A 10-year-old girl presents with a swelling in the lower neck. Her mother reports that since infancy, the child has had regurgitation and difficulty swallowing. The swelling increases after eating, and when pressed, the girl feels food coming back into her throat. On examination, there is a cough impulse over the swelling.
What is the most probable diagnosis?
Decoding the Stem
Explanation
D. Pharyngeal Pouch (Correct): Arises through Killian’s dehiscence (between thyropharyngeus & cricopharyngeus). Regurgitation of undigested food and swelling reduction on pressure are hallmark signs.
A. Goiter: Moves with swallowing but does not fill with food or cause regurgitation upon external pressure.
E. Thyroglossal Cyst: A midline swelling that moves with tongue protrusion; it does not communicate with the pharynx in a way that causes food regurgitation.
B & C: Laryngomalacia presents with stridor, not a neck mass. Subclavian aneurysms are pulsatile and unrelated to eating.
🧠High-Yield Pearls
| Feature | Description | Key Fact |
|---|---|---|
| Anatomy | Killian's Dehiscence | Area between 2 parts of Inferior Constrictor |
| Type | Pulsion Diverticulum | A "False" diverticulum (mucosa/submucosa only) |
| Diagnosis | Barium Swallow | Best initial and diagnostic test |
Integrated Clinical Questions
1. Site of origin of pharyngeal pouch?
2. Most common presenting symptom?
3. Recommended treatment for symptomatic pouch?
⚡ Exam Pearls
- Boyce's Sign: Gurgling sound on pressing the neck swelling.
- Avoid Endoscopy (OGD) initially as the scope can perforate the pouch.
- Classic presentation: Elderly male (though pediatric cases occur as in this stem).
- Most common complication: Aspiration pneumonia.
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