A 24-year-old man has had a sore throat for 5 days. He now has severe right-sided throat pain radiating to the ear, drooling, a muffled 'hot potato' voice and trismus. The right soft palate bulges and the uvula is pushed to the left. In this condition, the pus collects between:

The tonsil capsule and the superior constrictor

The crypts within the tonsil itself

The superior constrictor and the medial pterygoid

The prevertebral fascia and the vertebrae

A 22-year-old hostel student with poor oral hygiene has had a painful throat and foul breath for five days. One tonsil shows a punched-out ulcer covered by a greyish membrane that leaves a bleeding surface when wiped; the other tonsil is normal. Gram stain of the ulcer shows fusiform bacilli with many spirochaetes. Which treatment is most appropriate?

Penicillin with metronidazole and oral hygiene

Diphtheria antitoxin with erythromycin

Oral fluconazole with nystatin gargles

During a tonsillectomy under general anaesthesia in a 19-year-old, dark venous blood keeps welling up from the upper part of the tonsillar bed after the tonsil has been removed. Which vessel is the commonest source of such venous bleeding?

Paratonsillar (external palatine) vein

A 45-year-old diabetic labourer is brought to casualty with a swelling under the chin for three days after a tooth infection. He is sitting upright, drooling and cannot close his mouth. The floor of the mouth is woody and raised, the tongue is pushed up against the palate, and there is soft inspiratory stridor. SpO2 is 93% on room air. The surgeon plans drainage and IV antibiotics. What should be done first?

Secure the airway awake, by fibreoptic intubation or tracheostomy under local anaesthesia

