pressure ventilation PPV.
4-elective procedure: in any major procedure in mouth ,pharynx or larynx.
49. A
Aspiration pneumonia is bronchopneumonia that develops due to the entrance of
foreign materials into the bronchial tree, usually oral or gastric contents (including food,
saliva, or nasal secretions). Depending on the acidity of the aspirate, a chemical
pneumonitis can develop, and bacterial pathogens (particularly anaerobic bacteria) may
add to the inflammation.
Aspiration pneumonia is often caused by an incompetent swallowing mechanism, such as
occurs in some forms of neurological disease or injury including multiple sclerosis, CVA
(stroke), Alzheimer's disease or intoxication. An iatrogenic cause is during general
anaesthesia for an operation and patients are therefore instructed to be nil per os (NPO)
(aka Nothing By Mouth) for at least four hours before surgery.
50. D
Post-operative care of tracheostomized patient:-
1. Nursing care: constant attention is essential for the first 24 hours at least.
2. Fixation of the tracheostomy tube.
3. Removal of secretions by suction.
4. Humidification: by wet gauze.
5. Changing the tube.
6. Care of the inflatable cuff.
7. Removal of the tube.
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