A 10-year-old girl is admitted to the hospital with tonsillitis. A tonsillectomy is performed and the tonsils are removed. On physical examination one week later the patient has absence of the gag reflex on the left when the posterior part of the tongue is depressed. The sensory portion of which of the following nerves was most likely injured?

**Core Concept:** The gag reflex is a complex reflex involving the integration of sensory inputs from various structures, including the tonsils, pharyngeal mucosa, and the posterior part of the tongue. The gag reflex is mediated by the pharyngeal branch of the vagus nerve (cervical vagus), which supplies sensory information to the posterior pharyngeal wall and tonsils.

**Why the Correct Answer is Right:** In this case, the absence of the gag reflex on the left side after tonsillectomy suggests that the injury occurred in the vicinity of the tonsils and/or the posterior part of the tongue, where the cervical vagus nerve (C8-T1) innervates. The injury is most likely to the pharyngeal branch of the vagus nerve, which is responsible for the gag reflex in this region.

**Why Each Wrong Option is Incorrect:**

A. The pharyngeal branch of the vagus nerve (C8-T1) is the correct answer, as it supplies sensory information to the posterior pharyngeal wall and tonsils, causing the gag reflex. Other options are incorrect for the following reasons:

- B: The glossopharyngeal nerve (C0-9) is responsible for taste sensation and innervates the posterior pharynx, not the gag reflex.
- C: The hypoglossal nerve (CN XII) innervates the tongue and muscles involved in tongue movement, not the gag reflex.
- D: The recurrent laryngeal nerve (C3-4) innervates the larynx and vocal cords, not the gag reflex in the region of tonsils and posterior pharynx.

**Correct Answer:** Cervical vagus nerve (C8-T1) supplies the gag reflex to the posterior pharyngeal wall and tonsils.

**Clinical Pearl:** A precise knowledge of the anatomy and innervation of the pharyngeal region is essential for understanding the gag reflex and its potential injury following tonsillectomy. This understanding helps in interpreting clinical findings, formulating a proper diagnosis, and guiding appropriate management strategies.

✓ Correct Answer: B. Glossopharyngeal