Start IV antibiotics and observe in the ward for 24 hours

Rapid sequence induction with paralysis and direct laryngoscopy

Incise the floor of the mouth in the casualty under local anaesthesia

Pharynx, tonsils and deep neck infections

21 NEET-PG practice questions on Pharynx, tonsils and deep neck infections, part of ENT. The first 21 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
A 24-year-old man has had a sore throat for 5 days. He now has severe right-sided throat pain radiating to the ear, drooling, a muffled 'hot potato' voice and trismus. The right soft palate bulges and the uvula is pushed to the left. In this condition, the pus collects between:
1. AThe tonsil capsule and the superior constrictor
2. BThe crypts within the tonsil itself
3. CThe superior constrictor and the medial pterygoid
4. DThe prevertebral fascia and the vertebrae
Show answerHide answer
Answer: A · The tonsil capsule and the superior constrictor
Unilateral bulging of the soft palate with uvular shift, trismus and a hot-potato voice after tonsillitis is a peritonsillar abscess (quinsy). Pus collects in the peritonsillar space, between the capsule of the tonsil and the superior constrictor muscle of the tonsillar bed. Trismus comes from spasm of the nearby medial pterygoid. Treatment is needle aspiration or incision and drainage with IV antibiotics, followed by tonsillectomy about 6 weeks later.
- B: Pus in the crypts is follicular tonsillitis, with no palatal bulge or trismus.
- C: Pus lateral to the constrictor is a parapharyngeal abscess, which swells the neck.
- D: Pus behind the prevertebral fascia is a chronic (tuberculous) retropharyngeal abscess.
Question 2 · Medium
A 22-year-old hostel student with poor oral hygiene has had a painful throat and foul breath for five days. One tonsil shows a punched-out ulcer covered by a greyish membrane that leaves a bleeding surface when wiped; the other tonsil is normal. Gram stain of the ulcer shows fusiform bacilli with many spirochaetes. Which treatment is most appropriate?
1. ADiphtheria antitoxin with erythromycin
2. BPenicillin with metronidazole and oral hygiene
3. COral fluconazole with nystatin gargles
4. DOral acyclovir with analgesics
Show answerHide answer
Answer: B · Penicillin with metronidazole and oral hygiene
A unilateral ulceromembranous tonsillitis with fusiform bacilli and spirochaetes on Gram stain is Vincent angina, a synergistic infection by Fusobacterium and Treponema (Borrelia) vincentii in a person with poor dental hygiene. Penicillin and metronidazole cover these anaerobes, and mouth washes and dental care prevent recurrence. The membrane is easily removed and the patient is not toxic, which helps separate it from diphtheria. A smear is cheap and quick, so it should be taken in any membranous tonsillitis.
- A: Diphtheria shows club-shaped Gram-positive bacilli, not fusiform bacilli and spirochaetes.
- C: Antifungals treat candidiasis, which gives white curd-like plaques with yeasts and hyphae.
- D: Acyclovir treats herpetic ulcers, which are multiple small vesicles, not a single membrane-covered ulcer.
Question 3 · Medium
During a tonsillectomy under general anaesthesia in a 19-year-old, dark venous blood keeps welling up from the upper part of the tonsillar bed after the tonsil has been removed. Which vessel is the commonest source of such venous bleeding?
1. AParatonsillar (external palatine) vein
2. BPterygoid venous plexus
3. CRetromandibular vein
4. DInternal jugular vein
Show answerHide answer
Answer: A · Paratonsillar (external palatine) vein
The paratonsillar (external palatine) vein descends from the soft palate across the lateral surface of the tonsillar capsule before piercing the superior constrictor, so it is torn when the tonsil is dissected out. It is the commonest source of venous bleeding during tonsillectomy, while the tonsillar branch of the facial artery is the main artery of the tonsil. Bleeding is controlled with pressure, ligation or bipolar diathermy before the patient is extubated. Checking the fossae carefully at the end of the operation prevents reactionary haemorrhage.
- B: The pterygoid plexus lies in the infratemporal fossa, outside the tonsillar bed.
- C: The retromandibular vein lies within the parotid region, away from the tonsil.
- D: The internal jugular vein lies well lateral to the tonsillar bed and is not met in routine tonsillectomy.
Question 4 · Hard
A 45-year-old diabetic labourer is brought to casualty with a swelling under the chin for three days after a tooth infection. He is sitting upright, drooling and cannot close his mouth. The floor of the mouth is woody and raised, the tongue is pushed up against the palate, and there is soft inspiratory stridor. SpO2 is 93% on room air. The surgeon plans drainage and IV antibiotics. What should be done first?
1. AStart IV antibiotics and observe in the ward for 24 hours
2. BRapid sequence induction with paralysis and direct laryngoscopy
3. CSecure the airway awake, by fibreoptic intubation or tracheostomy under local anaesthesia
4. DIncise the floor of the mouth in the casualty under local anaesthesia
Show answerHide answer
Answer: C · Secure the airway awake, by fibreoptic intubation or tracheostomy under local anaesthesia
Bilateral board-like swelling of the floor of the mouth after a dental infection, with tongue displacement and stridor, is Ludwig angina with impending airway obstruction, the main cause of death in this condition. Muscle relaxants can make the airway collapse completely, and trismus with a raised tongue makes direct laryngoscopy unlikely to succeed, so the airway is secured with the patient awake, by fibreoptic intubation or by tracheostomy under local anaesthesia. After that, IV antibiotics and surgical decompression of the submandibular space follow, along with control of diabetes. Observation alone risks sudden obstruction.
- A: Antibiotics alone do not deal with a threatened airway, which can close without warning.
- B: Paralysis can convert a partial obstruction into a 'cannot intubate, cannot oxygenate' emergency.
- D: Incision without a secured airway can provoke bleeding and spasm, and does not protect the airway.
Question 5 · Medium
A 27-year-old man has a right peritonsillar abscess with trismus, a bulging right soft palate and the uvula pushed to the left. The ENT resident considers four statements: 1. Needle aspiration is an acceptable first drainage procedure. 2. If it is incised, the cut is made at the point of maximum bulge above the upper pole of the tonsil. 3. Interval tonsillectomy can be done about 4-6 weeks later. 4. The abscess lies within the substance of the tonsil, deep to its crypts. Which statements are correct?
1. A1, 2, 3 and 4
2. B1 and 3 only
3. C1, 2 and 3 only
4. D2, 3 and 4 only
Show answerHide answer
Answer: C · 1, 2 and 3 only
Statements 1, 2 and 3 are correct for quinsy. Needle aspiration is an effective first step in many patients, and incision and drainage is made at the point of maximum bulge, usually above the upper pole of the tonsil, opening the cavity with sinus forceps. Because quinsy tends to recur, tonsillectomy is advised about 4-6 weeks later, or occasionally as an abscess (hot) tonsillectomy. Statement 4 is wrong: the pus lies outside the tonsil, between its capsule and the superior constrictor.
- A: Includes statement 4, which misplaces the abscess.
- B: Omits the correct site of incision.
- D: Places the pus within the tonsil, whereas it lies outside the capsule.
Question 6 · Medium
A 30-year-old man had a sore throat 10 days ago. He now has high fever, trismus and a tender, firm swelling of the left side of the neck below the angle of the mandible. The left tonsil and lateral pharyngeal wall are pushed towards the midline, but the soft palate above the tonsil does not bulge. CECT neck shows a collection lateral to the superior constrictor. How should the pus be drained?
1. AExternal incision in the neck below the angle of the jaw
2. BImmediate abscess (hot) tonsillectomy
3. CIntraoral incision over the most prominent part of the tonsil
4. DNeedle aspiration through the posterior pharyngeal wall
Answer and explanation in LearnFree account
Question 7 · Hard
A 19-year-old college athlete had a severe sore throat a week ago. He now has spiking fever with rigors, a tender swelling along the left anterior border of sternocleidomastoid and pleuritic chest pain. Chest CT shows multiple peripheral cavitating nodules, and Doppler shows thrombus in the left internal jugular vein. Blood culture grows an anaerobic Gram-negative bacillus. Which organism is most likely?
1. AFusobacterium necrophorum
2. BStreptococcus pyogenes
3. CHaemophilus influenzae type b
4. DStaphylococcus aureus
Answer and explanation in LearnFree account
Question 8 · Medium
A 4-year-old boy's teacher reports that he does not respond when called. He breathes through the mouth and snores. Both tympanic membranes are dull and retracted, tympanometry shows flat (type B) curves on both sides and pure tone audiometry by play shows a 30 dB conductive loss. The effusion has persisted for over three months despite medical treatment. A lateral X-ray shows large adenoids. What is the best management?
1. AAdenoidectomy with myringotomy and grommets
2. BTonsillectomy with adenoidectomy
3. CA further three-month course of antibiotics
4. DMyringotomy with grommets alone
Answer and explanation in LearnFree account
Question 9 · Medium
A 2-year-old boy is brought to casualty with three days of fever, refusal to feed, drooling, a stiff neck held extended and noisy breathing. Examination shows a smooth bulge on the right side of the posterior pharyngeal wall. A lateral neck X-ray shows widened prevertebral soft tissue. Why is this condition seen mainly in children under about 5 years?
1. AThe prevertebral fascia is incomplete in infants
2. BCervical vertebrae are mostly cartilage until then
3. CRetropharyngeal lymph nodes regress with age
4. DThe adenoids are largest at this age
Answer and explanation in LearnFree account
Question 10 · Medium
A 5-year-old boy from Kanpur snores every night with pauses in breathing, sleeps restlessly with his neck extended and is falling behind at school. Both tonsils meet in the midline and the adenoids are enlarged. If this is left untreated for years, which serious complication can develop?
1. ARheumatic mitral valve disease
2. BPulmonary hypertension with cor pulmonale
3. CPeritonsillar abscess
4. DAcute post-streptococcal glomerulonephritis
Answer and explanation in LearnFree account
Question 11 · Medium
A 5-year-old girl is listed for adenoidectomy for snoring and mouth breathing. At the pre-operative check the anaesthetist notices a bifid uvula, a bluish midline zone on the soft palate and a palpable notch at the back of the hard palate. Her mother says milk sometimes came out of her nose as an infant. What is the main risk of going ahead with adenoidectomy?
1. ASevere primary haemorrhage
2. BPersistent hypernasal speech
3. CPostoperative nasopharyngeal stenosis
4. DAtlantoaxial subluxation
Answer and explanation in LearnFree account
Question 12 · Easy
A 6-year-old boy is brought to the paediatric OPD because he snores loudly, sleeps with his mouth open and has a pinched nose with a high-arched palate. A lateral soft-tissue X-ray of the nasopharynx shows a large adenoid mass narrowing the airway. Which change in his speech is expected?
1. ABreathy, weak voice from glottic gap
2. BHyponasal speech (rhinolalia clausa)
3. CHypernasal speech (rhinolalia aperta)
4. DHoarse voice from vocal cord nodules
Answer and explanation in LearnFree account
Question 13 · Hard
A 32-year-old man from Bihar has had neck pain and stiffness for three months, evening fever and weight loss. He now has difficulty swallowing. Examination shows a soft, non-tender midline bulge of the posterior pharyngeal wall. Sputum is negative. X-ray of the cervical spine shows destruction of the C4-C5 disc space with a large prevertebral soft-tissue shadow. Besides antitubercular treatment, how should the collection be drained if it does not resolve?
1. AThrough an intraoral incision on the pharyngeal wall
2. BBy hot tonsillectomy on the larger side
3. CBy repeated needle aspiration through the mouth
4. DThrough an external incision in the neck
Answer and explanation in LearnFree account
Question 14 · Medium
A 14-year-old girl had an uneventful tonsillectomy at a district hospital and went home the next day. On the 6th post-operative day she returns with bright red bleeding from the mouth. The tonsillar fossae are covered with dirty grey slough, her temperature is 38.4 °C and her pulse is 110/min. What is the most likely cause of the bleeding?
1. AA slipped ligature on an artery
2. BAn undiagnosed bleeding disorder
3. CInfection of the tonsillar fossa
4. DNormal separation of the white membrane
Answer and explanation in LearnFree account
Question 15 · Easy
A 38-year-old man with uncontrolled diabetes has had a painful lower left third molar for a week. He now has a tense, board-like swelling under both sides of the jaw, the floor of the mouth is raised and the tongue is pushed up and back. There is no fluctuation. Where did this infection most likely begin?
1. ARoots of the lower molar teeth
2. BInfected submandibular salivary gland
3. CPeritonsillar space after tonsillitis
4. DRetropharyngeal lymph nodes
Answer and explanation in LearnFree account
Question 16 · Easy
A 9-year-old girl from a government school in Nagpur has fever of 39 °C, painful swallowing, enlarged tonsils with white exudate and tender nodes at the angle of the jaw, with no cough or runny nose. A rapid antigen test for group A streptococcus is positive. Her mother asks why she must keep giving penicillin for the full 10 days when the fever settles in two. What is the main reason?
1. ATo prevent post-streptococcal glomerulonephritis
2. BTo prevent spread to the middle ear
3. CTo prevent a later peritonsillar abscess
4. DTo prevent acute rheumatic fever
Answer and explanation in LearnFree account
Question 17 · Medium
A 25-year-old woman has severe pain in the right ear on the second day after tonsillectomy. The ear canal and tympanic membrane are normal and hearing is unchanged. Through which nerve is this pain referred?
1. AGlossopharyngeal nerve
2. BFacial nerve
3. CGreat auricular nerve
4. DAuriculotemporal nerve
Answer and explanation in LearnFree account
Question 18 · Easy
A 7-year-old boy has had recurrent sore throats for two years. During the current episode the ENT resident palpates a single enlarged, tender node just below the angle of the mandible, deep to the anterior border of sternocleidomastoid. Which node is this?
1. APre-auricular node
2. BJugulodigastric node
3. CSubmental node
4. DSupraclavicular node
Answer and explanation in LearnFree account
Question 19 · Medium
A 10-year-old boy is reviewed in the ENT OPD for possible tonsillectomy. Consider four findings from his history: 1. Seven documented episodes of acute tonsillitis in the last year. 2. A peritonsillar abscess twice in the past 18 months. 3. Tonsillitis has caused febrile seizures. 4. He has an active acute tonsillitis today, with fever. Which findings support listing him for tonsillectomy?
1. A2, 3 and 4 only
2. B1, 2, 3 and 4
3. C1 and 2 only
4. D1, 2 and 3 only
Answer and explanation in LearnFree account
Question 20 · Hard
A 6-year-old girl is brought back to the ENT clinic eight days after an adenotonsillectomy. She holds her head tilted to the right and rotated to the left, and cries when her neck is moved. There is no fever, the wound is healing well and there is no history of a fall. Neurological examination is normal. What is the most likely diagnosis?
1. ADystonic reaction to an antiemetic drug
2. BInflammatory atlantoaxial subluxation (Grisel syndrome)
3. CAcute retropharyngeal abscess after surgery
4. DSpasm of sternocleidomastoid from a birth injury
Answer and explanation in LearnFree account
Question 21 · Medium
A 56-year-old man who chews tobacco notices that his right tonsil has been enlarging for three months. It is firm and smooth, with no ulcer, and is about twice the size of the left. He has no fever or sore throat, but he has lost 4 kg and has a firm 2 cm node at level II. What is the next best step?
1. ATonsillectomy for histopathology
2. BFine needle aspiration of the tonsil
3. CAntibiotics and review in six weeks
4. DReassurance and annual follow-up
Answer and explanation in LearnFree account

Pharynx, tonsils and deep neck infections

A 24-year-old man has had a sore throat for 5 days. He now has severe right-sided throat pain radiating to the ear, drooling, a muffled 'hot potato' voice and trismus. The right soft palate bulges and the uvula is pushed to the left. In this condition, the pus collects between:

During a tonsillectomy under general anaesthesia in a 19-year-old, dark venous blood keeps welling up from the upper part of the tonsillar bed after the tonsil has been removed. Which vessel is the commonest source of such venous bleeding?

A 5-year-old boy from Kanpur snores every night with pauses in breathing, sleeps restlessly with his neck extended and is falling behind at school. Both tonsils meet in the midline and the adenoids are enlarged. If this is left untreated for years, which serious complication can develop?

A 6-year-old boy is brought to the paediatric OPD because he snores loudly, sleeps with his mouth open and has a pinched nose with a high-arched palate. A lateral soft-tissue X-ray of the nasopharynx shows a large adenoid mass narrowing the airway. Which change in his speech is expected?

A 25-year-old woman has severe pain in the right ear on the second day after tonsillectomy. The ear canal and tympanic membrane are normal and hearing is unchanged. Through which nerve is this pain referred?

A 7-year-old boy has had recurrent sore throats for two years. During the current episode the ENT resident palpates a single enlarged, tender node just below the angle of the mandible, deep to the anterior border of sternocleidomastoid. Which node is this?